Insomnia disorder is the most common sleep–wake disorder, defined by persistent difficulty initiating or maintaining sleep or experiencing early morning awakenings despite adequate opportunity for sleep, accompanied by clinically significant daytime impairment (1, 2). Diagnostic guidelines specify that these symptoms must occur at least three nights per week and persist for at least 3 months to confirm a diagnosis (1, 3). Its prevalence increases with age (1), posing a substantial public health challenge. Among adults aged ≥60 years, the prevalence of clinically diagnosed insomnia disorder ranges from 12 to 20% (2), compared to 6–10% in the general population (1). This elevated risk is closely associated with age-related physiological changes, multimorbidity, decreased mobility, retirement, and reduced social interaction (2).

The consequences of insomnia disorder extend far beyond nighttime sleep disturbance, affecting multiple health domains. Evidence indicates that insomnia disorder is a significant risk factor for hypertension, diabetes, obesity, and cardiovascular disease (4–6), as well as mood disorders such as depression and anxiety (7, 8). A meta-analysis links it to an increased risk of cognitive decline and dementia (9), while other studies associate it with falls (10, 11), frailty (12), reduced quality of life (13), and increased healthcare utilization and costs (14). Addressing insomnia in older adults is therefore essential to promote healthy aging and reduce societal disease burden.

Compared with insomnia disorder, insomnia symptoms—frequent difficulty falling or staying asleep without meeting full diagnostic criteria—are even more widespread. Globally, these symptoms affect 30–48% of individuals aged ≥60 years (2). In China, prevalence varies by measurement tool and setting. For example, a study showed that 33.9% of Chinese community-dwelling adults aged≥60 years had insomnia symptoms, measured by the Pittsburgh Sleep Quality Index (12). The prevalence of insomnia symptoms was 45.7% among rural Chinese older adults aged 60 years and above, measured by the Insomnia Severity Index (ISI) (15). These symptoms may persist for months or years, substantially increasing health risks even without a formal diagnosis. For instance, a longitudinal cohort study examined the trajectories of insomnia symptoms over 12 months during a time of stress and uncertainty and found that insomnia symptoms demonstrated a high persistence rate of 54% over time; Only 10.05% of participants with insomnia symptoms at baseline remitted over 12 months (16). These findings underscore the critical need for timely management of insomnia symptoms, not just insomnia disorder.

Currently, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia across all age groups, while pharmacological therapies remain widely used (17, 18). However, both approaches face major challenges in older adults. Although CBT-I is the gold standard, its clinical uptake is very low, ranging from 1 to 29% (19). In China, its promotion is hindered by limited accessibility and acceptability: a severe shortage of qualified therapists (especially in primary care), cultural stigma toward psychological treatment, high costs, geographic disparities, and an underdeveloped mental health service system (20, 21). Current hypnotics (Z-drugs, benzodiazepines, low-dose doxepin, suvorexant) carry notable risks in older adults; thus, short-term or intermittent use is advised (22). Ramelteon may offer safer sleep-onset benefits but has limited efficacy for sleep maintenance, while melatonin is relatively safe but lacks robust safety data in older populations (22, 23). Additionally, many older adults perceive insomnia as a “normal” part of aging and avoid professional care; only 2.1% of adults with insomnia symptoms sought sleep-related healthcare in the past year (24). These structural and perceptual barriers highlight an urgent need for alternative, culturally acceptable, and scalable solutions, particularly in community settings.

Traditional Chinese Medicine (TCM) techniques, grounded in the principles of yin-yang balance, five elements, and holistic regulation, offer promising options for managing insomnia symptoms, especially among older adults in community settings (25, 26). Common techniques—such as acupuncture, tuina, moxibustion, auricular acupressure, and needle embedding—are generally safe, low-cost, easy to administer, and culturally appropriate (27). Randomized controlled trials and systematic reviews have provided preliminary evidence supporting their clinical effectiveness in improving sleep quality (25–30). However, existing research has largely focused on efficacy under controlled conditions, with little attention to real-world implementation. In particular, little is known about how older adults in community settings actually use different TCM techniques, how they perceive the effectiveness of TCM techniques and their service experience, and what factors affect their use. Moreover, previous studies have rarely applied theoretical frameworks to systematically explain TCM utilization behaviors, limiting the interpretability and transferability of findings across settings.

To address these gaps, this study aimed to (1) describe the patterns of TCM technique use and users’ perceived satisfaction and effectiveness among older adults with insomnia symptoms, and (2) explore the associations between TCM technique use and a range of factors, as conceptualized by the Andersen Behavioral Model (ABM) —a widely applied framework for explaining healthcare utilization based on predisposing, enabling, and need factors (31). Predisposing factors reflect an individual’s tendency to use healthcare services and include demographics, social structure, and health beliefs; Enabling factors refer to resources and conditions that facilitate or hinder access, such as personal, family, and community resources; Need factors represent the immediate reasons for service use, including perceived and actual health status (31). In this study, 13 potential associated factors were examined: eight predisposing factors (sex, age, marital status, education level, pre-retirement occupation, place of residence, awareness of TCM techniques, and attitude toward TCM techniques), four enabling factors (monthly personal income, type of medical insurance, availability of TCM medical institutions within 5 km, and having relatives or friends working in TCM-related industries), and one need factor (insomnia severity).

By addressing these gaps, this study contributes to existing literature in several ways. First, it provides real-world evidence on utilization and user evaluation of TCM techniques for insomnia symptoms in community settings, where most older adults actually seek care. Second, by applying the ABM, this study offers a theoretically grounded framework for understanding TCM utilization behaviors, thereby facilitating interpretation of findings and enhancing their relevance to other community and primary care contexts. Third, by focusing on older adults with insomnia symptoms rather than clinically diagnosed insomnia, the study captures an often overlooked but high-risk population, offering insights that may inform the design of scalable, culturally appropriate, community-based interventions to support healthy aging.

This exploratory study provides initial real-world evidence on the use of TCM techniques for managing insomnia symptoms among community-dwelling older adults in China. We found that 51.1% of participants reported using at least one TCM technique, with tuina, moxibustion, needle embedding, and acupuncture being the most frequently used methods. Overall satisfaction with TCM services was generally high across domains such as safety and professionalism, yet fewer participants reported being “very satisfied.” Four associated factors of TCM use were identified based on the ABM: pre-retirement occupation and awareness of TCM techniques (predisposing); having relatives or friends working in TCM-related industries (enabling), and insomnia severity (need).

The prevalence of TCM technique use among older adults with insomnia symptoms in this study (51.1%) was substantially higher than the 17.7% reported in a previous study on TCM preventive service use among older adults (36). This discrepancy may be primarily attributed to differences in health needs: prior research focused on preventive care among individuals without acute health concerns, whereas our study targeted those with existing insomnia symptoms, likely increasing perceived need and motivation for service utilization. Additionally, participants were recruited from community activity centers, parks, or residences, which may underrepresent individuals who are less socially active or have more severe mobility limitations. Therefore, the observed usage rate of 51.1% should be interpreted with caution and needs verification in future studies employing probability sampling designs. When compared with the reported clinical uptake of CBT-I (1–29%) (19), TCM techniques use was significantly higher, underscoring their cultural acceptability and potential as community-based strategies for managing insomnia symptoms.

Regarding specific techniques, tuina (71.1%) and moxibustion (69.8%) were most frequently used, followed by needle embedding (59.1%) and acupuncture (58.5%), while auricular acupressure had the lowest uptake (39.6%). Notably, despite strong evidence supporting acupuncture and auricular acupressure for insomnia symptoms (27, 29), their real-world utilization was relatively low. Possible reasons include the minimally invasive nature of acupuncture, which may cause pain or fear of adverse events, and practical limitations of auricular acupressure such as discomfort, adhesive instability, and unfamiliarity among older adults. These findings highlight the gap between evidence and real-world implementation and suggest the need for strategies such as simplified application protocols, enhanced user education, and material improvements to enhance uptake.

Despite relatively high uptake, only 20.1% of participants reported being “very satisfied,” and just 22.6% perceived the interventions as highly effective in relieving insomnia symptoms. This pattern suggests that while TCM techniques were generally acceptable and positively received in community settings, their perceived benefits or service experience rarely reached a level of strong positive evaluation among most users. Such attenuation in satisfaction intensity may reflect real-world implementation factors. Although TCM techniques are increasingly guided by evidence-based principles (43), variability in practitioner training, treatment fidelity, and service delivery settings may limit the consistency of therapeutic effects. In this study, services were delivered across heterogeneous settings, including private clinics, wellness centers, community health service centers, and home-based care. Moreover, more than 60% of participants reported only occasional use or use once or twice per month, which may be insufficient to achieve optimal or sustained symptom improvement. Given the cross-sectional design, it is not possible to determine whether the relatively low proportion of “very satisfied” responses primarily reflects limitations in implementation quality or misalignment between user expectations and achievable treatment effects. Nevertheless, these findings underscore the importance of strengthening implementation quality and patient education to enhance both satisfaction intensity and perceived effectiveness of community-based TCM services.

Predisposing factors such as occupation and awareness significantly influenced TCM technique utilization. Participants who were former enterprise employees or workers were more likely than farmers to use TCM techniques, possibly reflecting socioeconomic differences, higher health literacy, and greater exposure to health information. In contrast, farmers may be more likely to perceive insomnia symptoms as a “normal” part of aging and therefore pay less attention to seeking treatment, supported by evidence showing lower sleep-related healthcare utilization in rural adults (any insomnia symptoms: adjusted OR = 0.45, p < 0.001; insomnia disorder: adjusted OR = 0.41, p < 0.001) (24). Awareness of TCM techniques emerged as the strongest determinant, consistent with previous findings (36), underscoring the critical role of health education and targeted outreach in improving uptake, particularly in populations with low awareness.

Among enabling factors, having relatives or friends engaged in TCM-related industries may facilitate utilization by providing social support or enhancing TCM health literacy (38), thereby increasing awareness and perceived accessibility of TCM techniques. However, our study did not empirically test these pathways, underscoring the need for future research to clarify the deeper mechanisms. These results highlight the potential of TCM universities to strengthen community engagement and expand outreach programs, which may serve as effective strategies to increase access and reduce disparities in TCM utilization. In addition, community-level interventions, such as integrating TCM services into primary care and leveraging social networks, could further enhance equitable access.

The need factor, insomnia severity, positively predicted TCM use, indicating that perceived or actual health need remains a powerful motivator for seeking care. This aligns with Andersen’s proposition that need factors are the most immediate cause of health service utilization (31) and is consistent with prior evidence showing that symptom burden drives demand for complementary therapies in older adults (24, 36).

Although the observed associations between TCM awareness, insomnia severity, and TCM utilization may appear conceptually intuitive, empirically demonstrating these relationships in community-dwelling older adults remains important. Such evidence supports the applicability of the ABM in the context of TCM use for insomnia and provides a theory-informed basis for designing targeted community interventions. Quantifying these associations also helps identify modifiable targets, such as awareness and perceived need, that can be addressed through health education and service delivery strategies.

This exploratory study provides preliminary evidence on the real-world use of TCM techniques for insomnia symptoms among older adults in China. More than half of participants reported using at least one TCM technique, yet only a minority rated the TCM services as “very satisfied” or “highly effective,” suggesting a gap between utilization and expected outcomes. Four associated factors of TCM use were identified under the ABM: pre-retirement occupation and awareness of TCM techniques (predisposing), having relatives or friends working in TCM-related industries (enabling), and insomnia severity (need). These findings may inform the design of culturally sensitive interventions to manage insomnia symptoms among community-dwelling older adults in similar contexts. Future research should continue to assess real-world implementation quality, determinants of perceived effectiveness, and strategies to improve both utilization and user satisfaction.