Review of Qualitative Exploration of Adolescent Perceptions of Healthy Sleep in Tuscon Arizona
Original Paper
Abstract
Background: Receiving insufficient sleep has wide-ranging consequences for health and well-beingness. Although educational programs take been developed to promote sleep, these accept had limited success in extending sleep elapsing. To address this gap, we adult a Web-based program emphasizing how concrete appearances change with varying amounts of sleep.
Objective: The aims of this report were to evaluate (i) whether participants tin can detect changes in appearances as a function of sleep and (2) whether this intervention can modify habitual sleep patterns.
Methods: We conducted a 5-calendar week, parallel-group, randomized controlled trial amongst lxx habitual short sleepers (healthy adults who reported having <vii hours of slumber routinely). Upon report enrollment, participants were randomly assigned (1:1) to receive either standard information or an appearance-based intervention. Both groups received educational materials about sleep, but those in the appearance group likewise viewed a website containing digitally edited photographs that showed how they would look with varying amounts of sleep. As the upshot variables, slumber duration was monitored objectively via actigraphy (at baseline and at postintervention weeks 1 and four), and participants completed a measure of sleep hygiene (at baseline and at postintervention weeks 2, iv, and 5). For each upshot, we ran intention-to-treat analyses using linear mixed-effects models.
Results: In total, 35 participants were assigned to each group. Validating the intervention, participants in the appearance group (1) were able to place what they looked like at baseline and (two) judged that they would wait more attractive with a longer slumber elapsing (t 26=x.35, P<.001). In plow, this translated to changes in sleep hygiene. Whereas participants in the appearance grouping showed improvements following the intervention (F 1,107.99=ix.05, P=.003), those in the information group did not (F i,84.7=0.xix, P=.66). Finally, at that place was no significant result of group nor interaction of group and fourth dimension on actigraphy-measured sleep duration (smallest P=.26).
Conclusions: Our findings suggest that an advent-based intervention, while not sufficient as a stand-alone, could have an adjunctive role in sleep promotion.
Trial Registration: ClinicalTrials.gov NCT02491138; https://clinicaltrials.gov/ct2/show/written report/NCT02491138.
doi:10.2196/12500
Keywords
Introduction
Background
Slumber is oftentimes described as i of 3 pillars of health, ranked alongside diet and exercise every bit modifiable targets of well-being. Underscoring this indicate, a large body of bear witness suggests that the habitual curtailment of sleep increases the risk of obesity [-], coronary heart disease [], stroke [], and all-crusade mortality [,]. Despite the centrality of slumber, i in 3 adults routinely obtain less than the recommended 7 hours of sleep for good for you adults [,]. Accordingly, the US Section of Health and Homo Services has outlined a nation-wide goal to reduce the number of habitual curt sleepers over a 10-year period [].
Despite this goal, sleep promotion campaigns accept met with limited success. In a typical programme, participants are briefed about the mechanics of sleep (eg, sleep compages), the importance of sleep, and sleep hygiene—lifestyle habits that facilitate slumber (eg, abstaining from excessive caffeine intake during the night []) [-]. Delivery of these programs range from simply providing a pamphlet [] to hosting multiple sessions (eg, viii sessions over 5 weeks []). Although slumber promotion programs may raise awareness, they fare poorly in changing actual behavior [,]. Fifty-fifty among programs that accept reported increased sleep duration, gains take been short-lived, observed but immediately afterwards the intervention [].
Reviewing this show, Cassoff et al suggested that merely providing information may not exist sufficient and that greater accent should be placed on motivational aspects of modifying sleep []. This concurs with surveys suggesting that—despite knowing the importance of sleep—many forsake it for immediate priorities such as meeting deadlines [,]. That is, they engage in temporal discounting, weighting short-term rewards (eg, completing 1's assignment) over long-term outcomes (eg, reduced risk of all-cause bloodshed) [,]. This aligns with inquiry in other health domains (eg, appetite regulation), where interventions emphasizing short-term gains (eg, fiscal incentives for weight loss or practise) were institute to encourage healthy behaviors [,]. Correspondingly, ane way to motivate better sleep patterns may exist to highlight brusk-term outcomes [,]—the proximate incentives of increased slumber elapsing or the proximate costs of sleep curtailment. To this cease, we evaluated a sleep promotion programme emphasizing ane immediate issue—how physical appearances change equally a role of sleep duration.
Developing an Appearance-Based Intervention for Slumber Promotion
Concrete appearance is highly valued across cultures [], and the desire to be bonny has motivated salubrious behaviors in both men and women []. For instance, in the prevention of skin cancers, showing participants how they would expect with connected sun exposure has been establish repeatedly to increment lord's day-protection behaviors and reduce indoor tanning frequency []. In smoking abeyance campaigns, showing the photoaging furnishings of tobacco has too increased readiness to change and actual quit attempts [,]. Finally, a recent written report found that when participants were shown how their pare color would vary as a function of diet, their intake of fruit and vegetable consumption increased, with effects lasting for 10 weeks postintervention [].
In the context of sleep, physical appearances track slumber elapsing within a brusk time window (eg, after 31 hours of total sleep deprivation [,] or post-obit 2 nights with four hours of sleep opportunity []). Relative to acceptable sleep (≥seven hours), sleep loss results in hanging eyelids, redder and swollen optics, darker eye circles, wrinkles and fine lines around the eyes, a droopy oral fissure, and poorer skin quality (eg, worsened skin hydration and elasticity and paler pare) [,]. In plough, these alterations are associated with looking sadder [], less intelligent [], less attractive [], less healthy [], and less desirable as a social companion []. Given the immediate and salient nature of these changes, physical appearances could serve every bit a motivator to overcome temporal discounting. Accordingly, we adult a novel Web-based intervention to capitalize on these changes.
To summarize, nosotros sought in this report to highlight the immediate impact of sleep loss on physical appearances. Cartoon from other health domains (sun protection, smoking cessation, and diet), we hypothesized that the appearance-based intervention would augment a standard advisory entrada in increasing sleep duration. Furthermore, because poor sleep hygiene predisposes a person to impaired nocturnal sleep and is targeted in sleep pedagogy programs [,], we tracked changes in sleep hygiene habits as an additional indicator of behavioral change [].
Methods
Study Pattern
This study involved a randomized controlled open-label trial with 2 arms: a standard information intervention and an appearance-based intervention. The trial design and outcomes were preregistered in ClinicalTrials.gov (NCT02491138) and remained unchanged throughout the study. All procedures were approved past the National University of Singapore's Institutional Review Board (A-fifteen-083).
Participants
A total of 70 immature adults were recruited from the National University of Singapore between July 2015 and December 2016. Participants responded to advertisements within the university and registered their interest via an online website. Thereafter, they were included if they were (1) aged between eighteen and 24 years; (2) had no history of psychiatric, sleep, neurological, or medical disorders (including insomnia); (3) had no history of substance corruption; and (4) reported habitual short sleep (as defined past current sleep guidelines: slumber duration of <7 hours []).
Following written informed consent (see ), participants were randomized to the 2 groups with a 1:1 allotment. The allocation sequence was prepared past the study coordinator before trial commencement and involved a figurer-generated list of random numbers. Both participants and research administration became aware of the allocation on the intervention day; all the same, research staff involved in data entry and data cleaning were blinded to participant group. Participants were not told what the intervention of interest was.
Procedures
Every bit a baseline measure, participants completed ane week of sleep monitoring where they kept a sleep diary [] and wore a wrist actigraph on the nondominant hand (Actiwatch; Philips Respironics, Inc, Pittsburgh, PA). Action was recorded in epochs of 2 min, and actigraphy measures were calculated using Actiware 6.0.5 (Philips Respironics, Inc, Pittsburgh, PA) later on photosensor data and sleep diaries were reviewed.
During the baseline stage, participants also attended the laboratory for a face up-to-face visit where they completed the Sleep Hygiene scale []. This scale involved 19 items assessing the number of days each week participants engaged in poor sleep hygiene practices (eg, slept in a room that was too brilliant; worried, planned, or idea about important matters in bed). The nineteen items were and then averaged to form a composite score, with higher scores indicating poorer slumber hygiene (Cronbach α=.72). As this component is targeted in typical sleep education programs, any improvements from baseline would represent a preliminary stride in behavioral modify.
As boosted baseline measures, participants were also characterized with two questionnaires assessing sleep quality and attitudes: (1) the Dysfunctional Behavior and Attitudes about Sleep scale (DBAS-sixteen) [], a 16-item measure out of insomnia-related cognition (Cronbach α=.87); and (2) the Pittsburgh Slumber Quality Alphabetize (PSQI) [], a 19-item mensurate of slumber quality over the by week (Cronbach α=.52). Finally, facial photographs were obtained from all participants (regardless of their intervention grouping).
For the photoshoot, 3 facial photographs were taken in a standardized room under constant lighting (resolution: 3648 × 5472 pixels, Canon Powershot G7X; Canon Inc, Tokyo, Japan). Before taking photographs, participants removed any spectacles and jewelry, combed their hair backwards, were clean shaven, and practical a facial wipe. They were and so instructed to look into the camera with a neutral expression, with photographs taken at a fixed distance from the camera.
Subsequently the baseline phase (week 0), participants visited the laboratory individually where they received either the data or appearance-based intervention. Following this visit, participants repeated the sleep hygiene scale (weeks two, four, and 5) and completed ii weeks of wrist actigraphy (weeks ane and 4). Finally, they repeated the DBAS-16 and PSQI questionnaires (in weeks two, 4, and five). Upon study completion, participants were reimbursed SGD $50. All written report visits took place at the behavioral laboratories of Yale-NUS College in Singapore, with procedures and measures administered in English—the lingua franca of the land (see for a schematic of written report procedures).
Interventions
Standard Information
In the standard information grouping, participants were shown a slideshow containing materials based on public wellness websites [,] and previous sleep pedagogy studies [-]. A trained research banana walked participants through the slide contents, introducing them to: the functions of sleep, the consequences of slumber curtailment, behavioral signs of bereft sleep, and sleep hygiene principles to promote sleep (eg, noise management in the sleeping environment). Participants were and then given a take-home pamphlet containing this aforementioned data and were not given the opportunity to ask questions. Each session was conducted individually and spanned approximately xx min.
Appearance-Based Intervention
In the advent group, transformed versions of baseline photographs were presented through an internet platform to testify how appearances would change with sleep elapsing. Sleep-related changes were ascertained from an earlier study where 25 healthy adults were photographed post-obit rested wakefulness (7-9 hours of sleep) and post-obit ii nights of sleep brake (where they were given 4 hours of sleep opportunity) []. Using Psychomorph half-dozen [] — a gratuitous software for photo transformation—these faces were blended to create 2 masks for each state (rested vs sleep restricted). Transformations were then practical by first delineating participants' photographs with 175 characteristic points aligned based on interpupillary distance. Using the masks, participants' photographs were transformed to create a continuum of 13 images, with Image 0 showing what participants would look like if they had insufficient sleep (300% of the divergence between the rested and sleep restricted masks; ). This progressed incrementally with Image vi equally the original image, and Image 12 showing what participants would expect similar if they received more sleep (300% of the departure in the opposite management; ).
During the intervention visit, participants were shown the same slideshow presentation every bit the information group. However, after hearing about the signs of insufficient sleep, they were shown a website where the 13 transformed images were presented on a continuum, with a sliding scale to manipulate appearance changes as a role of sleep duration (). Participants scrolled through the website in a cocky-paced way and were asked to (i) identify what they looked like at present and (2) to accommodate the scale to select their most attractive self. Upon making their choices, participants were again presented with Images 0 (their sleep-restricted selves) and 12 (their well-rested selves). Referring to these images, the trained research assistant highlighted how sleep curtailment affected their appearances (eg, hanging eyelids and droopy oral cavity), and how that could be perceived by others (eg, as less attractive). Thereafter, participants were reminded of the costs many incur for physical attractiveness (eg, paying a gym membership for $100/calendar month), relative to the benefits accrued from extending sleep elapsing. Finally, participants were presented information about slumber hygiene practices and were given a have-habitation pamphlet (similar to the information group). Each session was conducted individually and spanned approximately xxx min, with neither an invitation for participants to ask questions nor further access to the website (following the intervention).
Statistical Analysis
For the master outcome measures (actigraphy-measured sleep duration and slumber hygiene scores), we ran intention-to-treat analyses using linear mixed-effects models, with parameters estimated using maximum likelihood interpretation for a beginning-society autoregressive covariance structure. This examined individual change in each measure over time, with group (data or appearance), time (sleep elapsing: weeks 0, 2, 4, and 5; sleep hygiene: 0, one, and four), and the group × time interaction entered every bit fixed furnishings. Random intercepts accounted for correlated data due to repeated measures. Although the reliability of the PSQI was low in our sample (Cronbach α=.52), baseline scores differed between the groups and were entered as covariates []; nonetheless, the conclusions did not change with and without this adjustment. Finally, for sleep duration, divide models were run for weekdays and for weekends to account for differences in sleep patterns beyond the week [].
For the secondary outcome measures (global PSQI and DBAS-16 scores), we ran linear mixed-effects models identical to those used for the main issue measures, except that the model with global PSQI scores did not include covariates.
All analyses were conducted using SPSS 25 (IBM Corp, Armonk, NY) and R 3.4.0 (R Core Team, Vienna, Republic of austria), with the type 1 conclusion-wise error charge per unit controlled at α=.05. Power calculations for the main intention-to-care for analyses showed that there was statistical power at the recommended .80 level to detect a medium event size (computed through simulations, based on a meta-analysis evaluating advent-based interventions for sunday protection behaviors []). Accordingly, data drove was scheduled to terminate when 70 participants had been recruited.
Results
Participant Characterstics
Full details on participant menstruation are shown in . At baseline, actigraphy monitoring showed that participants slept an average of 5.9 hours on weekdays (SD 0.90 hours) and 6.iv hours on weekends (SD 1.32 hours). At that place were no significant grouping differences in baseline: gender, ethnicity, historic period, DBAS, sleep hygiene scores, and actigraphy-measured sleep variables ( and ). Even so, baseline global PSQI differed between groups and was included every bit a covariate.
| Characteristics | Information (northward=32), northward (%) | Appearance (north=31), n (%) | Chi-foursquare (df) | P value | |
| Gender | |||||
| Female | 25 (78) | 18 (58) | 2.92 (one) | .09 | |
| Ethnicity | 7.83 (8) | .45 | |||
| Chinese | 23 (72) | 22 (71) | —a | — | |
| Indian | 4 (12) | 7 (22) | — | — | |
| Others | 5 (sixteen) | 2 (six) | — | — | |
aNot applicable.
| Characteristics | Information (n=32), mean (SD) | Appearance (due north=31), hateful (SD) | t exam | P value | |
| Historic period (years) | twenty.66 (1.91) | 22.13 (two.14) | −0.93 (61) | .36 | |
| Mean slumber questionnaire scores | |||||
| Pittsburgh Slumber Quality Index (global score) | 10.72 (2.seventy) | 9.57 (1.65) | 1.99 (57) | .05 | |
| Dysfunctional Beliefs and Attitudes nigh Sleep | four.42 (1.32) | 4.67 (one.44) | −0.71 (61) | .48 | |
| Sleep Hygiene Score | ii.61 (0.74) | 2.52 (0.65) | 0.51 (61) | .61 | |
| Mean actigraphy metrics (averaged beyond the week) | |||||
| Bed fourth dimension (hours:min) | ii:18 (1:02) | 1:57 (ane:14) | 1.19 (56) | .24 | |
| Wake time (hours:min) | 8:57 (ane:05) | 8:47 (1:12) | 0.57 (56) | .57 | |
| Weekday slumber elapsing (hours:min) | 5:55 (0:52) | 5:54 (0:56) | 0.04 (56) | .97 | |
| Weekend slumber duration (hours:min) | 6:07 (1:18) | 6:42 (1:xviii) | −one.71 (55) | .09 | |
| Sleep latency (mins) | 12.77 (8.01) | 14.00 (8.81) | 0.55 (56) | .58 | |
| Wake subsequently sleep onset (mins) | xxx.78 (17.24) | 29.99 (17.36) | 0.17 (56) | .86 | |
| Sleep efficiency (%) | 85.16 (5.fourteen) | 86.12 (five.51) | −0.69 (56) | .49 | |
Validating the Appearance-Based Intervention
When participants in the advent group were asked to select what they looked similar, they identified Image six.81 on average (SD 3.32). A 1-sample t test found no show that this differed from the bodily baseline epitome (Image 6; t 26=1.28, P=.21, 95% CI for the mean difference: −0.50 to 2.xiii); in other words, participants correctly identified their current appearances.
On the other hand, participants selected Image nine.96 (SD ane.99) every bit the most attractive version of themselves. This differed from the baseline by an average increment of 3.96 steps (95% CI for the mean difference: 3.18-4.75; t 26=10.35, P<.001; d=ane.99). Together, the blueprint of website clicks validates the appearance-based intervention, showing how participants (ane) were sensitive to the photo transformations and (2) judged that they would look more attractive afterwards a longer sleep duration ().
Issue of the Appearance-Based Intervention: Slumber Hygiene
Compared with a standard information program, the appearance-based arroyo was more than successful in changing behaviors that could result in meliorate slumber. Namely, on the sleep hygiene measure, participants in the appearance grouping showed improved sleep hygiene after the intervention (effect of fourth dimension: F 1,107.99=9.05, P=.003), whereas those in the data grouping did non show significant changes (effect of time: F 1,84.seven=0.xix, P=.66; ). Comparison beyond time points, no grouping differences were observed at baseline or at week 2 postintervention (smallest P=.27). However, the appearance grouping reported better sleep hygiene than the information grouping in week 4 (F 1,38=6.fourteen, P=.02; 95% CI: −0.78 to −0.08; ηp²=0.14) and week 5 (F ane,49=half-dozen.23, P=.02; 95% CI: −0.68 to −0.07; ηp²=0.xi).
Effect of the Advent-Based Intervention: Actigraphy-Measured Sleep Duration
As shown in , there was neither whatever meaning event of time on weekday sleep duration (F ii,96.71=0.19, P=.83) nor a significant interaction between time and group (F two,96.71=1.38, P=.26). For weekend sleep duration, in that location was again no significant effect of fourth dimension (F 2,103.77=0.50), nor a fourth dimension × group interaction (F 2,103.77=0.xvi, P=.85; ). In , Table S1 shows adjusted means for the primary mixed-effects analyses, and , Table S2 shows the corresponding unadjusted means. Finally, , Table S3 shows how sleep quality and insomnia-related knowledge remained stable throughout the trial (smallest P for fourth dimension or the time-grouping interaction=.48).
Discussion
Principal Findings
In this written report, we adult a Spider web-based appearance-based intervention to promote slumber among habitual short sleepers. As a proof of concept, we start confirmed that participants (1) were sensitive to appearance changes and (ii) judged their well-rested selves every bit more than attractive. Correspondingly, this approach was more constructive than a standard information program in promoting slumber hygiene, with benefits sustained for 1 month subsequently the intervention.
Although these results are promising, the appearance-based intervention did not alter sleep elapsing itself. One possible caption is that many paths lead to brusk slumber, of which a motivational component is but one. Thus, while appealing to attractiveness likely motivated change in presleep habits, information technology was not sufficient to alter sleep patterns. This business relationship would suggest the need for a multipronged approach by public health agencies: for example, if slumber curtailment occurs because of immediate priorities such as pressing deadlines [,], an appearance-based intervention needs to be paired with techniques that help participants address their immediate priorities []. Alternatively, the intervention could be paired with structural changes such as a delayed schoolhouse beginning time or reduced work hours, both of which have been constitute to increment sleep duration [-]. Further enquiry volition need to explore whether these pairings volition ultimately address short slumber and how exactly motivation plays a role.
More broadly, our findings add to the growing torso of research showing how an emphasis on appearances—though not sufficient equally a stand up-alone—may supplement traditional education in public health [,,]. In recent years, appearance-based interventions accept gained traction through the technological advances of photo-transformation software. These have been implemented in mobile- and Web-based applications [,,] and take been applied across a range of health domains (sun protection [], smoking cessation [], diet [], and—with this study—slumber). Given the potential reach of internet dissemination, one way forward may be to create a single advent-based intervention that targets multiple health domains. If introduced in a timely manner (eg, incorporated into photo uploading features on a mobile dating application), this could heave existing public health campaigns, motivating healthy behaviors in a cost-effective manner.
Study Limitations
In presenting our report, nosotros note several limitations in participant choice and randomization. First, nosotros targeted participants with habitual short slumber, departing from earlier sleep pedagogy studies where participants were recruited regardless of sleep history []. Accordingly, we could not assess how the appearance-based intervention would touch the broader population. Second, we recruited university students, a group whose schedules are driven by high-stake deadlines inside a short xiii-week semester. It remains possible that stronger treatment furnishings would be observed in groups without similar deadlines (eg, adolescents or young working adults). Third, in choosing academy students, we sought—in a proof-of-concept trial—to maximize the potential bear on of our intervention. Across machismo, although the likelihood of existence a short sleeper is adequately fifty-fifty across age groups [], concerns about concrete appearances meridian in immature adults (≤24 years) and subtract linearly across the life bridge []. We thus reasoned that the selected historic period group (18-24 years) would exist nearly amenable to an advent-based intervention. However, in choosing these historic period cutoffs, we did not assess straight whether participants valued their appearances and recognize that our findings may not generalize to other age groups—for example, to older participants whose appearances may exist affected by normal aging. Moving forward, selection of the advent-based strategy can thus be customized based on the importance of physical attractiveness to the individual. Finally, as an eHealth trial, we were unable to blind the identity of which intervention participants were randomized to.
Conclusions
In determination, nosotros designed in this study a novel intervention emphasizing concrete attractiveness equally a part of sleep patterns. This was assessed through a rigorous randomized controlled trial blueprint with the following []: (one) the key intervention personalized (following all-time practices in advent-based interventions []), (two) sleep duration objectively assessed (via actigraphy), and (three) participants monitored for v weeks. Using this design, we establish that the advent-based intervention was more constructive than standard education in promoting sleep hygiene, a forerunner for healthier sleep. At the same time, these effects did not translate to sleep extension, suggesting the need to assess how appearance-based strategies tin be paired with other interventions. In summary, while urging further replication and extension of this work, our preliminary results suggest that dazzler—the driving strength that launched a thousand ships—may have an adjunctive role in promoting slumber.
Acknowledgments
This piece of work was supported past grants awarded to JCJL by the Singapore Ministry of Education (outset-upwards grant number: R-607-264-057-121 and AcRF Tier 1: IG15-B052). The authors gratefully acknowledge Benjamin Depression, Pramesh Due south/O Prabakaran, Eveline Tan, Cheslie dela Cruz, Jim Seet, and Roger Liew for aid with report preparation, information drove, and data entry.
Authors' Contributions
IP and SNT participated in research design, information collection, and the writing of the newspaper. KMV participated in research design, information collection, data assay, and the writing of the paper. MWLC, DIP, and JCJL participated in inquiry design, data assay, and the writing of the paper.
Conflicts of Interest
None declared.
Abbreviations
| DBAS-sixteen: Dysfunctional Beliefs and Attitudes about Sleep scale |
| PSQI: Pittsburgh Sleep Quality Alphabetize |
Edited past G Eysenbach; submitted 14.10.18; peer-reviewed by I Mircheva, Grand Miller, Five Rocío; comments to author 04.04.nineteen; revised version received 28.06.nineteen; accepted 23.07.19; published 26.09.xix
Copyright©Isabel Perucho, Kamalakannan M Vijayakumar, Sean Due north Talamas, Michael Wei-Liang Chee, David I Perrett, Jean C J Liu. Originally published in the Journal of Medical Internet Inquiry (http://www.jmir.org), 26.09.2019
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Source: https://www.jmir.org/2019/9/e12500
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