Using actigraphy feedback to improve sleep in soldiers: an exploratory trial

The ethical dimension of personal health monitoring in the armed forces: a scoping review

BACKGROUND

Personal Health Monitoring (PHM) has the potential to enhance soldier health outcomes. To promote morally responsible development, implementation, and use of PHM in the armed forces, it is important to be aware of the inherent ethical dimension of PHM. In order to improve the understanding of the ethical dimension, a scoping review of the existing academic literature on the ethical dimension of PHM was conducted.

METHODS

Four bibliographical databases (Ovid/Medline, Embase.com, Clarivate Analytics/Web of Science Core Collection, and Elsevier/SCOPUS) were searched for relevant literature from their inception to June 1, 2023. Studies were included if they sufficiently addressed the ethical dimension of PHM and were related to or claimed relevance for the military. After selection and extraction, the data was analysed using a qualitative thematic approach.

RESULTS

A total of 9,071 references were screened. After eligibility screening, 19 articles were included for this review. The review identifies and describes three categories reflecting the ethical dimension of PHM in the military: (1) utilitarian considerations, (2) value-based considerations, and (3) regulatory responsibilities. The four main values that have been identified as being of concern are those of privacy, security, trust, and autonomy.

CONCLUSIONS

This review demonstrates that PHM in the armed forces is primarily approached from a utilitarian perspective, with a focus on its benefits, without explicit critical deliberation on PHM's potential moral downsides. Also, the review highlights a significant research gap with a specific lack of empirical studies focussing specifically on the ethical dimension of PHM. Awareness of the inherent ethical dimension of PHM in the military, including value conflicts and how to balance them, can help to contribute to a morally responsible development, implementation, and use of PHM in the armed forces.

Insufficient Sleep and Behavioral Health in the Military: A 5-Country Perspective

PURPOSE OF REVIEW

The goal of this paper was to highlight the degree to which sleep, behavioral health, and leader involvement were interrelated using data from militaries in five English-speaking countries: Australia, Canada, New Zealand, the UK, and the United States.

RECENT FINDINGS

Many service members reported sleeping fewer than the recommended 7 h/night: 34.9%, 67.2%, and 77.2% of respondents from New Zealand, Canada, and the United States, respectively. Countries reporting shorter sleep duration also reported fewer insomnia-related difficulties, likely reflecting higher sleep pressure from chronic sleep loss. Across all countries, sleep problems were positively correlated with behavioral health symptoms. Importantly, leader promotion of healthy sleep was positively correlated with more sleep and negatively correlated with sleep problems and behavioral health symptoms. Insufficient sleep in the military is ubiquitous, with serious implications for the behavioral health and functioning of service members. Leaders should attend to these risks and examine ways to promote healthy sleep in service members.

Dawn of a New Dawn: Advances in Sleep Health to Optimize Performance

Optimal sleep health is a critical component to high-level performance. In populations such as the military, public service (eg, firefighters), and health care, achieving optimal sleep health is difficult and subsequently deficiencies in sleep health may lead to performance decrements. However, advances in sleep monitoring technologies and mitigation strategies for poor sleep health show promise for further ecological scientific investigation within these populations. The current review briefly outlines the relationship between sleep health and performance as well as current advances in behavioral and technological approaches to improving sleep health for performance.

Gill N, L. Zaslona J, W. Driller M. Automatic-Scoring Actigraph Compares Favourably to a Manually-Scored Actigraph for Sleep Measurement in Healthy Adults

Introduction  Actigraphy has been used widely in sleep research due to its non-invasive, cost-effective ability to monitor sleep. Traditionally, manually-scored actigraphy has been deemed the most appropriate in the research setting; however, technological advances have seen the emergence of automatic-scoring wearable devices and software. Methods  A total of 60-nights of sleep data from 20-healthy adult participants (10 male, 10 female, age: 26 ± 10 years) were collected while wearing two devices concomitantly. The objective was to compare an automatic-scoring device (Fatigue Science Readiband™ [AUTO]) and a manually-scored device (Micro Motionlogger® [MAN]) based on the Cole-Kripke method. Manual-scoring involved trained technicians scoring all 60-nights of sleep data. Sleep indices including total sleep time (TST), total time in bed (TIB), sleep onset latency (SOL), sleep efficiency (SE), wake after sleep onset (WASO), wake episodes per night (WE), sleep onset time (SOT) and wake time (WT) were assessed between the two devices using mean differences, 95% levels of agreement, Pearson-correlation coefficients ( r ), and typical error of measurement (TEM) analysis. Results  There were no significant differences between devices for any of the measured sleep variables ( p  ≥0.05). All sleep indices resulted in very-strong correlations ( all r  ≥0.84) between devices. A mean difference between devices of <1 minutes for TST was associated with a TEM of 15.5 minute (95% CI =12.3 to 17.7 minutes). Conclusion  Given there were no significant differences between devices in the current study, automatic-scoring actigraphy devices may provide a more practical and cost-effective alternative to manually-scored actigraphy in healthy populations.

Personal health monitoring in the armed forces - scouting the ethical dimension : A case study in the Netherlands Armed Forces during the Covid-19 pandemic

BACKGROUND

The field of personal health monitoring (PHM) develops rapidly in different contexts, including the armed forces. Understanding the ethical dimension of this type of monitoring is key to a morally responsible development, implementation and usage of PHM within the armed forces. Research on the ethics of PHM has primarily been carried out in civilian settings, while the ethical dimension of PHM in the armed forces remains understudied. Yet, PHM of military personnel by design takes place in a different setting than PHM of civilians, because of their tasks and the context in which they operate. This case study therefore focusses on obtaining insights into the experiences and related values of different stakeholders regarding an existing form of PHM, the Covid-19 Radar app, in the Netherlands Armed Forces.

METHODS

We carried out an exploratory qualitative study, using semi-structured interviews with twelve stakeholders in the Netherlands Armed Forces. We focussed on participation in the use of PHM, reflections on the practical use and use of data, moral dilemmas and the need for ethics support, all in regard to PHM. The data was analysed using an inductive thematic approach.

RESULTS

Three interlinking categories reflecting ethical dimensions of PHM emerged: (1) values, (2) moral dilemmas, and (3) external norms. The main values identified were: security (in relation to data), trust and hierarchy. Multiple related values were found. Some, but no broadly shared, moral dilemmas were identified and no strong need for ethics support was expressed.

CONCLUSION

This study shed light on key values, provide insights in the experienced and presumed moral dilemmas and bring to mind ethics support considerations when looking at PHM in the armed forces. Some values bring a certain vulnerability to military users when personal and organisational interests are not aligned. Furthermore, some identified values may hinder a careful consideration of PHM because they potentially conceal parts of ethical dimensions of PHM. Ethics support can assist in uncovering and addressing these concealed parts. The findings highlight a moral responsibility for the armed forces to devote attention to the ethical dimensions of PHM.

Sleep and high-risk behavior in military service members: a mega-analysis of four diverse U.S. Army units

Experimental sleep restriction and deprivation lead to risky decision-making. Further, in naturalistic settings, short sleep duration and poor sleep quality have been linked to real-world high-risk behaviors (HRB), such as reckless driving or substance use. Military populations, in general, tend to sleep less and have poorer sleep quality than nonmilitary populations due to a number of occupational, cultural, and psychosocial factors (e.g. continuous operations, stress, and trauma). Consequently, it is possible that insufficient sleep in this population is linked to HRB. To investigate this question, we combined data from four diverse United States Army samples and conducted a mega-analysis by aggregating raw, individual-level data (n = 2,296, age 24.7 ± 5.3). A negative binomial regression and a logistic regression were used to determine whether subjective sleep quality (Pittsburgh Sleep Quality Index [PSQI], Insomnia Severity Index [ISI], and duration [h]) predicted instances of military-specific HRB and the commission of any HRB (yes/no), respectively. Poor sleep quality slightly elevated the risk for committing HRBs (PSQI Exp(B): 1.12 and ISI Exp(B): 1.07), and longer duration reduced the risk for HRBs to a greater extent (Exp(B): 0.78), even when controlling for a number of relevant demographic factors. Longer sleep duration also predicted a decreased risk for commission of any HRB behaviors (Exp(B): 0.71). These findings demonstrate that sleep quality and duration (the latter factor, in particular) could be targets for reducing excessive HRB in military populations. These findings could therefore lead to unit-wide or military-wide policy changes regarding sleep and HRB.

Efficient embedded sleep wake classification for open-source actigraphy

This study presents a thorough analysis of sleep/wake detection algorithms for efficient on-device sleep tracking using wearable accelerometric devices. It develops a novel end-to-end algorithm using convolutional neural network applied to raw accelerometric signals recorded by an open-source wrist-worn actigraph. The aim of the study is to develop an automatic classifier that: (1) is highly generalizable to heterogenous subjects, (2) would not require manual features' extraction, (3) is computationally lightweight, embeddable on a sleep tracking device, and (4) is suitable for a wide assortment of actigraphs. Hereby, authors analyze sleep parameters, such as total sleep time, waking after sleep onset and sleep efficiency, by comparing the outcomes of the proposed algorithm to the gold standard polysomnographic concurrent recordings. The relatively substantial agreement (Cohen's kappa coefficient, median, equal to 0.78 ± 0.07) and the low-computational cost (2727 floating-point operations) make this solution suitable for an on-board sleep-detection approach.

Sleep leadership in the army: A group randomized trial

OBJECTIVES

Examine impact of training military leaders in sleep health on leaders and unit members.

DESIGN

Following a baseline survey, two-person platoon leadership teams were randomly assigned by company to a training or waitlist control condition. After training, leadership teams completed a post-training survey. Six weeks later, leaders and unit members completed a final survey.

SETTING

Classroom-style areas on a US military base.

PARTICIPANTS

US soldiers (76 leaders and 448 unit members) from 39 platoons across 14 companies in a brigade combat team.

INTERVENTION

One-hour training in sleep leadership.

MEASUREMENTS

Leaders were surveyed about sleep knowledge, sleep attitudes, sleep training, sleep quantity, sleep quality and sleep problems. Unit members were surveyed about sleep leadership behaviors, sleep hours, sleep quality and sleep problems.

RESULTS

Leaders rated the training highly and most knowledge and some attitudes about sleep improved from the baseline to post-training survey. Fewer leaders in the training condition reported sleep problems at follow-up than those in the waitlist control condition; there were no differences in sleep hours or sleep quality. More unit members with leaders in the training condition reported that their leaders engaged in sleep leadership behaviors at least sometimes and reported sleeping at least 7 hours/24 hours period than did unit members in the waitlist control condition; sleep quality and sleep problems did not differ by condition.

CONCLUSIONS

Results suggest a simple training intervention targeting leaders may be able to shift sleep health and the cultural perspective on sleep across an organization.

Poor Subjective Sleep Quality Is Associated with Poor Occupational Outcomes in Elite Soldiers

We aimed to assess the relationship between subjective sleep quality and occupationally-relevant outcomes in military personnel. Participants were from an elite unit of US Army soldiers who worked extended (~30 h) shifts (with minimal recovery time between shifts) during 3-week work sessions. Questionnaires assessing subjective sleep quality during the month prior (Pittsburgh Sleep Quality Index [PSQI]) were administered at the beginning of the session. Occupational outcomes (emotional exhaustion, functional impairment, role overload, daytime sleepiness) were assessed on the final day of the session. Regression analyses were conducted to link sleep quality and occupational outcomes. The study sample participants had relatively poor sleep prior to the exercise (PSQI Global score average = 6.3 ± 3.1). Higher PSQI Global Scores prior to the work session longitudinally predicted daytime sleepiness (f2: 0.56) after the work session. PSQI component 7, which queries daytime dysfunction attributed to poor sleep quality, longitudinally predicted emotional exhaustion, functional impairment, and role overload (f2 range: 0.19-0.70). In conclusion, poor sleep quality-in aggregation with occupationally-mandated sleep loss-is predictive of poorer subsequent occupational outcomes. Future work should aim to increase sleep opportunities prior to occupationally-mandated sleep loss in order to build resilience when sleep loss is unavoidable.

Practice parameters for the use of actigraphy in the military operational context: the Walter Reed Army Institute of Research Operational Research Kit-Actigraphy (WORK-A)

BACKGROUND

The Walter Reed Army Institute of Research (WRAIR) Operational Research Kit-Actigraphy (WORK-A) is a set of unique practice parameters and actigraphy-derived measures for the analysis of operational military sleep patterns. The WORK-A draws on best practices from the literature and comprises 15 additional descriptive variables. Here, we demonstrate the WORK-A with a sample of United States Army Reserve Officers' Training Corps (ROTC) cadets (n = 286) during a month-long capstone pre-commissioning training exercise.

METHODS

The sleep of ROTC cadets (n = 286) was measured by Philips Actiwatch devices during the 31-day training exercise. The preliminary effectiveness of the WORK-A was tested by comparing differences in sleep measures collected by Actiwatches as calculated by Philips Actiware software against WORK-A-determined sleep measures and self-report sleep collected from a subset of ROTC cadets (n = 140).

RESULTS

Actiware sleep summary statistics were significantly different from WORK-A measures and self-report sleep (all P ≤ 0.001). Bedtimes and waketimes as determined by WORK-A major sleep intervals showed the best agreement with self-report bedtime (22:21 ± 1:30 vs. 22:13 ± 0:40, P = 0.21) and waketime (04:30 ± 2:17 vs. 04:31 ± 0:47, P = 0.68). Though still significantly different, the discrepancy was smaller between the WORK-A measure of time in bed (TIB) for major sleep intervals (352 ± 29 min) and self-report nightly sleep duration (337 ± 57 min, P = 0.006) than that between the WORK-A major TIB and Actiware TIB (177 ± 42, P ≤ 0.001).

CONCLUSIONS

Default actigraphy methods are not the most accurate methods for characterizing soldier sleep, but reliable methods for characterizing operational sleep patterns is a necessary first step in developing strategies to improve soldier readiness. The WORK-A addresses this knowledge gap by providing practice parameters and a robust variety of measures with which to profile sleep behavior in service members.

Sleep problems and functioning during initial training for a high-risk occupation

OBJECTIVES

The current study sought to characterize the sleep problems of soldiers entering Basic Combat Training and to identify the link between sleep problems and subsequent performance, psychological distress, anger reactions, and attention.

DESIGN

Soldiers were surveyed at 4 time points throughout the standard 10 weeks of Basic Combat Training. Surveys were administered at weeks 1, 3, 6, and 9. Sleep problems were identified as either present or absent at each time point using a sleep problem screening questionnaire. Four sleep patterns were identified and then used to evaluate outcomes throughout training (n = 1577).

RESULTS

When compared to those who never had a sleep problem ("healthy "; 60.6%), those who recovered from their initial sleep problem ("recovered"; 12.8%) started training with higher psychological distress and anger reactions and lower attention but steadily improved throughout training. Those who developed a sleep problem during training ("new onset"; 20.0%) and those who had a sleep problem throughout training ("chronic"; 6.6%) also started off significantly worse than the healthy group. The new-onset and chronic groups saw slower psychological distress improvement and a decline in attention throughout the course compared to the healthy group. The chronic group also significantly increased their anger reactions throughout training compared to the healthy group.

CONCLUSION

Sleep problems during Basic Combat Training may be an indicator for difficulties managing entry into the military. These findings highlight the importance of improving sleep health for soldiers throughout Basic Combat Training and for others with similar training in high-risk occupations.

Employee Sleep and Workplace Health Promotion: A Systematic Review

OBJECTIVE

Workplace-based employee health promotion programs often target weight loss or physical activity, yet there is growing attention to sleep as it affects employee health and performance. The goal of this review is to systematically examine workplace-based employee health interventions that measure sleep duration as an outcome.

DATA SOURCE

We conducted systematic searches in PubMed, Web of Knowledge, EMBASE, Scopus, and PsycINFO (n = 6177 records).

STUDY INCLUSION AND EXCLUSION CRITERIA

To be included in this systematic review, studies must include (1) individuals aged >18 years, (2) a worker health-related intervention, (3) an employee population, and (4) sleep duration as a primary or secondary outcome.

RESULTS

Twenty studies met criteria. Mean health promotion program duration was 2.0 months (standard deviation [SD] = 1.3), and mean follow-up was 5.6 months (SD = 6.5). The mean sample size of 395 employees (SD = 700.8) had a mean age of 41.5 years (SD = 5.2). Measures of sleep duration included self-report from a general questionnaire (n = 12, 66.6%), self-report based on Pittsburgh Sleep Quality Index (n = 4, 22.2%), and self-report and actigraphy combined (n = 5, 27.7%). Studies most commonly included sleep hygiene (35.0%), yoga (25.0%), physical activity (10.0%), and cognitive-behavioral therapy for insomnia (10.0%) interventions. Across the interventions, 9 different behavior change techniques (BCTs) were utilized; the majority of interventions used 3 or fewer BCTs, while 1 intervention utilized 4 BCTs. Study quality, on average, was 68.9% (SD = 11.1). Half of the studies found workplace-based health promotion program exposure was associated with a desired increase in mean nightly sleep duration (n = 10, 50.0%).

CONCLUSIONS

Our study findings suggest health promotion programs may be helpful for increasing employee sleep duration and subsequent daytime performance.

Predicting Suicide Ideation in the Military: The Independent Role of Aggression

The purpose of this study was to examine the longitudinal relationship between aggression and suicide ideation when controlling for other externalizing (i.e., alcohol misuse and risk-taking) and internalizing (i.e., depression and sleep problems) risk factors in an active duty, military sample. Preexisting data from a longitudinal study were analyzed to assess the wellness of service members across the deployment cycle. Participants were 944 active duty service members (95% male, 48% between 18 and 24 years old) who completed surveys upon initial return from deployment and approximately 3 months later. After controlling for other externalizing (alcohol misuse, risk-taking) and internalizing (depression, sleep problems) risk factors, service members reporting aggression were significantly more likely to report suicide ideation than those reporting no aggression (OR = 3.19; OR 95% CI: 1.16-8.80). The independent nature of the relationship between anger and suicidality suggests aggression may be an important indicator of suicidality for service members. Understanding the role of aggression in suicidality may improve the ability to identify at-risk service members and to develop effective interventions to reduce suicide risk.

Sustaining sleep: Results from the randomized controlled work, family, and health study

Although calls for intervention designs are numerous within the organizational literature and increasing efforts are being made to conduct rigorous randomized controlled trials, existing studies have rarely evaluated the long-term sustainability of workplace health intervention outcomes, or mechanisms of this process. This is especially the case with regard to objective and subjective sleep outcomes. We hypothesized that a work-family intervention would increase both self-reported and objective actigraphic measures of sleep quantity and sleep quality at 6 and 18 months post-baseline in a sample of information technology workers from a U.S. Fortune 500 company. Significant intervention effects were found on objective actigraphic total sleep time and self-reported sleep insufficiency at the 6- and 18-month follow-up, with no significant decay occurring over time. However, no significant intervention effects were found for objective actigraphic wake after sleep onset or self-reported insomnia symptoms. A significant indirect effect was found for the effect of the intervention on objective actigraphic total sleep time through the proximal intervention target of 6-month control over work schedule and subsequent more distal 12-month family time adequacy. These results highlight the value of long-term occupational health intervention research, while also highlighting the utility of this work-family intervention with respect to some aspects of sleep. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Individual differences in compliance and agreement for sleep logs and wrist actigraphy: A longitudinal study of naturalistic sleep in healthy adults

There is extensive laboratory research studying the effects of acute sleep deprivation on biological and cognitive functions, yet much less is known about naturalistic patterns of sleep loss and the potential impact on daily or weekly functioning of an individual. Longitudinal studies are needed to advance our understanding of relationships between naturalistic sleep and fluctuations in human health and performance, but it is first necessary to understand the efficacy of current tools for long-term sleep monitoring. The present study used wrist actigraphy and sleep log diaries to obtain daily measurements of sleep from 30 healthy adults for up to 16 consecutive weeks. We used non-parametric Bland-Altman analysis and correlation coefficients to calculate agreement between subjectively and objectively measured variables including sleep onset time, sleep offset time, sleep onset latency, number of awakenings, the amount of wake time after sleep onset, and total sleep time. We also examined compliance data on the submission of daily sleep logs according to the experimental protocol. Overall, we found strong agreement for sleep onset and sleep offset times, but relatively poor agreement for variables related to wakefulness including sleep onset latency, awakenings, and wake after sleep onset. Compliance tended to decrease significantly over time according to a linear function, but there were substantial individual differences in overall compliance rates. There were also individual differences in agreement that could be explained, in part, by differences in compliance. Individuals who were consistently more compliant over time also tended to show the best agreement and lower scores on behavioral avoidance scale (BIS). Our results provide evidence for convergent validity in measuring sleep onset and sleep offset with wrist actigraphy and sleep logs, and we conclude by proposing an analysis method to mitigate the impact of non-compliance and measurement errors when the two methods provide discrepant estimates.