# Role and perception of healthcare professionals in referring cancer patients to online cognitive behavioral therapy for insomnia

Louise Zanni, Jonathan Journiac, Josée Savard, Estelle Guerdoux, Guilhem Paillard-Brunet, Léonor Fasse, Jean-Bernard Le Provost, Cecile Charles, Sarah Dauchy, Diane Boinon

► To cite this version:

Louise Zanni, Jonathan Journiac, Josée Savard, Estelle Guerdoux, Guilhem Paillard-Brunet, et al. Role and perception of healthcare professionals in referring cancer patients to online cognitive behavioral therapy for insomnia. Supportive Care in Cancer, 2025, 33 (3), pp.239. 10.1007/s00520-025-09284-1. hal-04996532

HAL Id: hal-04996532

https://hal.science/hal-04996532v1

Submitted on 19 Mar 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
# Role and Perception of Healthcare Professionals in Referring Cancer Patients to Online Cognitive Behavioral Therapy for Insomnia

### Louise Zanni

louise.zanni@u-paris.fr

Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité

### Jonathan Journiac

Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité

### Josée Savard

École de psychologie, Université Laval

### Estelle Guerdoux

Institut du cancer de Montpellier, Département de soins de support, Unité de Psycho-Oncologie

### Guilhem Paillard-Brunet

Centre Léon-Bérard, Unité de psycho-oncologie

### Léonor Fasse

Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité

### Jean-Bernard Le Provost

Gustave-Roussy, Unité de psycho-oncologie

### Cécile Charles

Centre de recherche Bordeaux Population Health, université de Bordeaux (MéRISP-U1219),

### Sarah Dauchy

Département Médico-Universitaire de Psychiatrie et d'Addictologie, AP-HP. Centre-Université Paris Cité
Hôtel-Dieu

### Diane Boinon

Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité

### Research Article

**Keywords:** Cancer, delivery of health care, healthcare professionals, Insomnia, Online cognitive-behavioral therapy, focus groups

**Posted Date:** August 23rd, 2024

**DOI:** https://doi.org/10.21203/rs.3.rs-4796161/v1
**License:** © Ⓟ This work is licensed under a Creative Commons Attribution 4.0 International License.

Read Full License

**Additional Declarations:** No competing interests reported.

**Version of Record:** A version of this preprint was published at Supportive Care in Cancer on February 28th, 2025. See the published version at https://doi.org/10.1007/s00520-025-09284-1.
# Abstract

# Purpose

Insomnia represents a major issue in oncology, which can be successfully treated by online Cognitive-Behavioural Therapy for Insomnia, such as the Insomnet program. However, promoting its successful implementation in routine care requires healthcare providers' involvement. This study aimed to explore healthcare professionals' perceptions of this online program.

# Methods

This qualitative study was a part of [anonymize for reviewing (AFR)]. It explored, through two focus groups including 19 healthcare professionals of three cancer centers, their perceptions regarding their role in patient referral, as well as the perceived barriers and facilitators in accessing this type of intervention. The content of the focus groups was subjected to a descriptive thematic analysis.

# Results

Four major themes were identified: (1) Ambivalent representations of online tools (including Patients convinced by remote intervention, Evolution of representations in relation to the health context, Adapted to sleep disorders, Professionals' preconceptions of online tools), (2) Barriers to implementation (including Few perceived barriers, Forgetting patients' particularities, Professionals' lack of knowledge, A possible threat to the patient-caregiver relationship, Financial cost), (3) Levers for implementation (including Real benefits for patients, Professionals who feel confident, Preserved patient-caregiver relationship, Institutional innovations to remedy dysfunctions), and (4) Professional involvement in implementation (What they need, What to avoid, What they already do, What they see themselves doing).

# Conclusion

Online (healthcare) services were reported to help increase access to healthcare, but that should not replace the relationship between patients and healthcare professionals. All professionals must be informed and trained to refer patients to these programs.

# Background

Insomnia is a distressing and enduring problem that affects 30-60% of cancer patients during and after treatments [1, 2]. Cognitive Behavioral Therapy for Insomnia (CBT-I) is the gold-standard treatment for insomnia with a documented efficacy across different cancer diagnoses and stages [2, 3]. However, its implementation in cancer care settings is still limited since its administration requires trained
professionals and is time-consuming. Distances from treatment facilities and frequent somatic
comorbidities in cancer patients represent additional barriers to access to care [3, 4].

While CBT-I has been recommended as the first-line treatment for cancer-related insomnia [2], pharmacotherapy remains the treatment most commonly used by patients [5]. This overuse of drugs is denounced given the risks associated with chronic daily usage [6]. In addition, patients express a preference for a non-pharmacological intervention to treat insomnia in cancer [7]. Online interventions hold promise to increase the accessibility to CBT-I. A video-based CBT-I (VCBT-I, [8]) has already been shown to be efficacious in Quebec breast cancer survivors [9]. In an earlier study, we evaluated the feasibility, among French adult cancer outpatients, of this validated program [10]. Results confirmed a request for this program, perceived as appropriate by our sample. Nevertheless, patients emphasized the need to provide remote professional support to personalize the guidance process both technically and clinically, and increase adherence to the online program [10]. It is now essential to explore healthcare professionals (HCP)' perceptions of an online version of this program to understand the conditions necessary for its successful implementation.

To fill these gaps, the [AFR] study evaluated an approach that combined a validated online CBT-I program (Insomnet, see Online resource Appendix 1 [11]) with phone-based guidance with a CBT psychologist. The current report presents the fourth objective of the study Sleep-4-All-2.0, which aimed at gathering HCP's perception about this program. More specifically, it explored facilitators and barriers to the implementation of online CBT-I programs in their clinical settings, and how they perceived their role in referring patients to this type of online intervention.

Method

Participants

HCP from three French cancer centers, involved in the Sleep-4-All-2.0 main study, were recruited by e-mail, via investigators (EG, GPB, DB). The participants were sent an e-mail with a description of the study that requested consent to participate and provide socio-demographic data. Professionals involved in the creation and organization of the study were not recruited.

Procedure

Two online focus groups (FG) were conducted via videoconference (Zoom) by the research engineer (JJ). They took place in June 2022 and February 2023, and lasted 1 hour 45 minutes and 1 hour 30 minutes respectively. JJ, a Rogerian and third-wave CBT (Acceptance and Commitment Therapy) male health psychologist with a PhD, was accompanied by LZ, a female PhD student and health psychologist, who observed the group dynamics, took notes, and ensured the smooth technical running. JJ and LZ did not know the participants.
Following a presentation of the study by JJ and a reminder of the FG procedures, the participants introduced themselves with their name and location. Four questions, developed by DB (principal investigator), were asked about participants' perceptions of the online CBT-I program (see Table 1).

<table><caption>Table 1
FG Moderator Guide</caption><thead><tr><th>Questions</th></tr></thead><tbody><tr><td>What do you think of online interventions for insomnia? Do you believe it is a tool that meets patients' needs? If yes, why? If not, why?</td></tr><tr><td>What could facilitate the implementation of this in cancer centers to meet patients' needs?</td></tr><tr><td>Do you believe there are barriers to the implementation? If yes, what are they?</td></tr><tr><td>In your opinion, what are the risks and benefits of using this online intervention?</td></tr><tr><td>How do you see your role in guiding patients to this kind of online intervention?</td></tr></tbody></table>

At the start of the FG, participants were asked where they were (home or at workplace). Audio recordings were made using Zoom and two recorders.

## Data analysis

The recordings were transcribed and pseudonymized by LZ. A descriptive inductive thematic analysis was conducted using the Braun and Clarke 2006 method [12]. After coding 1/3 of the verbatims, the researchers (LZ, JJ, DB) elaborated and discussed the code book by generating codes related to the transcripts, grouped into categories, sub-themes, and themes using QDA Miner lite software. The FG were recoded using this codebook by LZ.

The Consolidated Criteria for Reporting Qualitative Research (COREQ [13]) were used.

## Ethics approval

The Sleep-4-All-2.0 study received approval from the French Ethics Committee (N° ID RCB: 2021-A01891-40). All participants received information about the purpose and the procedures of the study, before giving their consent to participate in this study according to the French ethic comittee.

## Results

### Participants' characteristics

Out of the 32 people contacted to participate, 19 accepted to be included in the FG. Their characteristics are detailed in Table 2.
<table><caption>Table 2
Participants' characteristics</caption><thead><tr><th></th><th></th><th>FG1<br>(n = 9)</th><th>FG2<br>(n = 10)</th></tr></thead><tbody><tr><td rowspan="6">Professional status</td><td>Nursing Assistant</td><td>0</td><td>1</td></tr><tr><td>Healthcare Manager</td><td>0</td><td>2</td></tr><tr><td>Nurse</td><td>1</td><td>0</td></tr><tr><td>Advanced Practice Nurse (APN)</td><td>1</td><td>4</td></tr><tr><td>Physiotherapist</td><td>1</td><td>0</td></tr><tr><td>Physician</td><td>4</td><td>3</td></tr><tr><td>Psychologist</td><td>2</td><td>0</td></tr><tr><td rowspan="3">Cancer Center</td><td>[AFR]</td><td>3</td><td>6</td></tr><tr><td>[AFR]</td><td>6</td><td>2</td></tr><tr><td>[AFR]</td><td>0</td><td>2</td></tr><tr><td rowspan="2">Age (years)<sup>a</sup></td><td></td><td>41,7</td><td>42,8</td></tr><tr><td></td><td>[29-57]</td><td>[26-61]</td></tr><tr><td rowspan="2">Length of service (years)<sup>a</sup></td><td></td><td>11,3</td><td>13,3</td></tr><tr><td></td><td>[3-18]</td><td>[1,5-24]</td></tr><tr><td rowspan="2">Gender</td><td>Female</td><td>8</td><td>6</td></tr><tr><td>Male</td><td>1</td><td>4</td></tr><tr><td rowspan="2">FG location</td><td>Home</td><td>3</td><td>2</td></tr><tr><td>Workplace</td><td>6</td><td>8</td></tr></tbody><tfoot><tr><td colspan="4">Notes. <sup>a</sup> mean [minimum-maximum] ; FG: Focus Group [AFR].</td></tr></tfoot></table>

## FG settings

Both FGs were characterised by good participation and agreement among participants. Some of FG1's participants already knew each other and had worked together, particularly in the field of breast cancer, which facilitated discussions between them. Overall, they were very supportive of online programs. One participant left during the FG due to a medical emergency we have kept his data. FG2's participants did not know each other, worked with mixed cancer sites, and were a little wary of online programs. One participant had to leave early, without taking part in the FG; we haven't kept his data.

The two FGs experienced very few technical problems or interruptions.
# Findings

Out of 6 major themes, 4 (and 17 subthemes) were related to the research question. The remaining 2 themes were related to the context of care and research (Table 3). All these results reflect what the participants said.

<table><caption>Table 3
Themes and subthemes</caption><thead><tr><td>Themes</td><td>Subthemes</td></tr></thead><tbody><tr><td>Focus Group</td><td></td></tr><tr><td>Patients' experience in oncology</td><td></td></tr><tr><td rowspan="4">Ambivalent opinions of online intervention programs</td><td>Patients convinced by remote interventions</td></tr><tr><td>Evolution of opinions in relation to the health context</td></tr><tr><td>Adapted to sleep disorders</td></tr><tr><td>Professionals' preconceptions of online intervention programs</td></tr><tr><td rowspan="5">Barriers to implementation</td><td>For some, there are few perceived barriers</td></tr><tr><td>Forgetting patients' particularities</td></tr><tr><td>Professionals' lack of knowledge</td></tr><tr><td>A possible threat to the patient-caregiver relationship</td></tr><tr><td>A financial cost, but for whom?</td></tr><tr><td rowspan="4">Levers for a successful implementation</td><td>Real benefits for patients</td></tr><tr><td>Professionals who feel confident</td></tr><tr><td>Preserved patient-caregiver relationship</td></tr><tr><td>Institutional innovations to remedy dysfunctions</td></tr><tr><td rowspan="4">Professional involvement in implementing</td><td>What they have to do</td></tr><tr><td>What to avoid</td></tr><tr><td>What they already do</td></tr><tr><td>What they see themselves doing</td></tr></tbody></table>

## Ambivalent opinions of online intervention programs
# Patients convinced by remote interventions

FG1's professionals have noticed that patients, initially reluctant to switch to distance, well accepted doing so: "[The patients] said 'actually, in the end, I preferred being on video.' So, we were surprised, and they were too." (Océane, FG 1, Physiotherapist)

## Evolution of opinions in relation to the health context

The COVID-19 pandemic has accelerated the need for online care, thus contributed to evolve the perception that both professionals and patients had of it. Online care has become indispensable: "That's what we were saying about the post-COVID era, and the fact that people still need to get used to more digital tools, so... it's going well anyway." (Sarah, FG1, Physician)

## Adapted to sleep disorders

Reluctance towards remote interventions for managing sleep disorders is minimal due to a lot of evidence supporting it: "For the management of insomnia, I'm actually quite enthusiastic, even though, of course, digital tools in general are... raise questions." (Elodie, FG2, Physician)

## Professionals' preconceptions of online intervention programs

While some individuals show negative preconceptions and skepticism about digital solutions, most acknowledge the potential benefits of remote interventions. However, concerns persist regarding the impact on the patient-provider relationships and the role of caregivers, as well as the potential lack of information and sensory experiences associated with online interventions.

FG2's participants expressed too: combined with "the decline in medical workforce demographics" and institutional problems, remote interventions "ultimately result in a loss of the possibility of having human contact." (Julien, FG2, Physician). Remote interventions would then only serve to address the current challenges faced by hospitals.

On the other hand, both FGs generally had a positive view of remote interventions: clever, functioning properly, and serving as a real aid for users. Some highlighted the possibility of a hybrid approach: "We are really together, I mean it's almost like being in person. It's just that we see each other through a screen..." (Océane, FG1, Physiotherapist)

## Barriers to implementation

### For some, there are few perceived barriers

At the beginning of the conversation, FG1 found that there were very few barriers and risks: "I don't identify any actual risk, well the only risk, as Camille mentioned earlier, is that it doesn't work." (Chloé, FG1, Nurse)
Discussions and exchanges between participants led to the identification of the following sub-themes.

## Forgetting patients' particularities

"It depends on the patient we have in front of us [...] It depends on the patient and the type of patient who can be included in this kind of work or research." (Laura, FG2, Healthcare Manager)

For them, a major barrier would be the risk of leaving behind patients who may not be able to access the program due to their different characteristics. They were concerned about elderly individuals who may not be comfortable with digital technology, as well as those living in areas with poor internet access. Additionally, certain psychiatric conditions or cognitive impairments may hinder optimal online care. However, Sarah (FG1, Physician) reconsidered: "We might not necessarily offer it to them; they often have psychiatric and psychological follow-ups already, so they're not really the target either".

Participants also mentioned the fear that patients may "feel isolated" (Pauline, FG1, Physician). If they do not feel well supported, they may be at risk of discontinuing the program.

Thus, both FGs raised the question: "what about patients who can't benefit from this type of tool?" (Aurélie, FG2, APN)

## Professionals' lack of knowledge

Lack of familiarity with the program, as well as distrust towards it due to its non-pharmacological and CBT aspects, could hinder its implementation. For example, they think some colleagues preferred medication, while others were against CBT: "We're afraid sometimes, when we enter this field of non-drug intervention, that it's not recognized, that we might also be demonized a bit." (Pauline, FG1, Physician)

It is important to explain the program to the professionals. Indeed, if they are not familiar with the tool, they cannot offer it: "You could very well propose this... this tool there, I mean for my part, I don't feel like I know it well at all..." (Laura, FG1, Psychologist)

## A possible threat to the patient-caregiver relationship

A purely online program like Insomnet could damage the carer-patient relationship and weaken their bond. As a result, the support for patients would be less optimal. The fear of dehumanization of contact was present, notably in FG2 "with always the worry that the virtual will come to replace the contact." (Julien, FG2, Physician)

Participants feared that the possibility of redirecting people to this online program may lead to 'getting rid of patients.' They might try to solve the problem simply by redirecting instead of taking the time to support the patient. This leads to the risk of not identifying other symptoms and problems. Moreover, there would also be the risk of losing the connection with people who would be alone with the program, forcing them into autonomy. Aurélie (FG2, APN) summarized this fear: "We mentor them less efficiently, overall!"
## A financial cost: for whom?

A final institutional barrier was raised by the professionals: who would pay? If it's the hospital, they fear the facilities may refuse it by not seeing profitability.

*"So, that comes with a cost, and I imagine it has to be somewhat profitable for the institution afterward..." (Manon, FG1, APN)*

If patients need to pay, access will be limited.

## Levers for a successful implementation

### Real benefits for patients

As Insomnet is online, it can be accessed at any time and from anywhere. This addresses the issue of patients who "may not necessarily have the possibility to travel solely for the management of their sleep disorder." (Jeremy, FG2, APN), whether it's because they live far from the cancer center or because "it's a bit tiresome to come back to the center every time. [...] Coming back, especially after the illness, brings back memories, so it's also good that they can be at home and be remote." (Chloé, FG1, Nurse)

Furthermore, patients are increasingly demanding non-pharmacological treatments.

*"[They] don't want to take more and [...] are already in the demand of saying 'I don't want to be pumped with medications'." (Camille, FG1, Psychologist)*

Remote support by a psychologist in addition to the online tool helps professionals provide enhanced support: "They think, 'well, okay, I'll look into something, it might help, and if I don't understand or if I have a problem, there's someone behind who will be there.'" (Pauline, FG1, Physician)

It promotes trust and prevents the use of potentially dangerous alternative therapies.

Thanks to the possibility of being remote, the patient's timing is respected: "Patients can revisit the information and the tool, calmly at home, they can review videos, stop and start again." (Léa, FG2, Healthcare Manager).

Another important aspect for professionals is that the patient can play an active and central role and become a care decision-maker: "It's up to them to dig deeper, so it also allows them to take control of this problem, [...] having this tool also allows them to explore other things, and it's them who do it and who go where they want to go." (Elodie, FG2, Physician)

### Professionals who feel confident

On the professionals' side, a non-pharmacological approach avoids chemical interactions, especially in a cancer context, and is "very interesting: both to limit, when possible, the prescriptions of medications." (Nicolas, FG2, Physician).
Furthermore, professionals were familiar with the Sleep-4-All-2.0 research team, whom they trusted, and the program. They knew this program is scientifically proven, giving them confidence: "Is patient adherence much easier to obtain when we have some knowledge of what we're offering?" (Pauline, FG1, Physician)

This program is a solution to sleep disorders that has long been awaited by professionals who often felt limited in their therapeutic options for insomnia: "The existence of this program opens a door, you know." (Marie, FG2, APN)

It saves time and is easy to approach with patients. Professionals were reassured: "We also emphasized a lot on the human support aspect, it wasn't just the person facing their computer and their videos!" (Camille, FG1, Psychologist)

The fact that the program is evidence-based really helped to provide this good vision of the program to the professional and thus, ultimately, to implement it: "If there's research showing the benefits, well, it's something that will be integrated, almost trivialized, that will become part of everyday life like pain management..." (Laura, FG2, Psychologist)

## Improved patient-caregiver relationship

FG2's participants believed that Insomnet could even improve the patient-caregiver relationship, but only if there has been a meeting before the reference: "The relationship actually comes from the people we will direct to this device, they are people we will have already seen beforehand, for whom we will have detected a disorder, so I think the relationship will be there." (Jeremy, FG2, APN)

## Institutional innovations to compensate dysfunctions

The tool was highly requested but also kept the institution at the forefront of innovation: "There has to be an interest behind it, and perhaps also in line with the institution that can promote this type of project." (Laura, FG2, Healthcare Manager)

Additionally, it helped reduce the costs of usual care and addresses the shortage of trained and available professionals on the subject.

## Professional involvement in implementing

### What they have to do

Professionals must all be made aware of the significance of sleep disorders in the context of cancer. Participants were concerned about some colleagues who considered normal to have a sleep disorder, so they don't pay attention to it. Once this learning is done, professionals must become familiar with the program to be able to orient patients to it: "My intervention is just a coordination intervention, a connection actually. We identify a problem and then we find the professional who can better address the situation." (Julie, FG2, APN)
For them, everyone must be involved: all professionals must take part in the program's implementation. It will then be part of a comprehensive patient care and ensure patients are not left alone: "I really see it as an additional tool in a more comprehensive approach, and it doesn't prevent me from, well, either suggesting medications or another form of support, like psychotherapy... in real life." (Elodie, FG2, Physician)

## What to avoid

However, it is important to be careful to avoid some mistakes. Insomnet should not be used as a replacement for a comprehensive patient's follow-up: "it's complementary but... it's not instead of." (Sarah, FG1, Physician)

Nor should insomnia in patients be trivialized or the program used as one would use a drug, "it's like, 'well, you have insomnia, well, I propose this app or this platform to you,' you know. So there you go, and I'm not really for binary reasoning" (Laura, FG2, Healthcare Manager)

## What they already do

It should be noted that, in these FG, many professionals were already proposing the program or redirecting patients to professionals who could present it better: "As a psychiatrist, I'm naturally very often approached for sleep problems, so I frequently guide patients towards this study." (Nicolas, FG2, Physician)

## What they see themselves doing

The professionals envisioned continuing to redirect, support, and adapt themselves to each patient to offer the program as part of their follow-up. Romain (FG2, Healthcare Manager) noted it was important not to forget to meet again the patient during the program: "Still, probably some physical contact in one way or another is necessary. Firstly, at the beginning, and secondly, to repeat somewhat regularly to see where we really stand."

They proposed the presence of a resource person in each department/center dedicated to the program, citing other similar projects that have been presented this way. Making the program visible to patients was also crucial: "It's true that just the fact that it's a bit visible, also in the waiting room or in the corridors, well, I don't know, at admissions, but it's true that it also allows them to say, 'well yes, it's true that it concerns me, maybe I could talk about it during my consultation!' Well, I think it's also part of our role to identify at that moment that patients can simply see it displayed in the facility, too." (Camille, FG1, Psychologist)

## Discussion
Our objective was to explore the facilitators and barriers identified by French cancer healthcare professionals in providing access to an online CBT-I program and how they perceived their role in referring patients. Both FGs spoke positively about Insomnet and online programs, especially to manage insomnia. FG's members actively contributed to the discussion by sharing common perspectives. The analysis suggests that the Insomnet program addresses the needs of patients, professionals, and institutions, with barriers to implementation being overcome by levers. The program had real benefits and empowered patients to assume an active role. Moreover, professionals underlined the importance to keep in mind the need for human support through the machine, whether it's occasional face-to-face contact or support remotely. All professionals must be trained and knowledgeable to implement the program. FGs showed that research facilitates implementation and ensures credibility.

Our results are in line with those of a similar study conducted by Savard et al. in Quebec, Canada [14], the developers of Insomnet, who assessed the barriers and facilitators for the implementation of Insomnet as part of a stepped care program. They conducted semi-structured FGs with professionals and patients exploring the practices of assessment and management of cancer-related insomnia and the factors that could aid in the Insomnet implementation in routine cancer care. Like the professionals of our research, their participants emphasized the strong need for insomnia management, particularly due to organizational issues and overloaded psychologists. These programs can also help avoid over-medicalization. According to our study, insomnia is not taken seriously enough and discussed with patients, which has already been noted in the literature [15]. Participants of both studies also highlighted issues related to age and access to the internet. There is evidence [16] suggesting that older adults are inclined to use e-health if they are supported and guided.

The conclusions of Savard et al. [14], despite possible intercultural differences, echo ours, emphasizing that professionals must be aware of treatment options and familiar with them to effectively guide patients towards them while respecting their preferences. The common results suggest a need for technical and clinical support.

Similar research has been conducted in the context of psychiatric disorders [17]. The same strengths and barriers were found, as well as the fear of non-engagement of patients. However, these studies indicated that costs were lower, making treatments accessible "to all", with often proven efficacy. Davies et al. [18] also highlight the importance for HCP to receive information and be familiar with web-based therapies in their practices to offer them to patients.

## Study limitations

Despite our efforts to recruit professionals from different centers, professionals from GR are overrepresented as GR was the coordinating center of the study; this could positively impact their perception. Participants in FG were already interested in the theme of online management, even if they were not all familiar with Insomnet.

## Clinical implications
HCP seem to be ready to implement remote interventions like the Insomnet program for cancer-related insomnia. However, they emphasized the importance of maintaining human connections and not relying exclusively on asynchronous methods. Professionals expected raising awareness among healthcare providers about the existence of the program, as well as information for everyone on how to use the program. With confidence and informed guidance, they would be better able to direct patients toward programs, and everyone could play a role in its wider implementation.

## Conclusion

This qualitative study shed light on the implementation of an online CBT-I program. It was considered particularly awaited by HCP. They were in favor of implementing it, but they remained cautious. They emphasized the need for human guidance and to always maintain a connection with the hospital: there is a need to reintroduce real interaction and not be overtaken by online methods, to adapt to the individual needs of each patient.

## Declarations

**Ethics approval** This study was approved by the French regulatory and ethics authorities (Comité de Protection des Personnes Sud-Méditerranée II - N° ID RCB: 2021-A01891-40).

**Consent to participate** All participants received oral and written information about the purpose and the procedures of the study, before giving their oral consent to participate in this study.

**Consent for publication** We confirm that the manuscript has been read and approved for submission by all authors and that all persons listed as authors have contributed to preparing the manuscript and that no persons other than the authors listed have contributed significantly to its preparation.

**Conflict of interest** The authors declare no competing interests.

Funding This study was funded by a project grant from the National Cancer Institute (INCa SHS 2020 n°2020-1-PL SHS-03-IGR-1)

**Acknowledgement** The authors acknowledge the study participants.

**Financial and non-financial interests** The authors have no relevant financial or non-financial interests to disclose.

**Authors' contribution statements** [AFR] contributed to the study conception and design. [AFR] contributed to the participant recruitment. Material preparation, data collection and analysis were performed by [AFR]. The first draft of the manuscript was written by [AFR] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

## References
1. Savard J, Ivers H, Villa J, et al (2011) Natural course of insomnia comorbid with cancer: an 18-month longitudinal study. J Clin Oncol Off J Am Soc Clin Oncol 29:3580-3586.
https://doi.org/10.1200/JCO.2010.33.2247

2. Howell D, Oliver TK, Keller-Olaman S, et al (2013) A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer. Support Care Cancer Off J Multinatl Assoc Support Care Cancer 21:2695-2706. https://doi.org/10.1007/s00520-013-1823-6

3. Johnson JA, Rash JA, Campbell TS, et al (2016) A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev 27:20-28. https://doi.org/10.1016/j.smrv.2015.07.001

4. Savard J, Villa J, Simard S, et al (2011) Feasibility of a self-help treatment for insomnia comorbid with cancer. Psychooncology 20:1013-1019. https://doi.org/10.1002/pon.1818

5. Casault L, Savard J, Ivers H, et al (2012) Utilization of hypnotic medication in the context of cancer: predictors and frequency of use. Support Care Cancer 20:1203-1210.
https://doi.org/10.1007/s00520-011-1199-4

6. Guzman-Marin R, Avidan A (2015) Sleep disorders in patients with cancer. J Community Support Oncol 13:148-155. https://doi.org/10.12788/jcso.0126

7. Kwak A, Jacobs J, Haggett D, et al (2020) Evaluation and management of insomnia in women with breast cancer. Breast Cancer Res Treat 181:269-277. https://doi.org/10.1007/s10549-020-05635-0

8. Savard J, Ivers H, Savard M-H, Morin CM (2014) Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer? Results of a randomized controlled trial. Sleep 37:1305-1314. https://doi.org/10.5665/sleep.3918

9. Morin CM (2014) Insomnia Severity Index. https://doi.org/10.1037/t07115-000

10. Boinon D, Charles C, Fasse L, et al (2021) Feasibility of a video-based cognitive behavioral therapy for insomnia in French adult cancer outpatients: results from the Sleep-4-All-1 study. Support Care Cancer 29:5883-5894. https://doi.org/10.1007/s00520-021-06151-7

11. Savard J, Ivers H, Savard M-H, et al (2021) Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: a noninferiority randomized controlled trial. Sleep 44:zsab166. https://doi.org/10.1093/sleep/zsab166

12. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3:77-101.
https://doi.org/10.1191/1478088706qp063oa

13. Gedda M (2015) Traduction française des lignes directrices COREQ pour l'écriture et la lecture des rapports de recherche qualitative. Kinésithérapie Rev 15:50-54.
https://doi.org/10.1016/j.kine.2014.11.005

14. Savard J, Filion C, Gagnon M-P, et al (2022) Barriers and facilitators to implementing a stepped care cognitive-behavioral therapy for insomnia in cancer patients: a qualitative study. Support Care Cancer 30:6689-6698. https://doi.org/10.1007/s00520-022-07094-3
15. Reynolds-Cowie P, Fleming L (2021) Living with persistent insomnia after cancer: A qualitative analysis of impact and management. Br J Health Psychol 26:e12446.
https://doi.org/10.1111/bjhp.12446

16. Wilson J, Heinsch M, Betts D, et al (2021) Barriers and facilitators to the use of e-health by older adults: a scoping review. BMC Public Health 21:1556. https://doi.org/10.1186/s12889-021-11623-w

17. Stern E, Micoulaud Franchi J-A, Dumas G, et al (2022) How Can Digital Mental Health Enhance Psychiatry? The Neuroscientist 107385842210986. https://doi.org/10.1177/10738584221098603

18. Davies F, Shepherd HL, Beatty L, et al (2020) Implementing Web-Based Therapy in Routine Mental Health Care: Systematic Review of Health Professionals' Perspectives. J Med Internet Res 22:e17362. https://doi.org/10.2196/17362

**Supplementary Files**

This is a list of supplementary files associated with this preprint. Click to download.

* OnlineContentAppendix1.pdf