Evaluation of an interactive school-based sleep education program: a cluster-randomized controlled trial

A qualitative systematic review of adolescent's perceptions of sleep: Awareness of, barriers to and strategies for promoting healthy sleep patterns

AIMS

To consolidate adolescents' perspectives regarding various aspects of sleep and offer insights to promote healthier sleep habits during their critical developmental years.

METHODS/DATA SOURCES

Six electronic databases (PubMed, CINAHL, Embase, Scopus, PsycINFO and Web of Science) were searched from their inception dates to June 2023. Data were extracted and meta-summarised using Sandelowski and Barroso's approach and synthesised using Thomas and Harden's thematic analysis framework.

RESULTS

Meta-synthesis from 11 peer-reviewed published studies identified four main themes: (1) Awareness and understanding of sleep's significance, (2) The shadows and radiance of slumber, (3) Traversing the sleepscape: trouble bubbles and (4) Illuminating the path: Guiding lights to enhanced sleep.

CONCLUSION/IMPLICATIONS

Our review findings suggest a lack of awareness and guidance regarding the significance of sleep and the cultivation of good sleep habits among adolescents. Identified barriers to adequate sleep encompass various factors, including overthinking, poor habits, family/environmental influences, extensive technology use, peer pressure, the fear of missing out, academic demands and involvement in extracurricular activities. Strategies to improve adolescents' sleep health involve multiple sleep strategies, including sleep education, workshops/seminars, parental involvement, incorporating digital well-being practices, the promotion of relaxation techniques and the provision of essential resources. Prioritising sleep health and implementing targeted interventions are key steps to empower adolescents, create supportive environments and shape a healthier future generation. Future research endeavours should focus on evaluating the effectiveness of interventions and exploring the influence of cultural factors.

IMPACT

There exists a notable lack of awareness and guidance regarding the significance of sleep and the cultivation of good sleep habits among adolescents. Barriers to achieving adequate sleep among adolescents include overthinking, poor habits, family/environmental influences, extensive technology use, peer pressure, the fear of missing out, academic demands and involvement in extracurricular activities. The collaboration between healthcare institutions, professionals and educational institutions is crucial to facilitate (1) the implementation of sleep education workshops/seminars targeting adolescents, (2) increased parental involvement and role-modelling to instil good sleep practices among adolescents and (3) enhanced integration of digital well-being practices, the promotion of relaxation techniques and accessibility to essential sleep hygiene resources.

REPORTING METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

TRIAL AND PROTOCOL REGISTRATION

This review was registered on the Prospective Register of Systematic Reviews (CRD42023403775).

Re-Evaluating Recommended Optimal Sleep Duration: A Perspective on Sleep Literacy

A significant number of adolescents experience sleepiness, primarily due to sleep deprivation. The detrimental effects of inadequate sleep on both physical and mental health are well documented, particularly during adolescence-a critical developmental stage that has far-reaching implications for later life outcomes. The International Classification of Diseases 11th Revision recently introduced the disorder termed 'insufficient sleep syndrome,' characterized by a persistent reduction in sleep quantity. However, diagnosing this condition based solely on sleep duration is challenging due to significant individual variation in what constitutes optimal sleep. Despite this, managing sleep debt remains difficult without a clear understanding of individual optimal sleep needs. This review aims to reassess recommended sleep durations, with a focus on enhancing sleep literacy. Beginning with an exploration of insufficient sleep syndrome, this review delves into research on optimal sleep duration and examines foundational studies on sleep debt's impact on the developing brain. Finally, it addresses the challenges inherent in sleep education programs from the perspective of sleep literacy. By doing so, this review seeks to contribute to a deeper understanding of the chronic sleep debt issues faced by adolescents, particularly those affected by insufficient sleep syndrome.

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.

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.

Effectiveness of school-based sleep promotion programs for adolescents: a systematic review protocol

OBJECTIVE

This systematic review will assess the effectiveness of school-based sleep promotion programs on sleep knowledge, hygiene, quality, behavior, and efficiency in adolescents.

INTRODUCTION

Adolescents need to sleep between 8 and 10 hours per night; however, most sleep fewer hours due to peer and school pressure, stress, and excessive use of electronic devices at night. Sleep deprivation can lead to cardiovascular problems, issues with stress management, and suicidal ideation. Schools are an ideal space to implement intervention programs, providing the opportunity to reach a large number of adolescents. Considering the negative impacts of poor sleep, it is essential to assess the effectiveness of school-based sleep promotion programs on sleep knowledge, hygiene, quality, behavior, and efficiency.

INCLUSION CRITERIA

Studies with adolescents (10-19 years old) exposed to school-based sleep promotion programs will be included. Studies in English, Spanish, and Portuguese will be considered, with no time limits.

METHODS

Nine databases, CINAHL, Cochrane Central Register of Controlled Trials, ERIC (all via EBSCOhost), MEDLINE (PubMed), LILACS, SciELO, Psychology and Behavioral Sciences Collection, Web of Science Core Collection, and Scopus, will be searched from inception to identify relevant studies. Two independent reviewers will perform the study selection, critical appraisal using JBI tools, and data extraction. Studies will, where possible, be pooled in meta-analysis. Heterogeneity will be assessed using the standard χ 2 and I2 tests. Statistical analyses will be performed using the random effects model. If fewer than 5 studies are included, the fixed effects model will be used. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach will be used to grade the certainty of evidence and a Summary of Findings will be created.

REVIEW REGISTRATION

PROSPERO CRD42023374838.

Interventions to increase sleep duration in young people: A systematic review

This systematic review explored the outcomes of current interventions to increase sleep duration in healthy young people (14-25 years). Nine databases were systematically searched, and 26 studies were included in this review. Quality assessment of the included studies was evaluated using two tools: the Newcastle-Ottawa scale, and Cochrane Risk of Bias. The interventions incorporated a range of strategies including behavioral (46.2%), educational (26.9%), a combination of behavioral and educational (15.4%), and other strategies such as physical therapy (11.5%). The findings indicate that behavioral and combination interventions were consistently effective in increasing sleep duration in healthy young people. Educational interventions alone were less effective at increasing young people's sleep duration. Of all the included studies, only one randomized control trial but none of the non-randomized trials were rated as good quality. Our findings suggest a combination of strategies with an emphasis on personalization of intervention could possibly maximize the chances of success at improving sleep duration in healthy young people. More high-quality studies with long-term assessments (≥ 6 months) should be conducted to test the efficacy and durability of interventions to increase sleep duration in young people, as well as the clinical implications to mental and physical health.

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.

A Circadian Hygiene Education Initiative Covering the Pre-pandemic and Pandemic Period Resulted in Earlier Get-Up Times in Italian University Students: An Ecological Study

The aims of the present study were to obtain sleep quality and sleep timing information in a group of university students and to evaluate the effects of a circadian hygiene education initiative. All students of the University of Padova (approximately 64,000) were contacted by e-mail (major campaigns in October 2019 and October 2020) and directed to an ad hoc website for collection of demographics and sleep quality/timing information. Participants (n = 5,740) received one of two sets of circadian hygiene advice (“A regular life” or “Bright days and dark nights”). Every month, they were then asked how easy it had been to comply and provided with the advice again. At any even month from joining, they completed the sleep quality/timing questionnaires again. Information on academic performance was obtained post hoc, together with representative samples of lecture (n = 5,972) and examination (n = 1,800) timings, plus lecture attendances (n = 25,302). Fifty-two percent of students had poor sleep quality, and 82% showed signs of social jetlag. Those who joined in October 2020, after several months of lockdown and distance learning, had better sleep quality, less social jetlag, and later sleep habits. Over approximately a year, the “Bright days and dark nights” advice resulted in significantly earlier get-up times compared with the “A regular life” advice. Similarly, it also resulted in a trend toward earlier midsleep (i.e., the midpoint, expressed as clock time, between sleep onset and sleep offset) and toward a decrease in the latency between wake-up and get-up time, with no impact on sleep duration. Significant changes in most sleep quality and sleep timing variables (i.e., fewer night awakenings, less social jetlag, and delayed sleep timing during lock-down) were observed in both advice groups over approximately a year, mostly in association with pandemic-related events characterizing 2020. Early chronotype students had better academic performances compared with their later chronotype counterparts. In a multivariate model, sleep quality, chronotype and study subject (science and technology, health and medical, or social and humanities) were independent predictors of academic performance. Taken together, these results underlie the importance of designing circadian-friendly university timetables.

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.

Classical music, educational learning, and slow wave sleep: A targeted memory reactivation experiment

Poor sleep in college students compromises the memory consolidation processes necessary to retain course materials. A solution may lie in targeting reactivation of memories during sleep (TMR). Fifty undergraduate students completed a college-level microeconomics lecture (mathematics-based) while listening to distinctive classical music (Chopin, Beethoven, and Vivaldi). After they fell asleep, we re-played the classical music songs (TMR) or a control noise during slow wave sleep. Relative to the control condition, the TMR condition showed an 18% improvement for knowledge transfer items that measured concept integration (d = 0.63), increasing the probability of "passing" the test with a grade of 70 or above (OR = 4.68, 95%CI: 1.21, 18.04). The benefits of TMR did not extend to a 9-month follow-up test when performance dropped to floor levels, demonstrating that long-term-forgetting curves are largely resistant to experimentally-consolidated memories. Spectral analyses revealed greater frontal theta activity during slow wave sleep in the TMR condition than the control condition (d = 0.87), and greater frontal theta activity across conditions was associated with protection against long-term-forgetting at the next-day and 9-month follow-up tests (rs = 0.42), at least in female students. Thus, students can leverage instrumental music-which they already commonly pair with studying-to help prepare for academic tests, an approach that may promote course success and persistence.