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Published: 7 March 2025
Citation: Afzal, M.; Huang, C.-L.;
Huang, S.-H.; Li, C.-I.; Liao, W.-C.;
Yang, J.-C.; Ma, W.-L. Pilot Study on
the Effect of Cannabidiol-Coated
Fabric for Pillow Covers Improves the
Sleep Quality of Shift Nurses.
Healthcare 2025,13, 585. https://
doi.org/10.3390/healthcare13060585
Copyright: © 2025 by the authors.
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This article is an open access article
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Article
Pilot Study on the Effect of Cannabidiol-Coated Fabric for Pillow
Covers Improves the Sleep Quality of Shift Nurses
Mashita Afzal 1, †, Chieh-Liang Huang 2 ,† , Shih-Hao Huang 3, Chia-Ing Li 1,4, Wen-Chun Liao 5,
Juan-Cheng Yang 4,6,*,‡ and Wen-Lung Ma 1, 4, *,‡
1Graduate Institute of Biomedical Sciences, School of Medicine, China Medical University,
Taichung 40403, Taiwan; mashitaafzal@gmail.com (M.A.); 006446@tool.caaumed.org.tw (C.-I.L.)
2TsaoTun Psychiatric Center, Caotun Township, Nantou 54249, Taiwan; psyche.hcl@gmail.com
3SONG BEAM International Co., Ltd., Taichung 40650, Taiwan; louis@songbeam.com.tw
4Department of Medical Research, China Medical University Hospital, Taichung 40403, Taiwan
5School of Nursing, China Medical University, Taichung 40604, Taiwan; iwcl@mail.cmu.edu.tw
6Graduate Institute of Integrated Medicine, School of Chinese Medicine, China Medical University,
Taichung 40403, Taiwan
*Correspondence: qq9113054@gmail.com (J.-C.Y.); maverick@mail.cmu.edu.tw (W.-L.M.)
†Equal contribution as first authors.
‡Equal contribution as corresponding authors.
Abstract: Background: Sleep difficulty is common in the current society. Poor sleep
has a significant influence on health, social interactions and even mortality; therefore,
maintaining good sleep is of prime importance. Cannabidiol (CBD), a cannabis-derived
compound, is known for its medical significance with many positive effects in humans,
including decreasing anxiety and improving sleep for those with sleep disorders. Objective:
However, whether CBD skin absorption results in similar effects is unknown. Therefore,
examining CBD-coated fabric as a pillow cover to improve sleep quality in duty shift
nurses is the purpose of this paper. Methods: This study recruited 55 duty shift nurses
as participants to evaluate sleep patterns and quality using the Pittsburgh Sleep Quality
Index (PSQI) and a consumer-grade tracker (Fitbit Charge 3). Data were collected over
three phases: a one-week baseline period, a two-week intervention period using a CBD-
coated pillow cover and a one-week follow-up period, referred to as the post-intervention
phase, during which the use of CBD-coated pillow cover was continued. Results: Of
the
55 participants,
10 were men (18.2%) and 45 were women (81.8%). At baseline, all
participants exhibited poor sleep quality (PSQI
≥
5). However, after three weeks of using
CBD-coated pillow covers, subjective sleep quality significantly improved, with 7.3%
of participants achieving PSQI scores <5. Additionally, slight changes in sleep patterns
were observed, with increases in both light sleep and deep sleep durations. Light sleep
duration increased from a baseline of 196.21
±
65.28 to 206.57
±
59.15 min two weeks after
intervention (p= 0.337). Similarly, deep sleep duration showed a modest increase from
61.97 ±21.01 min
to 64.35
±
22.19 min (p= 0.288). Furthermore, a significant reduction
in anxiety levels was reported (p< 0.005). Conclusions: Using a CBD-coated pillow
cover was found to enhance sleep duration in healthy individuals experiencing poor sleep.
Consequently, for adults struggling with sleep difficulties, incorporating a CBD-coated
pillow cover may serve as an effective aid in improving sleep quality.
Keywords: cannabidiol (CBD); pillowcase; non-rapid eye movement (NREM); sleep
quality; nurses
Healthcare 2025,13, 585 https://doi.org/10.3390/healthcare13060585
Healthcare 2025,13, 585 2 of 13
1. Introduction
Poor sleep affects up to one-third of the global population and is considered a public
health epidemic [
1
]. Various causes, such as strenuous workloads for professional achieve-
ment, may contribute to poor sleep, which has a high impact on health, family life and even
mortality [
2
]. The maintenance of optimal sleep quality is an important issue, especially for
individuals working rotating shifts or permanent night shifts, who experience transient or
chronic sleep disturbance or even sleep deprivation [
3
]. Nurses working in rotating shifts
or permanent night shifts have reported transient or chronic sleep disorders [
4
]. In night
shift workers, sleep is usually initiated 1 h (SD = 30–60 min) after the termination of the
shift [
5
,
6
]. Sleep is reduced by 2–4 h, with longer sleep latency and sleep fragmentation [
7
,
8
].
After a night shift, sleep loss mainly involves stage 2 and rapid eye movement (REM) sleep,
whereas slow-wave sleep (SWS) stages 3 and 4 remain unaffected [
9
]. Day sleep after
night work is short; hence, a late afternoon nap of >1 h before the subsequent night shift
is added [
10
]. Night work is also characterized by increased subjective, behavioral and
physiological sleepiness [
11
,
12
]. The effects are particularly severe in the early morning and
often involve incidents of involuntary sleep. It usually takes two nights of sleep periods to
recover from the last night shift back to the normal low sleepiness level. The increased sleep
deprivation may be associated with an increased risk of accidents and errors and a feeling of
fatigue [
13
,
14
]. In the morning shift, the sleep pattern before a shift appears to be even more
disturbed compared to the night shift. EEG studies show that sleep duration is reduced by
2–4 h, with mainly stage 2 and REM being affected, whereas slow-wave sleep (SWS) stages
3 and 4 remain unaffected. Subjective complaints about morning shifts include difficulty in
awakening, non-spontaneous awakening and a feeling of not being refreshed by sleep [7].
The ability to tolerate and adjust to shift work varies significantly between individuals,
being influenced by factors such as chronotype (preferred time of activity), health status,
sleep habits and social characteristics [
14
]. Shift system features, including the length of
the shift, speed and direction of rotation and time of changeover, affect the adaptation
to shift work. Some studies suggest that a schedule consisting of four consecutive night
shifts, a clockwise rotation (morning–afternoon–night) and an end time around 07:00 may
optimize performance and minimize sleep disruptions. Usually, 1–2 days are needed to
adjust to a change in the shift, with a longer interval being better. Previous studies showed
that employees preferred a 21-day schedule of fixed shifts, which resulted in better health,
morale and performance and lower personnel turnover compared to the company aver-
age [
15
,
16
]. This type of fixed rotating shift over one month is adopted by most hospital
shift systems. Good shift-work adaptors usually have better daytime sleep before a night
shift, fewer social and family disruptions and greater alertness during the night shift than
poor shift-work adaptors [
17
]. To enhance shift-work adaptation, countermeasures are still
needed at work and in activity–rest schedules [
14
]. In addition to calmness before and
during the resting time, which is necessary for better sleep-in shift nurses, it is crucial to
address the challenges faced by nurses working in such conditions. This study aims to
explore alternative approaches to mitigating the effects of sleep deprivation and improving
recovery, which is of paramount importance in promoting the health and well-being of
shift-working nurses.
Cannabidiol (CBD) is a biologically active compound found in the Cannabis plant. CBD
has been known previously to reduce pain and alleviate a range of neurological conditions,
including severe seizures, depression, anxiety and neuroprotection. In a crossover trial,
CBD was found to extend sleep duration [
18
,
19
]. Several studies have highlighted that
CBD may have dose-dependent side effects and potential addiction-related risks when
used orally. However, controlled use of CBD appears to be challenging but generally well
tolerated, with only a few patients reporting mild side effects, such as fatigue, mild sedation,
Healthcare 2025,13, 585 3 of 13
increased inappropriate sexual behavior and dry eyes, which may be linked to dosage. A
clinical trial (NCT02548559) demonstrated the efficacy of a 4-week treatment with CBD,
showing favorable results with limited side effects [18,20,21]. Several studies suggest that
CBD holds therapeutic potential for managing anxiety, insomnia and epilepsy. However,
the optimal oral use of CBD remains a challenge and requires further investigation to
better understand its safety and therapeutic potential; as an alternative approach to address
this challenge, we examined the effects of a pillow cover made with CBD-coated fabric
on sleep in nurses undertaking shift work. By offering an alternative to traditional CBD
consumption methods, such as oral ingestion or vaping, the CBD-coated pillow may
minimize potential side effects while still delivering therapeutic benefits. This innovative
approach could provide a safer and more effective means of utilizing CBD to improve sleep
quality, particularly for individuals with insomnia or those exposed to shift-work-related
sleep disturbances.
2. Materials and Methods
2.1. Study Design and Procedure
This pilot study recruited 55 members of medical staff from hospitals affiliated with
the China Medical University (Figure 1). The participants were asked to wear a consumer
tracker, a Fitbit active sleep watch (Fitbit Charge 3), on their wrists to record active sleep
patterns and sleep quality during a baseline in the first week while using a pillow with a
CBD-coated cover in the second week, during follow-up for one week and finally during a
post-test at the end of the overall study (week 4). The study period was a total of four weeks.
Participants maintained their habitual activity and sleep schedule. Sleep quality (both
subjective and objective) was assessed using the Pittsburgh Sleep Quality Index (PSQI) and
Fitbit Charge 3. In addition, the Epworth Sleepiness Scale (ESS) and Hospital Anxiety and
Depression Scale (HADS) were applied to rate related changes, such as pre- or baseline test
and post-intervention drowsiness and mood (Figures 2and 3).
Healthcare 2025, 13, x FOR PEER REVIEW 3 of 13
linked to dosage. A clinical trial (NCT02548559) demonstrated the efficacy of a 4-week
treatment with CBD, showing favorable results with limited side effects [18,20,21]. Several
studies suggest that CBD holds therapeutic potential for managing anxiety, insomnia and
epilepsy. However, the optimal oral use of CBD remains a challenge and requires further
investigation to beer understand its safety and therapeutic potential; as an alternative
approach to address this challenge, we examined the effects of a pillow cover made with
CBD-coated fabric on sleep in nurses undertaking shift work. By offering an alternative to
traditional CBD consumption methods, such as oral ingestion or vaping, the CBD-coated
pillow may minimize potential side effects while still delivering therapeutic benefits. This
innovative approach could provide a safer and more effective means of utilizing CBD to
improve sleep quality, particularly for individuals with insomnia or those exposed to
shift-work-related sleep disturbances.
2. Materials and Methods
2.1. Study Design and Procedure
This pilot study recruited 55 members of medical staff from hospitals affiliated with
the China Medical University (Figure 1). The participants were asked to wear a consumer
tracker, a Fitbit active sleep watch (Fitbit Charge 3), on their wrists to record active sleep
paerns and sleep quality during a baseline in the first week while using a pillow with a
CBD-coated cover in the second week, during follow-up for one week and finally during
a post-test at the end of the overall study (week 4). The study period was a total of four
weeks. Participants maintained their habitual activity and sleep schedule. Sleep quality
(both subjective and objective) was assessed using the Pisburgh Sleep Quality Index
(PSQI) and Fitbit Charge 3. In addition, the Epworth Sleepiness Scale (ESS) and Hospital
Anxiety and Depression Scale (HADS) were applied to rate related changes, such as pre-
or baseline test and post-intervention drowsiness and mood (Figures 2 and 3).
Figure 1. Flowchart showing the inclusion and exclusion criteria.
Figure 1. Flowchart showing the inclusion and exclusion criteria.
Healthcare 2025,13, 585 4 of 13
Figure 2. Flowchart illustrating the study design of CBD-coated pillow cover.
Healthcare 2025, 13, x FOR PEER REVIEW 4 of 13
Figure 2. Flowchart illustrating the study design of CBD-coated pillow cover.
Figure 3. Flowchart showing the methodology of CBD-coated pillow intervention.
2.2. Sample Size
Participants were recruited from the China Medical University Hospital, located in
Taichung City. The sample of 55 subjects included 45 women (81.8%) and 10 men (18.2).
Participants aged 21~49 with poor sleep quality (PSQI score >5) were recruited (Figure 1).
Most participants were aged between 20~ and 40 years, with groups aged 21–30 years
(49.1%) and 31–40 years (36.4%) comprising the majority. The work paerns of the subjects
in the past three months were mainly fixed day shifts (58.2%), with 12 individuals (21.8%)
working rotating shifts. During the second phase, participants used a pillow with a CBD-
coated cover for approximately two weeks, continuing one week to the post-experiment
period (Figures 2 and 3).
Figure 3. Flowchart showing the methodology of CBD-coated pillow intervention.
2.2. Sample Size
Participants were recruited from the China Medical University Hospital, located in
Taichung City. The sample of 55 subjects included 45 women (81.8%) and 10 men (18.2).
Participants aged 21~49 with poor sleep quality (PSQI score >5) were recruited (Figure 1).
Most participants were aged between 20~ and 40 years, with groups aged 21–30 years
(49.1%) and 31–40 years (36.4%) comprising the majority. The work patterns of the subjects
in the past three months were mainly fixed day shifts (58.2%), with 12 individuals (21.8%)
working rotating shifts. During the second phase, participants used a pillow with a CBD-
coated cover for approximately two weeks, continuing one week to the post-experiment
period (Figures 2and 3).
Healthcare 2025,13, 585 5 of 13
2.3. Measures
Pre- and post-test sleep quality was measured using the PSQI. In addition, participants
wore a Fitbit Charge 3 bracelet for 28 days to capture the total sleep time, light sleep per
day, deep sleep, REM, wakefulness after sleep onset (WASO) and wake-up time and to
calculate sleep efficiency and sleep distribution percentages (Figure 2). The total score of
the PSQI is 0–21 points; the higher the score, the worse the sleep quality, with a cut-off of
≥
5 points indicating poor sleep quality. Data on demographic parameters, including age,
sex, education, marital status and work, the use of hypnotics and exercise habits, were also
recorded. Sleep patterns and sleep quality were assessed.
2.3.1. Sleep
Sleep patterns were measured using Fitbit Charge 3. Participants wore the tracker for
four weeks continuously, except when taking a shower (Figure 2). Data on sleep patterns
included the number of minutes and percentage of total sleep time, awake time, light
sleep, deep sleep, REM sleep and WASO. Fitbit Charge 3 has been shown to be accurate in
measuring sleep [22] and mobility [23].
2.3.2. Sleep Quality
The PSQI was used to assess the habitual sleep of adults at baseline and after inter-
vention over a two-week interval in the fourth week (Figure 2). It consists of nineteen
self-rated questions that yield seven components: subjective sleep quality, sleep latency,
sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication
and daytime dysfunction. A global PSQI score is obtained by summing the scores for
the components, with a range of 0–21. A higher score indicates worse sleep quality. A
post hoc score of
≥
5 is the cut-off point to discriminate between a “good” sleeper and a
“poor” sleeper. The overall Cronbach’s alpha, the global PSQI for internal consistency and
reliability, ranged from 0.77 to 0.83 [
24
,
25
]. The sensitivity and specificity of the PSQI was
80–89.6% and 86.5–86.6%, respectively [24–26].
2.4. Data Analysis
To assess the effectiveness of the CBD-coated pillow cover in sleep quality, inferential
statistics were employed. First, the Shapiro–Wilk test was used to test the normality of each
variable. Descriptive statistics were then calculated and presented as
means ±standard
de-
viations, medians, interquartile ranges, frequencies, percentages. Based on the distribution
of the data, appropriate inferential statistics were selected. McNemar change tests were
used for categorical data to compare sleep quality before and after pillow cover use. For
normally distributed data, paired-sample t-tests and time series analysis were conducted.
For non-normally distributed data, Wilcoxon signed-rank tests were utilized. Furthermore,
to explore the factors associated with changes in sleep outcomes following the intervention,
stepwise multiple regression analyses were conducted. All tests were two-sided, with a
significance level of p< 0.05.
3. Results
The sample of 55 subjects included 45 (81.8%) women. The participants’ ages were
mostly in the range between 20 and 40 years (85.5%). The work pattern of the participants
in the previous three months was mainly fixed day shifts (58.2%), with 12 individuals
(21.8%) working rotating shifts. Ten participants took hypnotics, and fifteen had an exercise
habit (Table 1). The sleep quality of all participants was poor (PSQI
≥
5), with a median
score of 9.0 (interquartile range: 6.0, 12.0) at baseline (Table 2). The global PSQI decreased to
7.0 (6.0, 9.0)
two weeks after intervention (Table 2). Four participants showed improvement
Healthcare 2025,13, 585 6 of 13
in sleep (p< 0.1) (Table 3). They slept about 6 h a night, with 86.3 sleep efficiency and 48.1%
of the sleep being light sleep and 15.8% deep sleep (Table 4). The total study period was
28 days,
which consisted of pre-test in the first week, using a pillow with a CBD-coated
cover in the second week, a follow-up for one week and finally a post-test at the end of the
overall study (week 4). The sleep quality in four participants improved to 7.3% (Table 3).
The Subjective Sleep Quality score remained consistent in terms of the median at 1.0 (1.0,
2.0) between baseline and post-intervention, as measured by PSQI. Changes in scores for
the drowsiness and HADS subscales for anxiety and depression were analyzed using paired
t-tests (Table 2). The CBD intervention resulted in statistically significant improvements
across all measures (all p< 0.05).
Table 1. Demographic characteristics of the subjects (N = 55; missing values: 0).
N %
Gender
Female 45 81.8
Male 10 18.2
Age (years)
21–30 27 49.1
31–40 20 36.4
≥40 8 14.5
Marital status
Unmarried 41 74.5
Married 14 25.5
Workplace
Surgical ward 6 10.9
Internal medicine ward 11 20.0
Acute/intensive care unit 8 14.6
Other 30 54.5
Work style in the past one year
Fixed day shifts 30 54.5
Fixed evening shift 5 9.1
Fixed night shift 2 3.6
Rotating shift 18 32.7
Work style in the last three months
Fixed day shifts 32 58.2
Fixed evening shift 7 12.7
Fixed night shift 4 7.3
Rotating shift 12 21.8
Taking adjunct sleeping medications
No 45 81.8
Yes 10 18.2
Exercise
No 40 72.8
Yes 15 27.3
Smoking habits
No 53 96.3
Yes 2 3.6
Table 2. The total score at baseline and two weeks after intervention (N = 55; missing values: 0).
Measurements Baseline Two Weeks After Intervention s/t p
PSQI
Global score 19.0 (6.0, 12.0) 7.0 (6.0, 9.0) 382 <0.001
Subjective sleep quality 21.0 (1.0, 2.0) 1.0 (1.0, 2.0) 315.5 <0.001
Healthcare 2025,13, 585 7 of 13
Table 2. Cont.
Measurements Baseline Two Weeks After Intervention s/t p
Sleep latency 33.0 (2.0, 5.0) 2.0 (1.0, 3.0) 315.5 <0.001
Sleep hours (hours) 6.5 (5.5, 6.5) 6.5 (5.5, 6.5) 315.5 <0.001
Sleep efficiency (%) 81.3 (73.7, 91.7) 81.3 (70.3, 87.5) 95.5 0.333
Sleep disturbance 410.0 (7.0, 13.0) 5.0 (3.0, 10.0) 421.5 <0.001
Sleeping pills were used 50.0 (0.0, 1.0) 0.0 (0.0, 0.0) 315.5 <0.001
Daytime dysfunction 62.0 (1.0, 3.0) 1.0 (0.0, 2.0) 314 <0.001
ESS 8.18 ±3.78 5.76 ±3.80 4.42 <0.001
HADS
Anxiety 10.50 ±4.43 7.42 ±4.14 5.68 <0.001
Depression 7.62 ±3.71 6.38 ±4.34 3.11 0.003
Due to the skewed distribution of the PSQI global score and its component scores, data are presented as median
(first quartile, third quartile), and Wilcoxon signed-rank tests are reported. For the normally distributed ESS and
HADS scores, data are presented as mean
±
standard deviation, and paired t-tests are performed.
1
. The overall
total score represents the total score for PSQI, 0–21 points; the higher the score, the worse the sleep quality; if the
score is
≥
5 points, sleep quality is classified as poor.
2
. The subjective sleep quality score ranges from 0 to 3 points:
very good (0), fair (1), somewhat poor (2) and very poor (3).
3
. The total score for sleep latency ranges from 0 to
6 points
; the higher the score, the worse the sleep quality.
4
. The total score for sleep disturbance ranges from
0 to 27 points; the higher the score, the more factors that interfere with sleep, and the worse the sleep quality.
5. Sleeping
drug use scores range from 0 to 3: never (0), less than once a week (1), once or twice a week (2) and
more than three times a week (3).
6
. The total score for daytime dysfunction ranges from 0 to 6, with higher scores
indicating poor sleep quality, which in turn affects daytime life/activities.
Table 3. Sleep quality determined using the PSQI at baseline and two weeks after intervention.
Baseline Two Weeks After Intervention
Measurements n % n % x2p
Sleep quality (PSQI global score) 44.08 <0.001
Good (<5) 0 0.0 4 7.3
Poor (≥5) 55 100.0 51 92.7
Subjective sleep quality 10.93 0.091
Very good 1 1.8 4 7.3
Fair 27 49.1 31 56.4
Poor 17 30.9 19 34.5
Very poor 10 18.2 1 1.8
Sleep latency 15.20 0.019
<15 min 12 21.8 23 41.8
16–30 min 20 36.4 20 36.4
31–60 min 15 27.3 10 18.2
>60 min 8 14.5 2 3.6
Sleep hours 2.23 0.898
>7 h 7 12.7 5 9.1
6–6.9 h 27 49.1 24 43.6
5–5.9 h 18 32.7 22 40
<4.9 h 3 5.5 4 7.3
Sleep efficiency 5.79 0.447
>85% 24 43.6 17 30.9
75–84% 16 29.1 20 36.4
65–74% 8 14.5 12 21.8
<65% 7 12.7 6 10.9
Medication use 10.17 0.118
None 37 67.3 46 83.6
<1 time/week 9 16.4 4 7.3
1–2 times/week min 2 3.6 0 0
>3 times/week 7 12.7 5 9.1
Daytime dysfunction 12.67 0.049
None 7 12.7 16 29.1
<1 time/week 27 49.1 32 58.2
1–2 times/week 16 29.1 7 12.7
>3 times/week 5 9.1 0 0
Healthcare 2025,13, 585 8 of 13
Table 4. Sleep hours and sleep distribution at baseline and two weeks after intervention (Fitbit data).
Measurements
Baseline Two Weeks After
Intervention s/t p
Sleep hours
TST (min) 362.29 ±63.72 365.18 ±63.71 0.60 0.550
WASO (min) 60.1 (46.8, 76.5) 58.3 (46.0, 69.0) −178.5 0.085
REM (min) 75.22 ±26.9 75.69 ±27.2 0.41 0.686
LS (min) 196.21 ±65.28 206.57 ±59.15 0.97 0.337
DS (min) 61.97 ±21.01 64.35 ±22.19 1.07 0.288
Sleep
distribution
SE (%) 86.3 (83.7, 87.8) 86.8 (85.1, 87.9) 121.5 0.245
WASO (%) 13.7 (12.2, 16.3) 13.2 (12.1, 14.9) −157.5 0.130
REM (%) 17.33 ±5.66 17.48 ±5.14 0.52 0.607
LS (%) 48.1 (42.1, 54.6) 49.3 (45.4, 55.3) 223.5 0.030
DS (%) 15.8 (11.7, 17.9) 15.0 (12.2, 18.2) −58.5 0.578
Due to the skewed distribution of WASO (min), SE (%), WASO (%), LS (%) and DS (%), data are presented as
median (first quartile, third quartile), and Wilcoxon signed-rank tests are reported. For the remaining variables
with normal distributions, data are presented as mean
±
standard deviation, and paired t-tests are performed.
TST: total sleep time. WASO: wakefulness after sleep onset. REM: rapid eye movement sleep. LS: light sleep.
DS: deep sleep. SE: sleep efficiency.
3.1. Sleep Quality (Subjective)
The 55 participants had an average overall score of 9.0 for subjective sleep quality at
baseline. After three weeks of intervention, the overall sleep quality score decreased to
7.0 (p< 0.001; Table 2); the sleep quality of 100% of the participants was poor (PSQI
≥
5;
Table 3). The total number of sleep hours (minutes) at baseline 362.29
±
63.72 increased
to 365.18
±
63.71 two weeks after intervention, and participants had longer sleep latency
mostly due to the following reasons: inability to fall asleep within minutes; getting up to
use the toilet; not easy to fall asleep again after waking up in the middle of the night; and
the influence of a hot or cold environment. Table 3shows that three weeks after using the
CBD-coated pillow cover, subjective sleep quality (PSQI < 5) improved in four participants
(7.3%; X2= 10.93, p= 0.091).
3.2. Sleep Quality (Objective)
Table 4shows the CBD-coated pillow cover intervention from baseline (7 days) to
2 weeks
after intervention with CBD-coated pillow cover and with one week of follow-up,
for a total of 28 days. The results of statistical tests did not find a significant difference
in sleep structure time but found a difference in sleep structure distribution. There was
a slight increase in light sleep duration from baseline 196.21
±
65.28 to 206.57
±
59.15,
p= 0.337
after the intervention (Table 4). Deep sleep time increased slightly from 61.97 min
a night at baseline to 64.35 min a night during the intervention.
3.3. Mood and Lethargy
Table 2shows the ESS scores for the total 21 days of the intervention using the CBD-
coated pillow cover, from baseline (7 days) to two weeks of follow-up with CBD-coated pil-
low cover and one week after CBD intervention. The total scores for drowsiness and HADS
(depression and anxiety) were compared using a paired t-test. Compared to improved
sleep quality, the CBD intervention significantly reduced anxiety (p< 0.005). Reduced
anxiety levels may contribute to improved sleep quality, as anxiety often interferes with the
ability to fall asleep and maintain restful sleep. A reduction in depressive symptoms could
also support better sleep quality, as depression often impacts sleep patterns negatively
Healthcare 2025,13, 585 9 of 13
(e.g., difficulty initiating or maintaining sleep) [
27
], making the pillow an effective tool for
improving overall mental and sleep health.
3.4. Factors Influencing Intervention Efficacy
The impact of the intervention seemed to be related to whether the participants had
an exercise habit; if they had an exercise habit, the impact of the CBD intervention on their
sleep was objectively less insensitive, but if they did not have an exercise habit, it showed a
more obvious or negative effect on sleep quality. Of those without an exercise habit, the
overall objective sleep efficiency trend improved in 20 (36.4%) individuals, and the trend
worsened or did not change in 20 participants.
To elucidate the factors associated with post-intervention changes in sleep outcomes,
stepwise multiple regression analyses were performed. The dependent variables included
changes in the global Pittsburgh Sleep Quality Index (PSQI) score (
∆
PSQI), Hospital Anxiety
and Depression Scale (HADS), anxiety subscale score (
∆
HADS-A), HADS depression
subscale score (
∆
HADS-D) and light sleep percentage (
∆
LS%). The following potential
predictors were incorporated into the models: sex, age, marital status, work schedule
during the preceding year and three months, use of adjunctive sleep medications and
exercise habits. Notably, exercise habits did not emerge as a significant predictor in these
regression models.
We found significant predictors for
∆
PSQI,
∆
HADS-D and
∆
LS%, while no significant
predictors emerged for the change in anxiety score (
∆
HADS-A). Males were associated with
a significantly greater decrease in global PSQI score (
∆
PSQI = 2.23, p= 0.037), indicating
greater improvement in sleep quality compared to females. Males were associated with
a significantly greater decrease in HADS depression subscale score (
∆
HADS-D = 1.98,
p= 0.044
), indicating greater improvement in depression compared to females. Participants
working fixed night shifts in the past 3 months had a significantly greater decrease in global
PSQI scores compared to those working fixed day shifts (
β
= 2.98, p= 0.049). Being in the
31–40 age group was associated with a greater increase in light sleep percentage compared
to the 21–30 age group (
∆
LS% =
−
3.18, p=.044). Taking adjunct sleeping medications was
associated with a decrease in light sleep percentage (∆LS% = −3.55, p= 0.028).
4. Discussion
Sleep is a vital process, especially for shift workers such as nurses. CBD shows
promise for improving sleep quality, potentially through its interaction with the skin’s
endocannabinoid system (ECS), which facilitates absorption and localized therapeutic
effects [28].
Daytime sleep after night work is typically short, prompting the addition of late
afternoon naps before subsequent night shifts. [
29
]. Cannabidiol has been considered by
many studies to be safe for short-term use. It has a neuroprotective role in Alzheimer’s and
Parkinson’s diseases, anti-inflammatory and antioxidant properties, making it valuable
for treating various diseases [
30
,
31
]. Therefore, it has the potential to be an important
part of the treatment for insomnia patients. After three weeks of CBD-coated pillow
cover intervention, the global score (overall sleep quality) decreased from a median of
9.0 (6.0, 12.0) at baseline to 7.0 (6.0, 9.0) after intervention. A lower global score suggests
an improvement in sleep quality. The subjective sleep quality score remained consistent
in terms of the median at 1.0 (1.0, 2.0) between baseline and after intervention, which
indicated improvement in subjective sleep quality, albeit less pronounced. These observed
improvements may be partly attributed to the transdermal absorption of CBD, which allows
localized and systemic interactions with cannabinoid receptors, potentially influencing
relaxation and sleep patterns [
32
]. Three weeks after using a CBD-coated pillow cover,
Healthcare 2025,13, 585 10 of 13
four participants showed 7.3% improvement in sleep quality. However, in the case of
objective sleep quality, there was no significant difference in sleep structure over time,
but there was a slight increase in both light sleep and deep sleep duration after using the
CBD-coated pillow cover. In the case of mood and lethargy, the total scores for drowsiness
and mood (depression and anxiety) were measured over the course of the intervention.
CBD’s transdermal absorption through prolonged contact may facilitate localized anti-
inflammatory and anxiolytic effects, which could explain the reduction in anxiety and
mood improvements observed during the intervention [
33
]. Compared to improved sleep
quality, the CBD intervention significantly reduced anxiety (p< 0.005). Reduced anxiety
levels may contribute to improved sleep quality, as anxiety often interferes with the ability
to fall asleep and maintain restful sleep. A reduction in depressive symptoms could also
support better sleep quality, as depression often impacts sleep patterns negatively (e.g.,
difficulty initiating or maintaining sleep), making the pillow an effective tool for improving
overall mental and sleep health.
The participants were classified into two groups based on objective sleep trends: those
with an overall improvement in sleep trends and those with unchanged or deteriorated
trends. In the comparisons of the basic attributes of these two groups, gender, age, work
style and sleeping drug use, smoking and drinking histories did not show significant
differences (p> 0.05). Only exercise habits showed a significant difference (p= 0.03).
Specifically, 36.4% of the participants who did not have an exercise habit showed an overall
improvement in objective sleep efficiency trends after using a CBD-coated pillow cover,
while 63.6% showed either a worsened trend or no change. This suggests that the impacts
of the CBD intervention on sleep quality may be less pronounced for individuals with
an exercise habit, while those without an exercise habit may experience more significant
changes, either positive or negative, in sleep quality.
The CBD-coated pillow cover demonstrated improvements in sleep quality, mood and
anxiety, highlighting its potential as a non-invasive intervention for shift workers. Through
transdermal absorption, CBD may exert both localized and systemic effects, promoting
relaxation and enhancing sleep. Its therapeutic benefits may be particularly valuable for
individuals with sleep disturbances associated with stress or anxiety disorders. Addition-
ally, CBD interventions appear to be more effective in individuals who do not engage in
regular physical activity, as exercise itself serves as a natural regulator of sleep. However,
individual responses to CBD may vary due to differences in metabolism, skin absorption
and baseline sleep conditions, resulting in varying degrees of effectiveness. These findings
underscore the need for personalized dosing strategies and optimized delivery methods to
maximize therapeutic outcomes. Further research is essential to refine CBD-based sleep
interventions and tailor treatment approaches to specific patient populations.
Limitations
This study only tracked and measured the sleep status of individuals using a CBD-
coated pillow cover for two weeks; the follow-up effects still need to be tracked continually.
In addition, this study did not control for other factors that could affect sleep. It only
considered the normal work and rest time of the cases. However, its effects may vary based
on individual exercise habits. Further research is needed to explore the potential of CBD in
enhancing sleep quality. The small percentage of participants (7.3%) showing significant
improvement may suggest that a larger sample size would be needed to detect stronger
effects. A longer intervention period might be necessary to see more substantial changes in
subjective sleep quality.
Healthcare 2025,13, 585 11 of 13
5. Conclusions
The use of pillow covers coated with CBD enhanced the sleep duration of healthy
adults with poor sleep, leading to an increase in duration in the form of deep sleep from
baseline to two weeks after intervention. This study also found that the CBD intervention
significantly reduced anxiety (p< 0.005). Therefore, the findings regarding sleep quality,
including light sleep and deep sleep, especially the slight increase in light sleep duration,
cannot be extended to other cases of poor sleep quality.
Author Contributions: Conceptualization, J.-C.Y. and W.-L.M.; Data curation, M.A.; Formal analysis,
C.-I.L.; Methodology, S.-H.H. and W.-C.L.; Resources, S.-H.H. and W.-C.L.; Writing—Original draft,
M.A., C.-L.H., J.-C.Y. and W.-L.M.; Writing—Review and editing, S.-H.H., W.-C.L. and W.-L.M. All
authors have read and agreed to the published version of the manuscript.
Funding: This study was financially supported through the following grants: National Health and
Research Institutes grant: NHRI-EX109-10705BI and NHRI-EX113-11105BI; National Science and
Technology Council (NSTC) grant: 111-2314-B-468-012-MY3, 112-2320-B-039-005,
111-2622-B-039-004,
112-2622-B-039-010,
112-2314-B-894-001, 113-2320-B-039-002, 113-2320-B-039-061-MY3,
113-2314-B-894-001;
and China Medical University grant: CMU109-MF-26, CMU113-MF-94, DMR-111-118, DMR-112-098,
DMR-113-117, DMR-113-081, DMR-114-111. Asia University Hospital grant: AUH-11351001.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the internal review board of China Medical University (CMU 110-REC
2-075 on 3 June 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The original contributions presented in this study are included in the
article. Further inquiries can be directed to the corresponding author.
Acknowledgments: This work is especially grateful to SONG BEAM International Co., Ltd. for
technical and material support.
Conflicts of Interest: Author Shih-Hao Huang was employed by the company SONG BEAM Inter-
national Co., Ltd. The remaining authors declare that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a potential conflict of interest.
SONG BEAM International Co., Ltd. provided CBD-coated pillow cover for the study. The remaining
authors have no conflicts of interest in this work. All authors certify that they have no affiliations
with or involvement with any organization or entity with any financial interest (such as honoraria;
educational grant; participation in speaker bureau; membership, employment, consultancies, stock
ownership, or other equity interest; and expert testimony or patent-licensing arrangement) or non-
financial interest (such as personal or professional relationship, affiliation, knowledge or beliefs) in
the subject matter or the materials discussed in the manuscript.
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