Analysis, evaluation, and reformulation of social cognitive theory: Toward parent-child shared management in sleep health

Abstract

Theoretical principles:

Social Cognitive Theory (SCT) is a middle-range theory with triadic determinism between behavioral, environmental, and personal. SCT has been a guiding framework in health promotion research as it helps understand people’s behaviors.

Phenomena addressed:

Behavioral Insomnia of Childhood (BIC) is highly prevalent, affecting up to 45% of typi cally developing children and 80% of children with special healthcare needs. BIC leads to sleep deficiency, disrupted physical and psychological health, poor school performance, behavioral dysfunction, and negatively affects parental and family functioning. Using Fawcett’s framework, we analyzed and evaluated SCT in a pe diatric sleep context and propose a reformulation of SCT to better inform sleep research.

Research linkages:

SCT is individually focused and does not account for interdependence within relationships. Pediatric sleep interventions have limited long-term effects and sustainability without considering the parent-child dyadic interdependency. We advance the argument that the parent-child shared management (PCSM) perspective is beneficial for understanding pediatric sleep health. PCSM is a concept that reflects the shared responsibility and interdependence that parent and child have for managing child health. It assumes that with parents’ ongoing support, children’s responsibility for their health management increases over time, along with developmental progression and health-related experiences. We propose reformulating SCT by integrating PCSM in the pediatric sleep context: SCT with Shared Management (SCT-SM). The proposed SCT-SM accounts for parent-child interdependence and role transition. Shared management interventions that engage parents and children in active roles in managing sleep have potential sustainable effects in improving sleep and quality of life. (250).

Introduction

Sleep problems in childhood are highly prevalent, affecting 25% to 45% of typically-developing children and up to 80% of children with special healthcare needs (Bruni et al., 2022; McLay et al., 2020; Phillips et al., 2020). Behavioral Insomnia of Childhood (BIC), including bedtime resistance and difficulty initiating and/or maintaining sleep, is the most common sleep problem (Freeman et al., 2020; Macias & Malhotra, 2021; Owens & Moore, 2017). BIC leads to sleep deficiency (insufficient sleep duration and poor quality), low sleep efficiency, sleep fragmentation, disrupted physical and psychological health, poor school performance, and behavioral dysfunction (Hayes & Bainton, 2020; Park et al., 2022). Sleep problems also negatively impact parental and family functioning (Chang et al., 2019; Nunes et al., 2020; Williamson et al., 2019). Parents of children with BIC are more likely to report distress, fatigue, and marital conflict associated with sleep deficiency resulting from their child’s sleep problems (Martin et al., 2019; Tyler et al., 2019).

Social Cognitive Theory (SCT) has been a guiding framework in health research as it is helpful for understanding people’s behaviors (Bagherniya et al., 2018; Moeini et al., 2019; Tougas et al., 2015; Xiang et al., 2022; Zare et al., 2020). SCT describes the influence of individual experiences, the actions of others, and environmental factors on individual health behaviors and emphasizes the primary role that cognition plays in encoding and performing behaviors (Bandura, 1986). A key concept is reciprocal determinism, which refers to the continuous interaction of personal, environmental, and behavioral factors; these three factors continuously interact through influencing and being influenced by each other in a triangular model (Bandura, 1998). The goal of SCT is to explain how people regulate their behavior through control and reinforcement to achieve and maintain the intended behavior (Luszczynska & Schwarzer, 2015).

In an effort to further understand SCT, advance sleep research guided by SCT, and inform pediatric sleep intervention development, we aimed to report on an analysis and evaluation of SCT in the context of pediatric sleep and propose a reformulation of SCT. A comprehensive analysis and evaluation of SCT in the context of pediatric sleep health have not yet been conducted, and this limits understanding of SCT and its potential to inform theory-driven sleep interventions for families experiencing BIC.

Methods

Theory analysis and evaluation framework

We used Fawcett’s framework to guide the analysis and evaluation of SCT (Fawcett & Desanto-Madeya, 2012). Fawcett’s framework provides a comprehensive structure for examining middle-range and grand theories. Theory analysis entails a non-judgmental and systematic examination of what the author has presented about the theory. There are three steps in theory analysis. These steps include investigating a theory’s 1) scope, 2) context, and 3) content. The sources used for analysis are the author’s writings; what others have written about the theory generally are not used in the analysis, unless necessary (for example, if the author is unclear on a particular point). Theory evaluation entails making judgments about the extent to which the theory meets six established criteria. The six criteria are 1) significance, 2) internal consistency, 3) parsimony, 4) testability, 5) empirical adequacy, and 6) pragmatic adequacy. Evaluation is based on the results of the theory analysis and may also draw on a published critique of the theory, research articles, and descriptions of the use of the theory in practice.

Results

Theory scope

Theory scope refers to a theory’s breadth and abstractness of its concepts and propositions (Fawcett & Desanto-Madeya, 2012). Grand theories have the greatest breadth and abstraction, while middle-range theories are less abstract and more applicable to clinical/social phenomena (Fawcett & Desanto-Madeya, 2012). SCT is a middle-range theory because it has specific concepts and relationships between propositions.

Theory context

Theoretical context considers the extent to which the concepts and propositions fit within the nursing metaparadigm, its philosophical claims (also called worldview), the conceptual model that guided theory development, and antecedent knowledge from which the theorist drew (Fawcett & Desanto-Madeya, 2012).

Metaparadigm Concepts and Metaparadigm Propositions.

SCT addresses the metaparadigm nursing concepts of human beings, health behavior, and environment, positing that human behavior is the product of and influenced by the dynamic interplay across personal, behavioral, and environmental factors (Bandura, 1986). A metaparadigm nursing proposition of SCT is that the behavior of human beings is “concerned with the patterning of human health experiences within the context of the environment” (Fawcett & Desanto-Madeya, 2012, p. 6).

Philosophical Claims.

The philosophical basis of SCT is human agency and human capability. Human agency underscores that individuals can direct their own thoughts, feelings, and actions in specific ways to attain goals (Bandura, 1986). People are not simply acted upon by their environment and others’ actions, but they also shape their environment to change their behavior.

Worldview.

SCT does not explicitly state its worldview, but contextualism can be inferred. Contextualism originated from philosopher Stephen C. Pepper, who emphasized: “act in context.” People continuously interact with the dynamic environment to change their behaviors (Morris, 1988; Zimmerman, 1983). The worldview of contextualism underpins SCT in that health behavior occurs within a social context, where a person’s experiences, expectations, and perceptions are shaped.

Conceptual Model.

The conceptual model of SCT is triadic determinism between behavioral, environmental, and personal factors (e.g., cognitions and emotions; Bandura, 1986). For example, in sleep health, children who feel more confident in soothing themselves to sleep (high self-efficacy/personal) tend to follow a consistent bedtime routine which, in turn, supports good quality sleep (behavior).

Antecedent Knowledge.

Social Learning Theory (SLT), the precursor to SCT published in 1977 by Bandura, holds that a person’s perceived self-efficacy, self-regulation, and observational learning significantly correlate with behavioral change (Bandura, 1977). In 1986, Bandura expanded and renamed SLT to SCT, emphasizing the importance of cognition in performing and changing behaviors (Bandura, 1986). As a result, SCT evolved from emphasizing behavior-oriented concepts in 1977 to cognitive concepts in 1986.

Theory content

Theory content includes the concepts and propositions of a theory (Fawcett & Desanto-Madeya, 2012). According to Fawcett, concepts give meaning, enable a theory to be interpreted, and structure phenomena. Propositions include statements that describe or define concepts (nonrelational propositions) and statements about relations between two or more concepts (relational propositions) (Fawcett & Desanto-Madeya, 2012). Table 1 shows key concepts and propositions of SCT.

Table 1.

Social Cognitive Theory Concepts.

Concept	Nonrelational Proposition	Example in Pediatric Sleep Health	Relational Proposition with Respect to Health Behaviors
Reciprocal determinism	Environmental factors impact people. People also influence their environment and adjust their behavior (Bandura, 1977, 1986)	Children’s sleep is a product of and reciprocally influences their own and their parents’ knowledge, attitudes, and beliefs about sleep; parents’ rewards or incentives for their child’s sleep behaviors; and parental modeling of sleep behaviors.	Dynamic, mutual, and continuous interaction among the person (an individual with learned experiences), environment, and behavior factors (Glanz et al., 2015).
Self-efficacy	“Self-efficacy is the belief in the personal ability to perform behaviors that bring desired outcomes.” (Bandura, 1986)	People base their self-efficacy upon mastery experiences (e.g., interpretation of actual daily sleep behavior), vicarious (modeled) experiences (e.g., sibling modeling), forms of social persuasion by others (e.g., “I know you can sleep really well through the night”), and physiological index (e.g., “I am feeling relaxed when I think about sleep”; Bandura, 1997)	Within a social cognitive system of triadic reciprocity, self-efficacy is hypothesized to influence behaviors and environments and, in turn, is affected by them. Higher self-efficacy is likely to result in better outcomes (Bandura, 1986, 1997)
Outcome expectation	Outcome expectation is the belief about the likelihood and value of the consequences of behavioral choices (Bandura, 1986)	Outcome expectation is a source of motivation. It includes external outcomes (e.g., “if I have a consistent sleep routine, I will sleep better”) and internal outcomes (e.g., “If I had a good night’s sleep, I would feel great”). People form outcome expectations about the likely results of given actions based on experience and observations of a model.	Outcome expectations sustain behaviors for a long time when people believe their actions will bring preferred outcomes. Higher outcome expectation is associated with better outcomes (Aardoom et al., 2020; Gunn et al., 2019; Khor et al., 2021).
Observational learning	People learn to perform new behaviors that they had not learned previously by modeling the behaviors of others (Bandura, 1986)	Observational learning takes four component processes: attention (observe the model, e.g., observe sibling/parent going to bed consistently each day and waking up refreshed), retention (cognitively organizing and transforming information for storage in memory, e.g., observing behavior daily and cognitively accepting the behavior), production (translating cognitive conceptions into behavior, e.g., establishing consistent sleep routines and schedules), and motivation (choosing to learn actions believed to result in the desired outcome, e. g., believing that consistent sleep routines and sufficient sleep will lead to physical and mental health; Bandura, 1986).	Observational learning is a process of learning by watching the behavior of others. The targeted behavior is observed and mimicked. For example, children learn to respond to others by observing how their caregivers interact with others (Carcea & Froemke, 2019; Qiu et al., 2021).
Self-regulation	Refers to the processes people use to activate and sustain behaviors, cognitions, and affects, which are systematically oriented toward attaining goals (Bandura, 1986)	People motivated to attain goals (e. g., healthy sleep) will likely engage in effective self-regulatory activities (e.g., maintaining consistent sleep routines, recording sleep time, modifying the bedroom environment). Throughout the self-regulatory process, people’s cognition (personal influences) directs their behaviors, and external feedback (behavior and environmental factors) can affect their cognition.	People regulate their behaviors through self-control, small attainable goal-setting, problem-solving, feedback, self-reward, self-reflection, and enlisting social support. Effective self-regulatory activities (e.g., implementing a strategy, monitoring performance, adjusting one’s approach as needed, reflecting on progress, and sustaining motivation) enhance self-efficacy of learning and support self-regulation (Panadero, 2017).

Theory evaluation

Significance.

The criterion of significance requires justification of the theory’s importance to the nursing discipline through the following aspects: explicit assertion of metaparadigm concepts and propositions, derivative philosophical claims, conceptual models, or antecedent knowledge (Fawcett & Desanto-Madeya, 2012). The worldview of contextualism can be inferred from SCT. The conceptual model of triadic reciprocal interactions is clearly documented, as is the theory’s antecedent knowledge. SCT is also widely applied across diverse disciplines and areas of study, including psychology, nursing, medicine, and other health professions (Glanz et al., 2015). These demonstrate the solid foundation upon which SCT was developed and have been cited throughout other SCT publications (Bandura, 1985, 1986, 1989, 2001, 2002, 2004).

Internal Consistency.

Internal consistency is achieved when all theory components are consistent and coherent, its concepts demonstrate semantic clarity and consistency, and its propositions demonstrate structural consistency (Fawcett & Desanto-Madeya, 2012). Semantic clarity is evident in the definitions of SCT concepts (see Table 1 for SCT concepts and propositions). Some elements that limit internal consistency include semantic inconsistency in interchangeable terminology, such as “observational learning” and “social modeling.” Before 2004, SCT used “observational learning.” However, after 2004, SCT used “social modeling” and “observational learning” interchangeably. Additionally, the relational propositions of SCT are not clearly stated. SCT primarily depends on the triadic reciprocal interactions between behavior, environment, and people. SCT does not indicate how the concepts interact (e.g., does high self-efficacy lead to high expectations or vice versa? Does goal setting promote self-efficacy?) and to what extent those key concepts impact an individual’s behavior (e.g., whether some are more influential on behavior than others)? The structural inconsistency of the relational propositions of SCT reduces the internal consistency of SCT.

Parsimony.

Parsimony requires a theory to be comprised of as few concepts and propositions as necessary to convey the meaning of the theory (Fawcett & Desanto-Madeya, 2012). SCT is a complex theoretical paradigm capable of accounting for all aspects of human behaviors, yet it is depicted in a simple structure. However, the theory may be oversimplified and wide-reaching without explicitly explaining all of the concepts in SCT. For example, SCT is not explicit about which concepts are contained under People, Environment, and Behavior. There is also a lack of clarity about how these concepts function differently in various contexts, such as individuals, teams, cultures, and gender. This lack of clarity diminishes parsimony and presents a challenge for intervention operations in future projects.

Testability.

Testability for a middle-range theory requires observable concepts and measurable propositions (Fawcett & Desanto-Madeya, 2012). Two elements limit SCT’s testability. First, SCT is unclear about which concepts are contained under People, Environment, and Behavior, which could lead to inappropriate applications of SCT. Second, SCT lacks a clear description of how the concepts interact in consistent and predictable ways toward explaining human behavior, which reduces testability and measurability. Nevertheless, many researchers have tested one or more concepts of SCT. Table 2 shows SCT concepts and instruments tested in pediatric sleep studies. The concept of self-efficacy has been intensively tested in pediatric sleep studies, mainly focused on the self-efficacy of managing their own sleep in children and adolescents with chronic conditions and insomnia, and the self-efficacy of managing children’s sleep disturbances in parents (Bihlmaier & Schlarb, 2016; Brandhorst & Hautzinger, 2016; Hammersley et al., 2019; Haraldstad & Stea, 2021; Kim et al., 2017; ten Brink et al., 2021). The most common instruments to measure self-efficacy were Bandura’s general self-efficacy scale (Chen et al., 2001), coping self-efficacy (Yeager et al., 2016), general self-efficacy scale (Schwarzer & Renner, 2000) and parenting self-efficacy scale questionnaire (Kim et al., 2017). By comparison, other concepts have not been widely tested in pediatric sleep research. For example, Bub et al. (2016) tested self-regulation with different instruments, including self-imposed waiting task (Mischel & Underwood, 1974), children’s stroop task (Gerstadt et al., 1994), continuous performance task (Beck et al., 1956), and child behavior questionnaire (Rothbart et al., 2001). Robinson and Knobloch-Westerwick (2020) tested outcome expectations among mothers of children with sleep problems by asking participants to rate their agreement to a specific intervention (Robinson & Knobloch-Westerwick, 2017). And Golem et al. (2019) tested observational learning among school-age children with sleep problems and their parents by conducting focus group interviews. Moreover, robust statistical methods such as regression analyses, structural equation modeling, and dynamic computational modeling have been employed to test the propositions of SCT (Dewar et al., 2013; Esmaeily et al., 2014; Kanekar et al., 2015; Lubans et al., 2012; Riley et al., 2016; Torkan et al., 2018).

Table 2.

Tests and Measures of Key Social Cognitive Theory Concepts.

Concept	Studies	Target Area	Instruments
Self-efficacy	• Bihlmaier & Schlarb, 2016 • ten Brink et al., 2021 • Brandhorst & Hautzinger, 2016 • Haraldstad & Stea, 2021 • Kim et al., 2017 • Hammersley et al., 2019	• Children with chronic insomnia • Adolescent sleep • Parents of children with sleep disturbances • Adolescents with pain and sleep problems • Parents of children with sleep disturbances • Childhood Obesity Prevention	• Bandura’s General Self-Efficacy Scale (Chen et al., 2001) • Coping Self-Efficacy(Yeager et al., 2016). • General Self-Efficacy Scale (Schwarzer & Renner, 2000) • General Self-Efficacy Scale (Schwarzer & Renner, 2000) • Parenting Self-Efficacy Scale Questionnaire (Kim et al., 2017)
Self-regulation	• Bub et al., 2016	• Children and adolescents	• Self-imposed waiting task (Mischel, 1974) • Children’s Stroop Task (Gerstadt et al., 1994) • Continuous Performance Task (Beck et al., 1956) • Child Behavior Questionnaire (Rothbart et al., 2001)
Outcome expectation	• Robinson & Knobloch-Westerwick, 2020	• Mothers of children with sleep problems	• Participants were asked to indicate their agreement that the five sleep assertions placed in a story would improve sleep hygiene on a scale from 1 = totally incorrect to 7 = totally correct (Robinson & Knobloch-Westerwick, 2017)
Observational learning	• Golem et al., 2019	• School-age children with sleep problems and their parents	• Focus group interview

Empirical Adequacy.

The empirical adequacy criterion assumes that the theory is congruent with empirical data (Fawcett & Desanto-Madeya, 2012). As shown in Table 2, SCT has been broadly applied across diverse disciplines. Self-efficacy, in particular, has been tested and validated in many studies. However, concepts such as observational learning, self-regulation, and motivation have not been as widely tested. Therefore, SCT partially meets the empirical adequacy criterion.

Pragmatic Adequacy.

Pragmatic adequacy refers to how the theory and research findings help enhance practice or solve problems arising from practice (Fawcett & Desanto-Madeya, 2012). SCT provides a framework for understanding and predicting behaviors, identifying and targeting pathways for changing those behaviors, improving health outcomes, and reducing disease burden (Glanz et al., 2015). Table 3 provides examples of how SCT has been applied to pediatric sleep intervention studies. Studies are categorized based on three types of theory utilization (Painter et al., 2008): 1) inform: SCT concepts are used to guide the development of the intervention, but the theoretical constructs are not described or measured; 2) applied: SCT is specified as the theoretical framework for developing the intervention, and the theoretical concepts are measured in the study; and 3) create/build: a new theory is developed based on SCT, and concepts are measured in the study. In summary, SCT-informed intervention development among children with sleep problems and their parents (Moorman & Harrison, 2019; Sonney et al., 2020; Tinker et al., 2020) and the concepts of self-efficacy, self-regulation, outcome expectation, goal setting, action planning, observational learning were used to guide the intervention development. Furthermore, SCT was applied to the interventions of high school students and parents of preschoolers (Wang et al., 2020; Wilson et al., 2014). The concepts of self-efficacy, knowledge and attitude, reciprocal determinism, behavior capacity, outcome expectation, expectancies, observational learning, and reinforcement have been used to develop interventions and also measured in the studies. To our knowledge, no new theory is developed based on SCT, and concepts are measured in the study.

Table 3.

Examples of SCT Related Interventions.

Pediatric Sleep Research	Employed Concepts	Use of the Theory	Population of Research	Sample size	Findings
Sleep health in preschoolers intervention (Tinker et al., 2020)	• Self-efficacy • Self-regulation • Outcome expectation	Inform	Parents of preschool-age children (2.5 to 5 years) with a behavioral sleep problem	433 parent-child dyads	Ongoing
Sleep education (Wilson et al., 2014)	• Self-efficacy • Knowledge and attitude	Applied	Parents of preschool children with sleep problems	152 parents	Parents’ knowledge, attitudes, and self-efficacy improved after the intervention; children in the intervention group significantly improved their weeknight sleep duration
Sleep health and academic functioning (Wang et al., 2020)	• Reciprocal determinism • Self-efficacy • Behavior capacity • Outcome expectation • Expectancies • Observational learning • Reinforcement	Applied	High school students	144 high school students	Students in the intervention group had decreased daytime sleepiness, less insomnia, and higher academic achievements
Sleep health in children with asthma (Sonney et al., 2020)	• Goal setting • Action planning • Self-monitoring	Inform	Children and their parents	25 parent-child dyads (children 6–11 years of age)	The sleep intervention was feasible, acceptable, and effective in improving the child’s and parent’s sleep outcomes, except for total sleep time
Sleep behavior and media use (Moorman & Harrison, 2019)	• Environment • Observational learning	Inform	Parents of preschoolers	278 parents	Quantity of media use, screen media in the bedroom, and sneaky media use associated with shorter nightly sleep and longer daily napping

SCT and parent-child shared management

Despite the utility of SCT in explaining, predicting, and changing human behavior, SCT is individually focused and does not account for interdependence or interaction within relationships. In pediatric sleep research, it is crucial to understand parent-child interdependence to effectively manage children’s sleep. Parents play critical roles in shaping children’s health management skills as they are essential care providers and teachers. Pediatric sleep interventions have limited long-term effects and sustainability without considering parent-child dyadic interdependency (Kieckhefer & Trahms, 2000; Sonney et al., 2020).

This paper advances the argument that taking a family-centered approach, specifically a parent-child shared management perspective (Kieckhefer & Trahms, 2000), is beneficial for understanding pediatric sleep. Parent-child shared management is a concept that reflects the shared responsibility and interdependence (being dependent upon one another) that parent and child have for managing child health. It assumes that with parents’ ongoing support, children’s responsibility for their own health management increases along with developmental progression and health-related experiences (Buford, 2004; Kieckhefer & Trahms, 2000). Shared management theorists contend that childhood is an opportune time for children to learn health management responsibility in a safe environment alongside their parent(s), to maximize the child’s management potential (Buford, 2004; Kieckhefer & Trahms, 2000; Schilling et al., 2006; Sonney et al., 2016). We believe that adding parent-child shared management as a central concept in SCT enhances its capacity to account for this interdependence and broadens its application to dyads.

Building on insights from the above SCT theory analysis and evaluation, we propose a reformulated Social Cognitive Theory by integrating parent-child shared management: Social Cognitive Theory with Shared Management (SCT-SM). Fig. 1 presents a conceptual model of SCT-SM. This reformulated SCT-SM acknowledges empirical evidence and has the potential to guide future sleep research on mechanisms that facilitate sleep health among children and their parents.

Fig. 1.

SCT-SM toward Sleep Health.

Reformulation

Maintaining the structure of triadic determinism, SCT-SM includes the three factors of people, behavior, and the environment but adds parent-child shared management as a central concept that influences and is influenced by each of the three factors of triadic determinism. The sections below define parent-child shared management and the three factors of triadic determinism in SCT-SM, then describes relationships between people, behavior, environment, and parent-child shared management in the context of pediatric sleep health using the reformulated model.

Parent-child shared management

Parent-child shared management is characterized by an interdependent connection, effective partnership, strategic collaboration, and role transition process within dyads. In early childhood, a child mainly depends on their parent(s) to provide care. As the child develops physically and cognitively, they are capable of assuming increasing responsibility for their health and self-management (Sonney et al., 2016). Development and capacity for self-management are highly variable among children; typically, developing adolescents will assume primary responsibility for healthy sleep behaviors, with the parent being available to consult and support them. Shared management is highly variable within families and dyads due to interpersonal and familial dynamics, the child’s developmental trajectory, and self-management capacity.

People

People refers to children and their parent(s) or family caregiver(s). People also refers to cognitive dimension, including 1) the dyad’s confidence to execute healthy sleep behaviors; 2) the dyad’s self-regulation, including the ability to manage their thoughts and behaviors to meet healthy sleep goals; 3) the dyad’s knowledge of sleep health; and 4) the dyad’s beliefs and attitudes toward sleep.

Environment

Studies found that contextual factors are closely connected to children and adolescents sleep duration and quality (Bobba et al., 2023). This study conceptualizes the environment from a social-ecological perspective (Bronfenbrenner & Morris, 2007). For example, family functioning, the social-physical environment, and the policy environment are contained within the environment concept.

Behavior

Behavior is the act people conduct with or without purpose. In sleep research, behaviors including sleep behaviors (actions directly related to sleep: bedtime, rise time, regularity of sleep timing, napping habits, sleep routine) and sleep-related behaviors (a lifestyle that may influence sleep: avoiding caffeine, tobacco, alcohol, night light exposure, as well as engaging in stress management and physical activity habits) (Hall & Nethery, 2019; McDowall et al., 2017).

Relationships between people, behavior, environment, and parent-child shared management in SCT-SM

As depicted in Fig. 1, the reformulated SCT-SM focuses on bidirectional and reciprocal relationships that explain how parent-child shared management mediates the multidimensional factors contributing to one’s sleep health.

People and behavior

Parent-child dyads and sleep outcomes reciprocally interact. Children’s health conditions (e.g., chronic disease, mental health conditions; Johnson et al., 2016, 2018; Koyanagi & Stickley, 2015; Medic et al., 2017), self-efficacy (Bihlmaier & Schlarb, 2016; Schlarb et al., 2012), and self-regulation (Dorrian et al., 2019; Owens et al., 2016; Williams & Sciberras, 2016; Zhang & Wu, 2020) are strongly associated with sleep behaviors. Reciprocally, healthier sleep habits, sleep behaviors, and better sleep outcomes are associated with parent-child dyads’ better overall physical, mental health, and life satisfaction (Blackwell et al., 2020; Dong et al., 2019; Grandner, 2017; Kaneita et al., 2009; Shanahan et al., 2014; Stranges et al., 2012), as well as sleep-related knowledge, beliefs, self-efficacy, and self-regulation (Owens et al., 2016; Przepiórka et al., 2019). Moreover, higher maternal knowledge, beliefs, and self-efficacy about sleep are correlated with fewer children’s sleep problems, depressive symptoms, and fatigue, as well as better daytime performance (Brandhorst and Hautzinger, 2016; Grandner, 2017; McDowall et al., 2017; Peltz & Rogge, 2019; Thakral et al., 2020; Werner et al., 2022).

Environment and behavior

Family Functioning.

Family functioning includes the process of communication, problem-solving, division of labor, conflict management, and a sense of attachment and engagement among family members (El-Sheikh & Kelly, 2017). Positive family functioning includes maternal sensitivity, children’s secure attachment to parents, and parents’ high-quality involvement (El-Sheikh & Kelly, 2017). Negative family functioning includes marital aggression and conflict, parents’ hostility toward each other, aggression between parents and children, and parental mental health conditions (Caicedo, 2014; Lewandowski, Palermo, Stinson, Handley, & Chambers, 2010). Children who experience positive family functioning tend to sleep longer and have better sleep quality, whereas children who experience negative family functioning tend to have sleep deficiency (Bélanger et al., 2015; Bernier et al., 2017; Bordeleau et al., 2012; El-Sheikh et al., 2012; Kelly & El-Sheikh, 2011; Maratia et al., 2023; Mindell et al., 2009; Ragni et al., 2019; Rhoades et al., 2012; Varma et al., 2021).

Physical and Social Environment.

Examples of the physical and social environment include housing quality and safety, noise, population density, transportation, and community cohesion (Billings et al., 2020; Hale et al., 2015; Hunter & Hayden, 2018; Johnson et al., 2018). Due to inequitable systems, predominantly live in under-resourced environments negatively affect minoritized and underrepresented populations’ sleep health (Bagley et al., 2018; El-Sheikh et al., 2013; Grimes et al., 2019; Johnson et al., 2019; Mayne et al., 2021; Rosen et al., 2003; R. Wang et al., 2017; Williams & Collins, 2001). For example, children who are living in environments with less green space, security and social cohesion, exposed to more noise, air pollution, and night light, are more likely to experience longer sleep onset latency, increased fragmented sleep, daytime sleepiness, and sleep disorders (Mayne et al., 2021). Furthermore, systemic racism has additional adverse effects on sleep health through the mechanism of psychosocial trauma, discrimination and micro-aggressions, and stereotype threats to sleep (Bailey et al., 2017). These experiences can serve as external threats and impair the ability to be vulnerable in sleep (Billings et al., 2021). People who experience micro-aggressions and racism have poorer quality sleep that result from greater racism-related vigilance and discrimination experiences (Alcántara et al., 2017; Gaston et al., 2020; Ong et al., 2017; Yip et al., 2020).

Policy Environment.

Policies profoundly influence sleep health, from operational issues in local schools to national-level legislation that governs safety and health matters related to sleep. As summarized by Barnes and Drake (2015), national middle and high school instructional hours could be delayed, work hours and schedules could be better regulated, daylight savings time could be eliminated, public awareness about the impact of electronic devices on sleep could be improved, and the access to diagnostic testing for sleep disorders needs to be enhanced.

People and environment

People live in and are influenced by their environment, and they also shape the environment (Bandura, 1986). For example, policies regulating quiet time between 9 pm to 7 am, delayed school start times based on age, and cancellation of daylight savings would promote better sleep health (Barnes & Drake, 2015). Higher sleep-related efficacy, self-regulation, knowledge, and beliefs toward sleep also contribute to a better sleep environment (e.g., no TV or screen in the bedroom, quiet and dark sleep environment). Family engagement in healthy sleep behaviors could contribute to building communities that support sleep health.

Parent-child shared management and behavior, people, and environment

Shared management is a dynamic process, given that parent and child responsibilities continuously evolve as the child develops. The shared management relationship could both influence and be influenced by the environment. Shared management relationships could foster positive family functioning by creating open communication channels, enhancing positive interaction and feedback, and strengthening family bonds by facing challenges and overcoming barriers as a team. In shared management relationships, parents’ knowledge, awareness, attitudes, and beliefs toward sleep health profoundly impact how children perceive sleep and perform sleep-related behaviors. Partnerships within families ultimately extend to collaboration and participation within neighborhoods and communities. With more families realizing and understanding the critical role of sleep and adopting shared management in managing sleep and other health conditions, more people will advocate for optimizing policies and strive to make the community a better “healthy-sleep friendly” place.

Discussion

To our knowledge, this is the first paper to comprehensively analyze and evaluate SCT and reformulate SCT toward parent-child shared management in pediatric sleep health. SCT provides strong theoretical foundations for explaining, predicting, and changing human behavior. Although SCT was not derived from the nursing discipline, it demonstrates the considerable social significance and has powerfully impacted empirical nursing research. However, SCT is individually focused and does not account for interdependence within relationships. Our proposed SCT-SM adds the active role of parent and child and accounts for parent-child interdependence and role transition, providing a promising framework for promoting children’s sleep health with sustained effects.

Implications for sleep research, intervention, and healthcare

Most of the literature on pediatric sleep focuses on children or parents alone, which decontextualizes pediatric sleep research by not considering connections within parent-child dyads. SCT-SM reconsiders pediatric sleep from a new theoretical perspective that includes parent-child shared management. Additionally, given that many behaviors happen in the context of relationships, SCT-SM has the potential to be applied across other health conditions within the parent-child caregiver dyads.

Validated and user-friendly assessment tools are needed to measure parent-child shared management for use in healthcare and research settings. To date, only one known shared measurement assessment tool has been created, and it is rarely used because the tool was designed only for parental respondents (Kieckhefer et al., 2009). Moreover, systemic racism and racial discrimination significantly mediate the relationship between race and insomnia symptom severity (Cheng et al., 2020). Future research could explore whether SCT-SM could mitigate sleep health disparities among children in underserved communities by addressing drivers of inequities including racism and discrimination.

Parents typically receive little preparation for shared management of their child’s health. Guided by SCT-SM, future research interventions could add a component of parent-child shared management, including strategies for how to maximize children’s engagement in self-management. Interventions could also meet families’ needs and priorities by applying participatory design in the development stage, allowing parents and children to provide suggestions and feedback on the intervention prototype (Bødker & Kyng, 2018). Leveraging mobile applications and other technology-enabled approaches may increase the accessibility and scalability of future shared management sleep health interventions (Lyon et al., 2020; Lyon & Koerner, 2016).

Furthermore, healthcare professionals are critical in promoting parent-child shared management within families (Kieckhefer & Trahms, 2000). SCT-SM theory has the potential to guide healthcare professionals to encourage and support the development of collaborative plans for dyadic care by increasing families’ awareness of shared management, coaching their practice and monitoring their progress at each appointment.

Strengths and limitations

This paper has some limitations. Our analysis and evaluation of SCT are limited to the sources we used, including Bandura’s writings about the theory (Bandura, 1986, 1997, 1998, 2004), Glantz and colleagues’ (2015) writings, and empirical research studies that have used SCT. We did not conduct a systematic review of all empirical research studies that used SCT, and the sources we used were limited to those written in English. However, the strengths of this manuscript include the application of an established theory analysis and evaluation framework (Fawcett & Desanto-Madeya, 2012), our focus on the use of SCT in pediatric sleep research, and the proposed reformulation. Reformulation is an accepted form of knowledge development (Reed & Shearer, 2017), and SCT-SM extends SCT to dyadic behavioral research concerned with shared management.

Conclusion

The reformulated SCT-SM allows researchers to better understand parent-child shared management of pediatric sleep. Our research team will soon test SCT-SM in children with juvenile idiopathic arthritis (JIA) and sleep problems, including their parents. We expect a sleep intervention guided by SCT-SM will improve sleep quality, enhance communication, and boost the capacity to manage chronic conditions in children and parents. We also anticipate that the reformulated SCT-SM could extend to other pediatric chronic conditions by providing a framework for a better understanding of shifting roles/responsibilities between parents and children.