A Qualitative Assessment of the Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents

Usability of an augmented reality bedtime routine application for autistic children

Sleep problems are highly prevalent in autism and negatively impact the physical and mental health of children and their caregivers. Sleep education programs are often recommended as a first line-treatment to help parents implement healthy sleeping habits and a bedtime routine at home; however, the accompanying paper-based toolkits used in the bedtime routines have limitations related to engagement and adherence. To address these gaps, we iteratively developed and tested the usability of an augmented reality (AR) bedtime routine application. Our single participant design study (n = 7 child/parent dyads) found 86% compliance with the program and suggested good-excellent usability of the app with a trend toward increased willingness and faster completion of children's bedtime routines. This work supports the feasibility of using technology-based tools in sleep education programs and informs future clinical studies examining the effectiveness of these approaches for mitigating sleep difficulties.

Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions

STUDY OBJECTIVES

This review synthesizes the pediatric behavioral sleep intervention (BSI) evidence base, summarizes challenges in translating BSIs from research to practice, and provides recommendations for integrating implementation science methods to advance pediatric BSI research.

METHODS

We briefly review the common behavioral sleep disturbances among youth, discuss the pediatric BSIs with well-established evidence, and identify gaps in pediatric BSI research. We then identify contributors to the dearth of research evaluating pediatric BSIs in accessible settings and present a model for applying implementation science strategies to address identified gaps across the continuum of translational research.

RESULTS

Relatively few BSI trials include older children and adolescents. Similarly, there is limited research evaluating BSIs among racially and ethnically minoritized children and families and/or those of lower socioeconomic status backgrounds. Access to scalable and easily disseminable tools to treat pediatric sleep disturbances early in their development is crucial for promoting positive child outcomes. To address these gaps, researchers should apply implementation science theories, models, and frameworks to design new interventions for implementation, adapt existing interventions with end users and settings in mind, conduct hybrid effectiveness-implementation trials, and test implementation strategies.

CONCLUSIONS

Given the prevalence and consequences of poor sleep across developmental periods, pediatric BSIs must be effective as well as adaptable, scalable, and easily disseminable. Implementation science theories, models, and frameworks can enhance access to, engagement in, and the implementation and dissemination of scalable BSIs across diverse pediatric care settings and heterogeneous populations.

CITATION

Levenson JC, Williamson AA. Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions. J Clin Sleep Med. 2023;19(7):1321-1336.

A protocol for applying health equity-informed implementation science models and frameworks to adapt a sleep intervention for adolescents at risk for suicidal thoughts and behaviors

Background

Effective and equitable strategies to prevent youth suicidal thoughts and behaviors (STB) are an urgent public health priority. Adolescent sleep disturbances are robustly linked to STB but are rarely addressed in preventive interventions or among Black and/or Hispanic/Latinx youth for whom STB risk is increasing disproportionately. This paper describes an application of health equity-informed implementation science models and frameworks to adapt and evaluate the evidence-based Transdiagnostic Sleep and Circadian (TSC) intervention for primary care implementation with adolescents of minoritized backgrounds with depression and STB risk.

Methods

This multiphase study protocol uses the Assessment, Decision, Adaptation, Production, Topical Experts-Integration, Training, Testing (ADAPT-ITT) model to adapt and evaluate TSC for primary care implementation with adolescents who are depressed, at risk for STB, and of primarily Black and/or Hispanic/Latinx backgrounds. We integrate the Consolidated Framework for Implementation Research (CFIR) in an initial qualitative inquiry of adolescent, caregiver, and clinician perceptions of TSC. Subsequent ADAPT-ITT phases include systematically and iteratively testing adaptations based on the qualitative inquiry, with ongoing key informant input, and then evaluating the adapted TSC for feasibility, acceptability, and efficacy in a pilot randomized trial.

Anticipated results

Based on youth depression and sleep health disparities research, we expect that TSC adaptations will be needed to enhance intervention content for adolescents with depression, STB risk, and primarily Black and/or Hispanic/Latinx backgrounds. We also anticipate adaptations will be needed to align TSC delivery methods with primary care implementation.

Conclusions

Adapting evidence-based interventions with end-users and contexts in mind can help ensure that intervention strategies and delivery methods are acceptable to, and feasible with, health disparate populations. Although TSC has shown effectiveness for adolescents with sleep disturbances, we expect that additional multiphase research is necessary to optimize TSC for primary care delivery with Black and/or Hispanic/Latinx adolescents with depression and STB risk.

Attitudes of children, adolescents, and their parents toward digital health interventions: a scoping review (Preprint)

BACKGROUND

The prevalence of mental health problems in children and adolescents is high. As these problems can impact this population's developmental trajectories, they constitute a public health concern. This situation is accentuated by the fact that children and adolescents infrequently seek help. Digital health interventions (DHIs) offer an opportunity to bridge the treatment gap between health care needs and patient engagement in care. Additional detailed research is needed to identify how children and adolescents can be empowered to access help through DHIs. In this context, an understanding of their attitudes toward digital health appears to be a necessary first step in facilitating the effective implementation of DHIs.

OBJECTIVE

This study aimed to establish an inventory of children's, adolescents', and their parents' attitudes toward DHIs.

METHODS

A scoping review following PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) recommendations was performed using the MEDLINE, Embase, and PsycINFO databases. This research was conducted using 3 key concepts: "child and adolescent mental health service users," "digital health interventions," and "attitudes." Data extracted included the name of the publishing journal, the methodology used, the target population, the DHI studied, and the principal results.

RESULTS

Of 1548 studies found, 30 (1.94%) were included in our analysis. Among these, 13 concerned satisfaction, 24 concerned preferences, 22 concerned the use of DHI, 11 concerned perception, and 10 concerned needs.

CONCLUSIONS

The results of this study provide a better understanding of the factors influencing children's and adolescents' attitudes toward digital health and DHIs. The continued growth of DHIs can help reduce barriers to mental health care. Future research on these interventions should investigate the needs of the targeted populations to increase their engagement in care.

Interpersonal Theory of Nursing for Anxiety Management in People with Substance Use Disorder (ITASUD): A Feasibility Study

This study aim to evaluate the feasibility, based on six feasibility study criteria, of using a one-week intervention of interpersonal theory of nursing for anxiety management in people who are taking part in a substance use disorders (ITASUD). The study adopted a feasibility mixed methods approach. The ITASUD was implemented with 39 male users of cocaine/crack as their principal drug with high levels of anxiety. The outcome (anxiety) was assessed by the Beck anxiety inventory. To address the feasibility criteria, data were gathered during appointments. Additionally, qualitative open-ended interviews were conducted in the final appointment. The assessment of the six feasibility criteria indicated the following: (1) demand: there was high demand among eligible participants; (2) acceptability: the ITASUD had better acceptability until the 3^rd appointment; (3) implementation: the ITASUD's complexity and design was acceptable for participants; (4) practicality: 61.54% of participants used strategies from the ITASUD to manage their anxiety; (5) adaptation: there was no contamination and cointervention; and (6) safety: the ITASUD was safe. The exploratory analysis showed a relation between the level of anxiety and ITASUD (p < 0.0001). The ITASUD appears to be feasible. The participants reported positive experiences with the implementation of the ITASUD. The findings support the design of a powered larger trial to evaluate the effectiveness of the ITASUD.

A scoping review of mobile apps for sleep management: User needs and design considerations

Sleep disorders are prevalent nowadays, leading to anxiety, depression, high blood pressure, and other health problems. Due to the proliferation of mobile devices and the development of communication technologies, mobile apps have become a popular way to deliver sleep disorder therapy or manage sleep. This scoping review aims to conduct a systematic investigation of mobile apps and technologies supporting sleep, including the essential functions of sleep apps, how they are used to improve sleep and the facilitators of and barriers to using apps among patients and other stakeholders. We searched articles (2010 to 2022) from Scopus, Web of Science, Science Direct, PubMed, and IEEE Xplore using the keyword sleep apps. In total, 1,650 peer-reviewed articles were screened, and 51 were selected for inclusion. The most frequently provided functions by the apps are sleep monitoring, measuring sleep, providing alarms, and recording sleep using a sleep diary. Several wearable devices have been used with mobile apps to record sleep duration and sleep problems. Facilitators and barriers to using apps were identified, along with the evidence-based design guidelines. Existing studies have proved the initial validation and efficiency of delivering sleep treatment by mobile apps; however, more research is needed to improve the performance of sleep apps and devise a way to utilize them as a therapy tool.

Engineering a mobile platform to promote sleep in the pediatric primary care setting

Study Objectives

Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion. The objective of this study is to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep.

Methods

Children aged 10–12 years were enrolled (Study #1: N = 30; Study #2: N = 43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms.

Results

In study #1, 1514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: −8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms.

Conclusions

We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.

Clinical Trials

Both studies included in this manuscript were registered at clinicaltrials.gov:

-Study #1: NCT03263338

-Study #2: NCT03426644

A Multiple Health Behavior Change, Self-Monitoring Mobile App for Adolescents: Development and Usability Study of the Health4Life App

BACKGROUND

The link between chronic diseases and the Big 6 lifestyle risk behaviors (ie, poor diet, physical inactivity, smoking, alcohol use, sedentary recreational screen time, and poor sleep) is well established. It is critical to target these lifestyle risk behaviors, as they often co-occur and emerge in adolescence. Smartphones have become an integral part of everyday life, and many adolescents already use mobile apps to monitor their lifestyle behaviors and improve their health. Smartphones may be a valuable platform for engaging adolescents with interventions to prevent key chronic disease risk behaviors.

OBJECTIVE

The aim of this paper is to describe the development, usability, and acceptability of the Health4Life app, a self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors.

METHODS

The development of the Health4Life app was an iterative process conducted in collaboration with adolescents and experts. The development process consisted of three stages: scoping the literature; end user consultations, which included a web-based survey (N=815; mean age 13.89, SD 0.89 years) and a focus group (N=12) among adolescents; and app development and beta testing. Following this development work, 232 adolescents were asked to rate the usability and acceptability of the app.

RESULTS

The process resulted in a self-monitoring smartphone app that allows adolescent users to track and set goals for the Big 6 health behaviors, using in-app rewards and notifications to enhance engagement. The overall adolescent feedback was positive in terms of user-friendly design, content, relevance, and helpfulness. Commonly identified areas for improvement were to increase interactive features and display recorded health behaviors differently to improve interpretability.

CONCLUSIONS

The Health4Life app is a co-designed, self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors. Adolescents rated the app as highly acceptable and usable. The app has the potential to efficiently and effectively modify important risk factors for chronic disease among young people and is currently being evaluated in a world-first trial of 6640 secondary school students in 71 schools across Australia.

Health Literacy in Schools? A Systematic Review of Health-Related Interventions Aimed at Disadvantaged Adolescents

Socioeconomically disadvantaged populations are at greater risk of adopting unhealthy behaviours and developing chronic diseases. Adolescence has been identified as a crucial life stage to develop lifelong healthy behaviours, with schools often suggested as the ideal environment to foster healthy habits. Health literacy (HL) provides a possible solution to promote such healthy behaviours. The aim of this study was to review school-based HL-related interventions targeting socioeconomically disadvantaged adolescents and to identify effective intervention strategies for this population. Searches were performed in six databases. Inclusion criteria included age: 12–16; the implementation of a school-based intervention related to HL aimed at socioeconomically disadvantaged populations; an intervention focused on: physical activity (PA), diet, mental health, substance abuse or sleep. Forty-one articles were included, with the majority focusing on PA and diet (n = 13), PA (n = 9) or mental health (n = 7). Few interventions focused solely on substance abuse (n = 2) or sleep (n = 1), and none targeted or assessed HL as an outcome measure. There was huge heterogeneity in study design, outcomes measures and effectiveness reported. Effective intervention strategies were identified that can be used to guide future interventions, including practical learning activities, peer support and approaches targeting the school environment, the parents or that link the intervention to the community.

Engineering a Mobile Platform to Promote Sleep in the Pediatric Primary Care Setting

Background

Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion.

Purpose

Under the preparation phase of the MOST framework, to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep.

Methods

Children aged 10-12y were enrolled (Study #1: N=30; Study #2: N=43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms.

Results

In study #1, 1,514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: -8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms.

Conclusion

We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.

Understanding sleep facilitators, barriers, and cultural dimensions in Native American urban youth

OBJECTIVES

American Indian/Alaska Native (AI/AN) youth are a high-risk group for sleep problems and associated chronic conditions. Urban AI/AN youth may face certain challenges, including specific psychosocial stressors (e.g., discrimination) and environmental factors (e.g., noise, light) that render them particularly vulnerable to poor sleep health. However, few studies have explored AI/AN adolescent sleep. To our knowledge, this is the first study to use systematic qualitative methods with AI/AN youth to explore their sleep environment and sleep behaviors.

DESIGN

In-depth interviews with 26 youth.

SETTING

Two urban areas in Central and Southern California.

PARTICIPANTS

Urban-dwelling AI/AN youth, age 12-16 years.

INTERVENTION

N/A.

MEASUREMENT

N/A.

RESULTS

We identified five main themes, each with subthemes: sleep patterns and desired sleep, sleep barriers inside the home, environmental factors, sleep facilitators, and cultural dimensions. Key concerns discussed were poor sleep hygiene, excessive use of electronics prior to bedtime, issues with temperature regulation, and noise both within and outside the home. Parents can be an important vehicle for messaging around sleep health and for behavior management. Participating adolescents also indicated differing levels of attachment to Native identity, suggesting that culturally-targeted sleep interventions should build in openness and flexibility to a range of identity starting points. Further, we identified cultural practices, such as sweat lodges and dreamcatchers, that could be incorporated in future sleep interventions for this population.

CONCLUSION

Findings increase our understanding of urban AI/AN youth's sleep environments and behaviors, thus potentially informing program development around sleep health for this vulnerable population.

Adapting sleep hygiene for community interventions: a qualitative investigation of sleep hygiene behaviors among racially/ethnically diverse, low-income adults

BACKGROUND

Despite the high prevalence of inadequate sleep in racially/ethnically diverse, low-income adults, there is scant research targeting sleep health interventions among underserved populations. Sleep hygiene (SH) recommendations may help promote sleep health for the general population; however, they likely require tailoring to optimize uptake and effectiveness in the "real world" given socio-contextual factors. As an initial step to developing contextually appropriate and effective community-based SH interventions, we conducted qualitative research to understand SH behaviors, beliefs, and barriers in a low-income, ethnically diverse sample of adults.

METHODS

We recruited 24 racially/ethnically diverse adults from an affordable housing community who self-reported sleeping ≤6 hours on average. Participants were invited to either an individual interview (n = 5) or a focus group (n = 3). A deductive, thematic-analysis approach was employed. Data collection and interpretation were informed by the Socio-Contextual Model of Behavior Change.

RESULTS

There was evidence of high acceptability of SH and interest in improving sleep health. Barriers to implementing SH were multifaceted, including individual (knowledge, motivation, habits, medical issues, stress, trauma), interpersonal (caregiving), organizational (job strain), and environmental (noise) factors.

CONCLUSIONS

Future strategies for adapting behavioral SH interventions should target knowledge, skill development, and behavioral change domains, such as motivation, social support, and self-efficacy. In addition, adapting SH beyond the clinical context for a high-need community population requires attention to multilevel sociocontextual factors that contribute to sleep health, particularly chronic stress, prior trauma, and adverse sleeping environments. Development of novel trauma-informed SH interventions may promote effective and safe implementation.

"Let's talk about sleep": a qualitative examination of levers for promoting healthy sleep among sleep-deprived vulnerable adolescents

OBJECTIVE

Deficient sleep is highly prevalent in disadvantaged adolescents and contributes to a range of adverse health and behavioral outcomes. We examined mediating mechanisms and strategies that adolescents adopt to improve sleep, and possible levers for promoting sleep in this population.

METHODS

We conducted three focus groups (N = 27 total, age 14-18 years) in adolescents living in low- and middle-income racially/ethnically diverse neighborhoods of Boston, Massachusetts. Participants completed a survey on their sleep and health habits prior to the moderator-led discussions. Discussions were audio-recorded, transcribed, and thematically analyzed.

RESULTS

The study population did not meet the minimum sleep recommendations, and we found a high prevalence of "social jet-lag." We also identified a disconnect between the acknowledgment of the importance of sleep and actual behavior, especially for electronic use. Phone use and screen time were the most commonly cited barriers to a good night's sleep, along with caffeine consumption, which was also high in this sample. There was also a general lack of awareness of sleep hygiene practices and recommendations. Participants reported regulating food intake and physical activity, using allopathic sleep aids, creating a comfortable sleeping environment, and a routine as some strategies to improve sleep.

CONCLUSION

Results from this study suggest facilitating the linkage between participant-generated mediating factors and strategies for better-designed interventions. These include making the negative impact of sleep on health more explicit, improving youth awareness about sleep hygiene, targeting caffeine consumption and electronic use, and introducing sleep recommendations through appropriate and effective channels.