Association of sleep quality with sociodemographic factors and lifestyle in adolescents from southern Brazil

Siesta characteristics mediated the association between siesta duration and sleep quality in Chinese incoming college freshmen

To investigate the sleep quality of incoming college freshmen who have completed college entrance exams but have not yet entered college, to identify associated factors, and the mediating role of siesta characteristics on the relationship between siesta duration and sleep quality. This study included 6,519 incoming freshmen from two colleges in Xuzhou city, China. Weighted multiple linear regression (MLR) and binary logistic regression (BLR) were employed to investigate the factors associated with sleep quality. Mediation analysis was conducted to examine the influence of siesta characteristics on sleep quality and siesta duration. Stratified analysis was conducted based on gender and college level to examine the correlation between sleep quality and siesta durations (1-29 min, 30-50 min, ≥ 60 min). Both regression models found that longer siesta duration was a risk factor for poor sleep quality. Mediation analysis demonstrated that sleep position, the interval between lunch and the siesta, and the subjective rating of sleepiness 30 min after the siesta mediated this relationship. Male students with 30-59 min siestas, junior college freshmen with 1-29 min siestas, and undergraduate freshmen with ≥ 60 min siestas exhibited an increased risk of poor sleep quality compared to their counterparts without siestas. Furthermore, lifestyle behaviors and physical activity were also found to impact sleep quality. Longer siesta duration has been identified as a risk factor for sleep quality, especially in incoming undergraduate and male students. Some siesta characteristics mediate the relationship between them.

Sleep Disturbances and Depression Levels among General Indonesian Population: A National Survey

Background

The correlation between sleep disturbance and depression is widely recognized in developed countries but relevant evidence is lacking in developing countries.

Objective

This study aims to assess the correlation between sleep disturbance and depression levels among the general Indonesian population.

Methods

This national cross-sectional survey was conducted using the Indonesian Family Life Survey. Sleep disturbance was assessed based on the questions related to sleeping experience. Depression levels were assessed with a modified Center for Epidemiologic Studies-Depression scale. Sociodemographic factors as confounders were obtained from the self-reported data. Logistic regression was performed after adjusting for confounders.

Results

A total of 22,024 respondents were included. Respondents with severe, moderate, and mild sleep disturbance were associated with depression compared to those with none or slight sleep disturbance.

Conclusions

Respondents with sleep disturbance had a higher possibility of experiencing depression. Screening of sleep quality among the general population is important to reduce the risk of depression.

The relationship between multiple sleep dimensions and obesity in adolescents: A systematic review

Sleep is an involuntary behaviour, biologically fundamental to survival and wellbeing. However, sleep is increasingly neglected, with significant health implications. Recent research has identified associations between sleep duration, quality, timing and risk of overweight/obesity in children and adults. The aim of this review was to systematically identify and examine research that investigates the relationships between multiple objective and subjective sleep outcomes and objective adiposity measures in adolescents. A systematic review of literature, published to December 2022, was conducted using ten bibliographic databases. Search terms included objective and subjective sleep/circadian rhythm outcomes, objective adiposity measurements, and adolescents aged 8-18 years. Eighty-nine studies were included in the final review. Sleep outcomes were synthesized into three sleep domains: pre-sleep, during sleep and post-sleep outcomes. In summary, pre-sleep outcomes (including poor sleep hygiene, later chronotype and increased variability and later sleep timings) and increased sleep disturbance are consistently significantly associated with increased obesity and adiposity in adolescents. The relationship between during-sleep outcomes (sleep quality and efficiency) with adiposity and obesity measures was mixed. These findings suggest that adapting an individual's schedule to best suit chronotype preference and improving sleep hygiene, including a consistent bedtime routine, could reduce adiposity and obesity in adolescents.

Prevalence of Sleep Disturbances in Latin American Populations and Its Association with Their Socioeconomic Status-A Systematic Review and a Meta-Analysis

BACKGROUND

The worldwide increase in the prevalence and incidence of sleep disturbances represents a major public health issue. Among multiple determinants affecting sleep health, an individual's socioeconomic status (SES) is the most ignored and underestimated throughout the literature. No systematic review on the relation between SES and sleep health has been previously conducted in Latin America.

METHODS

PRISMA guidelines were used.

RESULTS

Twenty articles were included in the final sample (all cross-sectional studies), and twelve among them were rated as fair or poor quality. Among these studies, 80.0% (n = 16) were performed in Brazil, 10.0% (n = 2) were performed in Peru, 5.0% (n = 1) were performed in Chile, and 5.0% (n = 1) were multicentric (11 countries). The combined total number of participants was N = 128.455, comprising 3.7% (n = 4693) children, 16.0% (n = 20,586) adolescents, and 80.3% (n = 103,176) adults. The results show the following: (1) The sleep outcomes analyzed were sleep duration, sleep quality/sleep disturbance, insomnia, excessive daytime sleepiness (EDS), obstructive sleep apnea (OSA)/sleep-disordered breathing (SDB) symptoms, and bruxism. (2) The most used determinants were income, education level, employment status/occupation, wealth/assets, and composite indices. (3) Higher SES was associated with shorter sleep duration. (4) Lower SES was associated with a decrease in sleep quality, less frequent snoring, more prevalent EDS, and sleep bruxism. (5) Lower education was associated with insomnia. (6) Higher education was associated with more sleep bruxism. (7) The pooled prevalence using a meta-analysis of the random effects model was 24.73% (95%CI, 19.98-30.19), with high heterogeneity (I2 = 100%). (8) The prevalence of sleep disturbances decreased with high education (OR, 0.83; 95%CI, [0.69-0.99]; I2 = 79%), while it increased with low income (OR, 1.26; 95%CI, [1.12-1.42]; I2 = 59%), unemployment (OR, 2.84; 95%CI, [2.14-3.76]; I2 = 0%), and being a housewife (OR, 1.72; 95%CI, [1.19-2.48]; I2 = 55%).

DISCUSSION

This meta-analysis shows that lower SES (education, income, and work) was associated with sleep disturbances in Latin America. Therefore, sleep disturbance management should be addressed with a multidimensional approach, and a significant investment in targeted public health programs to reduce sleep disparities and support research should be made by the government before the situation becomes uncontrollable.

Clustering of lifestyle behaviors and adiposity in early adolescents in Spain: findings from the SI! Program for Secondary Schools

BACKGROUND

Several unhealthy lifestyle behaviors in adolescence are often linked to overweight/obesity. Some of them may be present simultaneously, leading to combined effects on health. Therefore, the clustering of several unhealthy behaviors in adolescents might be associated with adiposity excess.

PURPOSE

To identify lifestyle patterns and analyze their association with adiposity in early adolescents.

METHODS

A cross-sectional cluster analysis was performed in 1183 adolescents (50.5% girls) with a mean age of 12.5 (0.4) years included in the SI! Program for Secondary Schools in Spain to identify lifestyle patterns based on healthy diet, step counts, sleep time, and leisure screen time. Generalized mixed models were applied to estimate the association between lifestyle patterns and adiposity indices.

RESULTS

Four lifestyle patterns were derived: Cluster 1-higher screen time and poorer diet (n = 213), Cluster 2-lower activity and longer sleepers (n = 388), Cluster 3-active and shorter sleepers (n = 280), and Cluster 4-healthiest (n = 302). Except for the number of steps (12,008 (2357) day), the lifestyle behaviors in our sample presented levels far below the recommendations, especially for sleep duration. Cluster 4 included the largest proportion of adolescents from high socioeconomic status families (47.7%) and the lowest prevalence of overweight/obesity (23.1%). Compared to Cluster 4-healthiest, adolescents in the remaining clusters presented a higher prevalence of overweight/obesity and central obesity, showing Cluster 3 the highest prevalences (PR:1.31 [95%CI: 1.31, 1.31] and PR:1.40 [95%CI: 1.33, 1.47]).

CONCLUSIONS

Clustering of lifestyle patterns in early adolescence allows the identification of individuals with excess adiposity, in whom health promotion strategies should be stressed, especially in socioeconomically disadvantaged groups.

TRIAL REGISTRATION

Clinical Trial Registry, NCT03504059. Registered 20/04/2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03504059 .

Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research

STUDY OBJECTIVES

This review aims to assess the association between socioeconomic status (SES) and sleep health in the general population and the mediating effects of lifestyle and mental and physical health in this relationship.

METHODS

Observational studies testing the independent association between objective or subjective SES indicators and behavioral/physiological or clinical sleep health variables in the general population were included. PubMed/MEDLINE was searched for reports published from January 1990 to December 2019. The direction of effect was used as the primary effect measure, testing the hypothesis that low SES is associated with poor sleep health outcomes. Results are presented in the form of direction effect plots and synthesized as binomial proportions.

RESULTS

Overall, 336 studies were identified. A high proportion of effects at the expected direction was noted for measures of sleep continuity (100% for sleep latency, 50-100% for awakenings, 66.7-100% for sleep efficiency), symptoms of disturbed sleep (75-94.1% for insomnia, 66.7-100% for sleep-disordered breathing, 60-100% for hypersomnia), and general sleep satisfaction (62.5-100%), while the effect on sleep duration was inconsistent and depended on the specific SES variable (92.3% for subjective SES, 31.7% for employment status). Lifestyle habits, chronic illnesses, and psychological factors were identified as key mediators of the SES-sleep relationship.

CONCLUSIONS

Unhealthy behaviors, increased stress levels, and limited access to health care in low-SES individuals may explain the SES-sleep health gradient. However, the cross-sectional design of most studies and the high heterogeneity in employed measures of SES and sleep limit the quality of evidence. Further research is warranted due to important implications for health issues and policy changes.

CITATION

Papadopoulos D, Etindele Sosso FA. Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research. J Clin Sleep Med. 2023;19(3):605-620.

The associations between working conditions and subjective sleep quality among female migrant care workers

Background

Subjective sleep quality may reflect the mental well-being of migrant care workers; however, the related occupational factors remain unclear. This study examines the association between the characteristics of care labor and the subjective sleep quality of female migrants.

Methods

In this cross-sectional study, Southeast Asian migrant care workers in Taiwan were recruited using convenience sampling. Data on working conditions, including workplace setting, wage, working hours, psychiatric symptoms of care recipients, and sleep quality measured using the Pittsburgh Sleep Quality Index (PSQI), were collected through computer-assisted personal interviews. Multiple linear regression analyses were performed to determine the independent relationship between working conditions and the PSQI global score.

Results

There were 220 institution-(47.7%) and home-based (52.3%) care workers, and 47.7% had a PSQI score higher than 5. After controlling for covariates, the lowest tertile of wages and daily working hours (> 8 h) were independently correlated with poor sleep quality. Moreover, in the stepwise regression model, wage and working hours remained the most explainable correlates of poor sleep quality.

Conclusion

This study lent support to the notion that low wages and long working hours are significant occupational factors that negatively impact the subjective sleep quality of female Southeast Asian migrant care workers in Taiwan.

Proposition of Cutoff Points for Anthropometric Indicators to Identify High Blood Pressure in Adolescents

Aim

To propose cutoff points for anthropometric indicators for high blood pressure (HBP) screening in adolescents and to identify, among these indicators, those more accurately for boys and girls.

Methods

This cross-sectional study was carried out in the city of São José, SC, Brazil with 634 adolescents aged 14 to 19 years. Blood pressure levels were measured using a digital oscillometric sphygmomanometer and adolescents were classified as having HBP or not. Anthropometric indicators were calculated based on anthropometric measurements such as body mass (BM), height, waist circumference (WC), hip circumference (HC) and triceps, subscapularis, suprailiac, and midcalf skinfold thickness (SF). The Receiver Operating Characteristic Curve (ROC) was used to analyze the predictive capacity of anthropometric indicators in the identification of HBP.

Results

Higher values of Area Under the Curve (AUC) were for the anthropometric indicators BM (0.67; 95%CI: 0.62-0.72), body mass index (BMI) (0.67; 95%CI: 0.62-0.72), and WC (0.67; 95%CI: 0.62-0.71) for males. For females, no anthropometric indicator had discriminatory power for HBP screening. The cutoff points for the anthropometric indicators with discriminatory power for HBP screening in males were BM > 64.80 Kg, BMI > 21.76 Kg/m2, fat percentage (FP) > 15.75, waist height to ratio (WHtR) > 0.41, WC > 73.00 cm, and HC > 92.25 cm.

Conclusion

Anthropometric indicators of body adiposity had greater discriminatory power of HBP screening in males. For females, caution is suggested because the anthropometric indicators showed AUC values (95%CI) below 0.60.

The effect of internet addiction and smartphone addiction on sleep quality among Turkish adolescents

Background: Sleep quality plays a principal role in the protection of health. There is an increasing number of studies in the literature demonstrating that internet addiction and smartphone addiction impair sleep quality. However, the number of studies on Turkish adolescents is very limited. Therefore, this study examined the effects of internet addiction and smartphone addiction on sleep quality among Turkish adolescents. Methods: Participants in this cross-sectional study were 910 adolescents aged 13-18 years. Data were collected with the Short Internet Addiction Test, Smartphone Addiction Scale, and Pittsburgh Sleep Quality Index. In addition, a questionnaire was used to gather information about the demographic, socioeconomic, and health-related characteristics. Pearson's Chi-square test, Chi-square test for trend, Mann-Whitney U test, logistic regression analysis, and Spearman's correlation analysis were used in the analysis. Results: The sleep quality of 58.7% of the adolescents was poor. Additionally, girls and adolescents ≥16 years old had poor sleep quality. Sleep quality deteriorated as perceived health status and perceived economic status of family deteriorated. Compared to participants with normal internet addiction scores, poor sleep quality was 1.83 (95% CI [1.22-2.74]) times higher in those with problematic internet addiction and 1.99 (95% CI [1.23-3.87]) times higher in those with pathological internet addiction. One point increase in Smartphone Addiction Scale total score increased poor sleep quality 1.01 (95% CI [1.00-1.02]) times. Sleep quality scale were positively correlated with the smartphone addiction and internet addiction. However, there was no positive correlation between habitual sleep efficiency subcomponent of sleep quality and smartphone addiction and internet addiction. Conclusions: Internet addiction and smartphone addiction were associated with poor sleep quality in adolescents. Older adolescents (≥16 years), gender (female), poor health perception, and perception of moderate economic status of the family were other factors associated with poor sleep quality.

Socioeconomic status and sleep disturbances among pediatric population: a continental systematic review of empirical research

To this day, no consensus has been established on the definition and the conceptualization of the socioeconomic status (SES), since all the available studies on the relation between SES and health did not use the same conceptual framework and operationalization to assess SES. While literature reported that SES markers (such as income, social support networks, education, employment or occupation) influence the health of populations by shaping living conditions; empirical research does not tell us which SES markers affect more strongly the sleep components of the individuals, as well as which sleep disorders (SD) are affected and how. Even though several original studies have tried to assess how changes in socioeconomic status of parents may affect the psychosocial environment and mental health of an individual directly or through his community, no systematic reviews on the influence of SES on children's sleep are available. This systematic review make an update on the different measures of SES and sleep disturbances used for pediatric population across the different regions of the world. Recommendations for a future standardization of SES measures is proposed, for a better understanding of its influence on sleep disturbances.

Prevalence of Brazilian children and adolescents who met health criteria for aerobic fitness: systematic review update for Report Card Brazil Project

abstract The aim of the study was to update Brazilian evidence on the prevalence of children and adolescents who met health criteria for aerobic fitness. This systematic review is part of the Report Card Brazil Project and the search was restricted to studies published during the period from January 2018 to December 2019 in nine electronic databases. Studies with different designs, which allowed extracting information about the prevalence of children and adolescents who met health criteria for aerobic fitness (age up to 19 years or average age up to 19 years) were included. Studies published from 2020 were not included due to the possible effect of the pandemic on this indicator and because there is no certainty as to when the pandemic will end. Of the 694 studies initially identified, 13 studies with information of 14,673 children and adolescents were included after reading titles, abstracts, full texts and references. The prevalence of children and adolescents who met health criteria for aerobic fitness was 26.9% (29.7% for girls; 44.6% for boys). In this search, eight different cutoff points were used to determine adequate aerobic fitness levels and five tests were used to determine aerobic fitness. Analyzing data from the present review with the previous systematic review of this project, one third of children and adolescents in Brazil meet health criteria for aerobic fitness.

Adequate sleep duration among children and adolescents: a review of the Brazil's Report Card

abstract – This study aimed to summarize existing research examining the prevalence of adequate sleep duration or meeting sleep recommendations among Brazilian children and adolescents. A systematic review was conducted on eight databases. The criteria for inclusion were original research, samples including Brazilian children and adolescents (age 0–18), studies that reported variables regarding sleep duration using both objective or subjective measures, school- or population-based surveys with random sampling, and cross-sectional or cohort studies. Of the 54 articles included, only 27 used data from different studies. Most of the studies were conducted in the southern region (n = 17) with only two studies having a nationally representative sample. Two studies included children below age five, and the age group most investigated was adolescents (>10 years old). A majority of the studies used a self-reported questionnaire and showed variability in the cutoff point applied for adequate sleep duration with the most reported being ≥8 hours. The proportion of adolescents who met recommendations or had adequate sleep duration ranged from 15% to 89%. Among children, the prevalence ranged from 17% to 95%. The least variability was observed among toddlers, ranging from 93% to 95%. No consistent gender differences were observed among the gender-stratified groups of children and adolescents across the studies. It can be observed that, because of the wide range of results and the lack of data with national representativeness, the prevalence of sufficient sleep among young people aged below 18 remains undefined in Brazil.

Impact of socioeconomic- and lifestyle-related risk factors on poor mental health conditions: A nationwide longitudinal 5-wave panel study in Japan

The association of socioeconomic status and lifestyle behaviours on mental health appears well-established in the literature, as several studies report that better socioeconomic status such as higher levels of disposable income and employment as well as practising healthy lifestyles can enhance mental well-being. However, the reliance on cross-sectional correlations and lack of adequate statistical controls are possible limitations. This study aims to add the evidence of longitudinal association to the literature by using Japanese representative longitudinal household panel data. We employed panel data analytical techniques such as the random-effects conditional logistic regression (RE-CLR) and the fixed-effects conditional logistic regression (FE-CLR) models with possible time variant confounders being controlled. Our sample was comprised of 14,717 observations of 3,501 individuals aged 22–59 years for five waves of the Japanese Household Panel Survey. We confirmed many of the factors associated with mental health reported in existing studies by analysing cross-sectional data. These significant associations are also longitudinal (within) associations estimated by the FE-CLR models. Such factors include unemployment, low household income, short nightly sleeping duration, and lack of exercise. However, we also found that several factors such as disposable income, living alone, and drinking habits are not significantly associated with mental health in the FE-CRL models. The results imply the reverse causality that poor mental health conditions cause lower disposal income, possibly due to the inability to exhibit higher productivity, but an increase in disposal income would not necessarily improve mental health conditions. In this case, aggressive policy interventions to increase the disposal income of people of lower socioeconomic backgrounds would not necessarily be effective to minimize health inequalities.

Aggregation of behavioral risk factors to noncommunicable chronic diseases: A national school-based study with Brazilian adolescents

There is an increasing interest in the study of the aggregation of risk factors for noncommunicable chronic diseases. However, there are no studies among adolescents stratified by alcohol use. This study investigated the aggregation of cardiovascular risk factors in adolescents considering the use or not of alcohol. A total of 73,624 Brazilian adolescents aged 12-17 years from public and private schools were evaluated in a national cross-sectional study (March-2013 to December-2014). The aggregation of cardiovascular risk factors was the main outcome. The regression model was adjusted for sex, age, region of Brazil, and school type. Most alcohol users were 16 to 17 years old, while nonusers were between 12 and 13 years. Alcohol users showed a higher prevalence of smoking (8.1% vs. 0.8%) and sleep inadequacy (59.9% vs. 51.4%) than nonusers did. On the other hand, a sufficient level of physical activity was more frequent among alcohol users (51.2% vs. 44.2%). The presence of only one cardiovascular risk factor was more frequent in nonusers (42.3%) than alcohol users (38.9%). Alcohol users tended to aggregate more for the category of 3-4 cardiovascular risk factors when compared with the non-alcohol-using population (10.9% vs. 7.9%). Aggregation of three cardiovascular risk factors was more likely to be observed among male adolescent alcohol users. Inadequate sleep and smoking habit tended to aggregate among alcohol users. This finding highlights the importance of public policies aiming to reduce alcohol consumption at early ages and, consequently, to decrease the risk of future morbimortality of noncommunicable chronic diseases.

Impact of Cumulative Unhealthy Sleep Practices in Adolescence on Substance Use in Young Adulthood Estimated Using Marginal Structural Modeling

Objectives

The purpose of this study was to identify the impact of chronic, unhealthy sleep practices in adolescence on substance use in young adulthood. Unhealthy sleep practices in adolescent samples exhibit a bidirectional relationship with substance use. The relationship is further complicated if we consider that confounders such as depression vary over time and are often in response to adolescents’ prior poor sleep practice, which can be addressed by a counterfactual approach using a marginal structural model.

Methods

Data in this study are from the Taiwan Youth Project, a longitudinal study that started in 2000 and surveyed 2,690 7th grade students at age 13. Outcomes include frequency of cigarette smoking and alcohol drinking at age 21. Three unhealthy sleep practices were included in this study: short sleep, social jetlag, and sleep disturbance. We used a marginal structural model with stabilized inverse probability-of-treatment weights to address time-varying confounders in each wave and a total sample of 1,678 adolescents with complete information for this study.

Results

Accumulated waves of sleep disturbance and social jetlag in adolescence were significantly associated with cigarette use in young adulthood. Accumulated social jetlag but not sleep disturbance was also associated with alcohol use in adulthood. Accumulated waves of short sleep were not associated with later alcohol use, but were negatively correlated with cigarette use.

Conclusion

Interventions that aim to reduce the likelihood of substance use in young adulthood should consider confronting unhealthy sleep practices, in particular the discrepancy between bedtimes on school days and weekends and sleep disturbance.

Bidirectional, Daily Temporal Associations between Sleep and Physical Activity in Adolescents

This study evaluated the daily, temporal associations between sleep and daytime physical activity and sedentary behavior among adolescents from the Fragile Families & Child Wellbeing Study. A sub-sample of the cohort at age 15 (N = 417) wore actigraphy monitors for one week during the school year from which we derived daily minutes in sedentary and moderate-to-vigorous physical activity (MVPA) and nighttime sleep measures. Multilevel models tested temporal associations of nightly sleep onset, offset, duration, and sleep maintenance efficiency, with daily MVPA and sedentary behavior. More MVPA than an individual's average was associated with earlier sleep onset (p < 0.0001), longer duration (p = 0.03), and higher sleep maintenance efficiency (p < 0.0001). On days with more sedentary behavior than an individual's average, sleep onset and offset were delayed (p < 0.0001), duration was shorter (p < 0.0001), and sleep maintenance efficiency was higher (p = 0.0005). Conversely, nights with earlier sleep onset predicted more next-day sedentary behavior (p < 0.0001), and nights with later sleep offset and longer sleep duration were associated with less MVPA (p < 0.0001) and less sedentary time (p < 0.0001, p = 0.004) the next day. These bidirectional associations between sleep and physical activity suggest that promoting MVPA may help to elicit earlier bedtimes, lengthen sleep duration, and increase sleep efficiency, critical for healthy adolescent development.

Relationship of sleep quality, smartphone dependence, and health-related behaviors in female junior college students

INTRODUCTION

Smartphone usage has become commonplace and impact on sleep quality among adolescents. Adolescent girls have a greater tendency toward sleep quality problems. However, relationship of sleep quality, smartphone dependence, and health-related behaviors in female junior college students has not been studied.

OBJECTIVES

This study had the two goals: to investigate the relationship between female college students' sleep quality, smartphone dependence, and health-related behaviors, and to identify predictors of sleep quality.

METHODS

This study employed a cross-sectional research approach to gather 409 subjects at a junior college in southern Taiwan, and used a structured questionnaire to collect data. The questionnaire consisted of four parts: basic demographic data, the Pittsburgh Sleep Quality Index, assessment of smartphone dependence, and the Health Promoting Lifestyle Profile (HPLP). Logistic regression analysis was employed to check for any association between sleep quality and smartphone dependence or HPLP.

RESULTS

Sleep quality was significantly associated with degree of smartphone dependence, total HPLP score, and scores on the four HPLP subscales of nutritional behavior, self-actualization, interpersonal support, and stress management behavior. The lower the subjects' degree of smartphone dependence was, the better their sleep quality was. Furthermore, the degree of smartphone dependence and total HPLP score were significant predictors of sleep quality.

CONCLUSIONS

Smartphone dependence is associated with poor sleep quality among female college students. Improving health-related behaviors (nutritional behavior, self-actualization, interpersonal support, and stress management behavior) can also promote improvement in sleep quality.