Chronic insomnia affects more than 30 million adults in the United States and is a significant public health concern linked to increased morbidity, mortality, and healthcare costs. Most individuals with insomnia turn to primary care providers for help, yet access to evidence-based behavioral treatments such as cognitive behavioral therapy for insomnia (CBT-I) remains limited. Hispanic adults are disproportionately affected and less likely than non-Hispanic Whites to receive CBT-I, due in part to high costs and a shortage of bilingual providers. While digital health tools offer a scalable solution to expand access, culturally adapted versions tailored to underserved populations remain scarce.
This study addressed disparities in access to insomnia treatment by adapting and testing the effectiveness of a Spanish-language version of Somryst®, a US Food and Drug Administration (FDA)-authorized, self-guided dCBT-I prescription digital therapeutic. Modeled on the core principles of face-to-face CBT-I, Somryst is an evidence-based, interactive web- and mobile-based intervention designed to reduce insomnia symptoms. Participants were primarily recruited from primary care settings, with a focus on Hispanic adults.
The specific aims of the research were as follows:
- Culturally adapt the first FDA-authorized dCBT-I for Spanish-speaking Hispanic patients.
- Describe the preliminary effectiveness of a culturally adapted dCBT-I vs. minimally enhanced usual care (mEUC).
- Examine the system-, provider-, and patient-level barriers and facilitators to implementation.
Researchers conducted a three-part mixed methods study to develop, test, and evaluate a Spanish-language version of Somryst tailored for Hispanic patients. First, they applied a structured cultural adaptation model to modify Somryst, incorporating feedback from a bilingual advisory board, focus groups, and interviews with patients, providers, and system stakeholders. Next, they enrolled patients into a randomized controlled trial to assess the preliminary effectiveness of the adapted program, delivered alongside enhanced usual care, in reducing insomnia symptoms. Finally, they conducted further interviews to examine implementation barriers and facilitators across patient, provider, and system levels. The study leveraged rising smartphone use among Hispanic adults to explore scalable, non-pharmacological strategies for improving sleep health and reducing behavioral health disparities.
Although the study’s sample size was limited, participants rated the adapted dCBT-I program as highly usable and acceptable. Participants in the dCBT-I group reported greater improvements in sleepiness, fewer dysfunctional beliefs about sleep, and higher satisfaction with care compared to those receiving mEUC. Deep cultural adaptations, including integration of sociocultural values and recognition of environmental stressors, were central to user engagement. Clinic-based referrals proved most effective for recruiting eligible participants, underscoring the role of provider involvement in reaching marginalized patients. Key factors for successful implementation included how the program was designed, the healthcare system’s integration of the program into the clinical workflow, provider involvement and support. These findings are especially timely as policy changes, including new Medicare billing codes for app-based behavioral therapies, could support broader dissemination of digital sleep treatments in underserved populations.
