Is an eight-week education program on sleep, breathing and self-empowerment an effective way to improve sleep habits and well-being among adolescents?
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
BSc in Psychology
Department of Psychology
Is an eight-week education program on sleep, breathing and
self-empowerment an effective way to improve sleep habits
and well-being among adolescents?
June, 2021
Student: Helga Hrund Halldórsdóttir
ID number: 080997 – 26492
Foreword
Submitted in partial fulfillment of the requirements of the BSc Psychology degree,
Reykjavik University, this thesis is presented in the style of an article for submission to a
peer-reviewed journal.
This thesis was completed in the Spring of 2021 and may therefore have been
significantly impacted by the COVID-19 pandemic. The thesis and its findings should be
viewed in light of that.3
Abstract
The purpose of this study was to see how successful an educational course about the
significance of sleep was and how it affected sleep among 9th graders. The emphasis was on
breathing methods, self-empowerment, and sleep instruction. There were 22 participants
between the ages of 14 and 15, all of whom were in the same 9th grade. Before the beginning
of the course participants completed a questionnaire about their sleep habits, sleep quality,
and overall well-being. The Pittsburgh Quality Sleep Index (PQSI) was used to evaluate sleep
quality at both the baseline and the follow-up. After the course, participants answered a
follow-up questionnaire on their experience of participating in this course. A significant
difference was found on how important participants considered a good night sleep. Results
revealed that participants were getting 7.30 hours of sleep on weekdays at baseline and 7.64
hours at follow-up. On weekends average sleep hours were 9.09 hours at baseline and 9.48
hours at follow-up. Additionally, most participants found the breathing exercises useful and
reported that they were likely to use them in the future. To conclude, difference was found on
participants knowledge about sleep at baseline and follow-up, but no change was found in
sleep quality or sleep duration.
Keywords: sleep quality, Pittsburgh Sleep Quality Index, sleep habits, breathing
techniques, adolescents, sleep knowledge
Útdráttur
Tilgangur þessarar rannsóknar var að kanna árangur námskeiðs um fræðslu á mikilvægi
svefns og hver áhrif þess væru á svefnvenjur meðal unglinga í 9. bekk. Áhersla var lögð á
öndunartækni, sjálfstyrkingu og fræðslu um svefn. Markmiðið var einnig að kanna hvort
unglingum þætti öndunaræfingarnar sem kenndar voru gagnlegar og hvort þeir væru líklegir
til að nota þær eftir námskeiðið. Þátttakendur voru 22 talsins, á aldrinum 14-15 ára og voru
þeir alllir í sama 9. bekk í grunnskóla. Í upphafi námskeiðs svöruðu þátttakendur
spurningalista um svefnvenjur, svefngæði og líðan. Pittsburgh Quality Sleep Index (PQSI)
var notaður til að mæla svefngæði unglinga fyrir og eftir námskeiðið. Eftir námskeiðið
svöruðu þátttakendur einnig spurningalista um reynslu sína af þátttöku á námskeiðinu.
Marktækur munur fannst á því hversu mikilvægan þátttakendur töldu góðan nætursvefn vera.
Niðurstöður leiddu í ljós að þátttakendur voru að sofa 7,30 tíma að meðaltali á virkum dögum
í upphafi námskeiðs og 7,64 klukkustundir í eftirfylgni. Um helgar var meðal svefntími 9,09
klukkustundir í upphafi og 9,48 klukkustundir í eftirfylgni. Niðustöður sýndu einnig fram á
aukina þekkingu þátttakenda á svefni í eftirfylgni. Einnig sýndu niðurstöður fram á að
meðaltali fannst þátttakendum öndunaræfingarnar gagnlegar og greindu frá því að þeir væru
líkleg til þess að nota þær í framtíðinni.
Lykilorð: svefngæði, svefngæðavísitala Pittsburgh, svefnvenjur, öndunartækni,
unglingar, svefnþekking4
Is an eight-week education program on sleep, breathing and self-empowerment
an effective way to improve sleep habits and well-being among adolescents?
Healthy sleep is defined by having enough sleep, at appropriate times and without any
disturbances that can affect sleep quality and quantity (Orchard et al., 2020). Sleep plays a
significant role in the health and well-being of adolescents, but in the past 20 years
insufficient sleep has become more frequent among adolescents (Chung & Cheung, 2008;
Keyes et al., 2015). Adequate sleep is an important element in the proper functioning of the
body and mind and affects the quality of life (Rognvaldsdottir et al., 2017). The National
Sleep Foundation recommends that adolescents from 14-17 years old, should get
approximately 8-10 hours of sleep every night (Hirshkowitz et al., 2015), but unfortunately
research show that most adolescents typically do not get enough sleep, especially on school
nights (Cain et al., 2011). Lack of good night sleep can have a major impact on daily life
(Tarokh et al., 2016). Research has shown that adolescents, who get enough sleep, are less
likely to show symptoms of depression and anxiety. They are more focused in school, more
focused when carrying out daily tasks, are less moody and generally engage in a healthier
lifestyle (Orchard et al., 2020; Pasch et al., 2010; Wolfson et al., 2007). Studies on sleep
within Icelandic adolescents have shown that only 11% are getting recommended hours of
sleep during school nights (Rognvaldsdottir et al., 2017). Adolescents who believe they
always get enough sleep consider both their mental and physical well-being good, whilst
among those who do not get recommended hours of sleep, only 35% consider their mental
health good and 50% consider their physical health to be good (Rannsóknir og greining,
2020; Rognvaldsdottir et al., 2017). Icelandic studies on adolescents (Rognvaldsdottir et al.,
2017; Thorleifsdottir et al., 2002) show as well that Icelandic adolescents tend to go later to
sleep than their peers in neighbouring countries, and their sleep duration shortens as they get
older.5
Usually, sleep education is not a part of the elementary school syllabus, rather just a
brief course held in elementary schools with little or no follow-up (Bootzin & Stevens, 2005).
Even though there is an emphasis on adolescent’s health in the Icelandic syllabus, there is no
focus on purposeful teaching of the importance of sleep among adolescence in the syllabus
(Mennta- og Menningarmálaráðuneytið, 2013). This suggest that adolescents are not
receiving sufficient education on sleep and are therefore deprived of the possible benefits
thereof.
Considering how many teenagers sleep too little, and the negative effect it has on
health and well-being, it is important to increase education and interventions that can
improve sleep habits among adolescents. One of the solutions to reach a large number of
adolescents could be school-based sleep education programs. Sleep educational programs
have shown to be effective in improving sleep habits and sleep knowledge (Bakotić et al.,
2009; Bonnar et al., 2015; Brown et al., 2006; Cassoff et al., 2013; Cortesi et al., 2004; Sousa
et al., 2007; Wing et al., 2015).
A study by Cortesi et al. (2004) with 540 students aged 17 to 19 years explored the
effectiveness of a 2-hour interactive sleep educational course. Participants were divided into a
experimental group and a control group, with the control group not receiving any intervention
but answering the same questionnaires. A pre-test evaluated baseline knowledge about sleep
and a post-test measured results after the course along with a 3-month follow up test to
measure long-term effects. Results showed that knowledge about sleep increased
immediately after the course and results for long-term retention of information were superior
for students in the intervention group compared to the control group. Furthermore, a study
was conducted by Rossi et al. (2002), where sleep habits and daytime sleepiness were
measured in a seven week-long sleep educational program. According to the findings, the
experimental group had significantly earlier weekend bed and rise times, as well as shorter6
weekend sleep delays, than the control group. In addition, students in the experimental group
had more consistent bedtimes, increased sleep duration, and were significantly less sleepy
during the day on weekends than students in the control group. Similar results were found in
a study by Wolfson et al. (2015) where both sleep patterns and habits showed trends towards
more consistence and sleep duration increased among the experimental group over the
control group. Furthermore, a study by Bonnar et al. (2015) aimed to evaluate the
effectiveness of a school-based motivational sleep education program among 193 adolescents
participating in a four weekly 50-minute classes. Online questionnaires measuring sleep
knowledge, sleep patterns and mood were used both pre- and post-program with a six-week
follow up. Results in the experimental group showed improved sleep knowledge, decreased
sleep onset latency, increased total sleep time and better mood, compared to the control group
which received no sleep education. In another study by Bakotić et al. (2009) sleep knowledge
was tested with a sleep knowledge test where adolescents in the intervention groups, aged 15-
18 years, received educational leaflets. Results show significantly more sleep knowledge in
the experimental groups over the control groups.
Two review papers about sleep educational programs have shown a great result of the
effectiveness of educational programs on sleep for adolescents (Blunden et al., 2012; Chung
& Cheung, 2008). However, although most sleep educational programs successfully enhance
adolescent sleep knowledge, there are number of studies that have shown not as effective
results on sleep habits and knowledge (Beijamini & Louzada, 2011; Kira et al., 2014;
Moseley & Gradisar, 2009; Rigney et al., 2015; Sousa et al., 2007).
Breathing techniques have been a part of a traditional relaxation methods to reduce
anxiety and relieve stress for years (Bertisch et al., 2012; Khng, 2017), however their
influence on sleep is still unclear (Sylvain Laborde et al., 2019). Research have shown that by
practicing breathing exercises, such as Buteyko Method breathing technique, it is possible to7
improve a number of complaints such as asthma, anxiety, and sleep disorders (“Learn How to
Breath - Buteyko Breathing Exercises,” n.d.; NZchildren.Pdf, n.d.; Mchugh et al., 2006;
Mendonca et al., 2017). In a study by Laborde et al. (2019) a 30-day slow-paced breathing
intervention was conducted. The experimental group had to perform a slow-paced breathing
exercise for 15 minutes every evening over the 30-day period, while the control group used
social media for the same duration. Results showed that slow-paced breathing technique
improved sleep quality and cardiac vagal activity among the experimental group, in
comparison to the use of social media among the control group. Another study by Laborde et
al. (2017) found that slow-paced breathing tasks improved stress management and was an
effective method for lowering stress in adolescents with intellectual disabilities. Furthermore,
in a study by Tsai et al. (2015); on individuals with insomnia where participants were
required to do a slow-paced breathing before sleep found that paced breathing helped
individuals with insomnia to maintain better sleep pattern and quality. These findings show
that the use of breathing relaxation techniques among individuals with insomnia, can be
useful.
Although there are not many studies on the use of breathing techniques to improve
sleep quality among adolescents, existing studies are promising and underline the importance
of doing further research on the effects of breathing techniques on the quality of sleep among
healthy adolescents.
The aim of the present study was to examine the effectiveness of an educational
course with the focus on breathing techniques, self-empowerment and education about sleep
among adolescents in 9th grade. The first hypothesis is that this course will positively affect
sleep habits among adolescents. The second hypothesis is that sleep knowledge will increase
after the course. The third hypothesis of the study is that teenagers will find breathing
exercises useful and will be more likely to use them after the educational course.8
Method
Participants
Participants of this study where 22 in total, 11 females and 11 males. All of them
were in the same age (14-15 years old) and all attend the same 9th grade in elementary school
in Iceland. Participants received a Garmin activity watch as a gift for participating, but the
watch was also used to measure their sleep duration during the educational course.
Participants could choose for themselves if they wanted to take part in this educational course
as a part of selection course in their elementary school. As participants where not old enough
to decide for themselves to participate, a request for participation was sent by email to their
parents where they had to consent to student’s participation in this study. Although, students
could take part in the educational course even if their parents did not agree for them to
participate in this study.
Measures
The questionnaire that was used for the adolescents was a translated version of the
Pittsburgh Sleep Quality Index (PSQI). The questionnaire included basic demographic
information about their gender, sleep habits, sleep quality and their sleep knowledge.
Sleep habits. Information about participants sleep habits consisted of five questions.
Both “How much or how little does it matter to you to sleep well at night?” and “How much
or how little does daily exercise matter for a good night's sleep?” had five possible response
options from 1 = very important to 5 = not important at all. The question “How many days of
the last seven days have you had a vigorous intensity physical activity for at least 60
minutes?” had eight possible responses from 1 = none to 8 = seven days. The question on
participants caffeine intake “How many of the following (coffee, tea, cola drinks and energy
drinks) do you think you consume every day” had the possible responses from 1 = none to 7
= six or more cans/bottles. The question on screen time, “How many hours per day do you9
use smart devices?” had nine possible response options from 1 = less than an hour to 9 =
more than 14 hours. The question “How many hours do adolescents your age need to sleep
each night?” had seven possible response options from 1 = less than 4 hours to 7 = more than
13 hours. The question regarding how caffeine affects sleep “How do you think drinking
caffeinated beverages shortly before bedtime affects your sleep?” had five possible response
options from 1 = very bad effect to 5 = very good effect. The question “Is it good or bad for a
good night's sleep to watch a screen just before going to bed?” also had five possible
response options from 1 = very bad to 5 = very good. In the last question, participants were
asked to mark one item that was most relevant to them. Examples of possible answers were
“I’ve never thought about whether I sleep well or enough”, “I know I need to sleep more but I
haven’t done anything about it” and “I always sleep well and enough and have no need to
worry about it in particular”.
Sleep quality. Sleep quality among participants was measured with the Pittsburgh
Sleep Quality Index (PSQI). PSQI includes seven components which are subjective sleep
quality, sleep latency, habitual sleep efficiency, use of sleep medications, sleep duration,
sleep disturbances and daytime dysfunction (Buysse et al., 1989). All seven components have
four possible responses with the range from 0-3 where a score of 0 indicates no difficulty and
score of 3 indicates much difficulty. All seven component scores where then computed to
yield one global score with the range of 0-21, where the higher scores indicate worse sleep
quality. An Icelandic version of PSQI that was originally published by Buysse et al., (1989)
was used in this study. Thordardottir et al. (2016) tested for the reliability of the Icelandic
version of the PSQI in their study showing internal reliability (Cronbach's alpha) α = .820. In
the current study the internal reliability (Cronbach's alpha) was only α = .446 at baseline and
on follow-up it was α = .406.10
Question like “When have you usually gone to bed in the last month?”, “When have
you usually gotten out of bad in the last month?”, “How many hours have you usually slept at
night in the last month?” and “How long has it usually taken you to fall asleep in the last
month” are example of questions that were asked about sleep habits in the PSQI
measurement. Also, “How often have you had trouble sleeping in the last month because...?”
and the possible responses where for example “You need to get out of bed to go to the
bathroom”, “You coughed or snored loud” and “You felt some pain”, and participants could
mark possible answers from 1 = not a problem at all to 4 = three or more times a week.
Finally, questions like “Overall, how do you rate the quality of sleep over the past month?”
had four possible response options 1 = very bad sleep to 4 = very good sleep. The question
“How often have you taken medication to improve your sleep in the last month?” also had
four possible response options from 1 = three or more times a week to 4 = not at all in the last
month. The question “How much of a problem has it usually been to have enough energy and
willpower to get things done in the last month?” also had four possible response options from
1 = very much problem to 4 = no problem at all.
Sleep knowledge. Questions regarding sleep knowledge where in total 11.
Participants were given either wrong or right for each question, and then the score was
computed to an overall score ranging from 0-11 on sleep knowledge among participants.
Example of questions asked on sleep knowledge are “What happens in the body when
we sleep?”, “What are the most important sleep stages?”, “What time of day is best for
attention and alertness?”, “What happens in the body at night?”, “What increases the
production of sleep hormones at night?” and “When is the best time to stop drinking caffeine
during the day?”.
Follow-up questions. At follow-up, questions about participants experience of the
course were added to the questionnaire. For example, questions like how they felt about11
participating in the course, if they thought the course would lead them to change their sleep
habits and if they learned something new about sleep. Questions regarding the hypothesis on
breathing where also at follow up where participants were asked about what they thought
about the breathing exercises they learned in the course, where the range of answer was from
1= very useful to 5 = not useful. They were also asked whether they thought they would be
likely to use the breathing exercises in the future and the range of answer was from 1= very
likely to 5 = very unlikely.
Procedure
An approval was gained from The National Bioethics Committee in Iceland. The
study took place in February 2021 and lasted for an eight-week period. At the start of the
intervention a questionnaire was submitted to participants who took part in the study to
obtain baseline data. Participants were under the instructions to answer the questions to the
best of their abilities. The study was conducted in one of the classrooms in the elementary
school in Iceland. Participants received an actigraph from Garmin that they were asked to
wear over the eight-week period. Before the education course began, written informed
consent was obtained from parents of the participants, as they are under 18 years of age. The
intervention consisted of sleep and breathing education via lectures and on video form.
Breathing techniques were thought in order to give participants a technique to relax the
nervous system before going to sleep, to sleep better and to reduce stress. After the course, a
questionnaire was submitted to participants to collect data on follow-up measures.
Data analysis
The statistics program SPSS (version 27) by IBM was used for statistical analysis.
Tables were made with Microsoft Word and figures with Microsoft Excel. A paired sample t-
test was used to test for significant difference on baseline and follow-up measures. A Pearson12
correlation model was used to test for correlation between the two questions regarding
breathing exercises.
Results
Questions on adolescents sleep habits
Descriptive statistics on the importance of good night sleep, caffeine intake and
physical activity and how these factors effect sleep are represented in Table 1.
Table 1
Descriptive Statistics on the Importance of Good Night Sleep, Caffeine Intake, Physical
Activity and Smart Devices usage and How These Factors Have Effect on Sleep
Variables Baseline Follow-up p-value
n (%) n (%)
Importance of good night sleep .034
Very important 3 (13.6) 12 (54.5)
Important 12 (54.5) 5 (22.7)
Both and / neither nor 7 (31.8) 5 (22.7)
Importance of physical activity on good night sleep .749
Very important 8 (36.4) 9 (40.9)
Important 7 (31.8) 7 (31.8)
Both and / neither nor 6 (27.3) 5 (22.7)
Not important 1 (4.5) 1 (4.5)
Physical activity .761
Four days or less per week 9 (40.9) 8 (36.4)
More than four days per week 13 (59.1) 14 (63.6)
Caffeine intake
Cola drinks per day .726
None 11 (52.4) 12 (54.5)
One can/bottle per day or more 10 (47.6) 10 (45.5)
Energy drinks per day .429
None 16 (76.2) 19 (86.5)
One can/bottle per day or more 5 (23.8) 3 (13.5)
Number of hours spent on smart devices .107
5-6 hours or more per day 15 (71.4) 14 (73.7)
Less than 5-6 hours per day 6 (28.6) 5 (26.3)13 The sample consisted of 22 participants, 11 females and 11 males. All of the participants were at the same age (14-15 years old) and all in 9th grade. A paired sample t-test was used to test whether participants sleep habits had improved after the course on follow-up measures. Participants were asked how important good night’s sleep was for them. At baseline, 3 participants said that it was very important but 12 at follow up. A significant difference (t(42) = 2.193, p = .034) was found on whether the participants regarded a good night sleep important between baseline and follow-up. There was not a high change on the importance of physical activity on good night sleep between baseline and follow-up. At baseline, 8 participants reported it being very important but 9 participants at follow-up measures. No significant difference was found on the importance of physical activity on good night sleep between baseline and follow-up (p = .749). Most participants reported that they exercised more than four days per week (59.1%) at baseline but at follow-up it had increased by one participant (63.6%). There was no significant difference between the participants physical activity on baseline measure and follow-up measures (p = .761). There were almost no participants who reported drinking coffee or tea, but cola drinks and energy drinks were more popular. In terms of energy drinks consumed, 16 (76.2%) reported drinking none at baseline but at follow-up 19 (86.4%) reported drinking none. Additionally, there was no significant difference (t(41) = .353, p = .726) on consumptions of cola drinks on baseline measures and follow-up measures, and same results for the consumption on energy drinks where no significant difference (t(41) = .799, p = .429) was found between baseline measures and follow-up measures. No significant difference (t(38) = 1.649, p = .107) was found on smart device usage within participants between baseline measures and follow-up measures. No significant difference was found on any variable between genders on baseline and follow-up measures on adolescents sleep habits.
14
Sleep duration
Mean score on participants sleep duration are presented in Figure 1.
Figure 1
Sleep Duration in Hours Before and After the Course on Weekdays and Weekends
10 9,48
9,09
9
8 7,64
7,30
Sleep duration score
7
6
5
4
3
2
1
0
Baseline Follow-up
Weekdays Weekends
At baseline, the average sleep duration on weekdays was 7.30 hours and 9.09 hours on
weekends. At follow-up, the average sleep duration was higher for weekdays where they
slept 7.64 hours on weekdays and 9.48 hours on weekends on average, but this difference
was non-significant on weekdays (p = .850) and on weekends (p = .930). On weekdays at
baseline 6 (27.3%) participants slept 7 hours or less and 16 (72.7%) slept more than 7 hours.
At follow-up 6 (30%) participants slept 7 hours or less and 14 (70%) slept more than 7 hours.
On weekends at baseline 1 (4.5%) participant slept less than 7 hours and 21 (95.5%)
participants slept more than 7 hours. At follow-up all participants slept more than 7 hours.
Sleep quality PSQI
The global score on the Pittsburgh Sleep Quality Index (PSQI) was used to measure
participants sleep quality at baseline and follow-up. The results from PSQI are presented in
Table 2. At baseline, 50% of participants scored lower than 5 which indicates good sleep15
quality and 50% scored 5 or higher which indicates poor sleep quality. On follow-up 44.5%
scored lower than 5 and only 55.5% scored 5 or higher. A paired sample t-test was run to test
whether participants sleep quality had increased after the course and the difference was non-
significant (p = .314).
No significant difference on sleep quality from baseline to follow up was found
among males (p = .305) or females (p = .823)
Table 2
Mean Score, Standard Deviation for Overall Sleep Quality and Global Score on the
Pittsburgh Sleep Quality Index
Variable Overall Female Male
Baseline Follow-up Baseline Follow-up Baseline Follow-up
Sleep quality overall
(M ± SD) 5.05 ± 2.31 4.33 ± 2.00 5.60 ± 2.46 5.38 ± 1.30 4.50 ± 2.12 3.50 ± 2.12
PSQI
Lower than 5 n (%) 10 (50) 8 (44.5) 3 (30) 1 (8) 7 (70) 7 (70)
5 or higher n (%)
10 (50) 10 (55.5) 7 (70) 7 (92) 3 (30) 3 (30)
Sleep knowledge
Mean score for sleep knowledge among participants is shown in Figure 2.
A paired sample t-test was used to test the hypothesis on increased overall sleep knowledge
among the adolescents after the course and between genders. There was a significant
difference (p = .001) on overall score between groups on baseline measures and follow-up
measures. A significant difference (t(18) = 5.305, p = .001) was also found on the sleep
knowledge score between males on baseline measures and follow-up measures. Additionally,
there was no significant difference (t(13) = 1.973, p = .070) found on scores between females
on baseline measures and on follow-up measures.16
Figure 2
Sleep Knowledge Before and After the Course for Females, Males and Overall
8
7 6,75*
6,35*
6 5,75
Sleep knowledge score
5
4,14
3,87* 3,63*
4
3
2
1
0
Overall Females Males
Baseline Follow-up
Note. *p < .05
Breathing
Descriptive statistics for thoughts and use of breathing exercises are listed in Table 3.
Table 3
Descriptive Statistics for Thoughts and Use of Breathing Exercises
Variable n Range M SD
Thoughts about breathing exercises 21 1-5 1.62 .80
Use of breathing exercises in the future 21 1-5 1.67 1.28
The range of answers in the question “what are your thoughts about the breathing exercises
you learned in the course” was from 1 “very useful” to 5 “not useful”. The range of answers
for the question “how likely do you think you will use the breathing exercise in the future”
was from 1 “very likely” to 5 “very unlikely”. The results revealed that the participants on
average thought the breathing exercises were useful or very useful. It was also found that the17
participants reported being likely or very likely to use the breathing exercises in the future.
To test this hypothesis a Pearson correlation test was used. Results found a positive
correlation between the two questions about breathing exercise (r(21) = .405, p = .068).
Garmin watch
The first week of the course lasted March 1st to 5th. The overall time measured from
the Garmin watch for the participants that week was in average 8.92 hours. The last week of
the course lasted from April 12th to 16th. The overall time measured from the Garmin watch
that week was in average 9.93 hours.
Discussion
The main purpose of this study was to examine if an educational program about the
importance of sleep and teaching of breathing exercises, was an effective way to improve
sleep habits and sleep quality among adolescents. Also, if breathing exercises were found
useful among adolescents and to explore whether they would find themselves likely to use
them in the future to cope with stress and to help them sleep better.
The results related to adolescents sleep habits did not reveal much difference on
baseline and follow-up measures. However, a significant difference was found on how
important participants considered good night´s sleep to be between baseline and follow-up.
Previous studies imply that sleep educational courses have a positive effect on sleep habits
among adolescents which we did not find in the current study (Cortesi et al., 2004; Rossi, C.
M., Campbell, A. L., Vo, O. T., Charron, T., Marco, C. A., & Wolfson, A. R., 2002; Wolfson
et al., 2015). This discrepancy may be due to the fact that it is difficult to change adolescents'
behavior in only eight weeks when it comes to both screen use and energy drink
consumption. These are factors that can have an effect on sleep habits among adolescents. It
should also be considered that the school had to close at week seven for a whole week due to
COVID-19 pandemic, which had the effect that there was less continuity in the course than18
planned for. Results from the Pittsburgh Sleep Quality Index on sleep duration and sleep
quality among adolescents showed that average sleep duration increased from baseline
measures to follow-up measures, but there was no significant difference on those results.
Furthermore, results on sleep quality showed no significant difference between baseline and
follow-up. This could be due to the small sample size in this study.
Results supported the hypothesis that sleep knowledge among adolescents would
increase after the course. The overall score on sleep knowledge increased from baseline to
follow-up measures and showed significant difference. Results on sleep knowledge among
males also showed significant difference between baseline and follow-up measures. Among
females, there was also a difference between baseline and follow-up measure on sleep
knowledge score, but it was non-significant. That may be due to the limited size of the
sample. Previous studies imply that an educational course on sleep is an effective way to
increase sleep knowledge among adolescents (Bakotić et al., 2009; Bonnar et al., 2015;
Cortesi et al., 2004). These results are in line with the results found in this current study.
Results were supportive for the third hypothesis on breathing exercises being useful
and likely to be used in the future among adolescents. The results showed that participants
thought breathing exercises that were taught on the educational course being very useful on
average. Additionally, the results showed that majority of participants reported that they
would very likely use these breathing exercises in the future. Previous studies imply that a
breathing technique, such as slow breathing, can help with improving sleep quality and sleep
habits and enhance stress managements among adolescents (S. Laborde et al., 2017; Sylvain
Laborde et al., 2019; Tsai et al., 2015). These results show that the use of breathing exercises
can have positive consequences among adolescents. These results indicate that breathing
exercises could be a good way for adolescents to manage their stress and feelings and
possibly lead to better sleep among adolescents.19
Results from the Garmin actigraph watch showed that participants slept fewer hours
on average per night before the intervention course started and increased their sleep after the
course. Although, the use of Garmin watch to measure participants sleep duration had some
limitations to it. Participants where to use the watch throughout the educational course but it
proved difficult to get every participant to wear it every day of the course period. As a result,
some days there were measurements from all of the participants, while on other days only
from a part of them. With that said, the data from the watches simply show how many hours
of sleep participants obtained, that worn the watch.
The current study had several limitations. Participations were quite few which can
lead to the mean difference in results not being significant. Despite that, it would have been
difficult to have much bigger sample in this kind of educational program intervention for
adolescents, where it would be more difficult to reach them with the educational material of
the course. During the intervention period there was a “winter break” in elementary schools
in Iceland which could have affected both sleep among adolescents and the winter break also
delayed the course for a week. In addition, the COVID-19 pandemic had some impact on the
intervention where one week after the “winter break” school went to a closedown due to
covid restrictions and therefore there was no intervention for two weeks. Questions regarding
sleep quality and sleep duration were self-assessment which could possibly skew the results
as there may be a difference in how participants interpret the questions and how they answer
them. It could also be possible that participants do not have full knowledge of how many
hours a day they spend on smart devices, and so the results from question regarding smart
devices may not be accurate enough. At the baseline of this current study the internal
reliability for PSQI (Cronbach's alpha) was α = .446 and on follow-up it was α = .406. This
means that the internal validity of the questionnaires is rather low and there is a possibility20
that the PSQI questionnaire is not measuring what it should be measuring. This could be due
to the small sample in this current study and the age of the participants.
Despite some limitation, there were also some strengths to this study. This is the first
study, to our knowledge, that explores how an eight-week education program on sleep,
breathing and self-empowerment among Icelandic adolescents can impact their sleep habits
and well-being and also uses Garmin watch actigraphy to measure sleep along with a
questionnaire. This study could be a great way to open up adolescents’ eyes to how important
good night sleep is for them, especially in their teen years. Since participants were all in the
same class in the same elementary school, they were all familiar with each other which can
be considered as a strength to this study.
Future studies on this topic should consider having a larger sample of participations as
it could increase the accuracy and significance of the results. Also, it could be useful to have
a participation number so it would be possible to match an individual results from baseline
and follow-up measures, after the intervention. In future studies, the use of Garmin
actigraphy should be improved so that the results can be used alongside the questionnaire for
each participant, but again, a participation number is required for that to work. Making a
change in one's behavior can take time, so future studies should consider focusing on making
sleep related education, such as the course in this study, last over a longer period of time. One
possibility could be to offer parents similar education along with adolescents education, so
every family are aware of the importance of sleep for adolescents and continue to pay
attention to this matter after the course. Future studies should look further into using
breathing exercises to increase sleep quality among adolescents, as the results of this study
showed a positive outcome. Results from sleep habits, sleep quality and sleep duration all
indicate that the course had a good impact on adolescents sleep, although few results had a
significant difference it gives future research a good insight into the effects of a small sample21
and could be transferred to a larger sample. Future studies should also consider finding a
solution on how to get better measurements from each participant with the Garmin watches,
so the measurements are as accurate as possible.
In conclusion, the current study's findings provide compelling evidence about
adolescent sleep habits and the factors that influence them. In summary, participations in this
study increased their knowledge on the importance of sleep and sleep duration, which
indicates that educational courses, such as this one, are helpful to educate adolescents.22
References
Bakotić, M., Radosević-Vidacek, B., & Kosćec, A. (2009). Educating adolescents about
healthy sleep: Experimental study of effectiveness of educational leaflet. Croatian
Medical Journal, 50(2), 174–181. https://doi.org/10.3325/cmj.2009.50.174
Beijamini, F., & Louzada, F. (2011). Are educational interventions able to prevent excessive
daytime sleepiness in adolescents? Biological Rhythm Research, 43, 603–613.
https://doi.org/10.1080/09291016.2011.630183
Bertisch, S. M., Wells, R. E., Smith, M. T., & McCarthy, E. P. (2012). Use of relaxation
techniques and complementary and alternative medicine by American adults with
insomnia symptoms: Results from a national survey. Journal of Clinical Sleep
Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine,
8(6), 681–691. https://doi.org/10.5664/jcsm.2264
Blunden, S. L., Chapman, J., & Rigney, G. A. (2012). Are sleep education programs
successful? The case for improved and consistent research efforts. Sleep Medicine
Reviews, 16(4), 355–370. https://doi.org/10.1016/j.smrv.2011.08.002
Bonnar, D., Gradisar, M., Moseley, L., Coughlin, A.-M., Cain, N., & Short, M. A. (2015).
Evaluation of novel school-based interventions for adolescent sleep problems: Does
parental involvement and bright light improve outcomes? Sleep Health, 1(1), 66–74.
https://doi.org/10.1016/j.sleh.2014.11.002
Bootzin, R. R., & Stevens, S. J. (2005). Adolescents, substance abuse, and the treatment of
insomnia and daytime sleepiness. Clinical Psychology Review, 25(5), 629–644.
https://doi.org/10.1016/j.cpr.2005.04.007
Brown, F. C., Buboltz, W. C., & Soper, B. (2006). Development and evaluation of the Sleep
Treatment and Education Program for Students (STEPS). Journal of American23
College Health: J of ACH, 54(4), 231–237. https://doi.org/10.3200/JACH.54.4.231-
237
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The
Pittsburgh sleep quality index: A new instrument for psychiatric practice and
research. Psychiatry Research, 28(2), 193–213. https://doi.org/10.1016/0165-
1781(89)90047-4
Cain, N., Gradisar, M., & Moseley, L. (2011). A motivational school-based intervention for
adolescent sleep problems. Sleep Medicine, 12(3), 246–251.
https://doi.org/10.1016/j.sleep.2010.06.008
Cassoff, J., Knäuper, B., Michaelsen, S., & Gruber, R. (2013). School-based sleep promotion
programs: Effectiveness, feasibility and insights for future research. Sleep Medicine
Reviews, 17(3), 207–214. https://doi.org/10.1016/j.smrv.2012.07.001
Chung, K.-F., & Cheung, M.-M. (2008). Sleep-wake patterns and sleep disturbance among
Hong Kong Chinese adolescents. Sleep, 31(2), 185–194.
https://doi.org/10.1093/sleep/31.2.185
Cortesi, F., Giannotti, F., Sebastiani, T., Bruni, O., & Ottaviano, S. (2004). Knowledge of
sleep in Italian high school students: Pilot-test of a school-based sleep educational
program. The Journal of Adolescent Health: Official Publication of the Society for
Adolescent Medicine, 34(4), 344–351.
https://doi.org/10.1016/j.jadohealth.2003.07.003
Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L., Hazen, N.,
Herman, J., Adams Hillard, P. J., Katz, E. S., Kheirandish-Gozal, L., Neubauer, D. N.,
O’Donnell, A. E., Ohayon, M., Peever, J., Rawding, R., Sachdeva, R. C., Setters, B.,
Vitiello, M. V., & Ware, J. C. (2015). National Sleep Foundation’s updated sleep24
duration recommendations: Final report. Sleep Health, 1(4), 233–243.
https://doi.org/10.1016/j.sleh.2015.10.004
Island & Mennta- og Menningarmálaráðuneytið. (2013). Aðalnámskrá grunnskóla almennur
hluti ; greinasvið 2013.
http://brunnur.stjr.is/mrn/utgafuskra/utgafa.nsf/xsp/.ibmmodres/domino/OpenAttachm
ent/mrn/utgafuskra/utgafa.nsf/7FC6618E765E116300257B2F003C2817/Attachment/
grunnskoli_greinanamskrar_netutgafa_2013.pdf
Keyes, K. M., Maslowsky, J., Hamilton, A., & Schulenberg, J. (2015). The great sleep
recession: Changes in sleep duration among US adolescents, 1991-2012. Pediatrics,
135(3), 460–468. https://doi.org/10.1542/peds.2014-2707
Khng, K. H. (2017). A better state-of-mind: Deep breathing reduces state anxiety and
enhances test performance through regulating test cognitions in children. Cognition &
Emotion, 31(7), 1502–1510. https://doi.org/10.1080/02699931.2016.1233095
Kira, G., Maddison, R., Hull, M., Blunden, S., & Olds, T. (2014). Sleep education improves
the sleep duration of adolescents: A randomized controlled pilot study. Journal of
Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of
Sleep Medicine, 10(7), 787–792. https://doi.org/10.5664/jcsm.3874
Laborde, S., Allen, M. S., Göhring, N., & Dosseville, F. (2017). The effect of slow-paced
breathing on stress management in adolescents with intellectual disability. Journal of
Intellectual Disability Research, 61(6), 560–567. https://doi.org/10.1111/jir.12350
Laborde, Sylvain, Hosang, T., Mosley, E., & Dosseville, F. (2019). Influence of a 30-Day
Slow-Paced Breathing Intervention Compared to Social Media Use on Subjective
Sleep Quality and Cardiac Vagal Activity. Journal of Clinical Medicine, 8(2), 193.
https://doi.org/10.3390/jcm802019325
Learn How to Breath—Buteyko Breathing Exercises. (n.d.). Buteyko Clinic. Retrieved
November 30, 2020, from https://buteykoclinic.com/breathing-exercises/
Mchugh, P., Duncan, B., & Houghton, F. (2006). Buteyko breathing technique and asthma in
children: A case series. The New Zealand Medical Journal, 119, U1988.
Mendonca, K. M. P. P., Freitas, D. A., Macedo, T. M. F., Silva, A. C. J. S., Amaral, C. T.,
Santino, T. A., & McKeown, P. (2017). Buteyko Method for ChiLdren with Asthma:
A Randomized Controlled Trial. In A66. THE MANY FACES OF ASTHMA IN
CHILDHOOD (Vol. 1–313, pp. A2203–A2203). American Thoracic Society.
https://doi.org/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A2203
Moseley, L., & Gradisar, M. (2009). Evaluation of a school-based intervention for adolescent
sleep problems. Sleep, 32(3), 334–341. https://doi.org/10.1093/sleep/32.3.334
NZchildren.pdf. (n.d.). Retrieved November 30, 2020, from
http://www.buteykoclinic.it/docu/NZchildren.pdf
Orchard, F., Gregory, A. M., Gradisar, M., & Reynolds, S. (2020). Self-reported sleep
patterns and quality amongst adolescents: Cross-sectional and prospective
associations with anxiety and depression. Journal of Child Psychology and
Psychiatry, and Allied Disciplines, 61(10), 1126–1137.
https://doi.org/10.1111/jcpp.13288
Pasch, K. E., Laska, M. N., Lytle, L. A., & Moe, S. G. (2010). Adolescent Sleep, Risk
Behaviors, and Depressive Symptoms: Are They Linked? American Journal of Health
Behavior, 34(2), 237–248.
Rannsóknir og greining. (2020). Ungt fólk 2020: Niðurstöður rannsókna á meðal
grunnskólanema í 8., 9. og 10. bekk á Íslandi 2020. https://rannsoknir.is/wp-
content/uploads/2020/11/1_Landid-005.pdf26
Rigney, G., Blunden, S., Maher, C., Dollman, J., Parvazian, S., Matricciani, L., & Olds, T.
(2015). Can a school-based sleep education programme improve sleep knowledge,
hygiene and behaviours using a randomised controlled trial. Sleep Medicine, 16(6),
736–745. https://doi.org/10.1016/j.sleep.2015.02.534
Rognvaldsdottir, V., Gudmundsdottir, S. L., Brychta, R. J., Hrafnkelsdottir, S. M.,
Gestsdottir, S., Arngrimsson, S. A., Chen, K. Y., & Johannsson, E. (2017). Sleep
deficiency on school days in Icelandic youth, as assessed by wrist accelerometry.
Sleep Medicine, 33, 103–108. https://doi.org/10.1016/j.sleep.2016.12.028
Rossi, C. M., Campbell, A. L., Vo, O. T., Charron, T., Marco, C. A., & Wolfson, A. R.
(2002). Middle school sleep-smart program: A pilot evaluation. Sleep.
Sousa, I. C. D., Araújo, J. F., & Azevedo, C. V. M. D. (2007). The effect of a sleep hygiene
education program on the sleep–wake cycle of Brazilian adolescent students. Sleep
and Biological Rhythms, 5(4), 251–258. https://doi.org/10.1111/j.1479-
8425.2007.00318.x
Tarokh, L., Saletin, J. M., & Carskadon, M. A. (2016). Sleep in adolescence: Physiology,
cognition and mental health. Neuroscience & Biobehavioral Reviews, 70, 182–188.
https://doi.org/10.1016/j.neubiorev.2016.08.008
Thorleifsdottir, B., Björnsson, J. K., Benediktsdottir, B., Gislason, T., & Kristbjarnarson, H.
(2002). Sleep and sleep habits from childhood to young adulthood over a 10-year
period. Journal of Psychosomatic Research, 53(1), 529–537.
https://doi.org/10.1016/S0022-3999(02)00444-0
Tsai, H. J., Kuo, T. B. J., Lee, G.-S., & Yang, C. C. H. (2015). Efficacy of paced breathing
for insomnia: Enhances vagal activity and improves sleep quality. Psychophysiology,
52(3), 388–396. https://doi.org/10.1111/psyp.1233327
Wing, Y. K., Chan, N. Y., Yu, M. W. M., Lam, S. P., Zhang, J., Li, S. X., Kong, A. P. S., &
Li, A. M. (2015). A School-Based Sleep Education Program for Adolescents: A
Cluster Randomized Trial. Pediatrics, 135(3), e635–e643.
https://doi.org/10.1542/peds.2014-2419
Wolfson, A. R., Harkins, E., Johnson, M., & Marco, C. (2015). Effects of the Young
Adolescent Sleep Smart Program on sleep hygiene practices, sleep health efficacy,
and behavioral well-being. Sleep Health, 1(3), 197–204.
https://doi.org/10.1016/j.sleh.2015.07.002
Wolfson, A. R., Spaulding, N. L., Dandrow, C., & Baroni, E. M. (2007). Middle school start
times: The importance of a good night’s sleep for young adolescents. Behavioral
Sleep Medicine, 5(3), 194–209. https://doi.org/10.1080/15402000701263809
Thordardottir, E., Valdimarsdottir, U., Hansdottir, I., Hauksdottir, A., Dyregrov, A.,
Shipherd, J., Elklit, A., Resnick, H., & Gudmundsdottir, B. (2016). Sixteen-year
follow-up of childhood avalanche survivors. European Journal of
Psychotraumatology, 7. https://doi.org/10.3402/ejpt.v7.30995You can also read
