Introducing a sleep disorder screening and management strategy for workers with future shift work requirements: a feasibility and acceptability study

Screening for sleep disorders and providing a cost subsidised treatment pathway is both feasible and acceptable in a cohort of tertiary education students with future shift work requirements. Students were able to engage with screening, sleep physician review, and in a small number of cases initiate treatment, within a 12-week window. Broadly, students felt that the ease of access with online screening, coupled with rapid review, meant they received care which may have been more challenging to access if they were required to self-refer and find time to attend appointments. However, barriers to engagement with health services were apparent at both the individual and health system levels. This made accessing treatment more challenging for some participants. Together, these findings provide support for screening, referral and management for sleep disorders before completion of education or training for careers which have future shift work requirements. The identified barriers and enablers are particularly important to address in future studies, given 20% of young Australian adults are living with a clinical sleep disorder, and > 80% are undiagnosed^1,2.

This study was intentionally designed to support referral and treatment which aligned with the current Australian healthcare system for sleep problems, including screening questionnaires (OSA) and use of mental health care plans (insomnia) which facilitate access to government subsidised services^32,33. The referral pathway was consistent between OSA patients, with scheduling difficulties cited as the main reason for not participating in an overnight (diagnostic) sleep study to confirm a diagnosis. On the other hand, the recommended treatment pathway for insomnia required consultation with a GP to attain a referral to a psychologist for frontline treatment (CBTi) with government subsidies. Participants reported challenges with obtaining the correct referrals, as well as miscommunication and confusion around the processes required to access government subsidised care, as some of the barriers to accessing treatment during the study. Although the referral process is not without its challenges for GPs who are often time poor, completion of a mental health care plan and referral to a psychologist is common practice for Australian GPs. This challenge may be specific to insomnia, and reflect broader sentiments about complexity with managing insomnia referrals in the primary care setting³³.

Although all participants were navigating the same healthcare system, there were notable differences in accessing treatment for insomnia within our modest pilot sample. At present, the government initiative provides patients with up to 10 subsidised sessions (annually) with a mental health practitioner following referral from a GP. This pathway is commonly utilised for access to psychological support for depression and anxiety, however, a recent study by Haycock et al.³³ identified that inconsistencies remain around awareness that insomnia is an eligible condition under the scheme.

An additional important finding from this study was the challenge of accessing treatment for insomnia by individuals who were already utilising psychological services on a mental health care plan for other conditions. This barrier is of particular importance given that not all psychologists are experienced with management of sleep disorders³⁴. As a result, while a current treating psychologist may be suited for management of broader mental health presentations, there may be additional need for a psychologist with competency in the management of insomnia. Yet, the current system may struggle to facilitate this option with an affordable service, especially considering managing insomnia was perceived in our participants as a lower priority relative to other mental health concerns. This is an interesting dilemma more broadly, especially given that effectively treating sleep disorders like insomnia has been shown to reduce symptoms of anxiety and depression³⁵.

Together, these findings suggest a need for multiple intervention targets, including education and awareness about the bidirectional nature of sleep and mental health, and advocacy for referral pathways which allow subsidised sleep management without the barriers associated with existing treatment subsidy schemes. Online sleep disorder symptom screening was successfully implemented in this study, in line with a large study of healthcare workers³⁶. Providing access to online screening and clear information about possible diagnosis and treatment pathways for future shift workers is a low cost intervention which could assist with improving awareness on sleep disorders, and provide a pathway to access help. This aligns with recommendations from shift workers with sleep disorders, who felt that having easily accessible information was an important step in the pathway to effective treatment¹³.

The translation from screening to diagnosis and management is more challenging. Our findings suggest that implementing pre-shift work sleep disorder screening and management strategies are likely to be negatively impacted if relying solely on government-supported and rebated health services. Consideration should be given to lower cost and more rapidly accessible services for future shift workers, such as diagnostic sleep testing at home and telehealth consultations, which have become common practice in Australia.

Time constraints were commonly reported as a barrier to help seeking by participants, irrespective of the presenting sleep disorder. This is not uncommon, particularly in young adults where time demands impact the priority they give to their sleep more broadly³⁷. While students can be time poor due to the combination of study, work and social commitments, motivation may also have been a contributing factor for those who did not seek help and ultimately, receive treatment. Rates of help seeking for sleep are often low more broadly, especially in young adults. A large postal survey conducted by Bartlett et al.³⁸ found that only 6% of individuals under the age of 25 years old with insomnia had seen their GP regarding their sleep. Further, in a representative community cohort of young, working Australian adults, less than 20% of those who met criteria for a common sleep disorder reported they had received a sleep disorder diagnosis². Of note in our study, only 18% of the potentially eligible students participated in the sleep health survey on their sleep and even fewer completed the survey (14%). We were not able to determine in this study what drives low rates of engagement for help seeking more broadly, and future studies should better explore the contributing factors to low engagement in young adults in the population.

Although there is limited population-level insight into rates of help seeking in existing literature, participants in our study expressed difficulty in making appointments with their GP as the consultation hours often overlapped with their work and study commitments. For participants at risk of OSA who did not have a diagnostic sleep study during the study, external commitments including social obligations and work were reported as the main barriers. As the added requirement to spend a night in the sleep laboratory for diagnostic polysomnography was logistically inconvenient for some participants, at home testing was mentioned as a possible solution to address this barrier. Another consideration is at which stage of change participants may have been during the study. According to the transtheoretical model, an individual will progress through a series of stages before successfully modifying a behaviour (in this instance, effective engagement with health services for sleep)³⁹. While we did not directly assess this, it is plausible that participants in this study who did not progress to making appointments or engaging in sleep treatment may still fall within the ‘precontemplation’, ‘contemplation’ or ‘preparation’ stages. The impact of poor sleep on an individual’s stage of change, subsequent behaviour⁴⁰ and motivation for change⁴¹ have been previously explored, and provide insight into the complexities of help seeking for a sleep problem. In future studies, tailoring interventions to the individual’s current stage could be beneficial for improving health services engagement specifically for sleep disorders.

Healthcare costs were predominantly subsidised for this study, with the only costs likely to be co-payments for GP appointments to receive referrals. To determine whether this had an impact on help seeking, participants were asked during interviews what influence cost has on their healthcare decision making. Cost was an important factor when considering access to healthcare, with participants often referring to the impact of low income associated with being a university student. Interestingly, one participant reported that they were likely going to seek out a new GP as their current provider no longer offers a completely bulk-billed service (e.g. no co-payment for consultation). However, a recent national report identified that only 35% of Australian GP clinics offer bulk billing services, with rates as low as 25% in South Australia⁴².

Accessing treatment through private health cover may be another option in Australia for a portion of private psychology fees. However, it is unclear how many participants in this study had private health cover, or would be willing to seek help through private healthcare providers for their sleep, particularly when there is still likely to be a co-payment. There can be a significant cost associated with management (CPAP, oral appliances) for OSA, and in young adults this may be prohibitively expensive without both financial support, and further education on the long-term benefit of treatment. Future interventions will need to consider the economic barriers over a longer period of time to better understand and inform recommendations specifically for sleep disorder management in young adults.

As the intent of this study was to assess the feasibility and acceptability of a tailored screening and referral process for sleep disorder management, longer-term treatment related outcomes were not reported. This study reported participant experience through qualitative interviews, providing a unique insight into screening and help seeking processes experienced by students through a sleep clinic co-located at their university campus. Whilst this is a strength of the study, the experience of our participants who had access to an on-site sleep service will likely differ from other cohorts where sleep services may not be as easily accessible. Additional considerations include the use of a non-randomised approach which could result in recruitment bias. However, this intentional recruitment strategy was needed to ensure that participants in the study met criteria for sleep disorders, as the focus was on accessing health services, rather than treatment effectiveness. Consideration of both OSA and insomnia is a strength of the study, as we were able to highlight that pathways through the healthcare system are markedly different according to diagnosis.