Sleep difficulties are common among university students, with 66% reporting some level of sleep disturbance [1]. Sleep disturbances typically include difficulty initiating sleep, frequent awakenings after sleep onset, early morning awakening, unrefreshing sleep, and short sleep duration [2]. At the more severe end of the sleep disturbance spectrum is insomnia disorder, which is defined by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) [3] as dissatisfaction with the quantity or quality of sleep despite adequate opportunity for sleep, that occurs at least 3 times per week over the duration of at least 3 months [3]. Insomnia disorder has been found in 18.5% of university students [4], a prevalence rate much higher than the 6% [5] found in general adult populations. Sleep disturbance is associated with negative consequences such as poor academic performance [6-8] and impaired social functioning [9].

Sleep disturbance is also associated with the development of mental illness and suicidality [10,11]. Indeed, in recent decades, there has been an increasing awareness of the fundamental role sleep plays in maintaining mental health [12]. Evidence from the general population suggests that poor sleep predisposes individuals to mental illnesses such as depression and anxiety [12-15]. It can also heighten the risk of suicidal thoughts and behaviors [16], worsen comorbid mental health conditions, increase the likelihood of relapse [17], prolong the course of depression [18,19], and blunt treatment effects [20]. This makes the effective treatment of sleep disturbance a priority [21,22]. This is particularly important for university students who, being young adults typically aged 18-25 years, have an increased vulnerability to the onset of mental disorders [23]. It is well documented that this age group has a high prevalence of mental health disorders relative to other age groups [24]. Furthermore, it has been suggested that university students have higher rates of mental health disorders when compared to age-matched nonstudents [25].

Psychological interventions designed to improve sleep are effective in general adult populations [26-29], comparable to the pharmacological approaches typically used in primary care [30]. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line psychological treatment recommended for insomnia by national and international peak bodies including The Australasian Sleep Association [31] and the American Academy of Sleep Medicine [32]. CBT-I is a multicomponent treatment package that is typically comprised of sleep hygiene education, sleep restriction, tension reduction techniques such as relaxation, cognitive therapy to target unhelpful beliefs about sleep, and techniques to help people deal effectively with their worries. A systematic review of 87 randomized controlled trials (RCTs) showed that CBT-I significantly improved sleep quality with large effect sizes (g=0.98) in adults (aged from 17 to 75 years) [33]. While CBT-I is well established as effective at improving sleep in the general population of adults [34], there is much less research into the effects of these interventions in university student groups [35,36].

To date, there have been 5 RCTs of CBT-I with university students [14,37-40]. Four of these studies used interventions designed for general adult populations, which do not consider the unique circumstances of university students [14,38-40]. University students’ living circumstances (in student dorms, share houses, or with their family of origin) often mean that they spend large amounts of time in their bedroom [41], this is contrary to typical sleep hygiene recommendations. Other factors disturbing their sleep include stress [1,42], irregular sleep-wake patterns [43], the lack of routine in their study timetables, and the tendency to stay up late to complete assignments or engage in social activities [41]. These aspects of university student life underscore the need for sleep interventions that specifically address their needs. Only 1 study used an intervention designed specifically for university students [37]. However, it was focused on students who had both sleep difficulties and excessive alcohol consumption. In this study, the intervention had a dual focus on both alcohol and sleep, limiting the relevance of the findings for more general student populations with sleep difficulties.

Other limitations of the available research include the use of small sample sizes [37,40], brief interventions designed for nonclinical populations [38], and low adherence to treatment [14]. Although speculative, it is possible that the use of generic programs that are not tailored to the needs of university students could have contributed to low adherence rates. The efficacy of CBT-I in this population cannot be firmly established without further research that overcomes these limitations.

User-centered design principles are being increasingly adopted in the development of mental health interventions [44]. This approach has roots in the fields of human-computer interaction, cognitive psychology, and industrial design. User-centered design principles espouse that effective programs are not simply adhering to evidence-based therapeutic components determined by expert clinicians but are also practical, convenient, memorable, efficient, and acceptable for those taking part in the intervention [45]. A user-designed development process involves consultation during the design process with the people who will be using the intervention, and harnessing their involvement to shape the features of the program being developed, including aspects such as format, content, timing, and delivery. Gaining an understanding of end user needs and preferences through a user-centered design approach is an important first step to developing a program that will be effective, practical, and accessible [45].

The aim of this study was to engage with university students to inform the development of a new sleep intervention, either digital or face-to-face depending on student preferences, that takes into account their unique circumstances and specific needs in relation to sleep. Through a series of focus groups, the primary goal of this study was to garner an understanding of student views and preferences on program format and content for a sleep-focused intervention. Subsidiary goals were to understand student concerns about sleep and associated help-seeking behavior for sleep.

The purpose of this research was to engage in a user-centered approach to develop a new sleep intervention to meet the unique needs of university students. The main findings resulting from a series of focus groups indicated that participants advocated for an intervention with social interaction that was delivered either one on one or in small groups. They were keen to have opportunities for in-person interaction with the facilitator and their peers throughout the program and were most in favor of weekly hour-long sessions of about 4 to 6 weeks duration. They saw web-based material or a mobile phone app as a helpful aide to a digital program and wanted a sleep program that was customized to their unique situation and would give recommendations that were realistic and suitable for the university student lifestyle.

A clear theme was that students found the lack of a consistent routine contributed significantly to difficulties with sleep. The fluctuating demands of university study along with the frequent late nights caused by finishing assignments, working in casual jobs, and socializing, regularly interfered with their sleep patterns. This finding led to the suggestion that an appropriate intervention designed for university students needed to be flexible and provide information about the consequences of shifts in routine rather than a blanket insistence on adherence to regular sleep times. Other issues students indicated an interest in being addressed included managing screen time and getting sufficient sleep during examination periods. To the best of our knowledge, there are currently no evidence-based sleep-focused interventions for young adult university students that specifically take these factors into account [36]. This highlights the need for a program to improve sleep in university students that consider the unique circumstances of the student lifestyle.

A strong preference for a live socially interactive program format was a recurring theme throughout the focus group discussions. This format was considered ideal because it allows for social interaction with the facilitator and peers. A need for social connection was identified as a theme, evidenced by the suggestion for a social media component of the program. They viewed this as an opportunity to develop peer relationships, which they thought would help maintain their motivation and engagement with the program. The centrality of social relationships for young adult university students and the importance of including social components when designing mental health interventions has been identified in previous research exploring the needs of university students in mental health interventions [51].

This overall finding that students preferred a program with real-time communication and interaction with a facilitator is consistent with previous research that shows the majority of adults [52] and university students [53-55] still prefer seeking out face-to-face support compared to receiving treatment on the internet [53] and e–mental health services [52,54]. This is despite the research showing that university students are willing to use digital interventions [56]. There is some evidence that students’ preference for face-to-face interventions could be influenced by the type of mental health concern they are seeking help for [57]. For example, past research has found that where people are seeking help for a problem that they perceive as less stigmatized, there is a preference for face-to-face interventions. In contrast, if they perceive the problem is highly stigmatized, then web-based interventions are preferred [57]. This could be explained by the greater privacy and anonymity that are possible with web-based interventions, which makes them particularly appealing when stigma is a barrier to accessing treatment. In this study, student responses aligned with earlier research [58] that there is less stigma associated with seeking help for sleep difficulties relative to other mental health problems. This may account for preferences for in-person treatment in this study.

Results from this study suggested that digital interventions requiring a self-directed approach were considered to be less engaging and too easy to ignore. Considering how much time students already spend engaging in self-directed learning [59], it is not surprising that interventions also requiring students to independently work through material may be unappealing. Students’ perception that they would more easily disengage with an unguided digital intervention is also consistent with the low levels of adherence commonly found in such interventions [60-62].

There are several study limitations that need to be considered. The participants in this study had a range of sleep difficulties, from no sleep difficulties to severe insomnia. The sample did contain very few (n=1, 3%) participants with severe sleep difficulties. The sample was also largely composed of females (n=23, 77%) studying psychology (n=13, 43%). Therefore, the findings of this study may not accurately represent the views of male students, those studying in other fields, and those with more extreme sleep disturbances. In addition, the focus groups were conducted in 2021 during the COVID-19 pandemic in Sydney during a period of sustained lockdown. Although speculative, the social isolation during this time could have been a factor in the results of this study, particularly the student preferences for a face-to-face interactive program and the theme of students seeking social interaction and opportunities to connect in the context of a sleep intervention.

The results from this study indicate that university students feel that the unique aspects of the student lifestyle contribute to sleep difficulties. In their view, an appropriate intervention should involve interactions in real time, either in person or via videoconferencing, specifically tailored to their lifestyles, and with a social component. These findings can help inform the development of psychological sleep interventions for this high-risk university student population.