A multilevel analysis of access and implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I)

Abstract

Despite the established efficacy of Cognitive Behavioral Therapy for Insomnia (CBT-I), a significant implementation gap prevents it from reaching diverse and complex populations. Grounded in the Stepped-Care Model, Socio-Ecological Model and the Theory of Access to Care, this three-study, mixed-methods dissertation investigates the systemic, clinical, and environmental variables that dictate treatment access and success. Study 1 utilizes a bibliometric and thematic analysis of 554 articles (2010–2026) to map the research landscape, revealing a profound neglect of policy-level access dimensions, such as affordability and geographic accessibility, in favor of individual-level acceptability. Study 2 tests these systemic gaps through a longitudinal Hierarchical Linear Modeling (HLM) analysis of a real-world clinical sample (N = 320). Findings identify a complexity paradox, in which patients with multiple comorbidities demonstrate the steepest improvement rates but require significantly higher treatment doses (averaging 13 sessions) to achieve remission compared to standard protocols. Study 3 provides qualitative context through Interpretative Phenomenological Analysis (IPA), uncovering how household dynamics and environmental stressors create barriers to independent protocol implementation following a brief workshop. Together, these studies highlight that clinical efficacy alone is insufficient for public health reach. The findings suggest that improving sleep equity requires a transition from rigid, one-size-fits-all delivery models toward flexible, environmentally informed, and policy-supported care. By integrating a social work perspective, this dissertation provides a roadmap for advancing a CBT-I delivery framework that accounts for the structural and social realities of the diverse populations it serves.