Why some embrace and others hesitate? A behavioral analysis of insomnia sufferers’ engagement with acupuncture treatment

Abstract

BACKGROUND

Acupuncture is emerging as a promising treatment for insomnia. However, the determinants driving patients’ decisions to pursue or adopt this treatment modality remain underexplored.

AIM

To identify the key factors shaping the willingness of patients with insomnia to seek and engage in acupuncture from a patient-centered perspective.

METHODS

A semi-structured focus group design was used, with a research framework integrating the capability, opportunity, motivation-behavior model, and theoretical domains framework. The results were mapped onto constructs of a behavioral wheel derived from the capability, opportunity, motivation-behavior/theoretical domains framework matrix. Data analyses employed abductive thematic analysis.

RESULTS

Data saturation was achieved after ten focus group sessions, involving a total of 45 participants. Key facilitators for patients with insomnia seeking acupuncture included: (1) Cultural beliefs in ethnic medicine; (2) Concerns about the adverse effects of, and dependence on, hypnotics; (3) Expectations of improvement in comorbid symptoms; (4) Desire for more communication with the clinician; and (5) Incentives from peers and online key opinion leaders. Barriers were: (1) Limited knowledge of acupuncture indications; (2) Accessibility burden; (3) Needle-phobia; and (4) Safety concerns. Additionally, prior acupuncture experiences, family/friend attitudes, and treatment costs (reimbursement rate in health insurance) served as both facilitators and barriers.

CONCLUSION

The interrelated facilitators and barriers underscore that the decision to use acupuncture for insomnia is a complex issue involving efficacy/safety, culture, economics, information dissemination, and communication factors. Expanding patient education on acupuncture, increasing media exposure, and improving governmental oversight of this process are essential. Investing in high-quality acupuncture services in public hospital nighttime clinics and community health centers is expected to address accessibility challenges. Acupuncturists need to improve doctor-patient communication, including guiding patients to set treatment expectations that are grounded in reality to enhance service quality. For patients with significant needle-phobia, cognitive manipulation or hypnosis techniques may be employed to improve treatment compliance.

Key Words: Qualitative study; Traditional Chinese medicine; Complementary and alternative medicine; Non-pharmacological therapy; Integrative care; Patient preference; Patient experiences; Patient-centered; Clinical decision-making; Sleep disorder

Core Tip: This medical-sociological interdisciplinary study examined factors influencing the decision of patients with insomnia to engage in acupuncture. Key facilitators included cultural beliefs, concerns about hypnotic dependence, and encouragement from key opinion leaders, while barriers encompassed limited knowledge, accessibility challenges, and needle-phobia. The findings underscore the multifaceted nature of this decision that is shaped by treatment efficacy, cultural context, economic factors, and communication dynamics. Recommendations for clinicians and policymakers include enhancing patient education, improving treatment accessibility through public health measures, fostering effective doctor-patient communication, and addressing needle-phobia through cognitive interventions to optimize treatment adherence and outcomes.

INTRODUCTION

Growing attention and use of acupuncture for insomnia management

Insomnia, the most prevalent sleep disorder, is characterized by dissatisfaction with sleep quantity and/or quality[1]. Core symptoms encompass difficulties initiating and/or maintaining sleep, frequent nighttime awakenings, and/or waking earlier than desired without the ability to return to sleep[2]. In the United States, insomnia prevalence is estimated at 15%-24%[3]. Across European countries, the rates vary widely, ranging from 5.7% in Germany to 19% in France[4]. In China, the prevalence is 15.0%, similar to those in other Asian countries such as Japan (15.3%) and Singapore (17.3%)[5]. Insomnia significantly impairs mood, cognitive function, and physical well-being[6] while increasing the risk for cardiovascular diseases[7] and metabolic syndrome[8]. It also imposes substantial societal and economic burdens, including annual productivity losses of 116%-144% among employees and a 62% higher risk of workplace injuries[9]. Annual costs are estimated at USD 30-107.5 billion in the United States[10], CAD 1.9 billion in Canada (in 2021)[11], and USD 81-135 million in South Korea (from 2018 to 2022)[12].

Treatment guidelines recommend cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia[2]. However, accessibility to CBT-I is often limited by cost and the scarcity of appropriately trained therapists[13]. Digital CBT-I can overcome these barriers, though its application without human guidance is linked to high rates of attrition (> 50%)[2]. Hypnotics and sedatives, particularly benzodiazepines and Z-drugs, are commonly prescribed for their immediate effects on sleep and ease of prescription[14]. However, their long-term use is restricted due to concerns about adverse effects, tolerance, dependence, abuse potential, and rebound insomnia[14,15].

Complementary and alternative medicine (CAM) is frequently employed to treat sleep disorders[16]. A national health survey in the United States found that 4.5% of individuals with insomnia or trouble sleeping used CAM therapies[17]. Insomnia ranks among the top five medical complaints for which CAM is sought[18]. Our team’s prior systematic review of global insomnia clinical practice guidelines identified 17 guidelines incorporating CAM, encompassing 22 modalities, such as nutritional products, acupuncture, light therapy, homeopathy, and aromatherapy[18].

Acupuncture, a low-risk, individually tailored treatment in traditional Chinese medicine (TCM)[19], involves inserting metal needles into specific skin sites for therapeutic purposes[15]. Numerous systematic reviews and meta-analyses have examined the efficacy, safety, and/or potential mechanisms of acupuncture for primary[13] and secondary insomnia, including post-stroke[20], cancer-related[21], and perimenopausal insomnia[22]. However, the factors that influence why some insomnia patients seek acupuncture while others do not remain unclear. Examining these factors (patients’ perceived facilitators and barriers to receiving acupuncture treatment) is crucial for understanding treatment preferences. After all, patient preferences are essential for personalized care[23], with a United Kingdom survey indicating that psychological issues, including insomnia, were the second most common reason for acupuncture use[24]. Identifying these factors could also improve clinician-patient communication and inform policy decisions, thereby enhancing the integration of acupuncture into comprehensive insomnia management and reinforcing its role as an adjunct to conventional therapies. No qualitative studies have directly addressed these specific factors, highlighting the necessity of the present study.

Theoretical framework and model

To address the complexity of behavior, researchers increasingly adopt composite theoretical frameworks, such as the social ecological model and the capability, opportunity, motivation-behavior (COM-B) model, to better understand behavior[25].

The COM-B model, developed by Michie et al[26], is considered an improvement over traditional health behavior models, such as the health belief model, protection motivation theory, and the theory of planned behavior, by comprehensively capturing factors influencing behavior change and more effectively explaining behavioral variance[27]. It conceptualizes behavior as part of an interactive system[28], where an individual must be physically and psychologically capable (C), have access to social and physical opportunities (O), and be driven by reflective or automatic motivators (M) to engage in a behavior (B)[29]. While each component directly influences behavior and interacts with the others[30], motivation serves as the central mediator[31], further linking capability and opportunity to behavior[32]. By accounting for multiple factors that support or compete with a given behavior, the COM-B model is widely applied to identify perceived barriers and facilitators[31]. This study utilized the COM-B model to examine patients’ attitudes towards using acupuncture for insomnia management, categorizing the reasons behind patients’ positive or hesitant responses to this target behavior as facilitators and barriers, respectively.

In our study, the COM-B model was integrated with the theoretical domains framework (TDF) to guide the interview design and data analyses. The TDF provides a lens for examining cognitive, affective, social, and environmental influences on behavior rather than testable relationships between elements[33]. It is widely used in qualitative research to identify behavior determinants[34] and explore factors contributing to suboptimal implementation[35]. The TDF consists of 14 domains, which align directly with the COM-B components[31], providing a more detailed theoretical understanding of behavior[36] and supporting the analysis of its proximal influences[37].

MATERIALS AND METHODS

Study design and participants

This qualitative study used focus groups for data collection, following the Consolidated Criteria for Reporting Qualitative Research guidelines[38]. Conducted at sleep medicine outpatient clinics in two TCM hospitals and two general hospitals in China, it employed purposive sampling[39] to recruit patients with insomnia. Each focus group comprised 4-5 participants. Recruitment targeted patients who actively sought acupuncture for insomnia or those approached by physicians with the question, “Would you be happy to try acupuncture treatment?” To minimize bias, physicians provided only basic information on cost, duration, and frequency, without explanatory recommendations. Those who were willing or hesitant to try acupuncture were further screened according to inclusion criteria, while those who immediately rejected the treatment were excluded, as the study focused on the adoption of acupuncture. Individuals who decisively rejected acupuncture, often due to deep mistrust or active opposition to TCM, would not meaningfully contribute to the discussion and risked introducing emotionally charged, unfounded statements, such as "TCM is superstition" or "TCM is a scam". Krueger and Casey[40] emphasized in the Focus Group Handbook that heightened emotions can hinder focus group discussions, particularly when participants hold strongly opposing views. Bloor et al[41], in their methodological work on focus groups, similarly cautioned against forming groups with "individuals with such conflicting views that the resultant discussion might cause distress to individual members".

Participants met the following criteria: (1) Age 18 years or older; (2) Diagnosed with chronic insomnia (7A00) or short-term insomnia (7A01) by a psychiatrist per ICD-11[42]; (3) Actively seeking or open to acupuncture or hesitant; (4) No communication barriers; (5) No significant neuropsychiatric disorders affecting cognition, such as schizophrenia or dementia; and (6) Voluntary participation.

Sample size was determined by data saturation, defined as the absence of the emergence of new themes. While no standard method exists for estimating the number of focus groups needed, Guest et al[43] found that 80% of themes emerge within two to three focus groups, and 90% within three to six. Based on this, four focus groups were conservatively considered the minimum to ensure saturation in our study. A termination criterion was set: If no new themes emerged after four rounds, followed by two additional rounds, saturation would be assumed.

Notably, participants who sought or were open to acupuncture were placed in separate focus groups from those hesitant about treatment. This separation prevented participants from altering their views or withholding responses to avoid conflict, thus maintaining the integrity of the data collection. Additionally, previous research has demonstrated that deliberately forming focus groups with participants who share similar characteristics and experiences enhances both the quality of the data and the comfort of the participants present[44].

Procedures

After reviewing the relevant literature and consulting two experts with extensive experience in qualitative CAM research, the initial interview guide was developed based on the COM-B model and TDF. Four eligible insomnia patients participated in a pilot focus group session, leading to refinements in the questions and finalization of the guide (Supplementary Table 1). The last question aimed to identify gaps in the interview protocol, and the semi-structured format allowed for open expression[45].

In January 2025, formal focus group interviews were conducted in a hospital meeting room, following the practical guidelines for focus groups outlined by Krueger and Casey[46]. With consent, interviews were audio-recorded. Each session was co-facilitated by a moderator and an assistant. The moderator (Zhao FY or Zhang WJ), a TCM practitioner with over 5 years of clinical and research experience in mental health and sleep medicine, explained the purpose, process, and confidentiality rules of the meeting, clarified questions, and provided prompts to facilitate interaction while maintaining neutrality. The assistant, a postgraduate student in TCM, ensured accurate understanding of TCM/acupuncture terminology, took detailed notes, including non-verbal cues, and operated the recording equipment. After each session, the moderator and assistant debriefed to review notes, impressions, and initial interpretations and wrote reflective journals to improve subsequent interviews.

Data collection and analysis

Interview recordings were transcribed verbatim into Chinese text using a speech-to-text application (iFlytek Listening 7.0.4101), with redundant filler words removed for clarity. Transcripts were verified by the focus group assistant and translated into English by a NAATI-certified translator (Xu PJ). Translation accuracy was checked by back-translation. The dataset was then uploaded to Nvivo 12.0 software for analysis. Using the COM-B model with TDF as the theoretical framework, abductive thematic analysis was employed to analyze the empirical data. This approach integrates inductive and deductive reasoning to iteratively explore and interpret data, generating plausible explanations for observed phenomena by aligning empirical findings with existing frameworks[47].

The analysis followed five steps: Immersion; line-by-line coding; category creation; theme generation; and mapping to the model. Initially, two analysts (Fu QQ and Zhao FY) independently coded the transcripts, identifying relevant statements and extracting meaning units. Double coding ensured clarity, mutual exclusivity, and coder agreement. Researcher triangulation further strengthened the findings, with five researchers (Zhang WJ, Fu QQ, Zhao FY, Xu PJ, and Ho YS) clustered similar meaning units and iteratively and abductively developed categories. These categories were then further grouped into higher-level themes, which were mapped to the domains of the COM-B model and TDF. Coding and thematic uncertainties were resolved through team discussions. Researcher perspectives, theoretical concepts, and frameworks enabled exploration of multiple facets of the problem, broadening scope, deepening understanding, and fostering consistent reinterpretation[48]. At each stage of analysis, the results were cross-validated with the research questions to create a more thorough examination of the data, ensuring accuracy and reliability. Descriptive statistics for all participants were computed using SPSS 26.0 software.

Methodological rigor

In accordance with Lincoln et al’s “Four-Dimensions Criteria” (i.e. credibility, dependability, confirmability, and transferability)[49], a range of measures were implemented to ensure trustworthiness and minimize bias (Supplementary Table 2). Self-reflection and reflexivity[50] was also maintained throughout the research process, including: (1) Transparently presenting the research background, design, implementation, and analysis to readers[51]; (2) Forming a multidisciplinary research team and fostering ongoing internal dialogue[51] on how the cultural backgrounds, expertise, experiences, and identities of the team shaped the research[52]; (3) Requiring reflective journals after each focus group[53]; and (4) Employing triangulation during data analysis[51].

Ethics approval and consent to participate

Only participants and researchers were present during the focus group sessions to maintain confidentiality. Participants were instructed not to record or film the sessions with mobile phones to ensure a safe, secure, and natural environment for the evolution of free unhindered communication.

After transcription, the original audio recordings were deleted. Each participant was assigned a unique identifier (P1, P2, P3, etc.) to preserve anonymity in the transcripts and this manuscript. Identifiable features were also removed. All participants provided written informed consent for participation and the publication of anonymized responses. Research ethics approval was granted by the Human Research Ethics Committee of Shanghai Sanda University (No. 2025001).

RESULTS

Ten focus group discussions were conducted. The group of participants actively seeking or open to acupuncture treatment (n = 28, Age: 45.4 ± 2.1 years) reached saturation after the fourth session, with two additional sessions held to confirm this. Among these participants, 71.4% (20/28) were currently using sedatives and hypnotics at the time of the study; of these, only 6 participants intended to complement their medication with acupuncture, while the remainder preferred to replace it. Additionally, 7.1% had previous experience with acupuncture for insomnia, and 28.6% had received it for other conditions, such as lumbar disc herniation, frozen shoulder, or primary dysmenorrhea. The group of participants hesitant or negative toward acupuncture treatment (n = 17, Age: 43.9 ± 2.7 years) reached saturation after two sessions, but four were conducted in total to ensure completeness. Among these, 58.8% preferred hypnotic medication over acupuncture. This group also had fewer individuals with prior acupuncture experience for insomnia (0%) or other conditions (11.8%; Table 1).

Table 1 Sample characteristics.

Items	Willing to undergo acupuncture treatment, n = 28	Reluctant to undergo acupuncture treatment, n = 17
Gender
Female	20 (71.4)	14 (82.4)
Male	8 (28.6)	3 (17.6)
Age	45.4 ± 2.1	43.9 ± 2.7
Duration of insomnia (months)	4.5 ± 0.7	2.3 ± 0.5
Short-term insomnia	9 (32.1)	13 (76.5)
Chronic insomnia	19 (67.9)	4 (23.5)
Previous acupuncture treatment experience	9 (32.1)	2 (11.8)
Previous acupuncture treatment experience for insomnia	2 (7.1)	0 (0)
Previous acupuncture treatment experience for other illness	7 (28.6)	2 (11.8)
Currently taking hypnotics/sedatives	20 (71.4)	4 (23.5)
Plan to take (or continue taking) hypnotics/ sedatives	6 (21.4)	10 (58.8)
Currently receiving CBT-I	0 (0)	1 (5.9)
Plan to receive (or continue receiving) CBT-I	2 (7.1)	2 (11.8)
Plan to receive (or continue receiving) Chinese herbal medicine	10 (35.7)	6 (35.3)

There was a total of 45 participants. Data are expressed as n (%) or mean ± standard deviation. CBT-I: Cognitive behavioral therapy for insomnia.

Regardless of their stance on acupuncture, most participants demonstrated limited awareness of CBT-I, with only 2 participants in each group expressing an interest in using it for insomnia management (Table 1). This aligned with previous research in the United States indicating that individuals with insomnia, primarily from a University of Pennsylvania teaching hospital and two affiliated community hospitals, preferred familiar treatments. CBT-I is often perceived as unfamiliar, and due to a lack of understanding of its mechanisms and potential benefits, some individuals considered it less effective than acupuncture[54]. Since attitudes toward CBT-I fall outside the scope of this study, they are not discussed any further.

Analyzed qualitative data were classified into facilitators, barriers, or dual-role factors influencing the clinical decision of patients with insomnia to engage in acupuncture treatment. These determinants were then mapped onto the COM-B/TDF matrix and visualized as the outermost components of the behavioral wheel, offering a multidimensional understanding of acupuncture participation behavior (Figure 1).

Figure 1 Behavioral wheel derived from the capability, opportunity, motivation-behavior model and theoretical domains framework matrix, mapping factors influencing patients with insomnia in seeking and receiving acupuncture treatment. The outer ring reflects facilitators and barriers identified in the current qualitative study. Green segments denote facilitators, pink segments indicate barriers, and orange segments represent factors that function as both. The icons utilized in this figure are adapted from Flaticon and Freepik under the Creative Commons CC-BY license (Supplementary material).

Motivation domain

Concerns about sedatives/hypnotics: Participants recognized the immediate efficacy of sedatives/hypnotics but expressed substantial concerns regarding their adverse effects and addictive potential. Acupuncture was perceived as a “greener” alternative to medication.

Representative statements included: “I know hypnotics can help me fall asleep, but I’m scared of their side effects,” (P42); and “Hypnotic medications help me fall asleep quickly, but the next morning I feel terrible—dizzy, weak, and totally drained. I even wonder if I actually slept at all,” (P2).

Many patients likened their reliance on hypnotic agents to “drug addiction” and wished to substitute the medication with acupuncture to break free from it.

A representative statement included: “I'm basically a ‘junkie’ right now, and it’s really stressing me out. I want to use acupuncture to kick this ‘addiction,’” (P27).

Expectation for improvement in comorbid symptoms: A well-known Chinese proverb asserts, “Western medicine treats the head when the head aches and treats the foot when the foot hurts; whereas TCM considers the person as a whole.” Many participants, possibly influenced by this perspective, believed that acupuncture not only alleviated insomnia but also improved other comorbid symptoms, making it a highly “cost-effective” treatment.

A representative statement included: “I’ve consulted both Western and Chinese doctors. The Western medicine doctor diagnosed my insomnia as due to perimenopause, with night sweats disrupting my sleep, and recommended administration of estrogen and hypnotic medications. The TCM doctor, however, suggested acupuncture to treat both the hot flashes and insomnia,” (P1).

Deep-seated cultural beliefs and confidence in ethnic medicine: Some participants expressed strong trust in TCM, viewing it as an essential branch of traditional Chinese culture and a cultural heritage passed down from their ancestors. Their decision to seek acupuncture was heavily shaped by these deeply ingrained cultural beliefs in ethnic medicine.

Representative statements included: “Thousands of years of practical history have validated the efficacy of acupuncture and Chinese herbal medicines. As Chinese people, it is natural for us to trust our own ethnic medicine,” (P12); and “I’ve always been a big supporter of acupuncture. It’s the ethnic medicine of the Chinese nation. Before the advent of Western medicine, our ancestors relied on acupuncture to heal and save lives. After developing insomnia, the first thing I thought of was going to a TCM hospital to receive acupuncture,” (P28).

Previous beneficial/negative treatment experiences: Previous positive or negative experiences with acupuncture influenced many participants’ attitudes toward its use in managing insomnia.

Representative statements included: “I have severe lumbar disc herniation and have tried various rehabilitation treatments, but none were effective. The doctor suggested surgery, but I was too scared to undergo it and only wanted to pursue conservative treatment. Then, someone recommended acupuncture, and I noticed a significant improvement in the pain. Since then, I’ve developed strong trust in acupuncture. Therefore, I believe it can also help with my insomnia,” (P7); and “I’ve had acupuncture before for allergic rhinitis. During the treatment, symptoms like a runny nose, stuffiness, itching, and sneezing improved slightly, but once the session ended, the symptoms returned immediately. Now, I’m concerned that treating my insomnia might have the same outcome: I sleep well during the acupuncture, but once the treatment is over, I might fall back into insomnia,” (P26).

Expectations for more time/opportunities to communicate with clinicians: Two participants noted that the 20-30 min needle retention time in acupuncture sessions offers a valuable opportunity for patient-clinician communication, an aspect they feel is often lacking in the current healthcare environment.

A representative statement included: “Doctors now attend to patients so quickly, and sometimes, before you've even finished describing your symptoms, the doctor has already prescribed medication. I understand that this is partly because there are so many patients and not enough doctors, so they have to speed things up. But as a patient, I still wish I could have more time to talk to my doctor. Acupuncture treatment gives me that chance: During the needle retention time, I have the opportunity to talk in detail with the doctor about my condition. This kind of thorough communication gives me more confidence in my treatment, and I feel like half of my recovery is already on the way,” (P9).

Significant needle-phobia: Many participants hesitant to undergo acupuncture treatment expressed a significant fear of needle penetration.

A representative statement included: “I've been afraid of injections since I was a child. With muscle injection the needle is pulled out quickly, but with acupuncture, it stays in the skin for a while. Does that mean it will hurt for a long time?” (P38).

Opportunity domain

Social support and peer experience sharing: Suggestions and recommendations were key factors motivating participants to seek acupuncture, with the most common sources being friends and colleagues, particularly those with prior insomnia experience. Family attitudes also played a significant role in influencing participants’ decisions.

Representative statements included: “I have a WeChat group with my old classmates, and now that we’re all retired, we chat in the group every day. Most of the things shared are either travel tips or wellness posts. Whenever someone has a good health or wellness suggestion, they’re always happy to share, and acupuncture for insomnia has been mentioned in the group as well,” (P10); “My aunt also suffers from insomnia. She’s over 70 and already takes a lot of medication for chronic conditions, so she didn’t want to take more pills. Her doctor suggested she try acupuncture. When she saw me struggling with insomnia, she shared her experience with me. My daughter also suggested that I could give it a try,” (P14); and “My colleague tried melatonin, but it didn’t work for her, so she searched online for other options. That’s how she found out about acupuncture and even invited me to try it with her. But my family doesn’t trust TCM—they think the stuff online is fake and keep telling me to just take hypnotic medication. So now, I’m really torn,” (P40).

Dissemination of information by key opinion leaders: Limited opportunities for discussing CAM with psychiatrists lead some insomnia patients to seek knowledge and management strategies through other networks. Key opinion leaders (KOLs) on social media play a significant role in encouraging these individuals to consider acupuncture. KOLs can be categorized into two groups: (1) Medical professionals who use social media to share medical knowledge; and (2) Internet influencers with large followings (often tens of thousands) who share personal health experiences (Note: due to lack of authorization, the names of the influencers mentioned below are pseudonymized as X).

Representative statements included: “One of the TikTok influencers I follow, ‘Ms. X,’ once shared that due to her live-streaming schedule, her sleep-wake cycle was completely reversed, which eventually led to insomnia. At one point she went more than 60 hours without sleep. She started taking sleeping pills and receiving acupuncture, and her insomnia improved significantly. I’m a big fan of hers, so I really trust the methods she recommends,” (P37); and “Dr. X regularly shares vlogs on TikTok about treating insomnia with acupuncture, featuring conversations with patients. Many patients even travel from far away to seek acupuncture treatment from Dr. X. Since the doctor’s clinic is in another province and I can’t travel that far, I can only try to find an excellent acupuncturist in my city for treatment,” (P20).

Burden in treatment accessibility: Most participants highlighted the accessibility burden of acupuncture treatment, which they weighed against the perceived benefits. This burden varied across individuals; for retirees, the distance to the clinic was a primary concern, while for employed individuals, waiting time and treatment frequency were more critical factors.

Representative statements included: “Even though I’m retired and have time, I’m hesitant because of the travel. My home is far from the hospital, and if I need to go several times a week, it will affect my ability to cook for my husband. Also, if treatments run late, no one can pick up my grandchild from school, and my daughter will complain,” (P25); “I could manage once on the weekend, but during the week, I’m too busy with work to take time off regularly. The doctor said treatment needs to be continuous for effectiveness, which I can’t manage. People like us who work full-time can’t commit to three visits a week,” (P39); and “I have two teacher friends who tried acupuncture during the summer break and found it effective. But once school started, they couldn’t continue due to their busy schedules,” (P32).

Capability domain

Treatment cost (whether covered by health insurance): Participants expressed relief that despite the relatively high cost of acupuncture for insomnia it was covered by the urban employee basic medical insurance, a mandatory government-run National Health Insurance Program in China.

A representative statement included: “Since acupuncture for insomnia is covered by insurance, I’m happy to go for it without worrying about extra costs,” (P16).

Some patients, while expressing strong support for acupuncture as “TCM enthusiasts,” acknowledged that if the treatment fell outside the reimbursable range, they might opt for alternative options covered by health insurance.

A representative statement included: “I have sleep apnea and insomnia due to obesity. The doctor suggested thread-embedding acupuncture for both conditions, but I found out it’s not covered by urban employee basic medical insurance. Despite trusting acupuncture, the cost made me choose a covered alternative,” (P43).

Inadequate knowledge of acupuncture indications: Some participants, while trusting acupuncture, had limited knowledge of the indications of acupuncture. They primarily associated acupuncture with the treatment of physical conditions, such as pain, post-stroke sequelae, or facial paralysis.

Representative statements included: “I only knew acupuncture was effective for pain and muscle issues, like back pain, stiff neck, or shoulder inflammation. I was surprised when the doctor mentioned it could also treat insomnia,” (P6); and “For conditions like knee osteoarthritis and lumbar strain, acupuncture can relieve pain by stimulating specific acupoints. However, insomnia is a neurological issue related to the brain, and acupuncture needles can only reach the skin and muscles, not the nerve centers within the brain,” (P24).

A few participants acknowledged the potential of acupuncture to address psychosomatic issues, including mood and sleep disturbances. However, they regarded acupuncture as a “superficial” treatment or “relaxation technique,” believing it primarily promotes sleep by alleviating stress rather than addressing underlying mechanisms, such as central nervous system disturbances, that contribute to insomnia.

Representative statements included: “When you receive acupuncture treatment, you lie down and relax while the needles stimulate certain acupoints. This helps with muscle relaxation and comfort, which may offer limited benefits for sleep,” (P36); and “Why can't people sleep? It is usually because they are worried, anxious, stressed, or dealing with too much pressure, like office workers. Acupuncture is more of a ‘relaxation technique,’ helping to relax muscles and relieve stress, but it likely does not regulate the brain’s nervous system. To truly solve insomnia, you probably still need medications that target the nervous system,” (P44).

Type of insomnia: One participant who used CBT-I believed that the type of insomnia determines the treatment choice.

A representative statement included: “It should be discussed separately. For physiological insomnia, such as that caused by pain or tinnitus, medication or acupuncture is effective. For psychological insomnia, like pre-exam anxiety or depression-related sleep issues, acupuncture may have limited effects, and psychological therapies should be used,” (P35).

Safety concerns: In addition to needle-phobia, some participants who were hesitant to undergo acupuncture also expressed apprehensions regarding the safety and potential adverse effects of acupuncture.

Representative statements included: “Are the acupoints for treating insomnia all located on the top of the head? If the needle isn't inserted deeply enough, won't it be ineffective? But if it's inserted too deeply, could it harm the brain or nerves?” (P11); “I have heard news reports about acupuncture accidents at massage shops leading to disabilities, so I’m a bit worried,” (P18); and “Everyone is built differently, so how can the doctor be sure that the acupoints they find are accurate for each person? I have doubts about that,” (P3).

DISCUSSION

Summary of findings

This study, based on a patient-centered perspective, discussed patients’ attitudes on seeking acupuncture services for insomnia management. Key barriers and facilitators contributing to their clinical decision-making were identified and mapped onto the relevant constructs of a behavioral wheel evolved from the COM-B/TDF matrix. These factors were intertwined and co-constructed, underscoring the complexity and multifaceted nature of the research topic.

Interpretation of the findings

The majority of participants sought acupuncture to address unmet therapeutic needs of conventional medicine, which can be divided into two aspects. First, participants valued efficacy but were cautious about the tolerance and dependency associated with hypnotic drugs. They turned to acupuncture as a replacement or adjunct to reduce adverse effects and enhance sleep improvement. These expectations have been supported by a substantial body of clinical evidence[15]. They are consistent with the status of acupuncture as a CAM modality where it serves as an “alternative” when replacing conventional therapy and as a “complement” when used alongside it[55]. Second, participants expressed a preference for acupuncture to address the comorbid symptoms of insomnia, aiming to avoid polypharmacy. Acupuncture demonstrates considerable potential in this context as well, aligning with the holistic principles of CAM. Its treatment framework integrates body systems through meridians while also addressing the affective domain[56]. Acupuncturists develop personalized strategies to improve overall health by targeting specific symptoms with a variety of combinations of acupoints[15]. This approach addresses not only insomnia but also the associated emotional, cognitive, and social dysfunctions, offering an advantage over hypnotic medication, which focuses solely on insomnia symptoms[15]. Our previous randomized controlled trial confirmed that acupuncture effectively improved comorbid insomnia, depression, and vasomotor symptoms in perimenopausal women with a high safety profile[57].

Most CAM therapies are culturally rooted, aligning with patients’ personal values[56]. Thus, the use of CAM represents a process where individuals identify with cultural elements during information-seeking and cultural creolization[56]. This explains why some participants seek acupuncture due to their strong cultural beliefs and confidence in Chinese ethnic medicine. A survey in Shanghai revealed that nearly 50% of elderly individuals believe in TCM, and this belief correlates with their use of acupuncture and other TCM therapies for chronic disease management[58]. Similar ethnic medicinal beliefs are pervasive in other regions, particularly in Asia, where traditional medicine is embedded in cultural contexts and spiritual foundations, independent of scientific validation[58]. For instance, 70% of rural populations in India consider traditional medicine as primary healthcare[59], and Traditional Korean Medicine has long been central to Korean practices and belief systems[60]. Even within overseas Chinese communities, TCM remains integral to their historical and cultural fabric[61]. A study on healthcare practices of Chinese-speaking immigrants in Canada found a strong demand for and belief in TCM, including acupuncture, with cultural and spiritual meanings attached[62]. Thus, belief in ethnic medicine supported by Chinese cultural influence and prior positive experiences plays a key role in facilitating acupuncture use among patients with insomnia.

In 2002, the World Health Organization Consultation on Acupuncture reviewed 225 clinical trials, confirming the effectiveness of acupuncture for 28 conditions, including various types of pain, depression, and nausea, and suggesting potential benefits for another 63 conditions, such as insomnia and schizophrenia, though further evidence was required[63]. However, nearly one-quarter of participants willing to try acupuncture only learned of its potential for treating insomnia after being asked, “Would you be happy to try acupuncture treatment?” While they were aware of the use of acupuncture for physical ailments, such as pain and post-stroke sequelae, they did not know it could treat insomnia, which they believed was addressed only by herbalism. One participant also believed acupuncture only worked for insomnia caused by physical conditions, not psychological causes like depression or anxiety. This reflects a significant lack of awareness about the broader applications of acupuncture. This persists even in China, the birthplace of acupuncture, and must be more pronounced in Western countries where acupuncture culture is less recognized. Similar misunderstandings have been observed in cancer survivors, who believed acupuncture was effective only for physical symptoms, such as pain and hot flashes, not mental conditions[64]. Even those who recognized the psychosomatic benefits of acupuncture still saw it only as a stress-relief or relaxation technique, not as a solution for the root causes of insomnia[64]. These misconceptions hinder acupuncture use for insomnia. Scholars suggest that this narrow understanding stems from the historical association of acupuncture with pain management, overshadowing its broader uses[64]. To address this, increasing evidence supporting the role of acupuncture in treating insomnia should be communicated more effectively to healthcare providers and patients, improving awareness, utilization, and/or referrals. After all, informed decision-making requires both patients and physicians to be knowledgeable about the evidence for available treatments[54]. Scholars also recommend consumer educational campaigns to raise public awareness about the applicability of acupuncture and advantages for specific conditions[65], helping patients form a more accurate understanding and reducing reliance on anecdotal accounts[54].

Patient education through social media accounts registered by TCM practitioners is an effective means for disseminating acupuncture knowledge. Specifically, vlogs allow patients to gain an intuitive understanding of the procedures and efficacy of acupuncture, thereby enhancing trust in the practice. In our study, 2 participants sought acupuncture treatment after watching an acupuncturist’s vlog, consistent with the findings from Chan et al[65] that trust in acupuncture is largely based on the reputation of individual practitioners, with word-of-mouth being pivotal in practitioner selection. Beyond raising awareness, social media platforms, including influencer livestreams and comment sections, provide a space for sharing medical resources, personal treatment experiences, and outcomes. Such exchanges can comfort or assist individuals in similar situations, while positive testimonials and success stories may encourage others to pursue treatment[66]. This may explain why many participants in our study relied on non-professionals, such as fellow patients, friends, or family, as primary sources of health-related information. Similar findings have been reported in prior studies. For example, a multicenter survey among 358 females with acne revealed that 88.4% of participants who used social media for acne information followed at least one treatment recommendation from these platforms[67]. A cross-sectional study across 14 European countries found that cancer patients primarily sourced CAM information from friends and family, with minimal input from physicians and nurses[68]. Similarly, an Australian study found that complementary medicine use was most influenced by friends and family[69]. This phenomenon arises from interpersonal contacts, which provide a personal perspective on the effectiveness of CAM and opportunities to ask questions and assess the trustworthiness of the modality[70]. Some participants learned about acupuncture from mass media reports, which aligns with the link between public trust in CAM and positive media portrayals[70]. Despite its relevance, no study has examined how online medical information sources (e.g., social media, online KOLs) and traditional sources (e.g., family, friends, mass media) differentially influence insomnia patients’ decisions to seek acupuncture treatment. Additionally, while the internet enhances access to health information, it may also widen disparities[71]. Research by Jacobs et al[71] suggested that older adults and individuals with lower socioeconomic status, limited education, and lower internet self-efficacy are less likely to obtain or utilize online health information. We encourage TCM practitioners to utilize social media as a platform to educate the public, promote evidence-based acupuncture recommendations, and present a more approachable image while upholding their professional integrity. Simultaneously, targeted interventions are needed to develop tailored e-health services for insomnia patients with limited digital literacy, mitigating inequities in health information access.

Insomnia patients seeking acupuncture based on anecdotal evidence from family, friends, or peers may not achieve the same benefits, as CAM treatment effectiveness varies across individuals[68]. While clarifying this, acupuncturists might still provide appropriate expectations, such as potential partial benefits, since expectations positively influence subjective outcomes[72]. Evidence from cancer survivors indicated that higher pre-treatment expectancy significantly predicted greater insomnia improvement in acupuncture recipients, but not in those receiving CBT-I[73]. Thus, clinical practitioners should guide patients in managing their expectations within reasonable limits. In addition, enhancing doctor-patient communication is crucial, as it strengthens patients' confidence in treatment. Research indicates that both patients' expectations and confidence significantly enhance treatment adherence[74].

Data indicate that at least 10% of patients report an excessive fear of needles, leading to avoidance, distress, and impairment[75]. In our study, many participants hesitant to undergo acupuncture attributed their fear to needle penetration, a form of instinctive needle-phobia, which can provoke pain even from fine needles[75]. This fear may also lead to complications, such as psychogenic syncope, causing hypotension and reduced cerebral perfusion, particularly in anxious or debilitated patients, exacerbated by needle stimulation[76]. Fear-induced trembling might deflect and curve needles inside the body, while muscle spasms could make needle removal difficult[76]. These issues can negatively impact treatment outcomes and overall patient health, making it essential to address needle-phobia before treatment[75]. Cognitive manipulation has been shown to alter pain perception and physiological responses to acupuncture[77], suggesting that needle-phobia could be alleviated through such techniques. In addition, acupuncturists might consider using suggestive or inductive hypnosis to ease needle-phobia as some studies have confirmed its effectiveness in reducing fear and improving treatment acceptance[76]. Some participants fear acupuncture because of concerns about its risk of adverse events. Clinicians should provide accurate information about potential side effects to correct exaggerated aversion to acupuncture[75]. Educational initiatives addressing the safety of acupuncture, acupuncture needles, and treatment procedures may also benefit patients with needle-phobia[78]. A review from our team demonstrated that acupuncture for insomnia is generally safe and well-tolerated with only minimal adverse events, such as mild bruising and localized pain, which typically resolve quickly after needle removal[15].

Nearly all participants cited cost, encompassing both economic and accessibility concerns, as a key factor. Economic costs, particularly acupuncture reimbursement rates under health insurance, have been shown to influence patients’ decisions to initiate or discontinue acupuncture treatment[79]. Acupuncture for insomnia is covered by national health insurance in only a few East Asian countries, such as China[80] and South Korea[12], likely due to the coexistence of TCM or Traditional Korean Medicine and Western medicine in the healthcare systems of these countries. However, many interviewees, even those who strongly support acupuncture, reported that out-of-pocket costs for treatments like thread-embedding acupuncture[81], which is not covered by insurance, deterred them. In Western countries including the United States, acupuncture is usually not covered by Medicare or Medicaid, and private insurance coverage is limited, creating financial barriers that may lead to financial toxicity for patients[79]. A study in the United Kingdom found that uninsured patients were more likely to discontinue acupuncture due to cost[82]. To enhance the accessibility of acupuncture for patients with insomnia in Western countries, particularly those in lower-income or medical resource-limited regions, health authorities could adopt several measures. First, prioritizing cost-effectiveness research on acupuncture for insomnia might provide evidence to support higher acupuncture reimbursement rates within national health insurance[83]. Second, tax incentives for acupuncture service providers, such as private clinics and wellness centers, could lower their operational costs, allowing them to offer more affordable services. Finally, private insurers could be encouraged to develop specialized acupuncture insurance packages for target audiences, leveraging the growing interest in incorporating CAM into private health insurance in European countries[84]. We suggest that private insurers may exploit the desire of people for access to acupuncture and explore a niche market by developing specialized acupuncture insurance packages for target audiences. Beyond financial constraints, participants expressed concerns about treatment accessibility, particularly scheduling and location. A prior review by our team found that 12 acupuncture sessions over 3-4 weeks are necessary to achieve significant sleep improvements[13]. However, this treatment schedule may be challenging for working individuals due to the need for multiple weekly visits. Offering acupuncture service through nighttime outpatient clinics, which have been already piloted in some first-tier Chinese cities, might address this concern. These clinics, operating from late afternoon to evening, cater to office workers and offer reduced waiting times and better confidentiality[85]. Patients’ concerns about distance may be mitigated by policy efforts in China to shift TCM services from hospitals to community health centers, which are intended to play a central role in primary care[86]. Although hospitals currently dominate TCM service delivery, this transition could enable patients with insomnia to access high-quality acupuncture services closer to their homes or workplaces in the future.

Limitations

Although this study provided novel insights into acupuncture-seeking behaviors among insomnia patients, several limitations should be noted. First, the sample was limited to patients in China, which may restrict the cultural scope of the findings. Given the strong cultural influence on acupuncture use, incorporating samples from diverse regions and cultural contexts in future research could offer a more comprehensive understanding of the issue. Nonetheless, our findings highlighted key factors that patients with insomnia commonly consider when seeking CAM services and provided valuable guidance for CAM practitioners to enhance service quality. Second, the study excluded insomnia patients who explicitly rejected acupuncture and may have introduced selection bias. Beyond a complete distrust of TCM, other specific reasons may contribute to their refusal. Investigating these reasons in future studies could yield deeper insights into the barriers to acupuncture adoption and provide a more balanced understanding of treatment decision-making factors. Additionally, incorporating a broader spectrum of patient perspectives is critical for estimating the demand for acupuncture across the entire patient population and accurately identifying potential clients, thereby supporting the sustainable development of acupuncture services. Finally, incorporating perspectives from clinical psychologists, psychiatrists, and acupuncturists in future studies would complement the patient-focused approach, offering a more holistic understanding of factors influencing acceptance of acupuncture.

CONCLUSION

The drive of patients with insomnia for seeking or accepting acupuncture treatment are multifaceted, including the desire to reduce reliance on hypnotic medications, incentives from peers and online KOLs, support from family and friends, prior beneficial experiences, strong cultural beliefs in ethnic medicine, expectations for enhanced doctor-patient communication, and the hope that acupuncture can address both insomnia and comorbid conditions. Conversely, hesitations may arise due to limited knowledge, needle-phobia, or concerns about side effects. Thus, promoting patient education on the efficacy, safety, and indications of acupuncture along with increased media coverage is essential. Healthcare authorities must regulate and ensure the accuracy and standardized dissemination of this information. Expanding access to high-quality acupuncture services in public hospital nighttime clinics and community health centers may help address accessibility barriers. Additionally, acupuncturists can enhance service quality by improving communication with patients and using cognitive manipulation to alleviate needle-related anxiety. Outside of China, patients are more likely to decline acupuncture due to financial toxicity. In response, governments could consider increasing acupuncture reimbursement under national health insurance or encouraging private insurers to offer acupuncture-specific coverage. These efforts could improve the opportunity for patients with insomnia from diverse backgrounds to comprehensively understand and evaluate acupuncture, ensuring more equitable access to an additional treatment option.

ACKNOWLEDGEMENTS

The author extends sincere appreciation to the research assistants for their contributions in moderating the focus group sessions and documenting the meeting proceedings. Additionally, gratitude is expressed to all the patients with insomnia who voluntarily participated in this study.