Project Title:
Cognitive Behavioral Therapy Informed Workshop on Sleep: A Preliminary Randomized Controlled Trial
Supervisor: Mr. Tay Kok Wai
Student’s Name:
1. Joanna Eileen Chan 2. Michele Chu Hiew Mun 3. Sanjeetra A/P Ravindharan
Student’s ID 1. 1906177 2. 1906810 3. 1906950
Year: Y3S3 Semester: May
For Supervisor Use:
FYP I score: FYP II score:
throughout this project. We would like to convey our deepest appreciation to Mr. Tay Kok Wai, our supervisor, who has provided guidance, advice, and support on completing this project. It is such an honor to be under his guidance while working on this project who was also willing to spend his time and assistance throughout the whole progress.
We would also like to take this opportunity to express our sincere gratitude to our participants who have devoted their time to participate and attend for all of our sessions. With their participation, we managed to complete our project in time.
Last but not least, we would like to thank to our family members and friends who have a played a big role in giving us the continuous social support on completing this project. Thank you for the unconditional love and the countless financial and psychological support throughout the whole journey.
Abstract
The aim of this study is to evaluate the effectiveness of CBT-informed workshop on sleep: A preliminary randomized controlled trial in improving sleep quality and life quality among undergraduate students in Malaysia. One of the challenges faced by university students is not having sufficient sleep and it may affect the quality of life. In this randomized controlled trial, participants were randomly allocated to intervention group (n= 15) and control group (n= 13).
The results showed that there is significant improvement (p =.038) in their sleep quality in the post-workshop when compared to the pre-workshop, with the effect size (η2) is = .358. For quality of life, physical health (p =.056) and social relations (p =.032) showed a significant results in this study. Findings supports the effectiveness of CBT-informed workshop on sleep among undergraduates and can be implemented as an effective health-care programme to improve sleep quality and quality of life through clinical and psychological practice.
Keywords: CBT, sleep, sleep quality, quality of life, undergraduates, workshop
Table of Contents
Page
Abstract...i
Introduction...1
Background of Study...1
Problem Statement...2
Research Objective...5
Research Hypothesis...5
Significance of Study...5
Conceptual Definition...6
Sleep Quality...6
Quality of Life (QoL)...6
Operational Definition...7
Sleep Quality...7
Quality of Life (QoL)...7
Methodology... 8
Research Design... 8
Participants... 8
Sample Size...8
Eligibility Criteria for Participants...8
Sampling Procedures... 9
Sampling Technique...9
Location...9
Ethical Clearance Approval... 9
Data Collection Procedures... 10
Recruitment of Participants...10
Allocation of Participants...10
Enrollment of Participants...11
Assessment of Participants...11
Statistical Analyses...12
Instruments... 12
Patient Health Questionnare (PHQ-9)...12
Pittsburgh Sleep Quality Index (PSQI)... 13
World Health Organization Quality of Life (WHOQOL-BREF)... 13
Demographic Characteristics... 14
Intervention...14
A CBT-Informed Workshop on Sleep... 14
Control Group...16
Cognitive Behavioural Therapy Informed Workshop on Procrastination... 16
Results... 17
Participant Flow...17
Recruitment... 19
Descriptive Statistics... 20
Response Rate... 21
Main Outcome Result...21
Independent Sample T-Test... 22
One-Way ANCOVA... 24
Adverse Effect... 25
Discussion and Conclusion...26
Implication of Study... 28
Limitations...29
Recommendations... 30
Conclusion...31
References...32
Appendices...49
Appendix A: Assumptions of Normality...49
Appendix B: Histograms... 51
Appendix C: Scatterplots...56
Introduction Background of Study
Sleep is an important daily activity in human life. It has grown into a global concern as more sleep problems are being aware by the public. These issues have become more serious, especially during the COVID-19 pandemic period (Partinen et al., 2020). Before the pandemic, a sleep survey conducted by Am Life International Sdn Bhd in 2018 stated that 9 out of 10 people in Malaysia had encountered at least one sleep problem such as insomnia symptoms,
sleepwalking or snoring. The problems happened at least once a week among 66% of them, which affects their sleep quality. National Sleep Foundation (2020) mentioned that the
recommended sleep duration for adults aged 18 to 64 is seven to nine hours per night. However, the finding from a pilot study conducted by Farah et al. (2019) showed that 45% among 106 of Malaysian adult participants have inadequate sleep. They reported having an average sleep duration that is considered lower than the recommended sleep duration due to problems they were suffering from sleep disturbance (job responsibility or family factor) and excessive daytime sleepiness. On the other hand, a cross-sectional survey study in Spain suggested that the sleep quality of the participants had decreased during the pandemic compared to pre-pandemic (Targa et al., 2020). This issue happened because of the tendency to alter their sleep latency
corresponding to extraordinary lifestyle changes. The study was consistent with the results found in Huang and Zhao (2020), Marelli et al. (2020), and Du et al. (2020), supporting the prevalence of poor sleep among their target participants across several countries due to the result of the COVID-19 outbreak.
To some extent, sleep problems are associated with one’s quality of life (QoL). Gothe et al. (2019) reported a low sleep quality is the predictor of poor QoL in older adults. In a past
longitudinal study carried out among adults with autism, the researchers also provided a consistent result stating that sleep problems predict a lower QoL as it reduces the daily
functioning of adults (Deserno et al., 2019). Since the topic of sleep has raised awareness among the public, good sleep quality is greatly emphasized because it could impact one’s daily
functioning to live a good life quality. In this case, various sleep interventions such as
mindfulness-based, multi-component, in-school group sleep intervention (Bei et al., 2012), early childhood sleep intervention (Williamson et al., 2020), behavioral intervention for sleep
problems (Rafihi-Ferreira et al., 2019; Vetrayan et al., 2013) or cognitive behavioral therapy for insomnia (CBT-I) (Dewald-Kaufmann et al., 2019; Kang et al., 2017) were implemented in Eastern and Western societies to test the feasibility of those interventions in improving sleep issues among different populations. According to some past studies, CBT-I is one of the most effective treatments for sleep problems. For example, American Psychological Association (2020) stated that CBT-I did achieve a success rate of up to 70% or 80% in the clinical setting for
treating chronic insomnia. Besides face-to-face CBT-I, some researchers have outlined the effectiveness of internet-delivered CBT-I in improving sleep quality or reducing negative sleep outcomes (Seyffert et al., 2016; Trockel et al., 2011; Zachariae et al., 2015). In this present study, some components of evidence-based sleep intervention will be adapted and implemented among Malaysian undergraduate students.
Problem Statement
Sleep has been a prominent need for healthy well-being. Getting enough quality sleep can help to maintain one’s well-being and quality of life. One of the challenges faced by university students is not having sufficient sleep (Ansari, 2015; Kloss et al., 2011). It was found that students entering university had less sleep time (Aysan et al., 2014). Bulbotz Jr et al. (2011)
reported that 73% of students who live in dormitories have experienced poor sleep quality.
Similarly, about 90% of university students stay with their roommates, and 41% of them often wake up at night due to external noises of others (Taylor et al., 2013). A study by Siraj et al.
(2014) found that 56.2% of students slept for 6-8 hours, while 29.1% slept for less than 6 hours, including weekdays and weekends on averagely. Most of these students cope with the challenges by changing their sleep time and sleep habits, and this has led to sleep problems (Pilcher et al., 1997). Gaultney (2010) revealed that 27% of university students are a threat to at least one sleep disorder. In line with that, 70.6% of university students have less than 8 hours of sleep, leading to inadequate sleep (Lund et al., 2010). Furthermore, past findings reported that at least 7.7% of students suffer from insomnia symptoms (Schlarb et al., 2012), 31% from morning tiredness (Buboltz et al., 2001), long-sleep latency was 8.4% (Saxvig et al., 2012), and daytime sleepiness exhibited by 50% university students (Oginska & Pokorski, 2006).
Sleep is an essential part of human life and it may also affect the quality of life. It is normal for students with sleep problems to suffer from issues such as fatigue, stress, anxiety and hopelessness which corresponds to a lower quality of life (Sing & Wong, 2010; Taylor et al., 2013). According to the World Health Organization Quality of Life assessment (WHOQoL) group, quality of life is the perception of the individual’s position in life in the context of culture and system values in which they live to their goals and expectations (Bonomi et al., 2000).
Quality of life comprises 4 dimensions which are physical health, psychological health, social relationships, and environment. The term accentuates the positive side of the concept of health and the positive beliefs of society towards the maintenance and development of health as the condition for well-being.
The research concerning the relationship between sleep quality and quality of life among undergraduates has shown that poor sleep quality is associated with lower quality of life (Howell et al., 2008; Lemma et al., 2012; Lund et al., 2010). Past studies showed that there is a significant correlation between sleep quality and quality of life among university students (Henning et al., 2012; Mohamad Hanapi et al., 2021; Rezaei et al., 2017). In line with that, Yilmaz et al. (2017) suggested that poor sleep quality is an indicator of many medical diseases and there is a strong relationship between sleep quality and quality of life. Although there was evidence reported that university students tend to have poor sleep quality, there are still no studies that focus on how to help undergraduates to cope with the issue in the Malaysian context (Nurismadiana & Lee, 2018).
A study conducted by Siraj et al. (2014) was done to investigate the reason behind poor sleep quality among university students in Malaysia, however, the study did not provide any treatment.
Therefore, it can be concluded that poor sleep quality is a common problem among university students and has increased risk for their quality of life.
Psychological interventions such as CBT can affect the quality of life among
undergraduates. CBT is an approach based on the concept that psychological distress occurs from distortions in the way an individual interprets events. These give rise to negative meanings leading to unhelpful beliefs among individuals which later affect the quality of life. CBT has been known to be effective in treatments such as insomnia (Jacobs et al., 2004; Morin et al., 2009; Sato et al., 2019), depression (Manber et al., 2008; Serfaty et al., 2020) and anxiety (Kaya
& Avci, 2016; Kehle, 2008). However, CBT is also designed to improve the quality of life through its cognitive and behavioral techniques. Previous studies have proved that CBT
improves aspects of quality of life (Chen et al., 2020; Nekouei et al., 2012; Trockel et al., 2011).
As web-based programs are now accessible, low cost and convenient, the present study aims to
develop a brief sleep intervention adapted with CBT methods to treat sleep quality and, in turn, lead to high QoL among undergraduates. Therefore, the present study is to adapt CBT methods to a brief sleep intervention to study if it is an effective treatment to improve sleep quality and the quality of life in Malaysia.
Research Objective
To evaluate the effectiveness of CBT-informed workshop on sleep in improving sleep quality and life quality among undergraduate students in Malaysia.
Research Question
1. Does the CBT-informed workshop on sleep help to improve sleep quality among undergraduates in Malaysia?
2. Does the CBT-informed workshop on sleep help to improve the quality of life among undergraduates in Malaysia?
Research Hypothesis
H1: The CBT-informed workshop on sleep help to improve sleep quality among undergraduates in Malaysia
H2: The CBT-informed workshop on sleep help to improve the quality of life among undergraduates in Malaysia
Significance of Study
In the present study, an intervention study is conducted to find out whether the sleep intervention can improve sleep quality and the quality of life among undergraduates in Malaysia.
Poor sleep quality can affect one’s quality of life. Thus it is necessary to develop an intervention
program for undergraduates to cope with this issue. In this manner, students can be more
productive in their life and improve their overall health. In addition, there is a lack of studies that can be found in Malaysia that explores the effects of CBT intervention on improving the sleep quality and quality of life among the Malaysian population. Although there were studies conducted using CBT to improve sleep quality (Asano et al., 2015; Hui et al., 2020; Manber et al., 2008; Ramsawh et al., 2015; Sato et al., 2019) however, these studies focused on other outcomes such as depression and anxiety. In contrast, the intervention program in this study aims to directly cope with sleep quality and quality of life. If it is found effective, the program will likely be used to promote the quality of life among individuals in Malaysia. The research will also be able to address the knowledge gap in clinical and psychological practice. Thus, further research is vital to guide the implementation of effective healthcare programs that aim to improve sleep quality and quality of life in the population.
Conceptual Definition Sleep Quality
Sleep quality is defined as the relationship between subjective sleep onset ease, sleep maintenance, total sleep time, and early awakening (Harvey et al., 2008). According to Kline (2013), sleep quality refers to a person's content with their sleep experience that includes factors such as sleep maintenance, sleep initiative, quality of sleep, and wakefulness.
Quality of Life (QoL)
The World Health Organization defined QoL as the individuals' view of their situation in life concerning their objectives, aspirations, standards, and the context of the culture and value systems they live in (WHOQOL-BREF| The World Health Organization, n.d.).
Operational Definition Sleep Quality
In this study, sleep quality will be determined by using the 19- item Pittsburgh Sleep Quality Index (PSQI). It is a self-report survey that assesses seven different components of sleep which are sleep latency, sleep disruption, sleep length, sleep quality, habitual sleep efficiency, daytime dysfunction, and the use of sleeping drugs. High scores in PSQI indicate worse sleep quality and vice versa.
Quality of Life (QoL)
The World Health Organization Quality of Life scale which consists of 26 items will be used to assess QoL in this study (WHOQOL- BREF). WHOQOLS identifies four conceptual domains of QoL which are social relationships, psychological health, environmental health, and physical health. Higher scores determine the better QoL, and lower scores determine the poorer QoL.
Methodology Research Design
The research design used in this study is Randomised Controlled Trial (RCT). This research method is used in this study to measure the effectiveness of a CBT-informed workshop on sleep to improve undergraduates’ sleep quality and QoL. The study consists of two-arms of randomised controlled trials where the participants will be randomly grouped either into the sleep intervention (treatment group) or procrastination group (control group). The study was conducted online via the Google Meets platform. The intervention was divided into four sessions, where each session took 45 minutes. The data collection method of this study is quantitative. The instruments used in this study are the Pittsburgh Sleep Quality Index (PSQI), World Health Organization Quality of Life (WHOQOL-BREF), and Patient Health Questionnaire (PHQ-9).
Participants Sample Size
The sample size for this study is 28 undergraduate students in Malaysia. Based on the rules of thumb, Julious (2005) suggested that a minimum sample size of 12 per treatment group is acceptable.
Eligibility Criteria for Participants
Eligible participants were undergraduate students 18 years or older studying in Malaysia.
The exclusion criteria were for participants currently taking prescribed medication for sleep problems or taking medications known to impact sleep.
Sampling Procedures Sampling Technique
A non-probability sampling technique, which is the purposive sampling technique, is applied to recruit the participants for the present study. According to Sharma (2017), this technique is a judgmental, selective, and subjective sampling (p. 751) because the participants were recruited based on certain criteria as stated by the researchers. The inclusion criteria of this study involve undergraduates who are 18 years or older studying in Malaysia. This is to select the appropriate participants that will contribute to a more effective and precise result for the study in order to meet the research objective (Kelly, 2010, as cited in Campbell et al., 2020).
Location
With the concern of accessibility and safety issues due to the pandemic, the CBT Informed Workshop on Sleep is an online-based intervention, and it was carried out via Google Meets. In a past study conducted by Lancee et al. (2016) in making a comparison between two kinds of CBTI, guided online and physical, the authors reported that online CBTI is more cost- effective and readily accessible than the physical mode of CBTI. It allows the CBTI to be available for lower-income families as they do not have to pay more than physical CBTI does.
Moreover, since it is an online-based intervention, people can still access it at their own location even though they might be living in remote areas.
Ethical Clearance Approval
Researchers in this study have applied for ethical clearance approval from University Tunku Abdul Rahman (UTAR) Scientific and Ethical Review Committee beforehand. This is to ensure that the recruitment process for participants and data collection can proceed after approval (Gelling, 2016). Ethical approval is important because it acknowledges that the researchers
considered the ethical issues and will conduct the research based on ethical practice. The ethical reference number for this study is U/SERC/299/2021 and there will be no significant adverse events or side effects in this study. However, the participants will have to answer the Patient Health Questionnaire (PHQ-9) to screen their depression level.
Data Collection Procedures Recruitment of Participants
An online sign-up form was generated using Google Forms and a link was generated.
Participants were recruited through a link and poster shared on online platforms such as
WhatsApp, Facebook, and Microsoft Teams. Participants were informed about the purpose of the trial and what participation will be involved, including voluntary participation, randomisation to a trial condition, confidentiality, and risk and benefits. The recruitment process took about 2 and a half months, and a total number of 31 participants registered for the study.
Allocation of Participants
After the participants have been screened for eligibility, the allocation of participants is done randomly through simple randomisation. Participants were asked to complete the consent form and pre-intervention questionnaire. According to Lim and In (2019), a simple
randomisation technique allows a study to minimise any bias and each subject can maintain complete randomness and independence. The ratio of participants’ allocation is 1:1. Generation of the random allocation of participants was conducted using PickerWheel, a tool to compute a randomly generated list of random teams. One researcher did the allocation sequence, and it was concealed from any participants or other researchers. The corresponding group of researchers only received the list of participants after the enrolled participants were assessed and it was time to allocate for intervention.
Enrollment of Participants
Using Qualtrics, the consent form and pre-intervention questionnaire link were generated and distributed to each participant individually through WhatsApp. The responses were collected and stored in Qualtrics. A screening process was conducted to assess participants’ eligibility for participation in the trial. The inclusion criteria of eligible participants in this study were
undergraduates 18 years or older. In this study, three participants were excluded. Initially, 31 participants were assigned to this study. However, due to circumstances such as a participant from China could not access Google Meets and another two did not answer the pre-questionnaire.
Thus, they were excluded from this study. In the end, only 28 participants are included in the analysis. The consent form contains a brief description of the project, information about random assignment to the trial conditions, the amount of time participation will involve, confidentiality, and contact information for the researchers. It was stressed to the participants throughout the project that their participation is entirely voluntary and that they may withdraw from the study at any time without penalty.
Assessment of Participants
Participants were asked to complete the Patient Health Questionnaire (PHQ-9) in the pre- intervention questionnaire to assess the presence of any depression symptoms. The initial
screening process was conducted before the first session. Nine people were screened with a total score of more than or equal to 10, or item 9 scored 1 and above. They were further contacted to have a result briefing with the supervisor via Google Meets and further support was provided on the spot when necessary. Researchers took the first step of mental health first aid by sending each participant individually concerning self-help strategies to improve mental health through email.
Statistical Analyses
All statistical analyses and missing data were performed in IBM SPSS V23.0. The data collected in this study is analysed using the analysis of covariance (ANCOVA) and independent sample t-test to measure the outcomes. ANCOVA compares the mean differences and treatment effects between groups in pre and post-intervention. Data assumptions were fulfilled, including the independence of variables, assumptions of normality, homoscedasticity, linearity, and homogeneity of regression slopes. Furthermore, an independent sample t-test was used to
compare the means difference of pre and post score. The assumptions of the t-test were tested by analysing the scales of measurement, independence of variables, assumptions of normality, and homoscedasticity.
Instruments
Patient Health Questionnaire (PHQ-9)
The PHQ-9 is a 9-item self-report that measures the frequency of symptoms of depressed mood symptoms (Kroenke et al., 2001). The questionnaire uses a 4-point Likert scale with scores of 0(not at all), 1(several days), 2(more than half the days),and 3(nearly every day). Scores of 0-4, 5-9, 10-14, 15-19, and 20-27 represent non-severe, mild, moderate, moderately severe, and severe depression scores respectively (Manea et al., 2012). The total score ranges from 0 to 27, with higher scores indicating greater depressive symptoms. Cronbach’s alpha value for PHQ-9 is α = .89 and the Pearson’s correlation of validity indicated thatp= .000, where p < .05 shows the value is significant. Hammash et al. (2013) supported that the construct validity of PHQ-9 is a reliable and valid measure for depressive symptoms.
Pittsburgh Sleep Quality Index (PSQI)
PSQI scale is used to measure participants' sleep quality over the past month (Buysse et al., 1989). PSQI contains self-rated 19 items, including five questions rated by a bed partner or roommate (if available). The items are combined into seven component scores which are
subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances (sleep problems), use of sleeping medication, and daytime dysfunction (sleepiness). Each component is scored based. However, due to the exclusion criteria of this study, the component of using sleep medication will be removed from this study. Thus, excluding five questions rated by bed partner or roommate, the study consists of 17 items with six component scores. A good internal
consistency (Cronbach α = 0.80) of the measurement is reported when using a cutoff ≤ 5 (Ali et al., 2020; Buysse et al., 1989; de la Vega et al., 2015). The scale uses a 4-point Likert scale with scores ranging from 0(no difficulty)to 3(severe difficulty)and four short answer questions. Sum score ranged from 0 to 21 of the global PSQI score, with a higher score indicating poor sleeping quality. In addition, the computed reliability for the scale is α = .74. and has a Pearson’s
correlation validity score ofp= .023, wherep< .05. The PSQI scale showed good convergent validity with a Malay version of the Epworth Sleepiness Scale (ESS-M), indicating that people with poor sleep quality are associated with daytime sleepiness that could influence daytime dysfunction (Farah et al., 2019).
World Health Organization Quality of Life (WHOQOL-BREF)
The WHOQOL-Bref consists of 26 questions which contain two general questions on QoL. The WHOQOL-Bref is categorised into four domains which are physical, psychological, social relations, and environment, including two individually scored items about an individual’s overall perception of QoL (Chang et al., 2015). Three items must be reversed before scoring.
Each domain is evaluated separately, with each item scored on a 5-point Likert scale. A mean score is calculated for each domain, and it will be multiplied by four. Higher scores indicate better QoL. The psychometric properties found in previous studies showed that the measurement is acceptable (Abdullah, 2014; Suarez et al., 2018). The scale has a reliability of α = .76 and validity of p< .000, using Pearson’s correlation. The content validity of WHOQOL-BREF test is supported with its adequate measurement for quality of life in a population of adult patients for mental health (Trompenaars et al., 2005).
Demographic Characteristics
Demographic data, such as age, gender, ethnicity, education level, and year of study was collected.
Intervention
A CBT-Informed Workshop on Sleep
The researchers delivered the intervention of this study. It was also guided by the CBTI Therapist Manual (Taylor et al., 2019). The intervention includes techniques and treatments such as psychoeducation, sleep hygiene, cognitive restructuring, and behavioural activities to improve sleep quality and QoL of undergraduate students. Before each session, researchers obtained consent from the participants to record for research purposes. At any point, participants can opt- out of the intervention. The intervention consists of four 45 minutes per session with a two-week gap in between after two sessions. At all intervention sessions, including follow-up, participants are asked for comments on the intervention, and the experiment had no adverse side effects.
Table 1 shows the description of each session of the intervention.
Table 1
Descriptions of Each Session of Intervention
Session Description
Session 1 Introduction & Psychoeducation
Provide a better understanding of sleep, sleep quality, insomnia, and CBTI to the participants.
Session 2 Sleep Hygiene
● Introducing healthy habits along with a regular sleep routine.
● Introducing helpful habits in practicing sleep hygiene.
Session 3 Stress Management: Relaxation Techniques
● Brief explanations on the cycle of stress and sleep
● Elaborate on the relaxation skills that help to improve sleep.
Videos were also played for participants to allow further understanding of the application of relaxation skills.
● A brief introduction to dysfunctional thoughts and negative beliefs on sleep. Identify dysfunctional thoughts on sleep and how to handle them.
● Explained how safety behaviours and sleep affects CBTI techniques and ways to cope with them.
Session 4 Cognitive Restructuring and Problem-Solving
● Discussed examples of dysfunctional thoughts and the alternative thinking to these thoughts.
● Provide problem-solving skills such as a “To Do” list in bed or before bedtime.
Control Group
Cognitive Behavioural Therapy Informed Workshop on Procrastination
The process will be the same as the intervention group, but the content of this
intervention is procrastination. Furthermore, there are chances for participants in this control group to access the recorded sleep workshop.
Results Participant Flow
Figure 1
CONSORT 2010 Flow Chart of the Screening Process for the Recruited Participants in this Study
Assessed for eligibility (n= 31)
Excluded (n= 0)
Not meeting inclusion criteria (n= 0)
Declined to participate (n=
0)
Analysed (n= 15)
Excluded from analysis (n= 0) Lost to follow-up (n= 0)
Discontinued intervention (n= 0) Allocated to intervention group (A CBT-informed workshop on sleep) (n= 15)
Received allocated intervention (n= 15)
Did not receive allocated intervention (n= 0)
Lost to follow-up (Did not answer the pre- questionnaire) (n= 2) Discontinued intervention (Could not access Google Meets;
participant is from China) (n= 1) Allocated to control group (A CBT-informed workshop on procrastination) (n= 16)
Received allocated intervention (n= 16)
Did not receive allocated intervention (n= 0)
Analysed (n= 13)
Excluded from analysis (n= 0) Randomised (n= 31)
Enrollment
Allocation
Follow-Up
Analysis
Figure 1 shows the screening process for the recruited participants in this study by using the CONSORT flow diagram; Randomised Control Trials (RCTs). In total, there are 31
participants assessed for the eligibility criteria. All participants were undergraduate students 18 years and older studying in Malaysia with mental distress. After that, the 31 participants were randomised into two groups which were the intervention group (a CBT-informed workshop on sleep) and the control group (a CBT-informed workshop on procrastination) in this study. As a result of the randomisation, 15 participants were allocated to the intervention group and 16 participants were allocated to the control group. All the participants in both groups received all the materials from the allocated intervention. No participant was lost to follow-up or
discontinuing the intervention for the intervention group. As for the control group, 2 participants lost to follow-up because they did not answer the pre-questionnaire and 1 participant
discontinued the intervention because he is currently in China and could not access Google Meets. At the end of the CBT-informed workshops, 15 participants were analysed for the intervention group and 13 participants were analysed for the control group.
Recruitment Figure 2
Flow of the Recruitment and Follow Up Process
Screening process (Inclusion and exclusion criteria)
26 June 2022
Pre-test (PHQ-9, PSQI, WHOQOL-BREF, APS, PWB)
27 June 2022 until 30 June 2022
Complete 4 sessions of CBT-informed workshop on sleep
Session 1 (1 July 2022) Session 2 (2 July 2022) Session 3 (15 July 2022) Session 4 (17 July 2022)
Post-test (PSQI, WHOQOL-BREF, APS, PWB)
29 July 2022 until 5 August 2022 Recruitment through social media via poster
13 April 2022 until 26 June 2022
Eligible participants were recruited from 13 April 2022 to 26 June 2022 through a recruitment poster that was posted on online platforms such as WhatsApp, Facebook, and Microsoft Teams by all the researchers in this study. A total of 31 participants were recruited.
The screening process of the participants and the randomisation were carried out on 26 July 2022.
After that, a pre-questionnaire of this study was given to all the participants one week before the CBT-informed workshops started. Then, four sessions of CBT-informed workshop on sleep were carried out on 1 July 2022, 2 July 2022, 15 July 2022, and 17 July 2022. All participants were encouraged to participate in all the sessions. Furthermore, all participants were given a post- questionnaire on 29 July 2022 after two weeks of the last session in the CBT-informed workshop on sleep.
Descriptive Statistics
Table 2 shows the baseline characteristics of the participants. In this study, there are a total of 28 participants with an average age ofMintervention=22.4;Mcontrol=22.7. Fifteen of them were assigned to the intervention group, while another 13 participants were in the control group.
The study included 46.4% of males (n= 13) and 53.6% of females (n= 15). The majority of the participants are Chinese (75%), followed by Indians (17.9%) and Malays (7.1%).
Table 2
Baseline Characteristics of Participants
Intervention Group
(n= 15) Control Group
(n= 13)
Age 22.4* 22.7*
Gender
Male 7(46.7%) 6(46.2%)
Female 8(53.3%) 7(53.8%)
Race
Malay 1(6.7%) 1(7.7%)
Chinese 12(80.0%) 9(69.2%)
Indian 2(13.3%) 3(23.1%)
University
UTAR 10(66.7%) 5(38.5%)
TARUC 0 3(23.1%)
UiTM 1(6.7%) 1(7.7%)
UCSI 3(20.0%) 2(15.4%)
UniKL 0 1(7.7%)
OU 0 1(7.7%)
KDU 1(6.7%) 0
*Data are means
Note.Frequency and percentage are calculated for gender, race, and university.
Response Rate
A total of 4 sessions of CBT-Informed Workshop on Sleep were conducted. Three participants had attended all the sessions (20%). In the first session, three participants did not attend (attendance rate; 80%), while 7 people did not attend the second session (attendance rate;
47%). As for the third session, 8 participants missed out (47%) the session, and for the last session 5 did not attend (67%).
Main Outcome Results
Table 3 shows the mean and SD for PSQI, and WHOQOL-BREF at baseline and pre intervention.
Table 3
Pre Scores Differences Mean and Standard Deviation
Group Intervention Group
(n = 15) Control Group
(n = 13)
PSQI 7.87 (3.720) 7.92 (2.019)
WHOQOL-BREF
Domain 1 (physical health) 64.05 (14.99) 65.11 (11.495) Domain 2 (psychological
health) 57.78 (13.807) 58.65 (8.914)
Domain 3 (social relations) 62.78 (19.124) 55.77 (17.475)
Domain 4 (environment) 61.25 (13.142) 62.50 (13.622)
Note.Scores are mean and in bracket, (), are standard deviation Independent Sample T-Test
An independent sample t-test was used to compare the mean difference of post-pre scores between the intervention group (n= 15) and the control group (n= 13). The results of the
Shapiro-Wilk test in PSQI stated that the assumption of normality was not violated with the significance ofp >.05 (refer to Table 6). Furthermore, Levene’s test was also non-significant, thus equal variances can be assumed. Thet-test was statistically non-significant, with the intervention group (M= -.67,SD= 3.132) reporting the sleep quality estimates the mean
differences of .103, 95% CI [-2.034, 2.239], than the control group (M= -.77,SD= 2.204),t(26)
= .099, one-tailed,d= .036, wherep> .05 indicates a lower significant value contributing to the fact that there is no significant difference between the two group means.
For the WHOQOL-BREF, the Shapiro-Wilk test indicated that domains 1 and 3 had violated the assumption of normality, whereas domains 2 and 4 were significant, showing that
the assumption of normality was not violated (refer to Table 6). A Shapiro-Wilk test with a p> .05 indicates that the null hypothesis cannot be rejected which states that the data is normally distributed. The test of equal variances was also not violated. Thet-test was statistically non- significant for three domains which are domains 1, 2, and 4. However, domain 3 showed a statistically significant difference with the intervention group (M= -2.38,SD= 14.866) reporting the social relations in participants’ QoL estimates the mean differences of -11.993, 95% CI [- 23.550, -.437], than the control group (M= 9.62,SD= 14.802),t(26) = -2.133,p< .05, one- tailed. The results shows a high significant value indicating there is a difference between the two group means. Cohen’sdof .809 indicated a significant large effect.
Table 4
Independent Sample t-Test
Note.Significance p < .05
Intervention
Group Control
Group
t p Cohen'
sd
95% Confidence Interval of the Difference
M SD M SD
PSQI -.67 3.132 -.77 2.204 .099 .778 .036 -2.034 2.239
Domain 1 (physical
health) 6.62 18.197 6.89 13.247 -.044 .922 .017 -12.814 12.272
Domain 2
(psychological health) 6.22 18.979 9.73 14.686 -.540 .593 .205 -16.853 9.836 Domain 3 (social
relations) -2.38 14.866 9.62 14.802 -2.133 .043 .809 -23.550 -.437
Domain 4
(environment) 4.62 15.453 6.65 15.619 -.346 .732 .131 -14.133 10.059
One-Way ANCOVA
A one-way analysis of covariance (ANCOVA) was used to compare the mean differences and treatment effects between pre and post-test of undergraduates undertaking CBT therapy. The examination of the Shapiro-Wilk test for PSQI indicated that the normality assumption was not violated with the significance ofp >.05, resulting in it being normally distributed (refer to Table 6). The histogram also illustrated that the scores for each group are approximately normally distributed. Scatterplots indicated that the relationship between the pre-test of PSQI and the post- test of PSQI was linear. The assumption of homogeneity of regression slopes was significant of F(1,25) = 0.05,p =.004, thus it is violated. Levene’s test showed that the homogeneity of
variances was non-significant. Thus, a high significant treatment effect was foundF(1,13) = 7.25, p =.038, indicating that treatment effect is more effective. The partial eta square (η2) is = .358, indicating a small effect size.
The assumptions test of WHOQOL-BREF was also analysed in this study. The Shapiro- Wilk test stated that domains 1 and 3 had violated the assumption of normality with the
significance ofp <.05 whereas the scores for domain 2 (p =.985) and domain 4 (p =.194) were not violated (refer to Table 6). The histogram for domain 2 achieved a bell-curved shape,
indicating the scores were normally distributed. The scatterplots for domains 1, 3, and 4 in WHOQOL indicated a linear relationship between the pre and post-tests. However, it is not the case for domain 2. The homogeneity of regression slopes was not violated for all the domains except domain 3. Domain 1 showed a significance ofF(1,25) = 0.05,p =.153; Domain 2F(1,25)
= 0.05,p =.968; Domain 3F(1,25) = 0.05,p <.001; Domain 4F(1,25) = 0.05,p =.095.
Levene’s test for all the domains in WHOQOL-BREF was not violated, showing that the
homogeneity of variances is non-significant. The results showed that domain 1F(1,26) = .134,p
=.056 and the partial eta square (η2) is = .294, indicating a small effect size. For domain 2 it showedF(1,26) = .379,p =.543 with a trivial effect size, η2= .033. Domain 3 indicatedF(1,26)
= .635,p =.032 with its partial eta square of .116. Domain 4 showed the results ofF(1,26)
= .003,p =.956. The partial eta square indicated a significantly small effect size of .014. In conclusion, Domain 3 indicated that there was a significant treatment effect while Domain 1, Domain 2 and Domain 4 did not.
Table 5
ANCOVA Table
F df p Partial eta squared (η2)
PSQI 7.254 28 .038 .358
Domain 1 4.571 28 .056 .294
Domain 2 .850 28 .365 .033
Domain 3 3.276 28 .032 .116
Domain 4 .344 28 .563 .014
As a result, hypothesis 1 is supported as CBT-informed workshop on sleep helped to improve the sleep quality among the undergraduates in Malaysia. Other than that, hypothesis 2 is supported as CBT-informed workshop on sleep helped to improve the QoL among the
undergraduates in Malaysia.
Adverse Effects
No adverse effects were observed during treatment.
Discussion and Conclusion
A preliminary randomised controlled trial was carried out to evaluate the effectiveness of a CBT-informed workshop on sleep in improving sleep quality and life quality among undergraduate students in Malaysia. The finding of this study showed that the CBT-informed sleep workshop has a significant effect in that it helps to improve sleep quality and QoL among undergraduates in Malaysia as compared to the control group that received the procrastination workshop.
Based on the result, an online CBT-informed workshop (four sessions) on sleep could increase the participants' sleep quality. The result is consistent with an RCT study conducted by Morris et al. (2015) in a higher education setting, stating that the students' sleep quality had significantly increased after they joined the six sessions of an internet-delivered CBT program (iCBT) to reduce their insomnia symptoms. Moreover, a quasi-experimental study in 2015 also outlined that the brief CBT for insomnia (CBTI) provided via email-newsletter was efficient in improving the sleep quality of the treatment group (p = .004), with a medium effect size. In the study, Asano and colleagues (2015) highlighted that the advantages of CBTI could work as a treatment to reduce the poor sleep experience of an individual, or it could be the prevention for one from developing a psychiatric symptom that is associated with any sleep issue. Besides focusing on the effect of CBT on healthy individuals only, several past studies also target
samples suffering from different disorders (Anderson et al., 2014; Dzierzewski et al., 2019; Fung et al., 2016) or have physical health issues (Abbasi et al., 2016; Asadnia et al., 2014). According to Taylor et al. (2014), researchers suggested that multicomponent CBTI treatment could
enhance the sleep quality of their participants who have insomnia. It benefits the participants in a treatment group by increasing their sleep efficiency (16%) and decreasing sleep onset latency
(68%), wake time after sleep onset (81%), and awakening number (64%) as compared to the control group. A brief CBTI to improve the sleep quality of a depressed adolescent had also shown treatment effects for the case study (Orchard et al., 2020). Generally, it is to say that CBT is widely applicable for different populations and its effectiveness was achieved by most of the studies.
In addition to CBTI having efficacious effects on sleep quality, CBTI was found to be effective in improving one’s QoL (Espie et al., 2019; Jungquist et al., 2010; Pillai et al., 2015).
Past studies that conducted RCT have shown an improvement in QoL with longer effects when using CBTI to treat their participants (Ishak et al., 2012; Taylor et al., 2014; Wong et al., 2021).
However, there is limited evidence from current studies showing that CBTI effectively improves QoL (Alimoradi et al., 2022). The effects of CBTI on QoL can be explained by the improvement of CBTI's effects on physical health, psychological health, social relationships, and the
environment.
The results in Domain 1 (physical health) showed a non-significant treatment effect on the treatment group (p = .056). In contrast, studies have found that individuals who have
insomnia are more likely to get better physical health, such as improved physical fitness, work productivity, and elevated energy after CBTI treatment (Kalmbach et al., 2019; Pakpour et al., 2020; Peddie et al., 2019). This could be due to CBTI effects have improved participants’ sleep duration and overall sleep quality, thus leading to reduced fatigue, improved daytime functioning, and increased energy levels for work productivity. Domain 2 which is psychological health was found to be not significant in this study. The results were inconsistent with previous studies where CBTI techniques can improve psychological health (Cheng et al., 2019; Christensen et al., 2016; Li et al., 2020; Ye et al., 2015). These studies showed an improvement in mental health
since their participants were experiencing mental health symptoms, whereas this study did not take into account participants who have mental health symptoms and mainly focused on
improving sleep in healthy patients. Thus, the results showed to be non-significant could be due to the fact that participants may require a more long-term approach to be treated effectively.
The social relationships domain of QoL has the most significant effect in this study (p
= .032). This could be attributed to the fact that participants who joined the workshop were asked to seek social support such as family or friends to help them go through changes in behavior when in difficulty during the treatment process. Even though CBTI's primary treatment goal is not aimed to improve relationships, the techniques help to be present and to communicate with a partner by changing negative thoughts into positive ones which will lead to better mood, and greater relationships, thus increasing QoL in all areas of life. Previous studies have found that CBTI was effective in improving social relationships which are important to one’s QoL (Eidelman et al., 2019; Fredette et al., 2016; Luong et al., 2020; Shayan et al., 2018). The environment domain did not show a significant result probably due to less or no information being given to participants about access to health services, coping with the home environment, improving financial activities, and participation in social activities.
Implication of Study
According to the theoretical framework, Maslow’s Hierarchy of Needs theory and biopsychosocial model were discussed in this study. For Maslow’s Hierarchy of Needs theory, it had stated that physiological needs are the essential things a person needs to survive (Corporate Finance Institute, 2019). Sleep belongs to physiological needs, and it is vital for many. The CBT sleep workshop could increase the QoL using Maslow’s theory because improving one’s sleep quality through the CBT workshop would enhance their overall well-being, which is essential in
one’s life. The better the satisfaction of the individual's needs in each society, the higher the individuals’ QoL (Sirgy, 1986). Maslow's quality of life theory for reaching happiness and true being is based on the idea of human needs and it is centered on personal growth (Feldman, 2008).
In this study, the results showed that a CBT sleep workshop could improve the QoL of
undergraduates in Malaysia. In the biopsychosocial model, this study mentioned that the sleep workshop could affect the biological aspect by improving one’s circadian rhythm. The CBT- informed workshop on sleep will enhance one’s problem-solving skills and the ability to cope with things as a psychological aspect. Then, this workshop could educate the participants more about sleep via psychoeducation. Hence, all the aspects of the biopsychosocial model were shown to be improved among the participants.
Based on the results of this study, it showed that sleep workshop such as CBT was able to improve sleep quality and QoL among undergraduates in Malaysia. This study could be a
reference for future researchers to continue to explore the effectiveness of CBT workshops on sleep quality and QoL among the population in Malaysia since there is a lack of studies conducted about this. Furthermore, the findings in this study would help to promote the QoL among people in Malaysia. In future practice, psychologists, counsellors, and other mental health practitioners may consider including CBT workshops in their treatment plans or health-care initiatives for clients who have a poor QoL.
Limitations
In the real-world setting, this study cannot be generalised to the population in Malaysia.
This is because the results are difficult to understand or generalise since the community under study is considerably different from the population treated in daily life (Collet, 2000). For instance, this study aims to improve sleep quality and QoL among undergraduates in Malaysia,
but the participants involved in this study were individuals without mental distress and currently not taking any prescribed medication for sleep problems. Other than that, the final sample size of this study is too small (n= 28). This might prevent the extrapolation of the results in this study (Faber & Fonseca, 2014). A small sample size could raise the possibility of false-positive
findings (Hackshaw, 2008). It also might be challenging to assess whether the result of this study is a true finding when there is a small sample size. Hence, it affects the significance of this study.
Moreover, the CBT workshop in this study can be time-consuming for the participants since all of the participants have to attend four sessions which are approximately 45 minutes long. Due to this, some participants could not make it to all the sessions and this could jeopardise the
effectiveness of CBT in this program. However, this could be one of the reasons why
undergraduates were not interested in participating in this study since the participants have other important commitments to attend to compared to the workshops.
Recommendations
This study recommends future researchers to use a well-planned observational study such as creating a three-dimensional informatics infrastructure with granular data, electronic health records, and patient-reported outcomes in order to address specific concerns so that it can be an effective tool for generalising the findings of randomised controlled trials (Health et al., 2013).
Additionally, researchers should be adept at extracting conclusions from RCT efficacy data applicable to clinical or non-clinical practice (Fuller, 2013). Furthermore, larger sample size is recommended for future research purposes. Researchers could find alternative ways to larger the sample size by contacting more potential participants, attracting future participants with rewards such as gift cards, and considering widening the targeted participants' group. A large sample size could interpret the significant results and allow a more accurate estimation of the treatment
impact. It typically makes it easier to judge the sample's representativeness and extrapolate the findings (Biau et al., 2008). For future studies, a research incentives program would be
recommended. This is to motivate and encourage the participants of the study by giving rewards to stay committed throughout the whole CBT workshop session, even though it is time-
consuming. Researchers could use different types of research incentives to attract and motivate the participants. For example, physical gifts, cash payments, coupon codes, and charitable donations on behalf of the participants. This method would attract more participants to participate in CBT workshop studies.
Conclusion
The preliminary study of the CBT-informed workshop on sleep supports the hypotheses (1) the CBT-informed workshop on sleep helped to improve sleep quality among undergraduates in Malaysia and (2) the CBT-informed workshop on sleep helped to improve the QoL among undergraduates in Malaysia in terms of domain 1 (physical health) and domain 3 (social
relations). Thus, the CBT sleep workshop can be an effective treatment to improve sleep quality and QoL among the population in Malaysia. Future research can implement this workshop as an effective health-care programme to improve sleep quality and QoL through clinical and
psychological practice.
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