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. 2023 Feb;9(1):18-25.
doi: 10.1016/j.sleh.2022.10.010. Epub 2022 Nov 28.

Racial disparities in treatment engagement and outcomes in digital cognitive behavioral therapy for insomnia among pregnant women

David A Kalmbach  1 , Philip Cheng  2 , Anthony N Reffi  2 , Grace M Seymour  2 , Melissa K Ruprich  2 , Luisa F Bazan  2 , D'Angela S Pitts  3 , Olivia Walch  4 , Christopher L Drake  2
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Racial disparities in treatment engagement and outcomes in digital cognitive behavioral therapy for insomnia among pregnant women

David A Kalmbach et al. Sleep Health. 2023 Feb.

Abstract

Objectives: In the United States, Black women are disproportionately afflicted with prenatal insomnia. Although cognitive-behavioral therapy for insomnia (CBTI) may represent a strategy to reduce disparities in insomnia, racial minorities attend fewer healthcare appointments and have poorer outcomes from prenatal care and mental health treatment relative to white patients. The present study examined differences in treatment engagement and patient-reported outcomes in non-Hispanic Black and white pregnant women receiving digital CBTI.

Methods: Secondary analysis of 39 pregnant women with clinical insomnia who received digital CBTI. Treatment engagement was operationalized as the number of sessions completed (≥4 considered an adequate dose). Treatment outcomes were assessed using the Insomnia Severity Index (ISI; insomnia) and Pittsburgh Sleep Quality Index (PSQI; global sleep disturbance).

Results: Black women were 4 times more likely than white women to discontinue CBTI before receiving an adequate dose (8.3% vs. 33.3%). Regarding treatment outcomes, white women reported a mean reduction of 5.75 points on the ISI and a reduction of 3.33 points on the PSQI (Cohen's dz = 1.10-1.19). By comparison, Black women reported reductions of 2.13 points on the ISI and 1.53 points on the PSQI, which were statistically non-significant. Differences in treatment engagement did not account for the disparities in patient-reported outcomes.

Conclusions: During pregnancy, Black women completed fewer CBTI sessions and experienced poorer treatment outcomes in response to digital CBTI relative to white women. Enhancements to insomnia therapy and its digital delivery may improve adherence and outcomes in Black pregnant women.

Keywords: Black women; CBTI; Mobile health; Pregnancy; Sleep.

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Figures

Figure 1.
Figure 1.
Patient enrollment flow diagram.
Figure 2.
Figure 2.
Mean (and 95% CI) Insomnia Severity Index (ISI) scores at pre-treatment and post-treatment for non-Hispanic white (n=24) and Black (n=15) pregnant CBTI patients.
Figure 3.
Figure 3.
Mean (and 95% CI) Pittsburgh Sleep Quality Index (PSQI) scores at pre-treatment and post-treatment for non-Hispanic white (n=24) and Black (n=15) pregnant CBTI patients.
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