Table 2.

Summary of qualitative studies on insomnia from the systematic review

1. EXPERIENCE OF INSOMNIA (n = 15)
Author(s), Year, Ref. Number & Country	Study Objective(s)	Sample N, age (years), gender	Qualitative Research Methodology (data collection/data analysis)	CASP*/12	Main Findings
Carey TJ et al 200548 USA	Document patients’ experience of insomnia and develop scale that assesses changes in daytime and nocturnal experience	N = 16 Pa (Mage = 47.1; 50% female)	Focus groups Content analysis	8	Insomnia viewed as hidden disorder with daytime experiences emphasized more than nocturnal phenomena Impact of insomnia was pervasive and misunderstood by others (e.g., family members, friends, practitioners)
Cheung JMY et al 201341 Australia	Document behavioral patterns and help-seeking experiences in patients with insomnia	N = 26 Pa (Mage = 42.6;range: 20–74; 61.5% female)	Semi-structured interviews Framework analysis	8	Three themes: patients’ sleep beliefs, treatment beliefs, and access to specialized care Daytime symptoms serve as cues for patients to seek medical help, few seek immediate medical help in early stages
Collier E et al 200349 UK	Examine the experience of insomnia for psychiatric inpatients and provide practitioners data on interventions	N = 7 Pa (Mage = 33.5; range: 28–47; 42.85% female)	Semi-structured interviews Content analysis	9	Ten themes: control, holistic wants or desires, conflict, assessment, beliefs, sleep signatures communication, resignation, and individualism Sleep viewed as an isolated and silent problem
Davidson JR et al 200739 Canada	Determine how to make non-pharmacologic insomnia treatments available to people with cancer	N = 26 Pa (Mage = 57.7, SD = 11.2; range: 44–79; 57.7% female)	Focus groups Semi-structured interviews Content analysis	12	Themes included: recognition and experience of sleep problem, need for information, importance of sleep, inclusion of insomnia assessment, reluctance to report, receiving help from others, no desire to use drugs
Dyas JV et al 201016 UK	Explore patients’ and clinicians’ experiences of sleep difficulties	N = 30 Pa (range: 25–70; 63.3% female) N = 11 GP + 4 NP (53.3% female)	Focus groups Constant comparative analysis	9	Patients describe insomnia in terms of impact on life; clinicians focus on underlying causes Clinicians need to elicit patients’ beliefs and expectations, and offer tailored treatments
Fleming L et al 201045 UK	Conduct qualitative analysis of onset and impact of insomnia in cancer survivors	N = 21 Pa (Mage = 62; ≥18y; 66.7% female)	Focus groups Content analysis	11	Insomnia usually follows cancer diagnosis and is exacerbated by cancer treatment Early identification of insomnia in cancer care settings should be a priority
Green A et al 200817 UK	Explore patients’ experience of insomnia Investigate what information patients want from health professionals	N = 6 Pa (Mage = 50; range: 20–30; 100% female)	Focus groups Open questions/vignettes Content analysis	9	Participants reported major disruption in daytime activities, felt misunderstood by others, wanted evidence of efficacy on insomnia treatment, responsibility in managing problem within collaborative relationship with practitioner
Henry D et al 200842 USA	Explore patients’ sociocultural aspects of insomnia in work place	N = 24 Pa (Mage = 53; range: 22–74; 79% female)	Semi-structured interviews Content analysis	8	Patients cite work as main catalyst in onset of insomnia, for needing “good” sleep, for seeking medical attention, and behavioral compliance with medication use
Henry D et al 201343 USA	Explore patients’ beliefs about insomnia, course, symptom evaluation, response, and treatment expectation	N = 24 Pa (Mage = 55; range: 22–72; 79.2% female)	Semi-structured interviews Content analysis	8	Themes discussed include first response: delay seeking medical attention, help-seeking behavior, self-treatment Patient’s lack of awareness of treatment options was a major reason for medical consultation
Hsu HC et al 200946 Taiwan	Generate descriptive theory framework on subjective experiences of sleep problems among perimenopausal women	N = 21 Pa (Mage = 51; range: 46–57; 100% female	Semi-structured interviews Constant comparative analysis	10	Key theme: “getting back a good night’s sleep”; process to recover quality sleep to reduce physical, psychological and social, health changes due to sleep problems
Kleinman L et al 201350 USA	Explore patients’ experience of insomnia Generate a conceptual framework and endpoint model on insomnia and daytime consequences	N = 28 Pa (Mage = 54.1; 57.1% female)	Focus groups Questionnaires (complementary data) Content analysis	9	Content analysis generated conceptual model (sleep and daytime impairments) and created an endpoint model for potential use in a clinical trial of a new or existing insomnia medication. Insomnia patients understand how amount and quality of sleep can affect activities and functions performed next day
Kyle SD et al 201040 UK	Document patients’ daytime experience of insomnia and impact on quality of life	Focus group: N = 11 Pa (Mage = 38; range: 20–64; 81.9% female) Audio-diary: N = 8 Pa (sub-sample of 11; Mage = 36; range: 20–64; 75% female)	Focus groups Audio-diaries Interpretative phenomenological analysis	8	Impact found for cognitive, emotional, and physical functioning, social life, work performance, and life aspirations Sleep disturbances limits overall quality of life
Moloney 200936 USA	Explore patients’ experience with insomnia, interactions with practitioners, patient attitude toward insomnia treatment	N = 27 Pa (Mage = 50; range: 31–78; 62.9% female)	Semi-structured interviews Content analysis	7	Patients “normalize” insomnia by linking it to aging or hormonal changes, report positive practitioner interactions, and prefer pharmacological interventions Practitioner-patient interaction were based on consultation time, practitioners’ attitude toward treatment, consumerism, pre-existing prescription
Vigeta SMG et al 201251 Brazil	Identify factors that influence perception of sleep quality in postmenopausal women	N = 22 Pa (Mage = 54.5; range: 46–60; 100% female)	Semi-structured interviews Discourse analysis	9	Sleep loss and being in menopause expressed as mood shifts and irritability Onset of sleep disorders may have occurred in childhood/stressful situations (not essentially linked with menopause)
Yung KP et al 201544 China	Explore patients’ experience of chronic insomnia in a Chinese population	N = 43 Pa (Mage = 50.7; range: 26–66; 72% female)	Focus groups Insomnia experience diaries Constant comparative analysis	11	Four main themes and 16 subthemes show that patients’ sleep-related beliefs, behaviors, arousal, and emotions are in general compatible with qualitative studies results in the West. However, some areas related to insomnia are largely influenced by Chinese cultural beliefs and values (e.g., being modest in sleep expectation) Cultural adaptation should be incorporated in the assessment and treatment of insomnia, particularly in non-Western societies
2. MANAGEMENT OF INSOMNIA (n = 5)
Cheung JMY et al 201433 Australia	Explore primary care health practitioners’ perspectives on the management of insomnia	N = 8 GP (50% female) N = 14 PH (36% female) (No information on age)	Semi-structured interviews Framework analysis	10	Health practitioners initially addressed sleep complaint non-pharmacologically, but limited to sleep-hygiene advice Health practitioners exhibited a distinct pattern of zolpidem prescriptions since the media coverage on the adverse effects of zolpidem
Davy Z et al 201337 UK	Explore primary care patients’ and health practitioners’ perceptions on the management of insomnia	N = 28 Pa (range: 20–70; 57.1% female) N = 23 HcP (9GP, 2NP, 5 PH, 7MHP). (65.2% female) (No information on age)	Focus groups Semi-structured interviews Thematic analysis	9	Practitioners focus on sleep hygiene, treat cause rather than insomnia itself, and are ambivalent about hypnotics Patients and practitioners want more options and training for insomnia
Hislop J et al 200334 UK	Explore medicalization and “healthicization” concepts for understanding the management of women’s sleep disruption (see note)	N = 82 Pa (> 40y; 100% female) N = 5 GP* (No information on age and gender)	Focus groups Semi-structured interviews* Thematic analysis	6	Themes: restoration of balanced sleep patterns maintained through on-going use of personalized strategies and interaction between medicalization and personalization Provide an alternative model for the management of women’s sleep
Hubbling A et al 201447 USA	Explore how mindfulness training is experienced by patients with chronic insomnia	N = 9 Pa (Mage = 47; range: 25–66; 89% female)	Focus groups Content analysis	11	Four themes: the impact of mindfulness on sleep and motivation to adopt a healthy sleep lifestyle, benefits of mindfulness on aspects of life beyond sleep, challenges and successes in adopting mindfulness-based practices and the importance of group sharing and support Practicing mindfulness and following sleep hygiene guidelines are useful in optimizing sleep benefits
Middlemass J et al 201235 UK	Explore patients’ and practitioners’ perspective on role of social networking to develop a Computerized CBT-I program to increase access	N = 28 Pa N = 23 HcP (No information on age and gender)	Focus groups Semi-structured interviews Thematic analysis	9	Themes: (1) trust (program, practitioner advocacy, patient-practitioner relation) and (2) functionality (accessibility, format, timing of program) Patient/practitioner views differed whether useful from less useful or potentially incorrect information could be distinguished
3. MEDICALIZATION OF INSOMNIA (n = 2)
Barter G et al 199638 UK	Explore patients’ experiences and cognitions concerning long-term use of benzodiazepines	N = 11 Pa (range: 60–89; 90% female) N = 20 Co (range: 60–79; 60% female)	Semi-structured interviews (Qualitative data analysis technique not specified)	6	Long-term users are highly heterogeneous group in patterns of use, in perceived efficacy of their tablets and in appraisal of doctor behavior in relation to their benzodiazepine use
Moloney 200936 USA	Explore medicalization of insomnia and factors in patient-practitioner dyad that may fuel medicalization process	N = 8 PHY (Mage = 45; range: 32–63; 25% female)	Semi-structured interviews Content analysis	7	Patients’ individual/cultural norms influence perceptions of sleep and ideas of what is abnormal and treatable Patient-practitioner interactions influenced by: consumerism, physician compliance, insurance companies, authority, knowledge

^*Quality appraisal of research methodology for qualitative studies: CASP score between 10 and 12 = “excellent”; between 7 and 9 = “very good”; between 4 and 6 = “good”; 3 and less = “poor”.

Pa: patients; Co: controls; Pr: practitioners; GP: general practitioners; PHY: Physicians; NP: Nurse prescribers; HcP: Health-care professionals; MHP: Mental Health professionals; PH: pharmacists

Note. “Healthicization” concept, according to the authors, is the link between personalization (personalized strategies) and medicalization in the patient help-seeking journey.