School-based sleep promotion programs: Effectiveness, feasibility and insights for future research

Sleep duration trends and trajectories among youth in the COMPASS study

OBJECTIVES

Limited Canadian studies have examined youth sleep over time. This study explored sleep duration over recent years among youth, patterns over the course of secondary school, and subgroups at greater risk of sleep deprivation and problematic trajectories.

DESIGN

Longitudinal survey.

PARTICIPANTS/SETTING

Secondary school students in Ontario and Alberta, Canada.

MEASURES AND ANALYSES

In cross-sectional analyses, student-reported sleep duration was analyzed in three waves of the COMPASS study (Y₂: 2013/2014, Y₃: 2014/2015, Y₄: 2015/2016), and differences by student-level (race/ethnicity, grade, sex) and school-level (urbanicity, median household income) variables were tested in the most recent wave. For the longitudinal analyses, group-based trajectory modeling was conducted using 3-year linked data, adding risk factors as predictors of problematic trajectories.

RESULTS

Average sleep durations declined over the 3 study waves, resulting in less than half of youth meeting the guideline of 8-10 hours per night. Four trajectory groups comprised almost 90% of participants, with 8.8% of students classified as long sleepers, whereas more than one-third of students belonged to 2 sleep-deprived trajectory groups (short [9.3%] and low-normal [26.7%]). In both the cross-sectional and longitudinal analyses, longer sleep durations were more likely among students who identified as male, White, in earlier grades, and attending schools in areas with higher median household income and classified as rural/small urban, relative to their counterparts.

CONCLUSIONS

Results support the necessity of continued surveillance and interventions to monitor and counteract what appears to be an ongoing trend of diminishing sleep and a growing number of sleep-deprived adolescents. Targeted efforts in less affluent and more metropolitan areas warrant consideration.

School-Based Sleep Education Programs for Short Sleep Duration in Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

Insufficient sleep among students is a major school health problem. School-based sleep education programs tailored to reach large number of students may be one of the solutions. A systematic review and meta-analysis was conducted to summarize the programs' effectiveness and current status.

METHODS

Electronic databases were searched up until May 2015. Randomized controlled trials of school-based sleep intervention among 10- to 19-year-old students with outcome on total sleep duration were included. Methodological quality of the studies was assessed using the Cochrane's risk of bias assessment.

RESULTS

Seven studies were included, involving 1876 students receiving sleep education programs and 2483 attending classes-as-usual. Four weekly 50-minute sleep education classes were most commonly provided. Methodological quality was only moderate, with a high or an uncertain risk of bias in several domains. Compared to classes-as-usual, sleep education programs produced significantly longer weekday and weekend total sleep time and better mood among students at immediate post-treatment, but the improvements were not maintained at follow-up.

CONCLUSIONS

Limited by the small number of studies and methodological limitations, the preliminary data showed that school-based sleep education programs produced short-term benefits. Future studies should explore integrating sleep education with delayed school start time or other more effective approaches.

Inadequate sleep as a contributor to type 2 diabetes in children and adolescents

Lack of sleep is a modifiable risk factor for adverse health in humans. Short sleep duration and poor sleep quality are common in the pediatric population; the largest decline in sleep duration over the past decades has been seen in children and adolescents. The objective of the present narrative review was to provide for the first time an overview of the literature on sleep and its association with type 2 diabetes mellitus (T2D) biomarkers in children and adolescents. For this narrative review, 23 studies were retained (21 observational and 2 experimental studies). Notwithstanding the conflicting results found in these studies and despite being attenuated by adiposity level, maturity, sex and age, there is still some compelling evidence for an association between sleep duration (for both objective or subjective measurements of duration) and architecture with one or more T2D biomarkers in children and adolescents. The majority of the studies reviewed did focus on sleep duration and one or more T2D biomarkers in children and adolescents, but sleep architecture, more precisely the suppression of slow wave sleep and rapid eye movement sleep, has also been shown to be associated with insulin resistance. Only two studies looked at sleep quality, and the association between sleep quality and insulin resistance was not independent of level of adiposity. Future experimental studies will help to better understand the mechanisms linking insufficient sleep with T2D. Work also needs to be carried out on finding novel and effective strategies aimed at improving sleep hygiene and health outcomes of children and adolescents.

Associations of Parent Health Behaviors and Parenting Practices with Sleep Duration in Overweight and Obese Children

STUDY OBJECTIVES

To examine the extent to which parent health behaviors and parenting practices are associated with school-age children's sleep duration.

METHODS

We surveyed 790 parents of children, aged 6 to 12 y, who had a body mass index (BMI) ≥ 90th percentile and were participating in a randomized controlled obesity trial. The main exposures were parent sleep duration, screen time and physical activity, parental limits placed on child TV viewing time and TV content, and parents' confidence regarding their ability to help their child get enough sleep. The primary outcome was child sleep duration. We used linear regression models to examine associations of parent behaviors and parenting practices with child sleep duration.

RESULTS

On average, children slept 9.2 h per night, whereas parents slept 6.9 h. Parents reported having an average of 1.9 h of screen time per day and 0.6 h of physical activity. There were 57.3% of parents who reported feeling very/extremely confident that they could help their child get enough sleep. In adjusted multivariate analyses, child sleep duration was 0.09 h/day (95% confidence interval: 0.03, 0.15) longer for each 1-h increment in parent sleep duration. Additionally, children whose parents reported being very/extremely confident they could help their child get age-appropriate sleep duration slept 0.67 h/day longer (95% confidence interval: 0.54, 0.81) than those whose parents were not/somewhat confident.

CONCLUSIONS

Educating parents about their own sleep health and enhancing parent confidence to help their children get enough sleep are potential areas of intervention to increase child sleep duration.

Is sleep education an effective tool for sleep improvement and minimizing metabolic disturbance and obesity in adolescents?

The prevalence of childhood obesity has increased significantly in recent years. Obesity is associated with a range of adverse physiological, psychological and social outcomes and places a huge economical burden on healthcare systems around the world. Insufficient sleep duration is common in adolescents and exacerbated by contemporary lifestyles, but may be a contributor to obesity onset and metabolic disruption. We briefly review the current evidence surrounding the associations between sleep and obesity as well as diabetes. Sleep improvement programs have been suggested as a potential avenue to raise awareness of the importance of sleep and ultimately enhance sleep behaviors/routines. A review of the current literature supporting the efficacy of such programs is tentative. Furthermore, very few studies have investigated if sleep enhancement has downstream positive effects on metabolic function or body weight in adolescents. We highlight biological and social factors that intensify sleep loss in adolescents and recommend that these be targeted components in future interventions aimed at improving adolescent sleep.

Effects of a sleep education program with self-help treatment on sleeping patterns and daytime sleepiness in Japanese adolescents: A cluster randomized trial

Subjective insufficient sleep and delayed sleep-wake patterns have been reported as the primary causes for daytime sleepiness, a reasonably significant and prevalent problem for adolescents worldwide. Systematic reviews have indicated that the success of sleep education programs has thus far been inconsistent, due to the lack of a tailored approach that allows for evaluation of individual differences in behavior patterns. One way to resolve this problem is to assess the individual sleep behaviors of adolescents by using a checklist containing the recommended behaviors for promoting sleep health. Such self-help education programs have already been implemented for elementary school children, school nurses and the elderly. The present study aimed to verify the effects of a sleep education program with supplementary self-help treatment, based on a checklist of sleep-promoting behaviors, in addition to evaluation of changes in sleeping patterns, sleep-promoting behaviors and daytime sleepiness in adolescents. A cluster randomized controlled trial involving 5 Japanese junior high schools was conducted, and 243 students (sleep education: n = 122; waiting list: n = 121; 50.6% female; 7th grade) were included in the final analysis. The sleep education group was provided with information on proper sleep health and sleep-promoting behaviors. The students in this group were asked to practice one sleep-promoting behavior as a goal for 2 weeks and to monitor their practice using sleep diaries. Both pre- and post-treatment questionnaires were administered to students in order to assess knowledge of sleep-promoting behaviors, sleeping patterns and daytime functioning. Students in the sleep education group showed significant improvement in their knowledge of sleep health (F1,121 = 648.05, p < 0.001) and in their sleep-promoting behaviors (F1,121 = 55.66, p < 0.001). Bedtime on both school nights (F1,121 = 50.86, p < 0.001) and weekends (F1,121 = 15.03, p < 0.001), sleep-onset latency (F1,121 = 10.26, p = 0.002), total sleep time on school nights (F1,121 = 12.45, p = 0.001), subjective experience of insufficient sleep (McNemar χ(2)(1) = 4.03, p = 0.045) and daytime sleepiness (McNemar χ(2)(1) = 4.23, p = 0.040) were also improved in the sleep education group. In contrast, no significant improvement in these variables was observed for students in the waiting-list group. In conclusion, the sleep education program with self-help treatment was effective not only in increasing sleep knowledge but also in improving sleep-promoting behavior and sleeping patterns/reducing daytime sleepiness for students in the sleep education group, in comparison with the waiting-list group.

Putting Children's Sleep Problems to Bed: Using Behavior Change Theory to Increase the Success of Children's Sleep Education Programs and Contribute to Healthy Development

Sleep is critical for the healthy development of children, yet most children simply don’t get enough. Whilst school based sleep education programs have been developed for parents and their children, they have had mixed success. We consider how existing school-based sleep education programs can be improved by applying a broader model to behaviour change theory. We find that the mixed success of school-based sleep education programs may be due to a plausible but misleading assumption that simply increasing information about the importance of sleep and the risks of insufficient and/or inefficient sleep, will necessarily result in improved sleep behaviours. We identify the potential benefits of using a more inclusive behavior change theory in the development of sleep education programs with a particular need for theories that incorporate the multiple biological, environmental and social impacts on children’s sleep. Bronfenbrenner’s Bioecological model is presented to illustrate how one such inclusive behavior change theory could significantly improve the success of sleep education programs and ultimately support the healthy development of children.

Pilot Study of a Sleep Health Promotion Program for College Students

OBJECTIVES

We conducted a pilot study of a sleep health promotion program for college students. The aims of the study were to 1) determine the feasibility of the program, and 2) explore changes in sleep knowledge and sleep diary parameters.

DESIGN

Open trial of a sleep health promotion program for college students.

SETTING

A small liberal arts university in southwestern Pennsylvania.

PARTICIPANTS

University students (primarily female).

INTERVENTION

Active intervention components included individualized email feedback based on each participant's baseline sleep diary and an in-person, group format presentation on sleep health.

MEASUREMENTS

Participants completed online questionnaires and sleep diaries before and after the health promotion intervention. Online questionnaires focused on sleep knowledge and attitudes toward sleep, as well as Patient Reported Outcomes Measurement Information System (PROMIS) sleep and psychosocial assessments.

RESULTS

Of participants who completed some aspect of the study, 89% completed at least one intervention component (in-person lecture and/or sleep diary). Participants reported significant improvement in sleep knowledge and changes in sleep diary parameters (decreased sleep onset latency and time spent in bed, resulting in greater sleep efficiency). Sleep duration also increased by 30 minutes among short sleepers who obtained <7 hours sleep at baseline.

CONCLUSIONS

Preliminary evaluation of a brief program to promote sleep health suggests that it is feasible and acceptable to implement, and that it can favorably alter sleep knowledge and behaviors reported on the sleep diary in college students. Controlled trials are warranted.

School Start Times, Sleep, Behavioral, Health, and Academic Outcomes: A Review of the Literature

BACKGROUND

Insufficient sleep in adolescents has been shown to be associated with a wide variety of adverse outcomes, from poor mental and physical health to behavioral problems and lower academic grades. However, most high school students do not get sufficient sleep. Delaying school start times for adolescents has been proposed as a policy change to address insufficient sleep in this population and potentially to improve students' academic performance, reduce engagement in risk behaviors, and improve health.

METHODS

This article reviews 38 reports examining the association between school start times, sleep, and other outcomes among adolescent students.

RESULTS

Most studies reviewed provide evidence that delaying school start time increases weeknight sleep duration among adolescents, primarily by delaying rise times. Most of the studies saw a significant increase in sleep duration even with relatively small delays in start times of half an hour or so. Later start times also generally correspond to improved attendance, less tardiness, less falling asleep in class, better grades, and fewer motor vehicle crashes.

CONCLUSIONS

Although additional research is necessary, research results that are already available should be disseminated to stakeholders to enable the development of evidence-based school policies.

School-based sleep education program improves sleep and academic performance of school-age children

STUDY OBJECTIVE

The objective of this study was to develop and evaluate the effectiveness of a school-based sleep education program aimed at improving the sleep and academic performance of school-age children.

METHODS

Using a community-based participatory research approach, we created a school-based sleep education program, "Sleep for Success"™ (SFS), composed of four distinct modules that addressed the children, their family and community, the school staff, and decision makers within the school setting. Implementation was carried out in three elementary schools. Seventy-one students participated in the evaluation of the program. The effectiveness of the SFS program was evaluated using non-randomized controlled before-and-after study groups (intervention and control) assessed over two time points (pre- and post-program implementation). Before (baseline) and after implementation, sleep and academic performance were measured using actigraphy and report card marks, respectively.

RESULTS

In the intervention group, true sleep was extended by 18.2 min per night, sleep efficiency improved by 2.3%, and sleep latency was shortened by 2.3 min, and report card grades in mathematics and English improved significantly. No changes were noted in the control group.

CONCLUSION

Participation in the sleep education program was associated with significant improvements in children's sleep and academic performance.

Sleep education with self-help treatment and sleep health promotion for mental and physical wellness in Japan

The purpose of this article was to provide an overview of the effects of the sleep education with self-help treatment for student, teacher, and local resident and sleep health promotion for mental and physical wellness for elderly with actual examples of public health from the community and schools. Sleep education with self-help treatment in schools revealed that delayed or irregular sleep/wake patterns were significantly improved. Also, it was effective for improving sleep-onset latency, sleep satisfaction, mood during the morning, and daytime sleepiness. The strategy of this sleep education included the acquisition of the correct knowledge about sleep and the sleep-related behaviors that are important for improving sleep. Sleep health promotion that included short naps and exercise in the evening (Sleep health class) was effective in promoting sleep and mental health with elderly people. The interventions demonstrated that the proper awakening maintenance, keeping proper arousal level during the evening was effective in improving sleep quality. Furthermore, sleep management that included sleep education and cognitive-behavioral interventions improved sleep-related habits and the quality of sleep. In this study, a sleep educational program using minimal cognitive-behavioral modification techniques was developed. Mental and physical health was also improved with better sleep in the elderly. These results suggest that sleep health promotion is effective for mental and physical wellness for the elderly.

Technology Use and Sleep Quality in Preadolescence and Adolescence

STUDY OBJECTIVES

The purpose of this study was to analyze differences between preadolescents and adolescents on the use of technology and to test the contribution of using Internet and mobile phone, and circadian preference on sleep quality.

METHODS

We recruited a sample of 850 (364 males) preadolescents and adolescents. Self-report questionnaires about sleep schedule, sleep wake behavior problems, circadian preferences, and the use of technology (e.g., Internet and mobile phone) were administered. Students were asked to fill out the School Sleep Habits Survey, a self-report questionnaire on the use of technology, the Mobile Phone Involvement Questionnaire (MPIQ), and the Shorter Promis Questionnaire (SPQ).

RESULTS

Adolescents reported more sleep problems, a tendency toward eveningness, and an increase of Internet and phone activities, as well as social network activities, while preadolescents were more involved in gaming console and television viewing. The regression analysis performed separately in the two age groups showed that sleep quality was affected by the circadian preference (eveningness) in both groups. Adolescents' bad sleep quality was consistently associated with the mobile phone use and number of devices in the bedroom, while in preadolescents, with Internet use and turning-off time.

CONCLUSIONS

The evening circadian preference, mobile phone and Internet use, numbers of other activities after 21:00, late turning off time, and number of devices in the bedroom have different negative influence on sleep quality in preadolescents and adolescents.

Effect of animated movie in combating child sleep health problems

OBJECTIVE

Sleep deprivation among teens is a major health issue. Only 15% of teens get 8.5 h of sleep on school nights. Sleep deprivation can lead to poor grades, sleepiness and moodiness. We undertook a study to assess the prevalence of sleep habit disturbance among elementary school students in South Texas with Hispanic ethnicity predominance. We also found how much a video based on sleep education had an impact on these children.

METHOD

Once the Corpus Christi Independent School District (CCISD) approved the collection of baseline sleep data, questionnaires were administered using the Children's Sleep Habit Questionnaire (CSHQ.) These questionnaires were distributed prior to the viewing of the educational and animated movie KNIGHTS (Keep Nurturing and Inspiring Good Habits in Teen Sleep). Four months later, a random follow-up was performed and the children were requested to respond to the same CSHQ.

RESULTS

264 children from two elementary schools participated in this educational program. At baseline, 55.56% of the children had trouble sleeping. When the questionnaire was administered four months later, only 23.26% (p < 0.05) had trouble sleeping. Additionally, at baseline, approximately 60-70% children had some baseline bedtime resistance, anxiety dealing with sleep, issues with sleep duration and/or awakenings in the middle of the night. In the follow up questionnaire, results showed significant improvements in overall sleep habits, bedtime resistance, sleep anxiety and night awakenings amongst students (p < 0.05). However, no significant differences were seen in sleep duration and daytime sleepiness.

CONCLUSION

Sleep deprivation and good sleep habits remain as a pervasive challenge among elementary school students. Administering an animated video about sleep education along with a provider-based education may be an effective tool for educating elementary school students and decreasing the prevalence of these sleep-related issues. Future prospective randomized studies are suggested.

Lessons Learned from Sleep Education in Schools: A Review of Dos and Don'ts

STUDY OBJECTIVES

Sleep duration and quality are associated with negative neuropsychological and psychosocial outcomes in children and adolescents. However, community awareness of this is low and sleep education programs in schools are attempting to address this issue. Several studies now exist assessing the efficacy of these sleep education programs for improving sleep knowledge, sleep hygiene and sleep patterns. This paper presents these sleep education programs, most particularly, it presents the strengths and weaknesses of the current available studies in the hope that this can identify areas where future sleep education programs can improve.

METHODS

A systematic search of all school-based sleep education studies in adolescents was undertaken. Studies were scrutinized for author, teacher and participant comment regarding strengths and limitations of each study, which were then extracted and summarized.

RESULTS

Two specific types of sleep education programs emerged from the review, those that sought to change sleep behavior and those that sought simply to disseminate information. Issues that dictated the strength or weakness of a particular study including who delivers the program, the theoretical basis, the tools utilized to measure sleep patterns, the content, and their capacity to engage students were assessed. Sleep education was considered important by teachers, students and parents alike.

CONCLUSIONS

Future sleep education programs need to take into account lessons learned from previous sleep education efforts in order to maximize the potential for sleep education programs to improve the sleep health of our young people.

COMMENTARY

A commentary on this article appears in this issue on page 595.

Sleep-patterns, sleep hygiene behaviors and parental monitoring among Bahrain-based Indian adolescents

Introduction:

Sleep plays an important role in adolescent's health and undergoes substantial changes with puberty and physical maturation with a preference for later bed times. Evidence shows that many adolescents are not obtaining the required amounts of sleep which is 9.25 h, due to inadequate sleep practices, academic and societal demands. This study aims at describing the (1) sleep patterns of adolescents on school days and weekends, (2) sleep hygiene practices and the extent of parental monitoring and (3) gender and grade level differences in sleep duration and sleep hygiene practices among Indian adolescents in Bahrain.

Materials and Methods:

Study used a descriptive correlational design. A total of 145 adolescents from 11 to 17 years from grade 6 to 12 were selected using convenience sampling. Data was collected from November 2012 to March 2013. A structured questionnaire for sleep patterns and Mastin et al.'s Sleep Hygiene Index for assessing sleep hygiene practices were used.

Results:

The adolescents’ total sleep duration was 7.07 ± 1.13 hours. A highly significant difference in sleep duration on school days and weekends between adolescents of various grade levels (P < 0.001 and 0.001, respectively) and between parental monitoring at the time of getting up on school days and sleep duration (P value 0.026 at 0.05 level of significance) was found. Gender was not significant with the sleep duration, and also with Sleep Hygiene Index scores.

Conclusion:

The results suggest that there is a high prevalence of insufficient sleep and irregular bed-time schedule among Indian adolescents in Bahrain. Interventions directed toward improving sleep and promoting good sleep hygiene strategies are required to improve the physical and emotional health of adolescents.