Sleep in context

Question 1

Sleep model- Grandner, 2019

Answer 1

Sleep →
Domains of functioning: general health, cardiovascular health, metabolic health, immunologic health, behavioural health, emotional heath, cognitive health, physical health (all these things interact) →
Longetivity

Question 2

Sleep Health Buysse, 2014
(sleep health and good sleep health)

Answer 2

• ‘Sleep health is a multidimensional pattern of sleep-wakefulness, adapted to individual, social and environmental demands, that promotes physical and mental well-being.’
• ‘Good sleep health is characterized by subjective satisfaction, appropriate timing, sufficient duration, high efficiency, and sustained alertness during waking hours’.

Question 3

Model of Sleep Health (Michael A. Grander)

Answer 3

Societal-Level Factors:
Globalisation, 24/7 society, geography, public policy, technology and progress, racism and discrimination, economics, natural environment

Social-Level Factors:
Home, family, work, school, neighbourhood, religion, culture race/ethnicity, socioeconomic states, social networks

Individual-Level Factors:
Genetics, beliefs, attitudes, behaviours, physiology, psychology, health, choices

→

Sleep

Question 4

What is stopping us?
- The obstacles to overcome in order to improve sleep?

Answer 4

• Genetic, psychological, personality factors, etc

The obstacles to overcome in order to improve sleep:
- Lack of time (work and TV and not so much other activities)
- Norms and Beliefs (we perhaps perceive sleep as not doing anything/ being lazy so could be perceived as a wasteof time, people might not appreciate and have norms that sleep should be the last thing they do)
- Health conditions and chronic pain
- Substance use
- Distractions and on-demand culture

Question 5

Perceived Social Norms About Sleep (Grandner, 2014)

My friends and family believe that not enough sleep can cause them to… (what did people strongly agree/ unsure about)

Answer 5

Strongly agree not enough sleep will lead to….
- feel tired
- have less energy
- feel sleepy during the day
- be more moody

Unsure that not enough sleep will lead to….
- raise cholesterol
- develop diabetes
- develop hypertension
- develop heart disease

Question 6

Knowledge and Awareness
1- what are public health professionals working towards
2- sometimes effort of public health is to do things…
3- question of would it be better to
4- however…

Answer 6

1- Public Health professionals are working towards changing the behaviour of the public

2- Sometimes effort of public health is to do things indirectly (to try to help people make better choices - prevent them from reaching for things bad for them). Sometimes the public is not aware of this effort (such as taxes on tobacco and alcohol).
- How effective is this approach?

3- Would it be better to pass on the knowledge and allow the person to make adjustments in their behaviour?
- Children of parents with higher levels of sleep knowledge have healthier sleep practices compared to children of parents with less sleep knowledge (McDowall et al, 2017)

4- However, knowledge does not always directly or immediately translate into action- it can take time for things to be implemented

Question 7

Knowledge and Awareness
1- how can change happen
2- what kind of process
3- what has received little attention

Answer 7

1- Change can happen in small steps - Not all healthy sleep behaviours can be achieved at the same time (can be gradual for interventions to be implemented)
2- This can be a gradual process as the person learns about each aspect of their life and how these may impact sleep
3- Sleep education has received very little attention in non-clinical populations
- it can be critical as adolescents and young adults gain more autonomy around bedtime and face increased life demands

Question 8

Knowledge and Awareness
1- how might education programmes be most effective
2- attention of sleep
3- how might it be more effective

Answer 8

1- Education programs may be most effective when combined with other intervention components, i.e. self-monitoring, role modelling) or as part of a greater context (i.e. increasing social support, policy changes)
2- Comparatively, sleep gets less attention than diet and exercise
3- Perhaps it would be more effective if health care professionals introduced the risks and benefits of performing a certain behaviour i.e. keeping a steady sleep and wake schedule

Question 9

Self-Efficacy (Bandura, 1997)

Answer 9

• Self-Efficacy (SE): the confidence in one’s ability to perform a particular behaviour
• The perceived level of SE may be low if there are barriers whereas perceived SE may be high if there are facilitating factors such as social support
• Sleep-related SE was correlated with healthy sleep hygiene behaviours – performing these behaviours increases SE toward this behaviour
• In addition, if a person watches others perform this behaviour successfully, they can gain a sense of SE (peers that adhere to a good sleep/wake routine)- because they feel if that person is managing to do it then I probably can too. Peers are important in being an influence.

Question 10

Self-Regulation (Bandura, 1997)

Answer 10

• Self-regulation: Intentionally control and monitor our own behaviour through self-monitoring (sleep diary), goal setting and self-reward (Bandura 1997)
• Those who keep a sleep diary to monitor their sleep, report improvements in their sleep hygiene behaviours compared to those who do not keep a diary (Mairs and Mullan, 2015; Todd & Mullan, 2014).
• Perhaps this and similar tools can be employed to help with monitoring

Taking initiative of own life/ decisions
For this to happen (regulating behaviour) it is better when it it monitored e.g. keeping a sleep diary

Question 11

Social Relationships and Sleep

Answer 11

• Individuals are more likely to sleep for shorter periods of time, if their friends are sleeping less as well (Mednick, Christakis & Fowler, 2010)
• Social media use daily, for +2h relative to 30min has been found to increase young adult’s odds of reporting sleep disturbances (Levenson et al 2016)
• Those with high levels of socially supportive relationships report better sleep health outcomes (Chung, 2017) even for relationships in the work environment (Linton et al 2015)

Having good relationships -> less stressed out -> better sleep

Question 12

Loneliness and Sleep

Answer 12

• Lonely individuals (perceived loneliness) had poorer sleep efficiency than non-lonely individuals
• Those lonely were more restless during sleep and had poorer self-reported sleep quality (Kurina et al 2011; Matthews et al 2017)
• Those married (an objective way of measuring loneliness) have lower odds of experiencing very short or very long sleep durations

Being married is a positive thing because you’re not alone and having someone there to do discuss things

Question 13

Social Norms

Answer 13

• Among college students the norm is probably that nobody sleeps the recommended number of hours each night because they have to study (or party)
• There may be social pressure to comply, in order to avoid facing rejection
• There is a tendency to overestimate unhealthy behaviours within a social network

Question 14

Role Modeling

Answer 14

• We are more likely to mimic people that we perceive to be similar to ourselves
• If a friend said that she does not respond to text messages or posts on social media past 9pm this would also be a good example
• If parents stopped watching television and electronic devices before bed to set a good example, that would help teach children better sleep-related behaviours

College students- sleep is not a priority (eg. aiming to make friends ect.)

Question 15

Racial and SES disparities

Answer 15

• Health disparities in the US - excess deaths in minority groups etc
• 1999-National Academy of Medicine convened to evaluate evidence of disparities in healthcare
• The committee concluded that even among those insured there were differences in healthcare utilization and treatment
• These differences occurred beyond the individual level factors (smoking and attitudes about treatment) and were due to factors within the healthcare system, prejudice and discrimination

Not able to afford insurance- less ability to get care

Question 16

Sleep Health Care

Answer 16

• Despite the prevalence of sleep disorders, sleep is often overlooked by primary healthcare providers - Sleep has less consideration (late into the game) compared to exercise and health
• Limited sleep health curriculum in medical school, only 0.6% of total classroom time (Nieto & Petersen, 2022)
• In 2007, the American Board of Medical Specialties began to offer an exam for board certification equivalent to that for other medical specialties. So, sleep medicine is now a formally recognised medical specialty requiring an additional year of training.
• In the UK, there is a Postgraduate Certificate in Sleep Medicine and according to the NHS “This programme is designed to support the delivery of services by different staff in different settings, by educating colleagues in the underpinning science to deliver a clinical role in a chronically understaffed speciality.”

Question 17

UK-Whitehall studies

Answer 17

• SES and Access to the NHS
• SES was related to age-adjusted mortality in 10 years
• There was a SES gradient effect for almost every cause of death meaning that higher-ranking employees had a lower risk of mortality compared to lower-ranking employees

Question 18

Racial and Ethnic Disparities

Answer 18

• Blacks are more likely than whites to work non-traditional shifts (especially night shifts), and to have longer work hours
• Blacks are also more likely to be employed in positions with low control/high demand, that involve low decision-making power
• These disparities exacerbate other health-related behaviours (obesity, smoking etc) and ultimate mortality and morbidity.

Question 19

Race and Sleep Characteristics

Answer 19

People belonging to minority racial/ethnic groups are more likely to experience extremes in sleep duration than white individuals and this has been documented for years with the gap only widening (Stamatakis et al 2007)

• Blacks are twice as likely to have short sleep (<6h) compared to whites
• Hispanics are 40% more likely to have short sleep compared to whites

Question 20

What is postulated that contributes to differences in sleep health

Answer 20

Perhaps a combination of SES and racial factors contributes to differences in sleep health

Question 21

Teti et al 2006- Actigraphy records of infant sleep fragmentation during the infants’ first year, broken down by sleep arrangement pattern
FINDINGS

Answer 21

recap- starts in womb, whatever the mother is doing is communicated to the baby

Sleeping communications is what the graph shows

When the infant is younger, they have increase fragmented sleep (more wakings). Then they start to have a more consolidated sleep.
In all conditions except co-sleeping, there is a tendency to wake up during the night but then with the mother they tend to sleep a bit better

Question 22

Teti et al 2006- Actigraphy records of mothers’ sleep fragmentation during the infants’ first year, broken down by sleep arrangement pattern
FINDINGS

Answer 22

Those that are in the consistent solitary condition or the early switch to solitary condition tend to have less sleep fragmentation (especially those who are consistently in their own bedroom) compared to mums who are co sleeping.

Question 23

SES and parenting

Answer 23

• Socioeconomic factors influence parenting quality and bedtime routine
• Lower SES is associated with greater chaotic home environments and higher parental stress
• Lower SES may have smaller living spaces and more room sharing among family members

Question 24

SES and Child Sleep

Answer 24

• Children from low SWS families tend to have worse sleep.
  – The mother’s educational level has been linked with differences in sleep assessed via actigraphy
  – Lower family income-to-needs ratio was linked to more sleep/wake problems
  – Better economic well-being predicted higher sleep quantity and lower sleep onset variability
• Children from groups of high poverty in the community slept less than other children
• Children from lower SES had poorer performance on maths and language tasks only when they had sleep problems (Buckhalt et al 2009)
• Parenting and bedtimes matter for both child and adolescent sleep
  – Those with the latest and nonadherent bedtimes (not following bedtimes parents implement) and insufficient sleep in childhood, were sleeping less as teenagers and had higher BMI (Lee, Hale and Chang, 2018)

Question 25

Adolescents in the household and family context

Answer 25

• National Sleep Foundation Sleep in America Poll 2014 (Buxton et al 2015):
• Parent reports suggested that half of adolescents and children were getting the minimum recommended time of sleep
• Parents said the child needed a minimum of 8.7 hours of sleep to be at their best during the day

Children as early people
Graph 1: Children tend to sleep more than adolescence
Graph 2: Adolescence tend to sleep less than children
Graph 3: Merge of the two

Question 26

Associations of family and parenting characteristics with children’s (6–17 years of age) sufficient sleep duration and sleep quality. Buxton et al. 2015

Answer 26

• Parent’s always enforcing limits on child caffeine is protective for child sleep duration, whereas parents always enforcing a bedtime was protective for child sleep quality.
• In contrast, children having ≥1 technology devices left on in their bedroom overnight was significantly associated with reduced sleep duration and sleep quality.

Parent limits on child caffeine:
if they always enforce against coffee, they seem to sleep better

Parent enforces child bedtime:
always enforcing them to go to bed, it is benefitting children to get better sleep quality

Number of devices left ON in children’s bedroom overnight:
- having electronic devices, leads to sleeping less (lower sleep duration)
- having no devices leads to better quality sleep

Question 27

Work Factors

Answer 27

• For adults, time asleep and time at work comprise the majority of their time
• There is an association between longer work hours and shorter sleep
• Well-designed longitudinal studies find that work stress predicts changes in sleep over time

– Van Laethem et al 2013: meta-analysis on workplace factors and sleep quality with 16 studies found evidence that high job demands were associated with decreases in sleep quality
– Linton et al 2015: High job demands predicted poor sleep
– Adverse effects of effort-reward imbalance on employee sleep with greater imbalance resulting in greater sleep disturbances (Siegrist et al 2004)

High job demands -> decreases in sleep quality

Question 28

Worksite Wellness

Answer 28

• A meta-analysis suggested that healthcare spending falls with each small investment in wellness programs (3 dollars saved in healthcare for every 1 dollar invested in wellness programs) - Baicker et al 2010
• Sleep quality was a strong predictor of the readiness to change, i.e. quitting smoking
• Sleep is a relatively new component in workplace-based health programs

Question 29

Neighborhood characteristics

Answer 29

• Living in adverse neighbourhoods is associated with less sleep on average
• The built environment (busy streets, population density etc) is associated with higher odds of short sleep (Johnson et al 2018)
• Higher density may promote health through walking, but it can also produce light, noise and air pollution that can hinder sleep
• Most studies are needed to address the complexities

Question 30

Housing

Answer 30

• Humans are indoors 80-90% of the time!
• The time spent indoors can be even more in disordered neighborhoods for safety reasons
• Adverse effects of time indoors - exposure to artificial light, air quality, social interactions can have negative effects on sleep
• Housing features can have an impact

if we are spending this much time inside it is good to think about environment/ living conditions

Question 31

Bedroom Environment

Answer 31

• A cave for sleep: dark, quiet and cool
• Minimum light exposure around bedtime and during the night
• Cool temperature of ~16-20 degrees Celsius
• Absence of noise in an optimal sleep environment

– Common sources of noise: transportation, bed partners, pets
– Management via the use of earplugs or use of white noise (constant background)
Keeping heating on is preventing us from easing ourselves to sleep – naturally, body temp will drop

Question 32

Bedroom Environment

Answer 32

• Air quality is also important, free of allergens
• Bedroom air quality as a result of bedroom ventilation and surrounding air pollution
  – Pollution from traffic was found to be related to sleep duration (Fange et al 2015) and to interfere with the ability to fall asleep, stay asleep and feel rested upon waking (Hunter & Hayden, 2018)
• Bedroom ventilation and corresponding CO2 levels as a marker of air quality (Strøm-Tejsen et al 2016)
  – Sleep efficiency was better on nights when ventilation was high and bedroom CO2 levels were low
• Smell – lavender has the greatest support as sleep-inducing using both objective and subjective measures
  – Increased time spent in SWS, self-rated sleep quality, self-reported vigor upon waking, decreased anxiety levels
  – A meta-analysis of aromatherapy in Korea, has confirmed that aromatherapy improves sleep in both healthy and unhealthy individuals with moderate effects (Hwang and Shin, 2015)
  – *still considered tentative – more research is needed

Question 33

Naps

Answer 33

• In several Mediterranean, Middle-Eastern and Asian nation, Latin and South America naps are the norm
• Napping in the US is higher among those that do not have rigid work schedules, including college students and retired people
• Longitudinal studies have documented an increase in the frequency of napping as individuals go through retirement (Harden Peppard and Palta 2019)
• When adults are placed in ‘time-free’ environments they nap even when they are asked not to do so (Zulley and Campbell, 1985)
• Recent studies with large samples associate napping with negative health outcomes unless naps are short (<30min)

Naps can be beneficial but only if they are up to 30 mins long
Naps longer than 30 mins have been shown to have neg impacts on our health
Timing of naps is important – having later naps can be non beneficial

Sum – shorter naps earlier

Question 34

Simplified social-ecological model of sleep health (Grandner, 2019)

Answer 34

Societal, social individual
→
Sleep
→
Health & Functioning

Its good to put sleep into its context and consider all implications- interactions occur

Question 35

Better sleep as a way to a healthier life

Answer 35

• Many of the causes of death are preventable
• Mokdad et al, 2000, JAMA - Actual causes of death in the United States:

~40% are due to behavioural factors that are preventable; smoking, poor diet, lack of physical activity, and alcohol consumption

• JAMA 2022, more than half of cancers worldwide are preventable as they are due to lifestyle choices (primarily smoking, obesity, alcohol, unprotected sex, etc)
• So we do have a choice
• Sleep is implicated in many of these behaviours and has been highlighted along with nighttime exposure to light as part of the reasons behind the rise of cancers in those under 40y which are on the rise