Table 2. Open in new tab Qualitative...

Table 2.

Qualitative Themes, Subthemes, and Exemplar Quotes from Black Breast Cancer Survivors (BBCS)

Barriers to high quality sleep

Cancer worry
“I think people don’t realize how, after having cancer, how stressful or how stressed you can be about worrying if it’s going to come back.”(Participant # 02)
Personal responsibilities
“Sometimes when there’s a crisis or some things that are going on, it needs to be taken care of… a lot of people do look up to me… That can be something on my mind before I go to sleep.”(Participant # 05)

Psychosocial impacts of sleep disturbance

Decreased energy during the day
“I already had sleep issues before I had cancer. But after… it’s worse. I’m always tired… I just feel like, even though you beat cancer, a good thing, like what did I really beat? I beat cancer to feel sick.”(Participant # 13)
Lower productivity
“I do get up early in the morning, and if I don’t sleep well, then I’m really sluggish and I’m not really that productive during the day.” (Participant # 05)
Psychological distress
“My anxiety’s kicking because I’d be tired, and every little thing agitates me… I tend to get anxious a lot and I get on people’s nerves because I’m tired.”(Participant # 14)

Commonly used strategies to improve sleep

Nightly routines with electronics
“Some nights I turn on old TV shows that I’ve already watched…and I’m asleep, just like that.”(Participant # 14)
“I just have to have something like that to make me fall asleep…Some background noise. No music or anything. Just something talking. And I have the radio right by my bed.”(Participant # 06)
Sleep environment
“I try to make sure that the house is cool so I can rest comfortably.”
“I try to have the house cool; very cool. Maybe around 66 [degrees], and that seems to help.”(Participant # 04)
Staying active
“Those are, up and down, tiring work… I was working in a preschool. So, you know I deal with the children a lot, back and forth on the playground. So, by the time you get home, and you do your little cooking and laundry and whatever, you’re ready for bed around 9:30-10 pm. You get a good rest. And so when I wake up, I’m fresh and busted with energy when I get up the next morning.” (Participant # 11)

Feedback on an existing mHealth CBT-I intervention

Sleep hygiene and behaviors
“I think the main thing… would be to identify the cause of not having a good sleep hygiene program. That would be number one…I like the fact that they give you a lot of information about potential problems you may be having, and it gives you the opportunity to evaluate yourself and see where you fit in.” (Participant # 05)
Sleep tracking
“This type of information can be used by doctors, like my cardiologist is asking me how I’m doing with my sleep. My therapist asking me, how my sleep is based on my anxiety. So it would be really quick and easy to pull this up and say, ‘The past, you know, three months I’ve had this poor sleep.” (Participant # 09)
Smartphone preference over computer
“If it’s an app or it’s on my phone…then I’m going to be a little more engaged.” (Participant # 09)
“More frequently because the other program that I’m using for weight loss is an app that I use, and I look at that every day.” (Participant # 05)
Diverse representation
“From what I was able to see…it just looks not like a typical African American household. This seems more catered to Caucasians.” (Participant # 04)
“If this is geared for an African American breast cancer survivor, most of the people… should represent us.” (Participant # 09)

Intervention topics suggested by BBCS

Anxiety and stress management
“Sometimes there’s nothing happening in my life and I just get anxiety. I mean, should I start humming or do yoga? Are there other techniques prior to going to bed to slow my mind down and make me unwind besides turning off the TV and phone?” (Participant # 14)
Sexual intimacy
“I actually know I can’t have sexual intercourse with my husband, because it rejuvenates me. It puts him to sleep and wakes me up…So that definitely could be an issue for people.” (Participant # 09)
Faith and religion
“The videos or maybe even having links or suggestions for meditation. Like something that helps relax a person…I do believe in prayer, so that helps a lot. I have a prayer session every night before I go to bed and when I wake up in the morning…It takes a lot of pressure off me when I pray to God; give him all my problems and I know he’ll work them out.” (Participant # 06)
Medication interference with sleep
“I feel that someone needs to analyze the medicines that we’re on to make sure that that’s not what’s keeping us awake at night…If we’re on a combination of medicines, and the pamphlet that comes with it says ‘will cause insomnia.’ Not all people will read that…so they could be thinking that they’re struggling…personally, but it could actually be a medical reason.” (Participant # 09)

Barriers to high quality sleep	Cancer worry “I think people don’t realize how, after having cancer, how stressful or how stressed you can be about worrying if it’s going to come back.”(Participant # 02) Personal responsibilities “Sometimes when there’s a crisis or some things that are going on, it needs to be taken care of… a lot of people do look up to me… That can be something on my mind before I go to sleep.”(Participant # 05)
Psychosocial impacts of sleep disturbance	Decreased energy during the day “I already had sleep issues before I had cancer. But after… it’s worse. I’m always tired… I just feel like, even though you beat cancer, a good thing, like what did I really beat? I beat cancer to feel sick.”(Participant # 13) Lower productivity “I do get up early in the morning, and if I don’t sleep well, then I’m really sluggish and I’m not really that productive during the day.” (Participant # 05) Psychological distress “My anxiety’s kicking because I’d be tired, and every little thing agitates me… I tend to get anxious a lot and I get on people’s nerves because I’m tired.”(Participant # 14)
Commonly used strategies to improve sleep	Nightly routines with electronics “Some nights I turn on old TV shows that I’ve already watched…and I’m asleep, just like that.”(Participant # 14) “I just have to have something like that to make me fall asleep…Some background noise. No music or anything. Just something talking. And I have the radio right by my bed.”(Participant # 06) Sleep environment “I try to make sure that the house is cool so I can rest comfortably.” “I try to have the house cool; very cool. Maybe around 66 [degrees], and that seems to help.”(Participant # 04) Staying active “Those are, up and down, tiring work… I was working in a preschool. So, you know I deal with the children a lot, back and forth on the playground. So, by the time you get home, and you do your little cooking and laundry and whatever, you’re ready for bed around 9:30-10 pm. You get a good rest. And so when I wake up, I’m fresh and busted with energy when I get up the next morning.” (Participant # 11)
Feedback on an existing mHealth CBT-I intervention	Sleep hygiene and behaviors “I think the main thing… would be to identify the cause of not having a good sleep hygiene program. That would be number one…I like the fact that they give you a lot of information about potential problems you may be having, and it gives you the opportunity to evaluate yourself and see where you fit in.” (Participant # 05) Sleep tracking “This type of information can be used by doctors, like my cardiologist is asking me how I’m doing with my sleep. My therapist asking me, how my sleep is based on my anxiety. So it would be really quick and easy to pull this up and say, ‘The past, you know, three months I’ve had this poor sleep.” (Participant # 09) Smartphone preference over computer “If it’s an app or it’s on my phone…then I’m going to be a little more engaged.” (Participant # 09) “More frequently because the other program that I’m using for weight loss is an app that I use, and I look at that every day.” (Participant # 05) Diverse representation “From what I was able to see…it just looks not like a typical African American household. This seems more catered to Caucasians.” (Participant # 04) “If this is geared for an African American breast cancer survivor, most of the people… should represent us.” (Participant # 09)
Intervention topics suggested by BBCS	Anxiety and stress management “Sometimes there’s nothing happening in my life and I just get anxiety. I mean, should I start humming or do yoga? Are there other techniques prior to going to bed to slow my mind down and make me unwind besides turning off the TV and phone?” (Participant # 14) Sexual intimacy “I actually know I can’t have sexual intercourse with my husband, because it rejuvenates me. It puts him to sleep and wakes me up…So that definitely could be an issue for people.” (Participant # 09) Faith and religion “The videos or maybe even having links or suggestions for meditation. Like something that helps relax a person…I do believe in prayer, so that helps a lot. I have a prayer session every night before I go to bed and when I wake up in the morning…It takes a lot of pressure off me when I pray to God; give him all my problems and I know he’ll work them out.” (Participant # 06) Medication interference with sleep “I feel that someone needs to analyze the medicines that we’re on to make sure that that’s not what’s keeping us awake at night…If we’re on a combination of medicines, and the pamphlet that comes with it says ‘will cause insomnia.’ Not all people will read that…so they could be thinking that they’re struggling…personally, but it could actually be a medical reason.” (Participant # 09)

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