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Table of Contents
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 107-111

Key catalysts for a better sleep disorders management in primary care

1 Department of Rehabilitation Services, Ministry of Health; Research Department, College of Graduate Studies and Research, Ahlia University, Manama, Kingdom of Bahrain
2 Department of Rehabilitation Services, Ministry of Health, Manama, Kingdom of Bahrain

Date of Submission03-Apr-2021
Date of Decision26-May-2021
Date of Acceptance27-May-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Ahmed Husain Ebrahim
Department of Rehabilitation Services, Ministry of Health
Kingdom of Bahrain
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hmj.hmj_16_21

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Sleep-related disorders necessitate adequate attention in the primary health care setting, the first point of contact for patients. Hence, this paper aims to identify factors reinforcing improvement strategies for sleep disorders management in primary health care. A narrative literature review was performed by examining sleep health-related scholarly sources identified in relevant databases. Subsequently, a comprehensive overview is shaped about potential factors catalysing active primary care practitioners' (PCPs') involvement in sleep disorders management. Eight key catalysts have been identified and described concisely based on current research. These eight catalysts could serve as an aide-memoire for primary care professionals for pursuing sleep-centric practices. Further, the identified catalysts could function as a reference for developing actions related to training, sleep medicine guidelines, policymaking, and public health programs dedicated towards sleep disorders' early detection, management, and education. As an important implication of this review, researchers interested in sleep health can utilize this review's outcome for crafting and validating a questionnaire to understand the involvement of PCPs in managing sleep disorders.

Keywords: Primary care, public health, sleep assessment, sleep health, sleep health literacy

How to cite this article:
Ebrahim AH, Mahmood WJ. Key catalysts for a better sleep disorders management in primary care. Hamdan Med J 2021;14:107-11

How to cite this URL:
Ebrahim AH, Mahmood WJ. Key catalysts for a better sleep disorders management in primary care. Hamdan Med J [serial online] 2021 [cited 2021 Dec 7];14:107-11. Available from: http://www.hamdanjournal.org/text.asp?2021/14/3/107/327424

  Introduction Top

Sleep quality is an essential factor for human health and performance.[1],[2],[3] It significantly influences physical functioning,[4],[5] physiological and hormonal balance,[6],[7] immune function,[8] regulation of body weight[9] and cardiovascular health.[10] There is a shred of pertinent evidence indicating healthy sleep's role in boosting the human psychological, cognitive and emotional well-being.[11],[12] In a broader context, poor sleep habits have remained associated with an increased risk of morbidity and mortality[13] and subsequent devastating implications on health care and economic outcomes.[14],[15]

Both primary care practitioners (PCPs') competencies and coordinated public health programs deem of utmost importance to address, monitor and manage the publics' sleep health and promote better public awareness. Altevogt and Colten emphasised three essential strategic pillars for health organisations to successfully introduce sleep-related health-care improvement strategies: public education, health practitioners training and surveillance and monitoring.[16] Given the importance of that, the most attention deserving role could be potentially referred to health-care professionals' knowledge and clinical practice model when encountering cases suffering sleep disorders or having a high vulnerability of developing health complications due to such disorders.[17] This is imperative for optimising the care plan and mitigating sleep disorders-associated risks. For that reason, some research attempts investigate the awareness and knowledge among practicing physicians and health-care providers, in general, to identify major gaps in managing and evaluating sleep disorders.[18],[19] However, a more significant element that has not received adequate research attention is the practitioners' willingness and perceived importance to engage in sleep improvement practices and knowledge enhancement activities.

  Sleep Disorders Epidemiology Top

Common and potentially serious sleep disorders that have been largely investigated through clinical observation studies include sleep apnoea which is characterised by abnormal patterns in breathing during sleep;[20] insomnia in which an individual experiences difficulty to initiate or maintain sleep throughout the night; restless legs syndrome causing an urgency to move the legs while attempting to fall asleep, usually accompanied by unpleasant sensations; and narcolepsy, a condition characterised by extreme sleepiness during the day and falling asleep suddenly during the day.[21]

Over the past decade, sleep epidemiology has received appreciable attention in clinical practice and research activities, which could be related to increased incidence, rapid evolution in diagnostic technologies or enhanced awareness. In regards to sleep disorders prevalence, a study conducted by Acquavella et al. in the United States of America to determine the figures of change in sleep disorders prevalence during the period between 2013 and 2016 found that there has been an increase in narcolepsy, obstructive sleep apnoea, idiopathic hypersomnia, periodic limb movement disorder and rapid eye movement sleep behavior disorder by 14%, 41%, 32%, 30% and 64%, respectively.[22] However, in the Middle East region, there is a deficiency in studies investigating sleep disorders prevalence.

  Sleep Medicine Technology Top

In recent years, there has been a significant advancement in terms of deploying state-of-the-art sleep-monitoring technologies, whether inside or outside the laboratory.[23] Such advancement has helped in improving the quality of sleep-related data acquisition, analysis and intervention prescription. Worth noting that the gold standard of sleep measurement method is “Polysomnogram” applied through an overnight sleep study.[20] Other escalating non-invasive methods include actigraphy and accelerometry capable of describing physical activity levels and monitoring sleep with reliability, affordability and scalability advantages. In general, there is an array of sleep monitoring technologies encompassing but not limited to WiFi and radio-signals, sensor modalities, smartphone sleep applications and artificial intelligence-based sleep modeling, which have become potential options in digital medicine.[23] Indeed, such a technology trend stresses investigating the level of health-care practitioners' possibilities, orientation, knowledge and willingness to use or consider these technologies in clinical practice or as part of counselling.

  Training on Sleep Disorders Management Top

Despite the potential impact that sleep disturbances have on human performance and general health alongside its relatively high prevalence, medical students' education and primary care clinicians' training on sleep medicine topics have been underscored in current literature.[24],[25],[26],[27] On the one side, future physicians need to be prepared through a sleep science focused-medical curriculum. On the other side, practitioners' knowledge and skills acquisition need to be elevated through a spectrum of opportunities including but not limited to research, training, professional development activities, education projects and fellowship programs. The demand for improving clinical sleep medicine is remarkable through research. For example, a cross-sectional study conducted in Saudi Arabia and included a sample of 223 primary care physicians found that they had a deficient awareness and low knowledge of sleep medicine and sleep disorders.[28] Simultaneously, sleep medicine scholars have stressed following standardized guidelines to provide sleep medicine training and practice. Remarkably, the recognition of sleep medicine in the Eastern world through research continues to grow. For a broader idea, it is recommended to refer to BaHammam et al.'s scholarly work in which they proposed systematic sleep accreditation models for physicians and technologists to be considered by health authorities and medical training agencies.[29]

  Patients' Awareness of Sleep Problems Top

Individuals' awareness of their increased risk of sleep disturbances plays a crucial role in mitigating their risk of going undiagnosed or untreated. Tentindo et al., (2018) who used the STOP-Bang sleep apnoea questionnaire to examine the prevalence and awareness of sleep apnoea in patients suffering chronic pain, found that most patients lacked awareness of their worsened risk and denied referring for specialist sleep assessment.[30] Worth noting, paying adequate attention to patients' or public' sleep quality awareness is of equal importance to promoting awareness among primary clinicians. Hence, it is significant to consider the general awareness and preventive aspects of sleep disorders at a national level. A fascinating model to refer to in that context is the National Healthy Sleep Awareness Project administered by the American Academy of Sleep Medicine and partnered with the centres for disease control and Prevention, the sleep research society and other partners;[31] such model could be inspired by regional health councils, like Gulf Health Council, to invest on public awareness campaigns and integrate sleep health into public health priorities.

  Clinical Reasoning and Consultation Top

Primary care clinicians, including doctors and physiotherapists, can play a vital role in investigating the effects of specific health problems on sleep quality for vulnerable patients, and vice versa, i.e. to recognise the adverse effects of sleep deprivation and disruption on daily functioning, metabolic health and psycho-occupational health on the short- and long-term prospects.[32] Sound clinical reasoning and consultation of sleep health are imperative for both patients' experiences and clinicians' behaviors; particularly, there is evidence indicating how sleep problems tend to be managed through “quick fix” approach or even practitioners' reluctance to discuss alternatives such as sleep hygiene.[33]

  Subjective Sleep Assessment Top

Therefore, primary care clinicians need to consider the necessity of being familiar with at least basic sleep assessment methods, like subjective sleep screens/questionnaires/diaries. According to a literature review study by Ibáñez, Silva et al., subjective methods have a sensitivity between 73% and 97.7% and a specificity interval of 50%–96%.[34] This makes them a viable option, which is almost costless, to develop a preliminary understanding of an individual's sleep quality. Common validated questionnaires for sleep assessment include self-reported Pittsburgh sleep quality index, insomnia severity index and global sleep assessment questionnaire.

  Promoting Sleep Health Literacy Top

“Sleep health literacy” is referred to as “the knowledge, motivation and competencies to promote healthy sleep and recognise a sleep problem” (Bonuck et al., 2016, p. 1).[35] An effective sleep health literacy demands reducing the gap between clinicians' competencies to promote healthy sleep and their capability to address sleep deprivations (Ibid). Important to mention in this context that relevant evidence indicates sleep consulting could be a complex task in the primary care setting, mainly due to the fact that patients initially tend to manage their sleep problems themselves, while consulting would often be the last option.[33]

  Liaison with Sleep Specialists Top

Liaising with or referring patients from primary care to a sleep specialist should not be undermined. According to a randomised clinical trial study by Edinger et al., a one-time sleep consultation significantly improved primary care physicians' orientation to sleep disorders and improved patients' sleep disturbances symptoms.[36] Hence, decision-makers in the primary care sector are at need to consider establishing criteria for sleep assessment referral, triaging severity and classifying high-risk candidates through feasible sleep diagnostic algorithms and economically sustainable pathways.[37] The question that presents itself in this context and demands a research inquiry is that to what extent that primary care sectors suffer from under-referral issues to specialist sleep clinics.

  Collaborative Paradigm with Physiotherapy Top

There is growing evidence of the promising and relevant role of physiotherapy in sleep improvement.[38] Physiotherapists have the aptitude to assess general sleep quality and sleep health, provide sleep hygiene education, design exercise programmes and deliver guidance to a healthy lifestyle.[39] Hence, PCPs are urged to recognise the potential and benefits of collaborating with physiotherapists and integrating sleep management approaches. This could include the inauguration of a coordinated inter-consultation mechanism and sleep health-focused preventive and wellness programs.

Based on the evidence reviewed in this study, a set of questions is proposed and presented in [Table 1]. Future researchers could use these questions to conduct quantitative studies on PCPs to get an insight into the extent of their involvement and orientation to sleep disorders management.
Table 1: List of questions for investigating the extent of primary care practitioners involvement in sleep disorders management

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  Conclusion Top

Conclusively, we stressed that sleep disorders management in a primary care setting should not be based on random clinical practices or the general preference of practitioners' but a systematic approach needs to be in place. This demands planning and implementing well-designed clinical and institutional guidelines, programmes, and processes, enabling and empowering practitioners' for evidence-based sleep medicine practice alongside competence development. Furthermore, PCPs need to recognise the potential of sleep technological resources and adopt practical mechanisms to promote sleep health literacy. Last but not least, warranting procedures and policies to systemise the collaboration and liaison with sleep specialists and relevant team members should be one of the utmost priorities in primary care sectors.


We are very grateful to Dr. Haitham Jahrami for creating an organizational culture of research and development, and his motivating and distinctive insights in sleep medicine.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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