A cluster randomized controlled trial of a theory-based sleep hygiene intervention for adolescents

Application of health action process approach model to promote toothbrushing behavior among Iranian elderly population: a cluster randomized controlled trial

BACKGROUND

Improving the oral health of elderly individuals, involving various healthcare providers, should be a key objective for multidisciplinary teams responsible for their care. We aimed to compare the effectiveness of an oral health education program based on the health action process approach (HAPA) model when provided by a dentist versus a health officer among elderly people.

METHODS

This cluster-randomized controlled trial included elderly residents aged more than 60 years from 24 municipal neighborhood houses (n = 190) in Tehran, Iran, in 2021. A questionnaire was administered through face-to-face interviews at baseline to collect sociodemographic characteristics and HAPA model constructs related to toothbrushing behavior. The Simplified Oral Hygiene Index (OHI-S) was also assessed. The neighborhood houses were assigned to two groups via simple randomization: Group A, which received oral and dental health education based on the HAPA model by a dentist and an educational pamphlet (N = 89); and Group B, which was educated by a health officer and an educational pamphlet (N = 101). Both groups received reinforcement every two weeks. Follow-up oral examinations were conducted after 1 and 3 months by a blinded, calibrated examiner. The marginal model of generalized estimating equations (GEEs) with Bonferroni post hoc correction was used for intragroup and intergroup comparisons.

RESULTS

The frequency of toothbrushing was not significantly different between the two groups (p = 0.09) after one or three months. However, the frequency of toothbrushing increased significantly in both groups (p < 0.001). Additionally, no difference was found in the OHI-S score between the two groups (p = 0.56); nevertheless, there was a statistically significant improvement in oral hygiene status in both intervention groups (p < 0.001).

CONCLUSION

No difference was observed in the effectiveness of educational interventions using the HAPA model when delivered by a dentist versus a health officer working in a municipal center. Both interventions were effective at promoting the oral hygiene status of elderly individuals. These interventions could be integrated into existing public health programs.

TRIAL REGISTRATION

The trial protocol was registered in the Iranian Registry of Clinical Trials (IRCT) on 7-12-2020 (registration number: IRCT20200928048868N1).

Classifying intervention components used in sleep duration interventions for children: A systematic review and meta-analysis

The Multiphase Optimization Strategy (MOST) is a three-phase iterative framework that could accelerate the development of behavioral interventions. This systematic review and meta-analysis was conducted within the MOST preparation phase and aimed to classify components included in pediatric sleep duration interventions, using the Behavior Change Technique (BCT) Taxonomy. Across 37 interventions, 46 out of 93 BCTs have been used, with an average of 8 techniques used per study. The most common BCTs used were instruction on how to perform the behavior (N = 29; code 4.1), practical social support (N = 22; code: 3.2), and behavioral practice/rehearsal (N = 22; code: 8.1). A latent class analysis identified two classes of interventions, distinguished by the presence of BCTs falling within the following behavior change groups: shaping knowledge, natural consequences, comparison of behavior, and repetition and substitution. Our meta-analysis revealed that interventions belonging to the latent class with these behavior change groups (N = 15) had a pooled positive intervention effect of 14 min (95 % CI: 8-21) versus 8 min (95 % CI: 1-15) for interventions without these behavior change groups (N = 19). This systematic review and meta-analysis will enhance the development of sleep promotion interventions and guide the selection of candidate intervention components for future optimization and randomized control trials.

Allowing time for 8+ hours of sleep: identification and validation of important beliefs using the reasoned action approach

Introduction

The present studies advance research using the Reasoned Action Approach to understand sleep behavior. Identification of the modal salient beliefs that individuals hold regarding their sleep habits is necessary to understand the attitudes, perceived normative pressure, and perceived behavioral control (PBC) that individuals hold.

Methods

Belief elicitation (Study 1) and follow-up validation (Study 2) studies of undergraduates at a Midwestern USA university were conducted to identify readily accessible and important beliefs regarding allowing time for 8+ hours of sleep each night.

Results

Important attitude relevant beliefs included positive effects on mood, thinking, health, and productivity. Important normative beliefs were perceived injunctive pressure from family, health professionals, and significant others. Because of the strong influence of PBC on intentions/behavior, most important were control beliefs about the need for good time management.

Discussion

The present studies increased our understanding why many individuals do not allow time to obtain adequate sleep. Identification of the beliefs that distinguish between those who intend to allow time for adequate sleep and those who do not is a necessary step toward the design of effective interventions to improve sleep duration. The results indicate that a focus on increasing time management skills and PBC may be an effective approach for sleep interventions.

Effectiveness of Group Health Education on "Perceived Stress" among High-School Children of Kolar: A Cluster Randomized Controlled Trial

BACKGROUND

Adolescents are exposed to various psycho-physiological stressors due to rapid changes in their bodies along with increased academic pressure, peer pressure, and pressures from other sources of society. Group health education sessions in schools could have a positive outcome in not only the way they perceive stress but also tackle it efficiently.

OBJECTIVE

The objective of the study was to assess the effectiveness of group health education intervention on "perceived stress" among the high school children of Kolar.

MATERIALS AND METHODS

An open-label cluster randomized controlled trial was conducted among high school students (8th, 9th, and 10th standard) in selected English Medium Schools of Kolar Taluk. The study was conducted in three phases spanning 5 months of duration. Phase I included baseline data collection wherein "perceived stress" level was captured using the Perceived Stress Scale (PSS) 10 questionnaire. Phase II was the interventional phase in the form of group health education sessions. Phase III was end-line assessment.

RESULTS

Before the intervention, 6.2%, 92.4%, and 1.5% of the students had mild, moderate, and severe stress, respectively, in the intervention group. After the intervention in the intervention group, about 57.9% had mild stress, 42.1% had moderate stress, and none had severe stress. The difference in difference analysis (DID) showed that the mean PSS scores in the intervention group changed by -8.84 while in the control group by 0.40.

CONCLUSION

Group health education delivered was effective in reducing the perceived stress levels among high school children and it is a feasible and acceptable intervention for stress in school-going adolescent children.

Sleep behavioral outcomes of school-based interventions for promoting sleep health in children and adolescents aged 5 to 18 years: a systematic review

Study Objectives

Insufficient sleep is common among children and adolescents, and can contribute to poor health. School-based interventions potentially could improve sleep behavior due to their broad reach, but their effectiveness is unclear. This systematic review focused on the effects of school-based interventions on sleep behavior among children and adolescents aged 5 to 18 years.

Methods

Five electronic databases were searched for randomized controlled trials of sleep health interventions initiated or conducted in school settings and in which behavioral sleep outcomes were measured. Cochrane risk of bias tools were used to assess study quality.

Results

From the 5303 database records and two papers from other sources, 21 studies (22 papers) met the inclusion criteria for this review. These studies involved 10 867 children and adolescents at baseline from 13 countries. Most studies (n = 15) were conducted in secondary schools. Sleep education was the most common intervention, either alone (n = 13 studies) or combined with other initiatives (stress management training, n = 2; bright light therapy, n = 1; health education, n = 1). Interventions were typically brief in terms of both the intervention period (median = 4 weeks) and exposure (median = 200 minutes). Behavioral outcomes included actigraphy-measured and self-reported sleep patterns, and sleep hygiene. All outcomes had high risk of bias or some concerns with bias. Sleep education interventions were typically ineffective. Later school start times promoted longer sleep duration over 1 week (1 study, high risk of bias).

Conclusions

Current evidence does not provide school-based solutions for improving sleep health, perhaps highlighting a need for complex, multi-component interventions (e.g. whole-of-school approaches) to be trialed.

Sleep as a mediator of the relationship between social class and health in higher education students

A substantial body of research indicates that higher education students from lower social class backgrounds tend to have poorer health than those from higher social class backgrounds. To investigate sleep as a potential mediator of this relationship, online survey responses of students from five large Australian universities, one Irish university and one large Australian technical college were analysed in three studies (Study 1 N = 628; Study 2 N = 376; Study 3 N = 446). The results revealed that sleep quality, sleep duration, sleep disturbances, pre-sleep worries and sleep schedule variability mediated the relationship between social class and physical and mental health. Sleep remained a significant mediator when controlling for related variables and other mediators. Thus, the findings suggest that sleep partly explains social class differences in health. We discuss the importance of addressing sleep issues among students from lower social class backgrounds.

Nonpharmacological Interventions to Lengthen Sleep Duration in Healthy Children: A Systematic Review and Meta-analysis

Importance

Adequate sleep duration is necessary for many aspects of child health, development, and well-being, yet sleep durations for children are declining, and effective strategies to increase sleep in healthy children remain to be elucidated.

Objective

To determine whether nonpharmaceutical interventions to improve sleep duration in healthy children are effective and to identify the key components of these interventions.

Data Sources

CENTRAL, MEDLINE, Embase, PsycINFO, Web of Science Core collection, ClinicalTrials.gov, and WHO trials databases were searched from inception to November 15, 2021.

Study Selection

Randomized clinical trials of interventions to improve sleep duration in healthy children were independently screened by 2 researchers. A total of 28 478 studies were identified.

Data Extraction and Synthesis

Data were processed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guideline. Random-effects meta-analytic models were used to estimate pooled effect sizes.

Main Outcomes and Measures

Difference in sleep duration, measured in minutes.

Results

A total of 13 539 child participants from 45 randomized clinical trials were included. Of these, 6897 (50.9%) were in the intervention group and 6642 (49.1%) in the control group, and the mean age ranged from 18 months to 19 years. Pooled results indicate that sleep interventions were associated with 10.5 minutes (95% CI, 5.6-15.4) longer nocturnal sleep duration. There was substantial variation between trials. Sources of variation that were not associated with the study effect size included age group, whether the population was identified as having a sleep problem or being at a socioeconomic disadvantage (eg, coming from a low-income family or area), method of assessment of sleep duration (objective vs subjective), location of intervention delivery (home vs school), whether interventions were delivered in person or used parental involvement, whether behavioral theory was used, environmental change, or had greater or lower intensity. Interventions that included earlier bedtimes were associated with a 47-minute sleep extension (95% CI, 18.9-75.0; 3 trials) compared with remaining studies (7.4 minutes; 95% CI, 2.9-11.8; 42 trials) (P = .006 for group difference). Trials of shorter duration (6 months or less) had larger effects.

Conclusions and Relevance

Interventions focused on earlier bedtimes may offer a simple, pragmatic, effective way to meaningfully increase sleep duration that could have important benefits for child health.

The day-to-day impact of nighttime noise disturbances on college students' psychological functioning

ObjectiveTo understand environmental predictors (i.e., nighttime noise disturbance) of sleep health (i.e., restedness) in residential college students and its potential mental health consequences, this study examined daily variation in restedness upon awakening as a potential mediator between nightly environmental noise disturbances and daily fluctuations in depressive and anxiety symptoms. Participants: The sample was comprised of 283 college students (M_age = 19.9, SD = 1.9; 79% female). Methods: Multilevel structural equation modeling was conducted based on an initial self-report, online questionnaire and an online 7-day daily sleep (morning) and mood (evening) diary. Results: Daily fluctuations in college students' reports of restedness (morning diary) mediated the association between the nighttime presence of noise disturbances (morning diary) and depressive and anxiety symptoms (evening diary). Conclusions: Given the high prevalence of mental health problems in college students, creating more conducive sleep environments may help to prevent depressive and anxiety symptoms in this population.

Sleeping through a Lockdown: How Adolescents and Young Adults Struggle with Lifestyle and Sleep Habits Upheaval during a Pandemic

OBJECTIVES

The objective of the present study was to investigate the relationship between chronotype, lifestyle habits during the pandemic, and changes in sleep timing during the first wave of the COVID-19 pandemic in youth.

METHOD

An online survey of adolescents and young adults (N = 449) was conducted in June 2020. Multivariate hierarchical regressions assessed the contribution of chronotype and changes in lifestyle habits to sleep timing during the COVID-19 pandemic in two age groups (12 to 17 years old and 18 to 25 years old).

RESULTS

Chronotype was a significant predictor of changes in sleep habits during the pandemic in both age groups. In adolescents, electronic device usage during the pandemic was a significant predictor of bedtimes and wake times on weekdays, and caffeine during the pandemic was a predictor of weekday wake times. The number of hours worked during the pandemic was a significant predictor of weekday wake times in both age groups. In young adults, cannabis consumption during the pandemic was a predictor of weekend bedtimes. A later chronotype, along with higher usage of electronic devices, fewer hours worked, as well as higher caffeine and cannabis consumption during the pandemic were associated with delayed sleep timing during the pandemic in youth.

CONCLUSION

These results highlight the importance of assessing lifestyle habits when exploring changes in sleep habits in youth.

The theory of planned behaviour and sleep opportunity: An ecological momentary assessment

Many American adolescents and adults report that they are not meeting sleep duration recommendations. Although insufficient sleep duration can occur due to factors outside an individual's direct control, many individuals choose to restrict their own sleep. The theory of planned behaviour (TPB) offers a framework to study this phenomenon. Recent research efforts have used the TPB to study sleep and have demonstrated success predicting sleep-related intentions and behaviour but have failed to consider volitional sleep behaviour or consider between- and within-person differences. The present study used an intensive longitudinal design to test how constructs of the TPB relate to nightly sleep opportunity. Healthy college students (N = 79) participated in a weeklong study in which they completed four ecological momentary assessment signals per day that measured their attitudes, subjective norms, perceived behavioural control, and intentions relating to their nocturnal sleep opportunity. Participants wore an actiwatch each night of the study to measure their sleep opportunity. Mixed linear models found that both intentions and perceived behavioural control were significant predictors of subsequent sleep opportunity, and that perceived behaviour control was the strongest within-day predictor of intentions. Results demonstrate that within-person changes in perceived behavioural control and intentions predict subsequent sleep opportunity and provide insight into the potential refinement of sleep promotion efforts.

Suicidal Ideation during the COVID-19 Pandemic among A Large-Scale Iranian Sample: The Roles of Generalized Trust, Insomnia, and Fear of COVID-19

The novel 2019 coronavirus disease (COVID-19) is still not under control globally. The pandemic has caused mental health issues among many different cohorts and suicidal ideation in relation to COVID-19 has been reported in a number of recent studies. Therefore, the present study proposed a model to explain the associations between generalized trust, fear of COVID-19, insomnia, and suicidal ideation during the COVID-19 pandemic among a large-scale Iranian sample. Utilizing cluster sampling with multistage stratification, residents from Qazvin province in Iran were invited to participate in the present study. Adults aged over 18 years (n = 10,843; 6751 [62.3%] females) completed 'paper-and-pencil' questionnaires with the assistance of a trained research assistant. Structural equation modeling (SEM) was applied to understand the associations between generalized trust, fear of COVID-19, insomnia, and suicidal ideation. Slightly over one-fifth of the participants (n = 2252; 20.8%) reported suicidal ideation. Moreover, the SEM results indicated that generalized trust was indirectly associated with suicidal ideation via fear of COVID-19 and insomnia. Furthermore, generalized trust was not directly associated with suicidal ideation. The proposed model was invariant across gender groups, age groups, and participants residing in different areas (i.e., urban vs. rural). Generalized trust might reduce individuals' suicidal ideation during the COVID-19 pandemic period via reduced levels of fear of COVID-19 and insomnia. Healthcare providers and policymakers may want to assist individuals in developing their generalized trust, reducing fear of COVID-19, and improving insomnia problems to avoid possible suicidal behaviors.

Sleep in an At Risk Adolescent Group: A Qualitative Exploration of the Perspectives, Experiences and Needs of Youth Who Have Been Excluded From Mainstream Education

The sleep needs, experiences and viewpoints were explored for UK adolescents who have been excluded from mainstream education. Qualitative data was gathered through interviews with 9 participants, aged 11-15 years, who also completed questionnaires. The participants had symptoms of inadequate sleep, poor sleep hygiene behaviours and were not getting the recommended amount of sleep on school nights. Participants described sleep patterns involving often staying up late and having different sleep timing on weekends than weekdays and having difficulties with their sleep. Use of technology and the relevance of family were identified as important and associated with facilitating and hindering factors for sleep. Participants communicated that they lack control over aspects of their sleep and their lives. The experiences and views of the participants can inform professionals' understanding of how to collaborate with adolescents to improve their sleep and highlight that continued development of sleep education programmes is timely.

Effects of mindful breathing combined with sleep-inducing exercises in patients with insomnia

BACKGROUND

Insomnia is the most common sleep disorder. It disrupts the patient’s life and work, increases the risk of various health issues, and often requires long-term intervention. The financial burden and inconvenience of treatments discourage patients from complying with them, leading to chronic insomnia.

AIM

To investigate the long-term home-practice effects of mindful breathing combined with a sleep-inducing exercise as adjunctive insomnia therapy.

METHODS

A quasi-experimental design was used in the present work, in which the patients with insomnia were included and grouped based on hospital admission: 40 patients admitted between January and April 2020 were assigned to the control group, and 40 patients admitted between May and August 2020 were assigned to the treatment group. The control group received routine pharmacological and physical therapies, while the treatment group received instruction in mindful breathing and a sleep-inducing exercise in addition to the routine therapies. The Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder 7-item (GAD-7) scale, and Insomnia Severity Index (ISI) were utilized to assess sleep-quality improvement in the patient groups before the intervention and at 1 wk, 1 mo, and 3 mo postintervention.

RESULTS

The PSQI, GAD-7, and ISI scores before the intervention and at 1 wk postintervention were not significantly different between the groups. However, compared with the control group, the treatment group exhibited significant improvements in sleep quality, daytime functioning, negative emotions, sleep latency, sleep duration, sleep efficiency, anxiety level, and insomnia severity at 1 and 3 mo postintervention (P < 0.05). The results showed that mindful breathing combined with the sleep-inducing exercise significantly improved the long-term effectiveness of insomnia treatment. At 3 mo, the PSQI scores for the treatment vs the control group were as follows: Sleep quality 0.98 ± 0.48 vs 1.60 ± 0.63, sleep latency 1.98 ± 0.53 vs 2.80 ± 0.41, sleep duration 1.53 ± 0.60 vs 2.70 ± 0.56, sleep efficiency 2.35 ± 0.58 vs 1.63 ± 0.49, sleep disturbance 1.68 ± 0.53 vs 2.35 ± 0.53, hypnotic medication 0.53 ± 0.64 vs 0.93 ± 0.80, and daytime dysfunction 1.43 ± 0.50 vs 2.48 ± 0.51 (all P < 0.05). The GAD-7 scores were 2.75 ± 1.50 vs 7.15 ± 2.28, and the ISI scores were 8.68 ± 2.26 vs 3.38 ± 1.76 for the treatment vs the control group, respectively (all P < 0.05).

CONCLUSION

These simple, cost-effective, and easy-to-implement practices used in clinical or home settings could have profound significance for long-term insomnia treatment and merit wide adoption in clinical practice.

Longitudinal Relationships between Nomophobia, Addictive Use of Social Media, and Insomnia in Adolescents

(1) Background: Temporal relationships between nomophobia (anxiety related to ‘no mobile phone phobia’), addictive use of social media, and insomnia are understudied. The present study aimed to use a longitudinal design to investigate temporal relationships between nomophobia, addictive use of social media, and insomnia among Iranian adolescents; (2) Methods: A total of 1098 adolescents (600 males; 54.6%; age range = 13 to 19) were recruited from 40 randomly selected classes in Qazvin, Iran. They completed baseline assessments. The same cohort was invited to complete three follow-up assessments one month apart. Among the 1098 adolescents, 812 (400 males; 49.3%; age range = 13 to 18) completed the baseline and three follow-up assessments. In each assessment, the participants completed three questionnaires, including the Nomophobia Questionnaire (NMP-Q), Bergen Social Media Addiction Scale (BSMAS), and Insomnia Severity Index (ISI); (3) Results: Multilevel linear mixed-effects regression analyses showed that participants demonstrated increased insomnia longitudinally over 3 months (B = 0.12 and 0.19; p = 0.003 and <0.001). Insomnia was associated with nomophobia (B = 0.20; p < 0.001) and addictive use of social media (B = 0.49; p < 0.001). Nomophobia and addictive use of social media interacted with time in associations with insomnia as demonstrated by significant interaction terms (B = 0.05; p < 0.001 for nomophobia; B = 0.13; p < 0.001 for addictive use of social media); (4) Conclusions: Both nomophobia and addictive use of social media are potential risk factors for adolescent insomnia. The temporal relationship between the three factors suggests that parents, policymakers, and healthcare providers may target reducing nomophobia and addictive use of social media to improve adolescents’ sleep.

Using Mindful Attention Awareness Scale on male prisoners: Confirmatory factor analysis and Rasch models

AIM

This study tested the construct validity (i.e., factor structure) of the Persian Mindful Attention Awareness Scale (MAAS) on a sample of male prisoners.

METHODS

All the participants (mean±SD age = 39.44±7.94 years) completed three scales-the Persian MAAS, the Insomnia Severity Index (ISI), and the 12-item General Health Questionnaire (GHQ-12). Confirmatory factor analysis (CFA) and Rasch analysis with differential item functioning (DIF) were applied to examine the construct validity of the MAAS. Specifically, the DIF was tested across different insomnia status (using ISI with a cutoff of 15), psychiatric well-being status (using GHQ-12 with a cutoff of 12), and age (using mean age of 39.44 as the cutoff).

RESULTS

The CFA results showed a single factor solution for the Persian MAAS. The Rasch results showed all MAAS items fit in the construct (infit mean square [MnSq] = 0.72 to 1.41; outfit MnSq = 0.74 to 1.39) without displaying DIF items (DIF contrast = -0.34 to 0.31 for insomnia condition; -0.22 to 0.25 for psychiatric well-being; -0.26 to 0.29 for age).

CONCLUSIONS

The Persian version of the MAAS is, therefore, a valid instrument to measure mindfulness among Iranian male prisoners.

Update on school-based sleep education programs: how far have we come and what has Australia contributed to the field?

OBJECTIVE

School-based sleep education programs help to promote sleep health information to many children and adolescents. The aim of this systematic review was to identify and describe school-based sleep education programs, to update previous reviews and identify recent advances and improvements in this field worldwide.

METHODS

Four electronic databases were searched. Eligibility criteria included children aged 5-18 years, sleep education intervention conducted in a school setting, and at least one pre-post-measure of a sleep variable.

RESULTS

A total of 32 articles met eligibility criteria with Australian sleep researchers constituting ∼ one quarter of these studies. Studies dated from 2007 to 2020 with sample sizes ranging from 9 to 3713 students. The majority of participants were high school students and predominantly female. Education programs generally took 4-6 weeks and content was consistent across studies. Overall, exposure to sleep education increased sleep knowledge, however changes in sleep behaviour variables and secondary outcome variables (eg, mental health; cognitive function; sleep hygiene practices) presented varied results. Studies conducted since 2015 were more likely to be randomised controlled trials and to include more interactive, online designs utilising innovative content such as mindfulness.

CONCLUSIONS

An exponential growth in school sleep education programs was identified since 2016. Future studies should consider utilising objective sleep measures, longer-term follow-ups, innovative delivery methods, and stronger attempts at implementing a knowledge-to-action approach for more sustainable programs.

Psychological distress and quality of life in Iranian adolescents with overweight/obesity: mediating roles of weight bias internalization and insomnia

PURPOSE

To examine whether weight-related self-stigma (aka weight bias internalization) and insomnia are potential predictors of psychological distress and quality of life (QoL) among Iranian adolescents with overweight (OW)/obesity (OB). To examine whether weight-related self-stigma and insomnia are potential mediators in the relationship between excess weight and health outcomes of distress and QoL.

METHODS

All participants (n = 934; 444 males; mean age = 15.7 ± 1.2 years; zBMI = 2.8 ± 1.0) completed questionnaires on weight-related self-stigma and insomnia at baseline. Six months later, they completed questionnaires on psychological distress and QoL to assess health outcomes. Relationships among variables were tested using mediation analyses with bootstrapping method.

RESULTS

Weight-related self-stigma significantly mediated the effects of zBMI on psychological distress (effect = 0.22; bootstrapping SE = 0.09; 95% CI = 0.08, 0.45), psychosocial QoL (effect = - 0.64; bootstrapping SE = 0.19; 95% CI = - 1.10, - 0.32), and physical QoL (effect = - 1.35; bootstrapping SE = 0.54; 95% CI = - 2.43, - 0.26). Insomnia also significantly mediated the effects of zBMI on psychological distress (effect = 2.18; bootstrapping SE = 0.31; 95% CI = 1.61, 2.81), psychosocial QoL (effect = - 0.89; bootstrapping SE = 0.33; 95% CI = - 1.60, - 0.28), and physical QoL (effect = - 0.83; bootstrapping SE = 0.42; 95% CI = - 1.69, - 0.02). Full mediations were found in psychosocial QoL; partial mediations were found in psychological distress and physical QoL.

CONCLUSIONS

Weight-related self-stigma and insomnia were significant mediators in the effects of excess weight on health outcomes. Therefore, it is important to identify and treat weight-related self-stigma and insomnia for adolescents with OW/OB.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Depression, anxiety, and stress mediate the associations between internet gaming disorder, insomnia, and quality of life during the COVID-19 outbreak

BACKGROUND

For many individuals, the COVID-19 outbreak has increased their psychological distress, changed their behaviors, and impacted their health. With more time spent indoors, many individuals have engaged in increased videogame playing. However, the associations between such behaviors during the COVID-19 outbreak period is unclear.

OBJECTIVE

The present study examined the mediating role of psychological distress (depression, anxiety, and stress) in the association between internet gaming disorder (IGD) and two health outcomes (insomnia quality of life) among adolescents during this COVID-19 pandemic.

METHODS

A cross-sectional study comprising adolescents (N = 1512) aged 13-18 years (mean age = 15.51 years) was utilized to assess measures on insomnia, depression, anxiety, and stress, IGD, and quality of life during the COVID-19 pandemic.

RESULTS

There were small to large significant relationships between the variables. Psychological distress (i.e., depression, anxiety, and stress) served as a strong mediator in the association between IGD and insomnia and quality of life. IGD directly influenced insomnia and quality of life among the participants.

CONCLUSIONS

IGD is associated with different psychosocial outcomes comprising multiple pathways. Parents need to pay special attention to how much time and how frequently their children play videogames. Parents may need to assist their children in coping with psychological distress during the ongoing COVID-19 pandemic period.

Evidence Base Update on Assessing Sleep in Youth

BACKGROUND

Sleep is vital to youth well-being and when it becomes disturbed - whether due to environmental or individual factors - mental and physical health suffer. Sleep problems can also be a symptom of underlying mental health disorders. Assessing different components of sleep, including quality and hygiene, can be useful both for identifying mental health problems and for measuring changes in well-being over time. However, there are dozens of sleep-related measures for youth and it can be difficult to determine which to select for a specific research or clinical purpose. The goal of this review was to identify sleep-related measures for clinical and/or research use in youth mental health settings, and to update the evidence base on this topic.

METHOD

We generated a list of candidate measures based on other reviews and searched in PubMed and PsycINFO using the terms "sleep" AND (measure OR assessment OR questionnaire) AND (psychometric OR reliability OR validity). Search results were limited to studies about children and adolescents (aged 2-17) published in English. Additional criteria for inclusion were that there had to be at least three publications reporting on the measure psychometrics in community or mental health populations. Sleep measures meeting these criteria were evaluated using the criteria set by De Los Reyes and Langer (2018).

RESULTS

Twenty-six measures, across four domains of sleep - insomnia, sleep hygiene, sleepiness, sleep quality - met inclusion criteria. Each measure had at least adequate clinical utility. No measure(s) emerged as superior across psychometric domains.

CONCLUSION

Clinicians and researchers must evaluate sleep measures for each use case, as the intended purpose will dictate which measure is best. Future research is necessary to evaluate measure performance in transdiagnostic mental health populations, including youth with serious mental illness.

Testing an app-based intervention to improve insomnia in patients with epilepsy: A randomized controlled trial

PURPOSE

Insomnia has adverse effects on people with epilepsy. We aimed to test a novel cognitive behavioral therapy for insomnia (CBT-I) app-based intervention on insomnia symptoms and social psychological factors in people with epilepsy and to examine the possible mechanisms among the factors.

METHODS

Participants were recruited from neurology clinics in Iran and comprised individuals diagnosed with epilepsy and having moderate to severe insomnia. A two-arm randomized controlled trial design was used, consisting of a treatment group (CBT-I; n = 160) and control group (patient education; n = 160). Primary outcomes were self-reported sleep quality, insomnia severity, and sleep hygiene behavior and objective sleep characteristics measured by actigraphy. Secondary outcomes were attitude, perceived behavioral control, intention, action planning, coping planning, behavioral automaticity, self-monitoring, anxiety, depression, and quality of life (QoL). All outcomes were measured at baseline, and at one, three, and six months postintervention, except objective sleep, which was assessed at baseline, and one and six months postintervention. Data were analyzed using linear mixed models.

RESULTS

Current findings showed that sleep quality, insomnia severity, sleep hygiene behavior, and sleep onset latency were significantly improved in the CBT-I group compared with the patient education group at all measurement points. Also, the CBT-I group had significantly improved anxiety, depression, and QoL compared with the patient education group. Mediation analyses showed that attitude, intention, coping planning, self-monitoring, and behavioral automaticity significantly mediated the effect of the intervention on sleep outcomes.

CONCLUSION

Results support the use of the CBT-I app to improve sleep outcomes among people with epilepsy.

Using an integrated social cognition model to predict COVID-19 preventive behaviours

Objectives

Rates of novel coronavirus disease 2019 (COVID‐19) infections have rapidly increased worldwide and reached pandemic proportions. A suite of preventive behaviours have been recommended to minimize risk of COVID‐19 infection in the general population. The present study utilized an integrated social cognition model to explain COVID‐19 preventive behaviours in a sample from the Iranian general population.

Design

The study adopted a three‐wave prospective correlational design.

Methods

Members of the general public (N = 1,718, M_age = 33.34, SD = 15.77, male = 796, female = 922) agreed to participate in the study. Participants completed self‐report measures of demographic characteristics, intention, attitude, subjective norm, perceived behavioural control, and action self‐efficacy at an initial data collection occasion. One week later, participants completed self‐report measures of maintenance self‐efficacy, action planning and coping planning, and, a further week later, measures of COVID‐19 preventive behaviours. Hypothesized relationships among social cognition constructs and COVID‐19 preventive behaviours according to the proposed integrated model were estimated using structural equation modelling.

Results

The proposed model fitted the data well according to multiple goodness‐of‐fit criteria. All proposed relationships among model constructs were statistically significant. The social cognition constructs with the largest effects on COVID‐19 preventive behaviours were coping planning (β = .575, p < .001) and action planning (β = .267, p < .001).

Conclusions

Current findings may inform the development of behavioural interventions in health care contexts by identifying intervention targets. In particular, findings suggest targeting change in coping planning and action planning may be most effective in promoting participation in COVID‐19 preventive behaviours.

A theory-based intervention to promote medication adherence in patients with rheumatoid arthritis: A randomized controlled trial

Introduction/objectives

Adherence to prescribed medication regimens is fundamental to the improvement and maintenance of the health of patients with rheumatoid arthritis. It is therefore important that interventions are developed to address this important health behavior issue. The aim of the present study was to design and evaluate a theory-based intervention to improve the medication adherence (primary outcome) among rheumatoid arthritis patients.

Methods

The study adopted a pre-registered randomized controlled trial design. Rheumatoid arthritis patients were recruited from two University teaching hospitals in Qazvin, Iran from June 2018 to May 2019 and randomly assigned to either an intervention group (n = 100) or a treatment-as-usual group (n = 100). The intervention group received a theory-based intervention designed based on the theoretical underpinnings of the health action process approach (HAPA). More specifically, action planning (making detailed plans to follow medication regimen), coping planning (constructing plans to overcome potential obstacles that may arise in medication adherence), and self-monitoring (using a calendar to record medication adherence) of the HAPA has been used for the treatment. The treatment-as-usual group received standard care.

Results

Data analysis was conducted based on the principle of intention to treat. Using a linear mixed-effects model (adjusted for age, sex, medication prescribed, and body mass index), the results showed improved medication adherence scores in the intervention group (loss to follow-up = 16) compared to the treatment-as-usual group (loss to follow-up = 12) at the 3-month (coefficient = 3.9; SE = 0.8) and 6-month (coefficient = 4.5; SE = 0.8) follow-up. Intervention effects on medication adherence scores were found to be mediated by some of the theory-based HAPA variables that guided the study.

Conclusion

The results of the present study support the use of a theory-based intervention for improving medication adherence among rheumatoid arthritis patients, a group at-risk of not adhering to medication regimens.

Trial registration (in Iranian Registry of Clinical Trials)

irct.ir, IRCT20180108038271N1

Key Points • Theoretical underpinnings of the health action process approach are useful to improve medication adherence for RA patients.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-05224-y) contains supplementary material, which is available to authorized users.

The Mediating Effects of Eating Disorder, Food Addiction, and Insomnia in the Association between Psychological Distress and Being Overweight among Iranian Adolescents

With obesity and excess weight remaining a serious concern worldwide, investigating the mechanisms underlying this is of great importance. Psychological distress is a possible trigger contributing to excess weight for adolescents. Moreover, the association between psychological distress and excess weight may be mediated by eating disorder, food addiction, and insomnia. The present study utilized parallel mediation analysis to assess the aforementioned associations and possible mediation effects among Iranian adolescents. Through stratified and clustered sampling, adolescents (N = 861; mean ± SD age = 15.9 ± 3.2; 372 males) participated and were followed for a one-year period. Excess weight (standardized body mass index, z-BMI); psychological distress (Depression, Anxiety, and Stress Scale-21); eating disorder attitudes (Eating Attitude Test-26); food addiction (Yale Food Addiction Scale for Children); and insomnia (Insomnia Severity Index) were assessed. Eating disorder attitudes, food addiction, and insomnia were significant mediators in the association of psychological distress and z-BMI. Additionally, psychological distress had direct effects on z-BMI. Given that eating disorder attitudes, food addiction, and insomnia showed mediated effects in the temporal association of psychological distress and excess weight, healthcare providers are encouraged to design programs on improving these three mediators to help adolescents overcome excess weight problems.

Mediating role of screen media use on adolescents' total sleep time: A cluster-randomized controlled trial for physical activity and sedentary behaviour

BACKGROUND

The present study aimed to analyse the effect of an intervention for increasing physical activity (PA) and reducing sedentary time on adolescents' total sleep time (TST) and to examine whether the effect on adolescents' TST was mediated by the intervention changes on screen-based sedentary time.

METHODS

This study was a school-based cluster-randomized controlled trial conducted with Brazilian adolescents in Grades 7 to 9 (in 2017). Three schools participated in each of the intervention group (IG) and control group (CG). The intervention involved the following three strategies designed to increase PA and reduce sedentary time: (a) teacher training, (b) environmental improvements, and (c) health educational component. TST and screen-based sedentary time (television use, cell phone use, playing on computer/video game, and computer use that is not for gaming purposes) on weekdays and weekends were assessed using a standardized questionnaire. Generalized linear mixed models were conducted to verify the effect of the intervention on TST. Mediation analyses were used to examine the mediator role of changes in screen-based sedentary time in the relationship between the intervention and TST.

RESULTS

Overall, 597 students participated in this study (mean age: 13.0 ± 1.0 years; IG: n = 351; CG: n = 246). The intervention had no effect on TST on weekdays and weekends. Adolescents in the IG were more likely to report ≤2 hr of television viewing per day on weekdays at follow-up. Mediated effects by screen media use were not significant.

CONCLUSIONS

The school-based intervention for increasing PA and reducing sedentary time had no effect on adolescents' TST.

Efficacy of a Theory-Based Cognitive Behavioral Technique App-Based Intervention for Patients With Insomnia: Randomized Controlled Trial

Background

Sleep hygiene is important for maintaining good sleep and reducing insomnia.

Objective

This study examined the long-term efficacy of a theory-based app (including cognitive behavioral therapy [CBT], theory of planned behavior [TPB], health action process approach [HAPA], and control theory [CT]) on sleep hygiene among insomnia patients.

Methods

The study was a 2-arm single-blind parallel-group randomized controlled trial (RCT). Insomnia patients were randomly assigned to a treatment group that used an app for 6 weeks (ie, CBT for insomnia [CBT-I], n=156) or a control group that received only patient education (PE, n=156) through the app. Outcomes were assessed at baseline and 1 month, 3 months, and 6 months postintervention. Primary outcomes were sleep hygiene, insomnia, and sleep quality. Secondary outcomes included attitudes toward sleep hygiene behavior, perceived behavioral control, behavioral intention, action and coping planning, self-monitoring, behavioral automaticity, and anxiety and depression. Linear mixed models were used to evaluate the magnitude of changes in outcomes between the two groups and across time.

Results

Sleep hygiene was improved in the CBT-I group compared with the PE group (P=.02 at 1 month, P=.04 at 3 months, and P=.02 at 6 months) as were sleep quality and severity of insomnia. Mediation analyses suggested that perceived behavioral control on sleep hygiene as specified by TPB along with self-regulatory processes from HAPA and CT mediated the effect of the intervention on outcomes.

Conclusions

Health care providers might consider using a CBT-I app to improve sleep among insomnia patients.

Trial Registration

ClinicalTrials.gov NCT03605732; https://clinicaltrials.gov/ct2/show/NCT03605732

Effects of a HAPA-based multicomponent intervention to improve self-management precursors of older adults with tuberculosis: A community-based randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a multicomponent intervention based on the Health Action Process Approach (HAPA) model to improve the self-management precursors of older adults with tuberculosis (TB).

METHODS

A cluster-randomised controlled trial was conducted. Older adults with TB in the intervention communities received HAPA-based multicomponent interventions at the beginning of treatment and in the first and sixth months after treatment initiation, and those in the control communities received health education alone. Self-management precursors were measured at baseline and 1 week after each intervention.

RESULTS

Among 262 randomized patients, 244 (93%) completed the trial. Compared with the control group, self-management precursor scores for the intervention group increased significantly over time (β_group*time = 2.92, p < 0.001) in the following 3 precursors: behaviour belief (β_group*time = 0.35, p < 0.001), behaviour plan (β_group*time = 0.72, p < 0.001), and self-efficacy (β_group*time = 1.85, p < 0.001). Education was significantly associated with behaviour belief (β = 0.18, p < 0.05). Chronic comorbidity was significantly associated with behaviour plan (β=-0.26, p < 0.05).

CONCLUSION

Compared with single health education, the HAPA-based multicomponent interventions significantly improved the self-management precursor of older adults with TB.

PRACTICE IMPLICATIONS

This HAPA-based multicomponent intervention strategy may be a promising self-management mode for the routine health care of TB patients.

Can a modified theory of planned behavior explain the effects of empowerment education for people with type 2 diabetes?

BACKGROUND

The effectiveness of the Patient Empowerment Program (PEP) has been demonstrated in people with diabetes mellitus (DM); however, the underlying reasons for its effectiveness remain unclear. To improve effectiveness, we need to study the psychological mechanism(s) of PEP to understand why it is effective. This study hypothesized that the Theory of Planned Behavior (TPB), modified specifically for people with DM, could describe the mechanism explaining PEP effects.

METHODS

A longitudinal design was used. Patients with type 2 DM (n = 365; 151 males; mean age = 62.9 ± 9.6 years) received two education sessions (i.e. seminars delivered by registered nurses to provide disease-specific knowledge), and some (n = 210) further enrolled afterwards in five empowerment sessions (i.e. small-group interactive workshops conducted by social workers to practice action planning, problem solving, and experience sharing). Validated questionnaires were used to measure risk perception, health literacy, attitude, subjective norm, perceived behavioral control and behavioral intention on diabetes self-care behaviors, and four diabetes self-care behaviors (diet control, exercise, blood glucose monitoring, and foot care) at baseline. Three months later (i.e. at the end of PEP), all participants completed the behavioral intention and diabetes self-care behaviors measures again. Attitude, subjective norm, perceived behavioral control, behavioral intention, and diabetes self-care behaviors were assessed to represent the TPB constructs. Risk perception and health literacy elements relevant to people with DM were assessed and added to modify the TPB.

RESULTS

The behavioral intention was associated with three diabetes self-care behaviors: exercise, blood glucose monitoring, and foot care. The behavioral intention was found to be a significant mediator in the following relationships: empowerment session participation and exercise (β = 0.045, p = 0.04), and empowerment session participation and foot care (β = 0.099, p < 0.001).

CONCLUSIONS

The effects of enrollment of empowerment sessions in PEP on exercise and foot care were likely to be mediated through behavioral intention.

Parents still matter: the influence of parental enforcement of bedtime on adolescents’ depressive symptoms

Study Objectives

The aim of the current study was to test a multilevel mediation model that examined how adolescent sleep duration might be linked to depressive symptoms via their daytime energy levels. Furthermore, the study examined how parents’ enforcement of various types of bedtime rules predicted the duration of adolescent sleep.

Methods

A total of 193 adolescent (ages 14–17; Mage = 15.7 years old, SD = .94; 54.4% female; 71% Caucasian) and parent dyads completed baseline, online surveys, and adolescents also completed online 7-day, twice-daily (i.e. morning and evening) reports of their sleep duration (morning diary) and their energy levels and depressive symptoms throughout the day (evening diary). Parents (Mage = 47.6 years old, SD = 5.4; 80% female) completed assessments of enforcement of bedtime-related rules (i.e. bedtime, cessation of electronic media usage, prohibiting afternoon/evening caffeine consumption). Multilevel modeling enabled the testing of the mediation model both at the between-person level and within individuals.

Results

Results suggested that adolescents’ energy levels mediated the association between adolescents’ sleep duration and depressive symptoms. Furthermore, both greater enforcement of bedtimes and later school start times predicted longer sleep durations for adolescents, and were indirectly associated with adolescents’ depressive symptoms.

Conclusions

These findings underscore the importance of adolescents obtaining sufficient sleep to support their mental health and suggest a critical point of intervention for preventing or decreasing insufficient sleep. Given the diverse threats to adolescents’ sleep as well as adolescents’ desire for greater independence, collaborative, autonomy-promoting bedtime limit-setting is recommended to support adolescents’ well-being.

The Predictive Relationship of Health Related Quality of Life on Objectively-Measured Sleep in Children: A Comparison Across BMI Ranges

Sleep is considered a major factor related to children's general quality of life with regards to their health outcomes, general well-being, and daily life functions. Kid-KINDL, a health-related quality of life (HRQOL) measure, was used in a consecutive 12-week longitudinal study to compare the association between children's quality of life (QoL) and sleep duration across different BMI ranges. To reduce recall bias, each child wore an electronic pedometer on their wrist to record their sleep duration. The Pearson χ2 test, one-way analysis of variance (ANOVA), and mixed effect repeated measures analysis was used to investigate the association between children's QoL and their sleep duration. The original QoL scores showed that underweight children had lower emotional, family relationship, friendship, and school-related scores, and that overweight children had lower physical satisfaction and self-esteem scores. Emotional (beta = -0.3, p < 0.01) and family relationships (beta = 0.20, p = 0.01) significantly influenced the sleep duration of underweight children. The score of emotional well-being decreased by 0.3, while sleep duration increased by an hour. The poorer the emotional well-being of children, the longer they slept. The score of family well-being increased by 0.2, while sleep duration increased by an hour. The better family quality children had, the longer they slept; For overweight children, the score of family well-being increased by 0.08, while sleep duration increased by an hour (beta = 0.08, p = 0.04). Their sleep got longer when they had better family quality. Physical and school satisfaction scores also significantly affected the sleep duration of obese children. When the score of physical and school increased by 0.09, the sleep duration increases by an hour (beta = 0.09, p = 0.01; beta = 0.09, p < 0.01, respectively). The better the quality of physical condition and school life was, the longer sleep they would get. This study might be the first longitudinal study to evaluate the relationship between QoL and sleep duration, using an objective device but subjective questionnaires, across BMI ranges in a pediatric population.

Psychometric properties of the Russian version of the Pediatric Daytime Sleepiness Scale (PDSS)

Insufficient sleep could severely impair both cognitive and learning skills. More prominent changes are found in children and adolescents. Tools used to estimate sleepiness in the adult population are commonly inappropriate for children. The objective of our study was to provide a reliable instrument to measure excessive sleepiness for upcoming studies in Russian-speaking children, applying the Russian version of Pediatric Daytime Sleepiness Scale (PDSS). The following tasks were resolved in our study: translation, validation, and analysis of psychometric properties of the Russian adaptation of the PDSS by standard tests. After the semantic validation of the instrument through a multi-stage translation process we checked its psychometric validation. A total of 552 students, consisting of N = 285 for the exploratory factor analysis (EFA), N = 267 for the confirmatory factor analysis (CFA) and N = 204 for test-retest analysis of public elementary schools located in Northern Russia completed the PDSS and Munich Chronotype Questionnaire to estimate sleep parameters in the classroom during the lessons. Response rate was 90%; excluded cases contained no data. Further, 204 of our participants completed the PDSS in a 3 months interval to check the test-retest reliability. Internal consistency was measured by Cronbach's alpha coefficients and CFA was used to test factorial validity of the tool. Concurrent validity and test-retest reliability were assessed via intra-class coefficient. Internal consistency of the PDSS scale was high (Cronbach's α = 0.8). The construct validity of the PDSS was supported by CFA (factor loadings were from 0.438 to 0.727) and the test-retest reliability demonstrated by the intra-class coefficient was 0.70. The total PDSS score was independent of sex. The mean total value of PDSS was 11.95 ± 6.24. Higher scores on PDSS were negatively correlated with sleep duration. Thus, the construct validity of the instrument remains valid and could be used for Russian-speaking youth samples in the evaluation of daytime sleepiness. It could be useful in future applications by sleep scientists and health practitioners.

Negative Impacts of Self-Stigma on the Quality of Life of Patients in Methadone Maintenance Treatment: The Mediated Roles of Psychological Distress and Social Functioning

A sample of heroin users (n = 250) in methadone maintenance treatment (MMT) was used in this cross-sectional study to clarify the mechanisms of the effects of stigma on quality of life (QoL) through psychological distress and social functioning. All the participants had their self-stigma, psychological distress, social functioning, and QoL measured. Psychological distress and social functioning were proposed to be mediators between self-stigma and QoL. Several linear models using structural equation modeling were conducted to examine the mediated effects. The negative effects of self-stigma on QoL were significantly mediated by psychological distress, as self-stigma directly and significantly influenced psychological distress, but not social functioning. This study demonstrated a linear model describing the effects of self-stigma on QoL for opioid-dependent individuals; psychological distress was also an important mediator between self-stigma and their QoL. Clinicians were able to notice the importance of reducing self-stigma for opioid-dependent individuals according to the following results: higher levels of self-stigma were associated with high psychological distress, decreased social functioning, and impaired QoL. Our mediation findings suggest that treating psychological distress is better than treating social functioning if we want to eliminate the effects of self-stigma on QoL for heroin users.

Evaluating the Psychometric Properties of the 7-Item Persian Game Addiction Scale for Iranian Adolescents

The 7-item Gaming Addiction Scale (GAS) is a brief instrument based on DSM criteria to assess gaming addiction. Although the psychometric properties of the GAS have been tested using classical test theory, its psychometric properties have never been tested using modern test theory (e.g., Rasch analysis). The present study used a large adolescent sample in Iran to test the psychometric properties of the Persian GAS through both classical test and modern test theories. Adolescents (n = 4442; mean age = 15.3 years; 50.3% males) were recruited from Qazvin, Iran. In addition to the GAS, all of them completed the following instruments: the nine-item Internet Gaming Disorder Scale-Short Form (IGDS-SF9), Depression Anxiety Stress Scale (DASS), Pittsburgh Sleep Quality Index (PSQI), and a generic quality of life instrument. Two weeks later, all participants completed the GAS again. Confirmatory factor analysis (CFA) and Rasch analysis were used to test the unidimensionality of the GAS. Pearson correlation coefficients were used to test the test-retest reliability, and a regression model was used to test the criterion-related validity of the GAS. Both CFA and Rasch analysis supported the unidimensionality of the GAS. Pearson correlations coefficients showed satisfactory test-retest reliability of the GAS (r = 0.78 to 0.86), and the regression model demonstrated the criterion-related validity of the GAS (β = 0.31 with IGDS-SF9; 0.41 with PSQI). Based on the results, the Persian GAS is a reliable and valid instrument for healthcare providers to assess the level of gaming addiction among Persian-speaking adolescents.