Evaluation of an Internet-Based Behavioral Intervention to Improve Psychosocial Health Outcomes in Children With Insomnia (Better Nights, Better Days): Protocol for a Randomized Controlled Trial

Usability of an eHealth sleep education intervention for university students

Background

It has been estimated that more than one-third of university students suffer from insomnia. Few accessible eHealth sleep education programmes exist for university students and of the ones that do exist, fewer were developed using a user-centred approach, which allows for student input to be systematically collected and utilized to provide students with a programme that they consider to be easy to use and implement and to be effective. Better Nights, Better Days-Youth (BNBD-Youth) is a four-session eHealth sleep education programme designed for youth but previously only evaluated in younger adolescents (ages 14-18 years).

Aims

The purpose of this study is to evaluate the usability of the BNBD-Youth programme with university students using Morville's User Experience Honeycomb framework to determine if this programme would meet the needs of university students and if so what modifications would be needed.

Methods

Canadian undergraduate students (n = 46) completed the BNBD-Youth programme. Students completed online usability questionnaires based on the seven dimensions of Morville's User Experience Honeycomb (i.e. useful, usable, valuable, credible, desirable, accessible and findable) after each session and after completion of the programme. Open- and closed-ended questions were used to obtain both quantitative and qualitative responses.

Results

Average quantitative ratings were positive across user experience dimensions, ranging from 3.43 to 4.46 (out of 5). Qualitative responses indicated overall positive experiences with the programme. The only constructive feedback that met the criteria for revising the programme was to include more interactive features in Session 4.

Conclusions

This study demonstrates that university students found BNBD-Youth to be a usable programme for older youth. Demonstrating usability is an essential step in developing a programme with a user-centred design that university students will want to use in the future. Once the BNBD-Youth programme is revised to create the BNBD-University (BNBD-Uni) programme, additional usability and effectiveness testing will be conducted.

An eHealth Program for Insomnia in Children With Neurodevelopmental Disorders (Better Nights, Better Days): Protocol for an Economic Evaluation of a Randomized Controlled Trial

BACKGROUND

Children with neurodevelopmental disorders have a high risk of sleep disturbances, with insomnia being the most common sleep disorder (ie, chronic and frequent difficulties with going and staying asleep). Insomnia adversely affects the well-being of these children and their caregivers. Pediatric sleep experts recommend behavioral interventions as the first-line treatment option for children. Better Nights, Better Days for Children with Neurodevelopmental Disorders (BNBD-NDD) is a 5-session eHealth behavioral intervention delivered to parents to improve outcomes (eg, Pediatric Quality of Life Inventory [PedsQL]) for their children (ages 4-12 years) with insomnia and who have a diagnosis of mild to moderate attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, or fetal alcohol spectrum disorder. If cost-effective, BNBD-NDD can be a scalable intervention that provides value to an underserved population.

OBJECTIVE

This protocol outlines an economic evaluation conducted alongside the BNBD-NDD randomized controlled trial (RCT) that aims to assess its costs, efficacy, and cost-effectiveness compared to usual care.

METHODS

The BNBD-NDD RCT evaluates the impacts of the intervention on children's sleep and quality of life, as well as parents' daytime functioning and psychosocial health. Parent participants were randomized to the BNBD-NDD treatment or to usual care. The economic evaluation assesses outcomes at baseline and 8 months later, which include the PedsQL as the primary measure. Quality of life outcomes facilitate the comparison of competing interventions across different populations and medical conditions. Cost items include the BNBD-NDD intervention and parent-reported usage of private and publicly funded resources for their children's insomnia. The economic evaluation involves a reference case cost-effectiveness analysis to examine the incremental cost of BNBD-NDD per units gained in the PedsQL from the family payer perspective and a cost-consequence analysis from a societal perspective. These analyses will be conducted over an 8-month time horizon.

RESULTS

Research funding was obtained from the Kids Brain Health Network in 2015. Ethics were approved by the IWK Health Research Ethics Board and the University of Calgary Conjoint Health Research Ethics Board in January 2019 and June 2022, respectively. The BNBD-NDD RCT data collection commenced in June 2019 and ended in April 2022. The RCT data are currently being analyzed, and data relevant to the economic analysis will be analyzed concurrently.

CONCLUSIONS

To our knowledge, this will be the first economic evaluation of an eHealth intervention for insomnia in children with neurodevelopmental disorders. This evaluation's findings can inform users and stakeholders regarding the costs and benefits of BNBD-NDD.

TRIAL REGISTRATION

ClinicalTrial.gov NCT02694003; https://clinicaltrials.gov/study/NCT02694003.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46735.

Healthy sleep for healthy schools: A pilot study of a sleep education resource to improve adolescent sleep

ISSUE ADDRESSED

Insufficient sleep and unhealthy sleep practices in adolescents are associated with significant health risks. Sleep education programs in schools aim to improve sleep behaviour. A new eLearning sleep education program, Healthy Sleep for Healthy Schools (HS4HS), was developed focused on these goals and is distinguishable from other sleep education programs because it is delivered by teachers, making it more sustainable and adaptable for schools. We aimed to evaluate if HS4HS would improve student sleep knowledge, healthy sleep practices, sleep duration and reduce sleepiness. We also aimed to understand if this intervention could be successfully implemented by trained teachers.

METHODS

Teachers trained in sleep delivered HS4HS to 64 South Australian students in year 9 (aged 13-14 years) over 6 weeks during regular school curriculum. A sleep education survey assessing sleep patterns (such as healthy sleep practices, time in bed and sleepiness), and a sleep knowledge questionnaire was completed pre- and post-HS4HS delivery. Evaluations were also completed by teachers.

RESULTS

Sleep knowledge and healthy sleep practices significantly improved post intervention. Time in bed on both school days and weekends increased slightly and sleepiness decreased slightly, but these changes were not statistically significant. Teachers found the program useful, comprehensive and easy to incorporate into their curricula.

CONCLUSIONS

After short training, teachers can deliver sleep education during class and improve sleep practices in their students. This suggests that this program may offer potential as an effective and useful resource for teachers wanting to include sleep health in their curriculum. SO WHAT?: Sleep is the foundation of good health and teachers can promote and integrate sleep education into their curricula for the first time with this online teacher focussed program, which has the potential to be a sustainable sleep health promotion resource.

Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial

IMPORTANCE

Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration.

OBJECTIVE

To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data.

INTERVENTIONS

A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school.

MAIN OUTCOMES AND MEASURES

Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used.

RESULTS

The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months.

CONCLUSIONS AND RELEVANCE

The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03556462.

Internet-delivered Cognitive Behavioral Therapy for insomnia in youth with autism spectrum disorder: A pilot study

Adolescents with ASD often suffer from sleep disorders affecting their development and quality of life. Research concerning psychological treatment of insomnia in this population is scarce. The objective of this pilot study was to examine the feasibility of internet-delivered CBT for insomnia (iCBT-I) and the participants' experiences after completing the treatment. Both quantitative and qualitative methods were used. Six adolescents with ASD and insomnia, aged 13 to 17, participated in the study. The results of the qualitative investigation showed general satisfaction with the iCBT-I. The participants experienced both better sleep and insights into their sleep patterns. Thematic analysis revealed five themes: experience of the structure of the treatment, treatment content, experienced outcomes, experienced difficulties, and suggested improvements. The results indicate the need for additional support for some participants and suggest distinct recommendations for further studies. The quantitative investigation showed large reductions in insomnia symptoms indicating the feasibility of the treatment in this population. The findings suggest promising results, but more studies are needed to define the efficacy of iCBT-I for adolescents with ASD.

REDCap Delivery of a Web-Based Intervention for Patients With Voice Disorders: Usability Study

BACKGROUND

Web-based health interventions are increasingly common and are promising for patients with voice disorders because web-based participation does not require voice use. To address needs such as Health Insurance Portability and Accountability Act compliance, unique user access, the ability to send automated reminders, and a limited development budget, we used the Research Electronic Data Capture (REDCap) data management platform to deliver a patient-facing psychological intervention designed for patients with voice disorders. This was a novel use of REDCap.

OBJECTIVE

We aimed to evaluate the usability of the intervention, with this intervention serving as a use case for REDCap-based patient-facing interventions.

METHODS

We used REDCap survey instruments to develop the web-based voice intervention modules, then conducted usability evaluations using (1) heuristic evaluations by 2 evaluators, and (2) formal usability testing with 7 participants, consisting of predetermined tasks, a think-aloud protocol, ease-of-use measurements, a product reaction card, and a debriefing interview.

RESULTS

Heuristic evaluations found strengths in visibility of system status and real-world match, and weaknesses in user control and help documentation. Based on this feedback, changes to the intervention were made before usability testing. Overall, usability testing participants found the intervention useful and easy to use, although testing revealed some concerns with design, content, and terminology. Some concerns were readily addressed, and others required adaptations within REDCap.

CONCLUSIONS

The REDCap version of a complex web-based patient-facing intervention performed well in heuristic evaluation and formal usability testing. REDCap can effectively be used for patient-facing intervention delivery, particularly if the limitations of the platform are anticipated and mitigated.

Social Media for ImpLementing Evidence (SMILE): Conceptual Framework

Background

Social media has become widely used by individual researchers and professional organizations to translate research evidence into health care practice. Despite its increasing popularity, few social media initiatives consider the theoretical perspectives of how social media works as a knowledge translation strategy to affect research use.

Objective

The purpose of this paper is to propose a conceptual framework to understand how social media works as a knowledge translation strategy for health care providers, policy makers, and patients to inform their health care decision-making.

Methods

We developed this framework using an integrative approach that first involved reviewing 5 long-standing social media initiatives. We then drafted the initial framework using a deductive approach by referring to 5 theories on social media studies and knowledge translation. A total of 58 empirical studies on factors that influenced the use of social media and its messages and strategies for promoting the use of research evidence via social media were further integrated to substantiate and fine-tune our initial framework. Through an iterative process, we developed the Social Media for ImpLementing Evidence (SMILE) framework.

Results

The SMILE framework has six key constructs: developers, messages and delivery strategies, recipients, context, triggers, and outcomes. For social media to effectively enable recipients to use research evidence in their decision-making, the framework proposes that social media content developers respond to target recipients’ needs and context and develop relevant messages and appropriate delivery strategies. The recipients’ use of social media messages is influenced by the virtual–technical, individual, organizational, and system contexts and can be activated by three types of triggers: sparks, facilitators, and signals.

Conclusions

The SMILE framework maps the factors that are hypothesized to influence the use of social media messages by recipients and offers a heuristic device for social media content developers to create interventions for promoting the use of evidence in health care decision-making. Empirical studies are now needed to test the propositions of this framework.

A Transdiagnostic Self-management Web-Based App for Sleep Disturbance in Adolescents and Young Adults: Feasibility and Acceptability Study

Background

Sleep disturbance and its daytime sequelae, which comprise complex, transdiagnostic sleep problems, are pervasive problems in adolescents and young adults (AYAs) and are associated with negative outcomes. Effective interventions must be both evidence based and individually tailored. Some AYAs prefer self-management and digital approaches. Leveraging these preferences is helpful, given the dearth of AYA treatment providers trained in behavioral sleep medicine. We involved AYAs in the co-design of a behavioral, self-management, transdiagnostic sleep app called DOZE (Delivering Online Zzz’s with Empirical Support).

Objective

This study tests the feasibility and acceptability of DOZE in a community AYA sample aged 15-24 years. The secondary objective is to evaluate sleep and related outcomes in this nonclinical sample.

Methods

Participants used DOZE for 4 weeks (2 periods of 2 weeks). They completed sleep diaries, received feedback on their sleep, set goals in identified target areas, and accessed tips to help them achieve their goals. Measures of acceptability and credibility were completed at baseline and end point. Google Analytics was used to understand the patterns of app use to assess feasibility. Participants completed questionnaires assessing fatigue, sleepiness, chronotype, depression, anxiety, and quality of life at baseline and end point.

Results

In total, 83 participants created a DOZE account, and 51 completed the study. During the study, 2659 app sessions took place with an average duration of 3:02 minutes. AYAs tracked most days in period 1 (mean 10.52, SD 4.87) and period 2 (mean 9.81, SD 6.65), with a modal time of 9 AM (within 2 hours of waking). DOZE was appraised as highly acceptable (mode≥4) on the items “easy to use,” “easy to understand,” “time commitment,” and “overall satisfaction” and was rated as credible (mode≥4) at baseline and end point across all items (logic, confident it would work, confident recommending it to a friend, willingness to undergo, and perceived success in treating others). The most common goals set were decreasing schedule variability (34/83, 41% of participants), naps (17/83, 20%), and morning lingering in bed (16/83, 19%). AYAs accessed tips on difficulty winding down (24/83, 29% of participants), being a night owl (17/83, 20%), difficulty getting up (13/83, 16%), and fatigue (13/83, 16%). There were significant improvements in morning lingering in bed (P=.03); total wake time (P=.02); sleep efficiency (P=.002); total sleep time (P=.03); and self-reported insomnia severity (P=.001), anxiety (P=.002), depression (P=.004), and energy (P=.01).

Conclusions

Our results support the feasibility, acceptability, credibility, and preliminary efficacy of DOZE. AYAs are able to set and achieve goals based on tailored feedback on their sleep habits, which is consistent with research suggesting that AYAs prefer autonomy in their health care choices and produce good results when given tools that support their autonomy.

Trial Registration

ClinicalTrials.gov NCT03960294; https://clinicaltrials.gov/ct2/show/NCT03960294

Children's Sleep During COVID-19: How Sleep Influences Surviving and Thriving in Families

OBJECTIVE

The COVID-19 pandemic has the potential to disrupt the lives of families and may have implications for children with existing sleep problems. As such, we aimed to: (1) characterize sleep changes during the COVID-19 pandemic in children who had previously been identified as having sleep problems, (2) identify factors contributing to sleep changes due to COVID-19 safety measures, and (3) understand parents' and children's needs to support sleep during the pandemic.

METHODS

Eighty-five Canadian parents with children aged 4-14 years participated in this explanatory sequential, mixed-methods study using an online survey of children's and parents' sleep, with a subset of 16 parents, selected based on changes in their children's sleep, participating in semi-structured interviews. Families had previously participated in the Better Nights, Better Days (BNBD) randomized controlled trial.

RESULTS

While some parents perceived their child's sleep quality improved during the COVID-19 pandemic (14.1%, n = 12), many parents perceived their child's sleep had worsened (40.0%, n = 34). Parents attributed children's worsened sleep to increased screen time, anxiety, and decreased exercise. Findings from semi-structured interviews highlighted the effect of disrupted routines on sleep and stress, and that stress reciprocally influenced children's and parents' sleep.

CONCLUSIONS

The sleep of many Canadian children was affected by the first wave of the COVID-19 pandemic, with the disruption of routines influencing children's sleep. eHealth interventions, such as BNBD with modifications that address the COVID-19 context, could help families address these challenges.

Standing on the shoulders of giants: A decade of research on digital pediatric sleep interventions

The purpose of this letter to the editor is to highlight previous research on digital approaches to managing pediatric insomnia and other sleep problems, to complement a recently published study by Tedford and colleagues that asserts there is a paucity of research in this regard. In this letter, selected studies of Internet- and mobile application-based behavioral sleep interventions designed for pediatric populations are reviewed. This letter aims to provide foundational information about the science of digital pediatric sleep interventions, to avoid contributing to a siloed field of research and to better inform efforts to disseminate evidence-based sleep treatment to children, families, and practicing clinicians.

Sleep-Wake Disorders in Childhood

PURPOSE OF REVIEW

The presentation of sleep issues in childhood differs from the presentation in adulthood and may be more subtle. Sleep issues may affect children differently than adults, and distinct treatment approaches are often used in children.

RECENT FINDINGS

Sodium oxybate was approved by the US Food and Drug Administration (FDA) in October 2018 for an expanded indication of treatment of sleepiness or cataplexy in patients with narcolepsy type 1 or narcolepsy type 2 aged 7 years or older, with side effect and safety profiles similar to those seen in adults. Restless sleep disorder is a recently proposed entity in which restless sleep, daytime sleepiness, and often iron deficiency are observed, but children do not meet the criteria for restless legs syndrome or periodic limb movement disorder.

SUMMARY

Children's sleep is discussed in this article, including normal sleep patterns and effects of insufficient sleep. Sleep disorders of childhood are reviewed, including insomnia, obstructive sleep apnea, restless legs syndrome, parasomnias, narcolepsy, and Kleine-Levin syndrome. Children with neurologic issues or neurodevelopmental disorders frequently have sleep disorders arising from an interaction of heterogeneous factors. Further attention to sleep may often be warranted through a polysomnogram or referral to a pediatric sleep specialist. Sleep disorders may cause indelible effects on children's cognitive functioning, general health, and well-being, and awareness of sleep disorders is imperative for neurologists who treat children.

Using Parental Report to Identify Children at Risk for Poor Sleep and Daytime Problems

OBJECTIVE

To examine objective sleep patterns and the daytime behavioral, emotional and academic functioning of school-age children above and below the clinical cutoff score for the Child Sleep Habits Questionnaire (CSHQ), which is a parental-report-based measure of sleep disturbances.

PARTICIPANTS

48 boys and 74 girls aged 7-11 years.

METHODS

Participants' sleep was assessed in their home environment using a miniature actigraph (AW-64 series; Mini-Mitter, Sunriver, OR, USA) for five consecutive weeknights. The parents provided their child's report card and completed a battery of questionnaires that included the CSHQ, the Child Behavior Checklist, a demographic questionnaire and a health questionnaire.

RESULTS

Children that were above the cutoff score of the CSHQ had later objectively measured sleep schedule, were less likely to obtain the recommended amount of sleep for their age, had higher levels of internalizing and externalizing symptoms and a higher prevalence of clinical levels of externalizing and internalizing problems, had lower grades in English and French as a Second Language, and were more likely to fail these subjects. Discriminant analysis revealed that information from the objective sleep and emotional/behavioral and academic measures could significantly discriminate between those with or without parent-reported sleep disturbance.

CONCLUSION

Parental reports of sleep disturbances can be used to identify children at increased risk for sleep, emotional, behavioral and academic problems. Such questionnaires should be incorporated into clinical practice and school-based evaluations with the goal of identifying undiagnosed children who might be at risk for poor adjustment related to night- and daytime difficulties.

A usability study of an internet-delivered behavioural intervention tailored for children with residual insomnia symptoms after obstructive sleep apnea treatment

Better Nights, Better Days (BNBD) is a 5-session online intervention designed to treat insomnia in 1-10-year-old children (Corkum et al. 2016). Obstructive sleep apnea (OSA) and insomnia commonly occur in children and, after surgical treatment for OSA, it is estimated that up to 50% of children may continue to suffer from insomnia symptoms. Access to insomnia interventions following OSA treatment is limited as there are few programs available, few trained practitioners to deliver these programs, and limited recognition that these problems exist. The current study involved the usability testing of an internet-based parent-directed session of BNBD tailored towards the needs of children (ages 4-10 years) who experience residual insomnia symptoms after treatment of OSA. This new session was added to the BNBD program. Participants (n = 43) included 6 parents, 17 sleep experts, and 20 front-line healthcare providers who completed and provided feedback on the new session. Participants completed a feedback questionnaire, with both quantitative and qualitative questions, after reviewing the session. Quantitative responses analyzed via descriptive statistics suggested that the session was primarily viewed as helpful by most participants, and open-ended qualitative questions analyzed by content analyses generated a mix of positive and constructive feedback. The results provide insights on how to optimally tailor the BNBD program to meet the needs of the target population and suggest that testing the session on a larger scale would be beneficial.

Assessment and treatment of pediatric behavioral sleep disorders in Canada

OBJECTIVES/BACKGROUND

This paper outlines the current state of Canadian training, clinical services, research, and advocacy initiatives related to non-respiratory sleep disorders, with a specific focus on insomnia, the most common sleep problem in children.

METHODS

Information for this narrative review was collected from peer-reviewed publications, web-resources, and personal communications and experiences.

RESULTS

It is estimated that approximately one-third of Canadian children and youth present with insomnia, and that this is impacting their physical and mental health, as well as learning in school. Training in pediatric sleep is limited and highly inconsistent within and across disciplines. While there are some publicly and privately funded pediatric sleep services available, these are mostly focused on respiratory sleep problems and are not equally accessible across the country.

CONCLUSIONS

Pediatric assessment and treatment services for non-respiratory sleep disorders needs to be more integrated into the Canadian health care system.