Lay-led Brief Cognitive Behavioural Therapy for Insomnia (CBT-I) Group for Older Adults in Hong Kong: A Pilot Study
Phase: NA
Conditions: Sleep Quality
Sponsor: The University of Hong Kong

Research Protocol 
Lay-led Brief Cognitive Behavioural Therapy for Insomnia 
(CBT-I) Group for Older Adults in Hong Kong: A Pilot Study 
 
NCT ID not yet assigned 
Unique Protocol ID: EA260143 - Amendment 1 
Date of the document: 13 March 2026 
 
Principal Investigator: 
Dr. Branda Yu Yee Man 
Department of Social Work and Social Administration 
Email: branda.yu@hku.hk 
Co-Investigators: 
Ms. Wong Long Ni 
Department of Social Work and Social Administration 
Email: lonniw@hku.hk 
 
 
 
 

Background 
Insomnia is a prevalent issue among older adults. Estimates indicate that as many as 50% of this 
population report difficulties in initiating or maintaining sleep (Crowley, 2011). Furthermore, a 
pooled analysis revealed that the prevalence of sleep disturbances among older Chinese adults is 
approximately 35.9% (95% CI: 30.6%–41.2%), based on data from 47 studies involving 242,010 
subjects (Lu et al., 2018). Research has shown that older adults experiencing insomnia exhibit a 
significantly lower quality of life (OR = 1.95, 95% CI = 1.89-2.00) (Lee et al., 2021). Additionally, 
insomnia is associated with numerous mental health risks. For instance, poor sleep patterns—
characterized by prolonged sleep duration coupled with low quality—are linked to impaired 
cognitive functioning in older Chinese individuals and an increased risk of dementia (Li et al., 2022). 
Moreover, poor sleep quality at baseline has been found to correlate strongly with neurocognitive 
disorders after a 6 year follow-up among older Chinese adults (Lai et al., 2022), as well as with 
depression (Becker et al., 2016), physical disability (OR = 2.03; 95% CI: 1.02–4.05) (Chien & Chen, 
2015), and a heightened mortality rate among both middle-aged and older adults (Del Brutto et al., 
2023). However, research has found that helping-seeking behaviours for sleep disturbances are still 
not prevalent among Hong Kong Chinese adults. In a sample size of 3,483, only 51% actively 
sought help for their insomnia, and only 11% have ever tried the Cognitive Behavioural Therapy 
for Insomnia (Wing et al., 2024). 
 
Consisting of 5 key treatment components: Sleep Hygiene, Stimulus Control, Sleep Restriction and 
Relaxation, the Cognitive Behavioural Therapy for Insomnia (CBT-I) It has been demonstrated to 
be an effective intervention for reducing insomnia symptoms (Trauer et al., 2015) and improving 
overall quality of life (Alimoradi et al., 2022). Additionally, CBT-I delivered in group has also been 
identified as an effective strategy for alleviating insomnia symptoms when administered by 
healthcare professionals (Davidson et al., 2017; Hrozanova et al., 2025). However, despite its 

efficacy, the accessibility of CBT-I is often limited by the lack of professional manpower, 
requirements for intensive training and time commitment. In response to these challenges, task-
shifting models and app-based interventions have been developed. While app-based CBT-I 
intervention has been found to be an effective and more accessible tool for reducing insomnia and 
depression symptoms in Chinese youth and younger adults (Chen et al., 2025), its effectiveness 
among older Chinese adults has yet to be explored on a similar scale. Furthermore, the 
implementation of digital interventions is often limited by older adults' digital literacy, skepticism, 
and disinterest in digital health care (Frishammar et al., 2023), which may lead to fear and 
frustration in adaptation. Therefore, in-person delivered CBT-I remains necessary for addressing 
insomnia in older adults. The task-shifting model, defined as “specific tasks are moved from highly 
qualified health workers to health workers with shorter training and fewer qualifications” (WHO, 
2007), has been implemented in various layperson-led support and psychotherapies. Although one 
study found that layperson-led CBT sessions for older adults could significantly improve insomnia 
through a mixed method of in-person and phone call interventions (Stanley et al., 2014), evidence 
for lay-led psychotherapy primarily pertains to approaches such as Behavioural Activation Therapy 
and Problem-Solving Therapy, which have proven helpful to participants (Shorey & Chua, 2022). 
Therefore, lay-led CBT-I should be adapted and studied further. 
 
Among the five components of CBT-I, research indicates that stimulus control and sleep restriction 
are particularly effective (Steinmetz et al., 2024). However, the challenges in delivery pose barriers 
to the broader implementation of CBT-I. For instance, advanced training and supervision are 
requested from qualified professionals who were trained to deliver CBT-I, including psychologists 
and general practitioners (Sweetman et al., 2024), as well as from psychology graduate students 
specifically trained in these methodologies (Meaklim et al., 2025). Having said that, systematic 
reviews have shown that the components of CBT-I can be modified based on the characteristics of 
different populations and therapeutic aims, with psychoeducation about sleep included in all studies 

(Cheung et al., 2018). The American Academy of Sleep Medicine further recommends that both 
stimulus control and sleep restriction can be used as individual components in CBT-I (Edinger et 
al., 2020). On the other hand, sleep restriction is related to hindering barriers such as low tolerance 
for frustration and an inability to commit to recording a sleep diary (Simon et al., 2025).  
 
Objectives 
The current study aims to examine (1) the effectiveness of layperson-led group of brief Cognitive 
Behavioural Therapy for Insomnia (CBT-I) and (2) the feasibility and acceptability in older Hong 
Kong Chinese adults of this modified brief intervention. 
 
Hypotheses 
• 
Participants will experience significantly increased levels of subjective sleep quality 
• 
Participants will experience significantly reduced levels of both psychological and 
physical arousal prior to sleep 
• 
The proposed lay-led, brief CBT-I group invention will be operationally feasible to 
implement 
• 
The proposed lay-led, brief CBT-I group invention will be therapeutically acceptable to 
participants 
 
Design 
This study is an open-label, non-randomized, two-arm clinical trial, consisting of an intervention 
group and a control group. Participants in the intervention group will be existing members of JC 
JoyAge, while participants in the control group will be recruited publicly. Upon screening, eligible 

JoyAge members with sleep complaints will be assigned to participate in the 4-week intervention 
group. The intervention group will complete assessments before the first group session and after 
the last one, which is anticipated to occur within 4 weeks. Meanwhile, eligible control group 
participants will receive a booklet on sleep health, and be invited to complete two assessments, 
the first and second of which will be separated by 4 weeks. The research is expected to run from 
March 2026 to June 2027. 
The JC JoyAge is a territory-wide collaborative stepped-care intervention programme involving 
District Elderly Community Centres (DECCs) and Integrated Community Centres for Mental 
Wellness (ICCMWs) across all districts in Hong Kong, targeting to provide standardized 
prevention and intervention to middle-aged or older adults according to the severity of their 
depressive symptoms based on the PHQ-9. 
 
Participants 
As a rule of thumb, research has recommended a participant range of 12-30 per arm (Julious, 2005; 
Browne, 1995). Considering that the data collection process lasts for a short period of 4 weeks and 
that an incentive is provided in the control group, an attrition rate of 15% is anticipated. Therefore, 
a total of 50 participants are planned for recruitment, with 25 participants in each group. The 
inclusion criteria for the study are as follows: participants must be aged 45 or older. Additionally, 
they should have a PHQ-9 score between 5-9, and item 3(Trouble falling or staying asleep, or 
sleeping too much) must be scored at 2 or higher. Participants should be capable of providing 
informed consent for their participation in the study. Participants will be excluded, if they have a 
known history of intellectual disabilities, schizophrenia spectrum disorders, bipolar disorder, 
Parkinson’s disease, or dementia. Additionally, individuals assessed to be at active suicidal risk 
will not be eligible for participation. Those who experience significant difficulties in 

communication will also be excluded from the study. 
 
Intervention Group: The Emotional Support Assistant Group (ESAG) 
Participants will be invited by the partnering organizations of the Jockey Club Holistic Support 
Project for Elderly Mental Wellness (JC JoyAge) to participate in a brief in-person group for CBT-
I, consisting of four sessions. The group will be held at the centres of the partnering organizations, 
with each session lasting approximately 1.5 hours and expected to be completed within a month. 
The sessions will cover four treatment components: sleep hygiene, stimulus control, cognitive 
restructuring, and relaxation exercises, all facilitated by trained Emotional Support Assistants. 
Emotional Support Assistants are peer supporters aged 45 or above who are trained to provide 
mental health-related services to individuals of similar age who are struggling with depressive 
emotions. They have completed approximately 98 hours of basic training and have received CBT-
I training from psychologists affiliated with JC JoyAge. After each session, participants will be 
encouraged to incorporate the skills learned into participants’ daily life and share their experiences 
or challenges in the following session. In the first session of the group, participants will be invited 
to fill out a questionnaire regarding their sleep habits, attitudes, and pre-sleep state, which will 
take about 10-15 minutes. In the final session, they will also be invited to complete the same 
questionnaire, along with an additional feedback form about the group. No incentive will be 
provided to ESAG group participants. 
 
Control Group: The Control Group (CG) 
Participants will be recruited publicly through social media. Eligible participants will receive a 
booklet on sleep hygiene education and will be asked to record their sleep hygiene practice in the 
logbook provided in the booklet for 4 weeks for the same duration as the intervention group. The 

sleep hygiene education is often adapted as control group in sleep intervention research (Yeung et 
al., 2022; W. Yeung et al., 2025). They will be invited to complete two questionnaires over 4 weeks 
regarding their sleep habits, attitudes, and pre-sleep state, each taking approximately 10-15 
minutes. An incentive of HKD$50 will be provided upon completion of the second questionnaire. 
Procedure 
Participants will be invited by the partnering organizations of the Jockey Club Holistic Support 
Project for Elderly Mental Wellness (JC JoyAge) to participate in a brief in-person group for CBT-
I, consisting of four sessions. Or they will be invited to participate in the control group and receive 
a booklet on sleep health. 
 
The Emotional Support Assistant Group (ESAG) 
The group will be held at the centres of the partnering organizations, with each session lasting 
approximately 1.5 hours and expected to be completed within a month. The sessions will be 
facilitated by two trained Emotional Support Assistants (ESA). In the first session of the group, you 
will be invited to fill out a questionnaire which will take about 10-15 minutes. In the final session, 
you will also be invited to complete the same questionnaire, along with an additional feedback form 
about the group. 
 
Control Group (CG) 
Participants will be recruited publicly through social media. Eligible participants will receive a 
booklet on sleep health. They will be invited to complete two questionnaires over 4 weeks, each 
taking approximately 10-15 minutes. An incentive of HKD$50 will be provided upon completion 
of the second questionnaire. 

Measure  
Basic demographics, including age, gender, marital status, ethnicity, education (years and highest 
attainment), employment status and  household type will be collected. Other study outcomes are 
listed below: 
1. Brief Version of the Pittsburgh Sleep Quality Index (B-PSQI) 
A 6-items scale assessing sleep quality from past month, including self-reported sleep time and 4-
points Likert scale with a global scoring ranging from 0 to 15 (Sancho-Domingo et al., 2020). A 
higher score indicates worse sleep quality. 
2. Dysfunctional Beliefs and Attitudes about Sleep (DBAS) 
A 16-items scale ranging from 0 (Strongly Disagree) to 10 (Strongly Agree). Stronger endorsement 
of these beliefs indicates greater maladaptation in detecting therapeutic changes and effectiveness, 
as well as in identifying domains that therapy may need to address. 
3. Pre-sleep Arousal Scale (PSAS) 
Rated on a 5-point Likert scale, ranging from 1 (Not at all) to 5 (Extremely), with total scores 
ranging from 8 to 40 for both subscales (Nicassio et al., 1985). Higher scores indicate an increased 
level of pre-sleep arousal. 8 items assess cognitive arousal (PSAS-C), a score of 20 of higher, and 
8 items assess somatic arousal (PSAS-S) with a score 14 or higher indicate clinical significance 
(Puzino et al., 2019). 
Data Collection and Analysis 
Descriptive statistics will summarize the baseline characteristics of participants and evaluate 
feasibility and acceptability by assessing the completeness of intervention participation and 
satisfaction. To test treatment efficacy and report the effect size, a Mixed-Design ANOVA will be 
utilized to examine changes within groups from pre to post assessments and to compare between-

group post-assessment results at week 4. Additionally, ANCOVA will be employed to compare 
post-treatment results at week 4 while adjusting for baseline sleep quality and demographic 
covariates such as age and gender. To maintain the Intention-to-Treat (ITT) principle, missing data 
will be addressed using multiple imputation. 
Data retention 
Data containing personal identifiers will be kept for five years after the publication of the first 
paper. Personal identifiers will be removed for long-term retention of the research data without an 
end date. 
 
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