Let them sleep, for when they are awake, they will move mountains: A multisectoral approach to promoting children’s sleep health

Sleep health is an important part of children’s physical- and psychosocial health, and crucial for their cognitive development. Sleeping well also contributes to a healthy weight, learning new things, performing well in different aspects of their lives, and feeling mentally healthy. Alongside the various health-related and social benefits of good sleep health, promoting sleep health among those in a vulnerable position (e.g. living in a deprived neighbourhood or coming from a family with a lower socioeconomic position (SEP)) leads to reducing social disparities and economic costs throughout society. Therefore, the total impact of promoting sleep health reaches far wider than population health. Over the last decades, children’s sleep health has deteriorated. Evidence-based health promotion programmes are urgently needed to reverse this trend. Therefore, the aim of this thesis is to describe the systematic development of a programme to promote sleep health for children aged 4-12 years old. For this, we combined Intervention Mapping (IM) with the Health in All Policies perspective (HiAP) to guide the development of a children’s sleep health promotion programme. This thesis primarily focuses on the context of the City of Amsterdam, the Netherlands, but also sheds light on how the results may be transferred to other contexts. To successfully inform intervention programme development, we first conducted a thorough needs assessment to get a clear overview of the determinants of children’s sleep health. This needs assessment, described in chapters 2 to 5, consisted of several studies, i.e. a systematic literature review, two concept mapping studies, and a cross-sectional study using a questionnaire and a sleep diary. All studies provided information about potential determinants of children’s sleep health. Applying the evidence from the needs assessment, we designed a blueprint for the development of a sleep health promotion programme using IM and HiAP. The studies described in this thesis illustrate that children’s sleep health is a complex phenomenon, since it is influenced by many (potentially interacting) personal, behavioural- and environmental determinants, which exist on several social-ecological levels and are often influenced by multiple different actors and sectors. This complexity further increases when children’s sleep health is seen as part of a wider system in which sleep health is intertwined with other health behaviours such as diet, physical activity, and sedentary behaviour. To effectively impact one or more of these health-related behaviours, this complexity must be considered by all fields. In addressing sleep health inequalities, comprehensive multi-level systems approaches can be a valuable step forward. To promote sleep health equity, long-term collaboration between relevant actors across multiple sectors is needed, which is precisely what the ‘Health in All Policies’ (HiAP) perspective aims to achieve. In addition, strong collaboration is needed between research, policy and practice to establish an integrated approach that includes multiple factors, social-ecological levels, and sectors. Children’s sleep health is a multifaceted phenomenon that includes multiple dimensions. However, there is still no consensus about the definition of all these dimensions. We therefore recommend that future research includes the multidimensionality of sleep health, and creates uniform, clear definitions for all dimensions of children’s sleep health. Furthermore, there is a need for valid and reliable child sleep health assessment instruments incorporating this multidimensionality. To conclude, the studies described in this thesis imply that children’s inadequate sleep health can be viewed as a complex problem, indicating that the promotion of children’s sleep health requires multifactorial, multilevel, and multisectoral action. We recommend the integration of children’s sleep health promotion in a wider municipal HiAP approach, in which all relevant policy, practice and research actors across sectors collaborate to improve the system and underlying mechanisms contributing to children’s sleep health equity

System frameworks for childhood obesity prevention: a scoping review

Protocol for a scoping revie

Co-creating a 24-hour movement behavior tool together with 9-12-year-old children using mixed-methods: MyDailyMoves

BACKGROUND: All 24-h movement behaviors, i.e. physical activity, sedentary behavior and sleep, are important for optimal health in children. Currently, no tools exist that include all 24-h behaviors and have been proven to be both reliable and valid. Potential reasons for the inadequate validity and reliability of existing questionnaires are the lack of focus on the content validity and lack of involvement of children in the development. Therefore, the aim of this study was to co-create a 24-h movement behavior tool together with 9-12-year-old children. METHODS: Concept mapping and photovoice meetings were held to identify children's physical activity behaviors. During concept mapping meetings with four groups of children (n = 40), children generated an extensive list of physical activities they engaged in, sorted the activities in categories and rated the frequency and perceived intensity of these activities. Using photovoice, three groups of children (n = 24) photographed their physical activities during one weekday and one weekend day, named the photographs, and placed them on a timeline. Furthermore, researchers obtained information on relevant items regarding sleep and sedentary behavior by screening existing questionnaires. Thereafter, we developed the first version of MyDailyMoves. Subsequently, we examined the content validity of the tool together with three groups of children (n = 22) and one group of researchers (n = 7) using focus group meetings. RESULTS: MyDailyMoves has a timeline format, onto which children add the activities they performed the previous day. Based on the concept mapping and photovoice studies, eight physical activity categories were included: playing inside, playing outside, sports, hobbies, chores, personal care, transport, and others. Sleep questions and two more sedentary categories (schoolwork and screen time) were added to MyDailyMoves to define and complete the timeline. The content validity study showed that all items in the tool were relevant. However, children mentioned that the activity category 'eating' was missing and the understandability of how to use the tool should be improved by adding an explanatory video. Both suggestions were adopted in the second version. CONCLUSION: Including the children's perceptions throughout the tool development process resulted in a comprehensive and practical tool which is easy for children to use

What are the determinants of children's sleep behavior? A systematic review of longitudinal studies

To develop evidence-based healthy sleep interventions for children, this review provides insight into the behavioral determinants of sleep behavior. Hence the objective of this review is to systematically review the longitudinal evidence on determinants of children's sleep behavior. Studies were identified from searches in PubMed, PsycINFO, and Web of Science, until January 2017. Longitudinal studies investigating the association between potential determinants and sleep behavior (duration, quality and timing) in healthy children aged 4–12 years were included. The methodological quality was scored and the results were summarized using a best-evidence synthesis. We followed the PRISMA statement guidelines in order to summarize the evidence accurately and reliably. Twelve of the 45 included studies were rated as ‘high quality’. We found strong evidence for child age and moderate evidence for screen time, past sleep behavior, and a difficult temperament as determinant of sleep duration. For determinants of sleep quality, evidence was either insufficient or inconsistent. We found moderate evidence for week schedule as a determinant of sleep timing, with later bed- and wake times in weekends. More high quality studies, which are extensive, collaborative, and multidisciplinary, are needed into the determinants of all dimensions of sleep behavior

Perceived determinants of children’s inadequate sleep health. A concept mapping study among professionals

An increasing number of children experience inadequate sleep, which negatively effects their health. To promote healthy sleep among children, it is essential to understand the underlying determinants. This online concept mapping study therefore explores potential determinants of children’s inadequate sleep as perceived by professionals with expertise in the sleep health of children aged 4–12 years. Participants (n = 27) were divided in three groups: (1) doctors (n = 9); (2) nurses (n = 11); (3) sleep experts (n = 7). Participants generated potential determinants (i.e., ideas) of children’s inadequate sleep. Subsequently, they sorted all ideas by relatedness and rated their importance. These data were analysed using multidimensional scaling and hierarchical cluster analysis. The results of all three groups were combined and validated by an additional group of professionals (n = 16). A large variety of perceived determinants were identified. The most important determinants perceived by all groups belonged to the categories psychosocial determinants (i.e., worrying, a change in daily life), daytime and evening activities (i.e., screen use before bedtime, stimulating game play before bedtime, inadequate amount of daytime physical activity), and pedagogical determinants (i.e., inconsistent sleep schedule, lack of a bedtime routine). These perspectives are valuable for future longitudinal studies on the determinants of children’s sleep and the development of future healthy sleep interventions

Child and parent perceived determinants of children’s inadequate sleep health. A concept mapping study

Many children do not meet the recommendations for healthy sleep, which is concerning given the potential negative effects on children’s health. To promote healthy sleep, it is crucial to understand its determinants. This concept mapping study therefore explores perspectives of children and parents on potential determinants of children’s inadequate sleep. The focus lies on 9– 12 year old children (n = 45), and their parents (n = 33), from low socioeconomic neighbourhoods, as these children run a higher risk of living in a sleep-disturbing environment (e.g., worries, noise). All participants generated potential reasons (i.e., ideas) for children’s inadequate sleep. Next, participants sorted all ideas by relatedness and rated their importance. Subsequently, multidimensional scaling and hierarchical cluster analyses were performed to create clusters of ideas for children and parents separately. Children and parents both identified psychological (i.e., fear, affective state, stressful situation), social environmental (i.e., sleep schedule, family sleep habits), behavioural (i.e., screen behaviour, physical activity, diet), physical environmental (i.e., sleep environment such as temperature, noise, light), and physiological (i.e., physical well-being) determinants. These insights may be valuable for the development of future healthy sleep interventions

Potential determinants during ‘the first 1000 days of life’ of sleep problems in school-aged children

Study objectives: Early life determinants of sleep problems are mostly unknown. The first 1000 days of life (ie, the time between conception and a child's second birthday) is a period where the foundations for optimum health, growth and neurodevelopment are established. The aim of this explorative study is to identify potential early life determinants of sleep problems at age 7–8 years. Methods: Data from the Amsterdam Born Children and their Development cohort study (n = 2746) were analyzed. Sleep problems at age 7–8 years were reported by the caregiver in the ‘Child Sleep Habits Questionnaire’. A higher total score indicates more sleep problems. After multiple imputation (n = 20), we studied multivariable associations between all potential determinants and sleep problems using regression analysis. Results: A higher pre-pregnancy body mass index (BMI) was associated with more sleep problems at age 7–8 years [β 0.12 (95% CI 0.05, 0.18)]. Children of mothers with symptoms of anxiety during pregnancy [β 0.06 (95% CI 0.03, 0.09)] and infancy period [β 0.04 (95% CI 0.00, 0.07)] had more sleep problems. Children of mothers drinking ≥1 glass of alcohol a day around 14 weeks of gestation had a 2 points higher sleep problem score [β 2.55 (95% CI 0.21, 4.89)] and children of mothers smoking ≥1 cigarette per day in that period had a one point higher score [β 1.07 (95% CI 0.10, 2.03)]. Infants with relative weight loss (delta BMI-SD) had a higher sleep problem score during childhood [β −0.32 (95%CI -0.60, −0.04)]. Conclusions: We identified several potential determinants during pregnancy and infancy associated with childhood sleeping problems. We encourage further research into these and other potential determinants to replicate results and to identify underlying mechanisms

Promoting children's sleep health: Intervention Mapping meets Health in All Policies

BACKGROUND: To design a comprehensive approach to promote children's sleep health in Amsterdam, the Netherlands, we combined Intervention Mapping (IM) with the Health in All Policies (HiAP) perspective. We aimed to create an approach that fits local infrastructures and policy domains across sectors. METHODS: First, a needs assessment was conducted, including a systematic review, two concept mapping studies, and one cross-sectional sleep diary study (IM step 1). Subsequently, semi-structured interviews with stakeholders from policy, practice and science provided information on potential assets from all relevant social policy sectors to take into account in the program design (HiAP and IM step 1). Next, program outcomes and objectives were specified (IM step 2), with specific objectives for policy stakeholders (HiAP). This was followed by the program design (IM step 3), where potential program actions were adapted to local policy sectors and stakeholders (HiAP). Lastly, program production (IM step 4) focused on creating a multi-sector program (HiAP). An advisory panel guided the research team by providing tailored advice during all steps throughout the project. RESULTS: A blueprint was created for program development to promote children's sleep health, including a logic model of the problem, a logic model of change, an overview of the existing organizational structure of local policy and practice assets, and an overview of policy sectors, and related objectives and opportunities for promoting children's sleep health across these policy sectors. Furthermore, the program production resulted in a policy brief for the local government. CONCLUSIONS: Combining IM and HiAP proved valuable for designing a blueprint for the development of an integrated multi-sector program to promote children's sleep health. Health promotion professionals focusing on other (health) behaviors can use the blueprint to develop health promotion programs that fit the local public service infrastructures, culture, and incorporate relevant policy sectors outside the public health domain

Promoting children's sleep health: Intervention Mapping meets Health in All Policies

Background: To design a comprehensive approach to promote children's sleep health in Amsterdam, the Netherlands, we combined Intervention Mapping (IM) with the Health in All Policies (HiAP) perspective. We aimed to create an approach that fits local infrastructures and policy domains across sectors. Methods: First, a needs assessment was conducted, including a systematic review, two concept mapping studies, and one cross-sectional sleep diary study (IM step 1). Subsequently, semi-structured interviews with stakeholders from policy, practice and science provided information on potential assets from all relevant social policy sectors to take into account in the program design (HiAP and IM step 1). Next, program outcomes and objectives were specified (IM step 2), with specific objectives for policy stakeholders (HiAP). This was followed by the program design (IM step 3), where potential program actions were adapted to local policy sectors and stakeholders (HiAP). Lastly, program production (IM step 4) focused on creating a multi-sector program (HiAP). An advisory panel guided the research team by providing tailored advice during all steps throughout the project. Results: A blueprint was created for program development to promote children's sleep health, including a logic model of the problem, a logic model of change, an overview of the existing organizational structure of local policy and practice assets, and an overview of policy sectors, and related objectives and opportunities for promoting children's sleep health across these policy sectors. Furthermore, the program production resulted in a policy brief for the local government. Conclusions: Combining IM and HiAP proved valuable for designing a blueprint for the development of an integrated multi-sector program to promote children's sleep health. Health promotion professionals focusing on other (health) behaviors can use the blueprint to develop health promotion programs that fit the local public service infrastructures, culture, and incorporate relevant policy sectors outside the public health domain