ABSTRACT
Introduction:
Shift in circadian clock of adolescence with delayed bedtime and early awakening to catch morning school effects their sleep. Present study elucidated sleep hygiene practices of school-going adolescents and explored its association with their sleep quality and mood.
Methods:
Students of 6th to 12th grade were enrolled after requisite permissions, parental consent, and written informed assent from students. Standardized questionnaires were used to evaluate for sleep hygiene practices-Adolescent Sleep Hygiene Scale (ASHS), sleep quality- Pittsburgh Sleep Quality Index (PSQI), daytime sleepiness-Pediatric Daytime Sleepiness Scale (PDSS) and mood (DASS-21-Depression Anxiety Stress Scale-21). CTRI/2022/06/043556 is the study number in Clinical Trial Registry of India.
Results:
Adolescents with mean age 14.28 ± 1.86 years, including 48.7% (479) males and 51.2% (503) females participated in this study. Mean sleep hygiene score was 4.37 ± 0.60, with no difference between males and females. On ASHS subscales comparison, females had poorer sleep quality (0.009), higher daytime sleepiness (P = 0.001), poorer cognitive/emotional factor (P = 0.001) and higher depression, anxiety, and stress (DASS-21). Young adolescents (10–14 years; N = 528) had better total sleep hygiene scores (P = 0.016), better bedtime routine, cognitive/emotional factor (P = 0.001), but had poor sleep environment factor (P = 0.001). Younger adolescents also exhibited better quality of sleep (P = 0.003), lesser daytime sleepiness, and lesser mood derangements compared to older adolescents (15–19 years; N = 453). Sleep hygiene scores showed a significantly negative correlation with mood and sleep quality.
Conclusion:
A clear relationship between sleep hygiene practices, mood and sleep quality has been observed among adolescents. Young adolescents who followed better sleep hygiene practices had lesser mood derangements and better sleep quality. Though ASHS scores were same among both genders but females had poor sleep quality, higher daytime sleepiness and mood.
Keywords: Adolescents sleep hygiene practices, adolescents sleep quality, ASHS and daytime sleepiness, sleep hygiene and sleep quality, sleep quality and mood
Introduction
Adequate sleep is essential for physical growth, psycho-social advancement, emotional regulation, cognition as well as learning.[1,2] It is vital for maintaining a hormonal balance as well as repairing and restoring the body system. Sleep hygiene is “a set of behavioral and environmental recommendations intended to promote healthy sleep,” and plays a crucial role in maintenance of overall physical and psychological health.[3] It includes maintaining consistent bedtimes/rise times; curbing light and sound levels; optimizing body and room temperature; refraining from caffeine consumption before bedtime; as well as keeping a healthy diet and fitness routine.[4]
The transition from childhood to adulthood during adolescence involves not only physical changes but also creates mental pressure regarding career planning. Sleep deprivation is prevalent among adolescents resulting from both natural shifts in their sleep pattern as well as increased late-night device usage, along with early school start timings. This leads teenagers, trying to “catch up” sleep on weekends and thus disturbing their circadian rhythm.[5,6] An extra hour of evening technology use has been shown to increase the odds of poor sleep efficiency by 20%.[5] Stress as well as low socioeconomic status have been shown to have negative influence on sleep hygiene of adolescents.[7] Researchers have reported that 65% of adolescents experience daytime sleepiness and have at least one poor sleep hygiene habit like studying in bed, staying up late, and/or engaging in chatting on mobile phones or watching television.[8] Galland et al. have shown affected arousal factors, sleep stability factors, and cognitive-emotional factors among adolescent girls with disturbed and poor sleep quality and Good sleep hygiene has been shown to have a positive association with high sleep quality.[9,10,11]
Though, several studies on adolescents’ sleep hygiene have been conducted but they have either failed to encompass the full range of habits that impact sleep health or have been conducted on a small population. Comprehensive research in this area including the broader spectrum of sleep hygiene factors, addressing a larger adolescent population will help in identifying the major common poor sleep hygiene practices among adolescents. The present study explored the prevalent sleep hygiene practices among adolescents and its association with their sleep quality and mood.
Material and Methods
Study design
A cross-sectional study was conducted among adolescent students in grades 6th to 12th. A list of eligible schools was acquired, and subsequent selection of schools was done using a computerized random number generator. The study was in accordance with the principles of Declaration of Helsinki. Ethical permission to conduct study was duly obtained from the institutional ethics committee. Requisite permissions were obtained from the respective school administrations, and the students of grades 6th to 12th from eligible schools were invited to participate. The study is registered as CTRI/2022/06/043556 in the Clinical Trial Registry India.
Procedure
Students were introduced to the study and those giving assent for participation and who submitted parental consent were enrolled in the study. Standardized questionnaires were used to ask about their sleep hygiene practices, sleep quality and mood. Explanations were provided in a readily comprehensible manner for each item of questionnaires. Students with epilepsy, attention deficit hyperactive disorder (ADHD) and/or chronic pulmonary disease, or those on any other chronic medication were excluded from the study.
Questionnaires used to obtain requisite details from the students are-
Adolescent Sleep Hygiene Scale (ASHS)[11]
ASHS is a 32-item self-reported inventory, which evaluates on a six-point Likert Scale. The scale is anchored with “Never” assigned a score of 1, followed by “once in a while” =2, “sometimes” =3, “Quiet Often” =4, “Frequently, if not always” =5, lastly “Always” scoring the highest score of six. It provides eight subscale scores, including physiological factor, behavioral arousal factor, cognitive/emotional factor, sleep environment factor, sleep stability factor, daytime sleep factor, substances factor, and bedtime routine factor, in addition to an overall sleep hygiene score. Higher scores mean better sleep hygiene score.[11] Overall sleep hygiene score was calculated as a mean score of all subscales.
Pittsburgh Sleep Quality Index (PSQI)[12]
PSQI evaluates various aspects of an individual’s sleep patterns over the past month. It is validated among adolescents and has 19 items grouped into seven distinct component scores.[13] Each item is evaluated using a four-point Likert scale of 0 to 3 and sum of seven items gives a Global PSQI score ranging from 0 to 21. Higher PSQI scores indicate a greater degree of sleep disturbance and poorer sleep quality.[12]
Pediatric Daytime Sleepiness Scale (PDSS)[14]
PDSS is a self-reported questionnaire that assesses daytime sleepiness in adolescents of school age, and scores range from 0 to 32. Elevated PDSS scores connotate amplified daytime sleepiness.[14] Values >26 for 6th and 7th grade and >30 for 8th grade is considered abnormal.[15]
Depression Anxiety Stress Scale-21 (DASS-21)[16]
DASS-21 is a 21-item scale for assessment of negative emotional state and is validated among adolescents.[17] It consists of seven items each for exploring levels of depression, anxiety, and stress.[16] All items are graded on a 0–3 Likert scale. A total of seven items each for depression, anxiety, and stress scores are summarized to assess the levels of respective emotional states. A cut-off level of >10 for depression, >8 for anxiety, and >15 for stress is used to classify further as normal, mild, moderate, severe, or extremely severe.[18]
Statistical method
Data was recorded in Microsoft Excel, and the statistical analysis was conducted using Statistical Package for Social Sciences version 22 (SPSS, Inc., Chicago, IL, USA). Descriptive data was presented using mean ± SD for continuous variables and percentage (N) for categorical variables. Independent-sample t-tests were employed to compare differences between groups. Spearman correlation analysis was performed to assess the relationship between two numerical variables. All statistical tests used a two-tailed confidence interval of 95% (α = 2) and a significance level of P < 0.05 to determine statistical significance.
Result
Our study evaluated sleep quality, mood, and status of sleep hygiene practices among 982 school-going adolescents with a mean age of 14.28 ± 1.86 years. 48.7% (479) males and 51.2% (503) females participated in this study. Mean sleep hygiene score was 4.37 ± 0.60, with no difference between male and female participants [Table 1]. However, on comparison of individual ASHS subscales, females had lower daytime sleepiness factor on ASHS (P = 0.001) and higher PDSS scores (P = 0.002), both suggesting an increased daytime sleepiness among females. They were poorer on cognitive/emotional factor (P = 0.001), while males had poorer scores on substances factor (P = 0.006). Sleep quality was poorer among females (P = 0.009), who experienced greater depression, anxiety, and stress.
Table 1.
Comparison of sleep quality, Mood, daytime sleepiness and sleep hygiene scores among male and female adolescents
| Variables | Total (n=982) | Male (n=479) | Female (n=503) | P |
|---|---|---|---|---|
| ASHS Subscales | ||||
| Physiological Factora | 4.29±0.98 | 4.23±1.02 | 4.35±0.94 | 0.062 |
| Behavioural Arousal Factora | 3.92±1.30 | 3.93±1.27 | 3.91±1.32 | 0.753 |
| Cognitive/Emotional Factora | 3.97±1.08 | 4.09±1.03 | 3.85±1.12 | 0.001* |
| Sleep Environment Factora | 4.87±1.02 | 4.82±1.05 | 4.92±0.99 | 0.1 |
| Sleep stability Factora | 4.08±1.42 | 4.13±1.48 | 4.02±1.36 | 0.241 |
| Daytime Sleepiness Factora | 4.68±1.17 | 4.81±1.15 | 4.56±1.17 | 0.001* |
| Substances Factora | 5.77±0.73 | 5.70±0.83 | 5.83±0.62 | 0.006* |
| Bedtime Routine Factora | 3.40±1.91 | 3.31±1.94 | 3.48±1.89 | 0.166 |
| ASHS Totala | 4.37±0.62 | 4.38±0.64 | 4.37±0.60 | 0.76 |
| Sleep Quality (PSQI)b | 4.99±2.86 | 4.75±2.68 | 5.22±3.01 | 0.009* |
| Daytime Sleepiness (PDSS)c | 13.58±5.62 | 13.01±5.78 | 14.13±5.42 | 0.002* |
| Depression | 8.91±8.21 | 8.47±8.02 | 9.33±8.37 | 0.102 |
| Anxiety | 8.48±7.90 | 8.27±7.83 | 8.69±7.96 | 0.411 |
| Stress | 9.01±7.75 | 8.70±7.75 | 9.30±7.76 | 0.221 |
*P<0.05 is significant. aHigher score indicates better sleep hygiene. bHigher score indicates poor quality sleep. cHigher score indicates more sleepiness
On comparison of the young (age 10–14 years; N = 528), and older adolescents (ages 15–19 years; N = 454), categorized as per the WHO categorization it was evident that young adolescents had better total sleep hygiene score (P = 0.016) with better bedtime routine, cognitive/emotional factor (P = 0.001), however they were poorer on sleep environment factor (P = 0.001) [Table 2].[19,20] Young adolescents exhibited better sleep quality (P = 0.003), lesser daytime sleepiness, and lesser mood derangements (P < 0.001).
Table 2.
Comparison of sleep hygiene, sleep quality, daytime sleepiness, and mood among young and older adolescents
| Variables | Young Adolescents (10–14 years) (n=528) | Older Adolescents (>14–19 years) (n=453) | P |
|---|---|---|---|
| ASHS Subscales | |||
| Physiological Factora | 4.29±0.97 | 4.31±0.98 | 0.758 |
| Behavioural Arousal Factora | 3.92±1.32 | 3.92±1.27 | 0.948 |
| Cognitive/Emotional Factora | 4.10±1.04 | 3.81±1.10 | <0.001* |
| Sleep Environment Factora | 4.77±1.07 | 4.99±0.94 | 0.001* |
| Sleep stability Factora | 4.13±1.42 | 4.02±1.42 | 0.254 |
| Daytime Sleepiness Factora | 4.71±1.17 | 4.65±1.16 | 0.400 |
| Substances Factora | 5.78±0.69 | 5.75±0.79 | 0.489 |
| Bedtime Routine Factora | 3.64±1.90 | 3.13±1.90 | <0.001* |
| ASHS Totala | 4.42±0.64 | 4.32±0.59 | 0.016* |
| Sleep Quality (PSQI)b | 4.75±2.85 | 5.28±2.85 | 0.003* |
| Daytime Sleepiness (PDSS)c | 12.46±5.79 | 14.88±5.13 | <0.001* |
| Depression | 7.58±7.54 | 10.47±8.68 | <0.001* |
| Anxiety | 7.45±7.40 | 9.69±8.30 | <0.001* |
| Stress | 8.12±7.43 | 10.02±8.01 | <0.001* |
*P<0.05 is significant. aHigher score indicates better sleep hygiene. bHigher score indicates poor quality sleep. cHigher score indicates more sleepiness
Based on sleep quality scores students were grouped as poor sleepers (PSQI >5) and good sleepers (PSQI ≤5). Good sleepers (N = 600) exhibited higher scores in almost all domains of ASHS in addition to total ASHS score. Individuals with good sleep quality (PSQI ≤5) reported significantly lower levels of depression, anxiety, and stress compared to poor sleepers (N = 382) [Table 3].
Table 3.
Comparison of sleep hygiene practices and mood of adolescents with good (PSQI ≤5) and Bad Sleep (PSQI >5)
| Variables | Good sleepers (PSQI ≤5) (n=600) | Poor sleepers (PSQI >5) (n=382) | P |
|---|---|---|---|
| Sleep Duration | 6:50±1:00 | 6:04±1:11 | <0.001* |
| Daytime Sleepiness (PDSS)a | 12.79±5.65 | 14.82±5.35 | <0.001* |
| ASHS Subscales | |||
| Physiological Factorb | 4.40±0.96 | 4.13±0.99 | <0.001* |
| Behavioural Arousal Factorb | 4.00±1.31 | 3.79±1.27 | 0.015* |
| Cognitive/Emotional Factorb | 4.18±1.01 | 3.62±1.10 | <0.001* |
| Sleep Environment Factorb | 4.98±0.96 | 4.70±1.08 | <0.001* |
| Sleep stability Factorb | 4.17±1.41 | 3.93±1.42 | 0.009* |
| Daytime Sleepiness Factorb | 4.76±1.11 | 4.56±1.25 | 0.014* |
| Substances Factorb | 5.79±0.70 | 5.74±0.78 | 0.274 |
| Bedtime Routine Factorb | 3.48±1.93 | 3.28±1.89 | 0.118 |
| ASHS Totala | 4.47±0.59 | 4.22±0.64 | <0.001* |
| Depression | 5.86±5.92 | 13.71±8.98 | <0.001* |
| Anxiety | 5.65±5.89 | 12.93±8.58 | <0.001* |
| Stress | 6.16±6.22 | 13.47±7.83 | <0.001* |
*P<0.05 is significant. aHigher score indicates more sleepiness. bHigher score indicates better sleep hygiene
To assess the most common behaviors that disrupted sleep hygiene, behavior/factor wise assessment was done as depicted in Table 4. Among the various sleep-disrupting behaviors, a substantial chunk of adolescents-72.1% (708)- reported “thinking about things they need to do” sometimes to always while going to bed. This was followed by 64.6% (634), who indulged in consumption of more than four glasses of liquid and 64.2% (630), who extended their sleep schedule beyond an hour on weekends. Additionally, 63.7% (625) were engaged in stimulating activities such as playing video games, watching TV, or conversing on mobile phones within an hour prior to bedtime; while 62.7% (616) mentally revisited the events of the day before falling asleep. [Table 4] 64.7% (635) practiced bedtime rituals such as brushing teeth, reading or bathing as a part of their night regimen and >90% had never smoked/chewed tobacco or consumed alcohol after 6 p.m. However, 6.8% (68) reported consuming alcohol, and 5.4% (54) adolescents admitted to smoking or chewing tobacco [Table 4].
Table 4.
Frequency distribution of Adolescents (n=982) for various factors on ASHS scale
| Variables | Always - Sometimes | Occasionally - Never |
|---|---|---|
| Physiological Factor | ||
| After 6 p.m., I have drinks with caffeine (e.g., cola, root beer, iced tea, coffee) | 37.98% (373) | 62.02% (609) |
| During the hour before bedtime, I am very active (e.g., playing outside, running, wrestling) | 62.53% (614) | 37.47% (368) |
| During the 1 hour before bedtime, I drink >4 glasses of water (or some other liquid) | 64.56% (634) | 35.44% (348) |
| I go to bed with stomach ache | 22.91% (225) | 77.09% (757) |
| I go to bed feeling hungry | 38.09% (374) | 61.91% (608) |
| Behavioural Arousal Factor | ||
| During the hour before bedtime, I do things that make me feel very awake (e.g., playing video games, watching TV, talking on the telephone) | 63.65% (625) | 36.35% (357) |
| I go to bed and do things in my bed that keep me awake (e.g., watching TV, reading) | 47.35% (465) | 52.65% (517) |
| I use my bed for things other than sleep (e.g., talking on the telephone, watching TV, playing video games, doing homework) | 59.67% (586) | 40.33% (396) |
| Cognitive/Emotional Factor | ||
| I go to bed and think about things I need to do | 72.10% (708) | 27.90% (274) |
| I go to bed and replay the day’s events over and over in my mind | 62.73% (616) | 37.27% (366) |
| I check my clock several times during the night | 45.21% (444) | 54.79% (538) |
| During the 1 hour before bedtime, things happen that make me strong emotions (sadness, anger, excitement) | 56.52% (555) | 43.48% (427) |
| I go to bed feeling upset | 41.65% (409) | 58.35% (573) |
| I go to bed and worry about things happening at home or at school | 61.41% (603) | 38.59% (379) |
| Sleep Environment Factor | ||
| I fall asleep while listening to loud music | 25.66% (252) | 74.34% (730) |
| I fall asleep while watching TV | 37.17% (365) | 62.83% (617) |
| I fall asleep in brightly lit room (e.g., the overhead light is on) | 28.31% (278) | 71.69% (704) |
| I fall asleep in a room that feels too hot or too cold | 39.61% (389) | 60.39% (593) |
| I fall asleep in one place and then move to another place during night | 30.96% (304) | 69.04% (678) |
| Sleep stability Factor | ||
| During the school week, I stay up more than 1 hour past my usual bedtime | 47.66% (468) | 52.34% (514) |
| During the school week, I sleep in more than 1 hour past my usual wake time | 44.70% (439) | 55.30% (543) |
| At weekends, I stay up more than 1 hour past my usual bedtime | 59.06% (580) | 40.94% (402) |
| At weekends, I sleep in more than 1 hour past my usual wake time | 64.15% (630) | 35.85% (352) |
| Daytime Sleepiness Factor | ||
| During the day, I take a nap that lasts >1 hour | 42.67% (419) | 57.33% (563) |
| After 6 p.m., I take a nap | 30.35% (298) | 69.65% (648) |
| Substances Factor | ||
| After 6 p.m., I smoke or chew tobacco | 5.50% (54) | 94.50% (928) |
| After 6 p.m., I drink beer (or other drinks with alcohol) | 6.92% (68) | 93.08% (914) |
| Bedtime Routine Factor | ||
| I use a bedtime routine (e.g., bathing, brushing teeth, reading) | 61.91% (608) | 38.09% (374) |
Sleep hygiene behavior from “Always” till “sometimes” has been clubbed in one and “Once a while” and “Never” another
ASHS score and its subscales showed a significantly negative correlation with mood and sleep quality [Table 5]. Correlation of individual PSQI components shows that sleep duration has a significantly positive correlation with emotional factor and sleep stability factor of ASHS scale. Reduction in any of the subscales of ASHS leads to increased sleep disturbances, daytime sleepiness as well as daytime dysfunction [Table 5].
Table 5.
Co-relation analysis of Sleep hygiene factors with mood, sleep quality and it’s components
| Sleep quality and Mood ASHS domains | PSQI r (P) | Sleep Duration r (P) | Sleep Disturbance r (P) | Sleep Onset Latency r (P) | Sleep Efficiency r (P) |
|---|---|---|---|---|---|
| Physiological Factor | −0.16 (<0.001*) | −0.001 (0.981) | −0.18 (<0.001*) | −0.119 (<0.001*) | 0.016 (0.612) |
| Behavioural Arousal Factor | −0.116 (<0.001*) | 0.036 (0.264) | −0.146 (<0.001*) | −0.05 (0.118) | 0.03 (0.35) |
| Cognitive/emotional factor | −0.293 (<0.001*) | 0.135 (<0.001*) | −0.255 (<0.001*) | −0.178 (<0.001*) | −0.101 (0.002*) |
| Sleep Environment Factor | −0.15 (<0.001*) | 0.043 (0.179) | −0.15 (<0.001*) | −0.11 (0.001*) | −0.021 (0.511) |
| Sleep stability Factor | −0.148 (<0.001*) | 0.131 (<0.001*) | −0.125 (<0.001*) | −0.135 (<0.001*) | −0.029 (0.369) |
| Daytime Sleepiness Factor | −0.109 (0.001*) | 0.034 (0.289) | −0.091 (0.004*) | −0.072 (0.024*) | −0.022 (0.495) |
| Substances Factor | −0.034 (0.293) | −0.004 (0.906) | −0.02 (0.53) | 0.022 (0.495) | 0.041 (0.201) |
| Bedtime Routine Factor | −0.071 (0.026*) | 0.04 (0.208) | −0.012 (0.705) | −0.012 (0.708) | −0.082 (0.010*) |
| ASHS Total | −0.257 (<0.001*) | 0.114 (<0.001*) | −0.214 (<0.001*) | −0.143 (<0.001*) | −0.058 (0.067) |
|
| |||||
| Sleep quality and Mood ASHS domains | Daytime Sleepiness (PDSS) r (P) | Daytime Dysfunction due to Sleepiness r (P) | Depression r (P) | Anxiety r (P) | Stress r (P) |
|
| |||||
| Physiological Factor | −0.112 (<0.001*) | −0.092 (0.004*) | −0.153 (<0.001*) | −0.228 (<0.001*) | −0.216 (<0.001*) |
| Behavioural Arousal Factor | −0.149 (<0.001*) | −0.112 (<0.001*) | −0.185 (<0.001*) | −0.201 (<0.001*) | −0.17 (<0.001*) |
| Cognitive/emotional factor | −0.244 (<0.001*) | −0.272 (<0.001*) | −0.398 (<0.001*) | −0.426 (<0.001*) | −0.389 (<0.001*) |
| Sleep Environment Factor | −0.103 (0.001*) | −0.067 (0.035*) | −0.171 (<0.001*) | −0.171 (<0.001*) | −0.171 (<0.001*) |
| Sleep stability Factor | −0.16 (<0.001*) | −0.12 (<0.001*) | −0.208 (<0.001*) | −0.189 (<0.001*) | −0.216 (<0.001*) |
| Daytime Sleepiness Factor | −0.16 (<0.001*) | −0.087 (0.007*) | −0.146 (<0.001*) | −0.146 (<0.001*) | −0.147 (<0.001*) |
| Substances Factor | −0.029 (0.365) | 0.043 (0.18) | 0.002 (0.942) | −0.023 (0.473) | −0.036 (0.254) |
| Bedtime Routine Factor | −0.124 (<0.001*) | −0.048 (0.133) | −0.069 (0.030*) | −0.086 (0.012*) | −0.059 (0.064*) |
| ASHS Total | −0.284 (<0.001*) | −0.179 (<0.001*) | −0.295 (<0.001*) | −0.323 (<0.001*) | −0.303 (<0.001*) |
*P<0.05 is significant
Discussion
The present study evaluated the frequency, at which school-going adolescents engage in sleep hygiene practices and explored its association with overall sleep quality and mood. Findings indicate that females experience poorer sleep quality and higher daytime sleepiness. Younger adolescents have better sleep hygiene practices and sleep quality. Adolescents having better sleep quality had longer sleep duration, fewer disturbances, and lower levels of depression, anxiety, and stress. The most prevalent sleep-harming behaviors included pre-sleep over-thinking and engaging in stimulating activities. Sleep quality, as well as mood both are associated with sleep hygiene routine practices. Poor sleep hygiene practices negatively affect mood as well as sleep quality and are primarily associated with increased sleep disturbances, daytime sleepiness, and dysfunction.
Gender differences among sleep hygiene practices
Though, no significant differences were observed between males and females on overall sleep hygiene however, specific sleep hygiene subscales showed contrasting patterns with females scoring better on substance factors (refraining from smoking, chewing tobacco, or consuming alcohol), while males were better on cognitive and emotional factor (behaviors and negative emotional states at bedtime) and daytime sleepiness factor (avoid napping for longer than an hour or after 6 p.m.). Females have been shown to display better sleep hygiene behaviors in behavioral arousal, daytime sleep factor, and sleep stability domain in a study by Chehri et al.,[21] though in our study, daytime sleepiness was higher in females in both PDSS scale as well as ASHS. Females showed poor sleep quality and higher mood scores, suggesting a higher prevalence of negative thoughts and emotional distress before bedtime. Galland BC et al.[22] have also reported significant sleep disturbance among adolescent girls, affecting behavioral arousal factors, sleep stability factors, and cognitive-emotional factors of ASHS. The behavioral gender differences observed in our study could be due to the more emotional nature of females in general; additionally, physiologically, females attain early pubertal changes compared to males, though in this study we could not explore the pubertal stage of the participants.[23] Targeted educational interventions could be beneficial for addressing these factors especially, among adolescent girls who pass through an early physiological and emotional transition during adolescence as compared to their male counterparts.
Sleep hygiene practices among young and old adolescents
Young adolescents had better sleep hygiene scores with significantly better scores on cognitive/emotional factor (P ≤ 0.001) and bedtime routine factor (P ≤ 0.001), however, young adolescents scored less on sleep environment factor (falling asleep, while watching TV; sleeping in a room that is too hot or cold etc.) [Table 2]. This may be because younger adolescents have less academic burden and experience more freedom for watching television or for sharing bed with parents and/or siblings. Noland et al.[24] too have reported that environmental factors such as watching television, improper bedroom temperature, and excessive noise are barriers for adequate sleep among high school students. Given the deteriorating sleep health and increasing academic pressure, especially among older adolescents, there is a pressing need to educate the students as well as parents to promote healthy sleep behavior to achieve a balance between academic rigor and adequate rest. Young adolescents had better sleep quality with less daytime sleepiness and better mood like previous studies.[25] An early sensitization of students at the stage of young adolescence would be beneficial to them in understanding the importance of sleep for their overall mental, physical, and academic well-being.
Sleep hygiene practices among good and poor sleepers
Good sleepers (PSQI <5) had significantly better scores on all factors of sleep hygiene and mood indicating that adherence to sleep hygiene practices not only promotes better sleep quality but also improves mood [Table 3]. Older adolescents were more depressed, anxious, and stressed compared to younger adolescents. Similar findings have been reported by Singh et al.,[25] in their study where teenagers aged 13–15 years were more depressed in association to delayed bedtime, shorter sleep duration and poor academic performance compared to preteens aged 11–12 years. School sleep education programs could play an important role in addressing sleep disturbances at an early age, with an emphasis on sleep hygiene being as important as food hygiene for mental and physical well-being.
Adolescents sleep hygiene practices and sleep quality
Overall, the adolescents were incompliant with sleep hygiene practices, with a total ASHS score of 4.37 ± 0.60. Similar findings were reported by Chehri A et al.[21] among a cohort of 600 individuals, with 53.3% (325) demonstrating a mediocre level of sleep hygiene (total ASHS score between 3.8 to 4.9), while 26.2% (160) displaying a poor sleep hygiene score (ASHS score <3.8) in adherence to sleep hygiene practices. Murugesan G et al.[8] too reported that among 538 school-aged teenagers between 10–17 years, 64% (345) had at least one kind of poor sleep hygiene behavior, and watching TV in bed was the most prominent one. A comprehensive review of studies reveals that various domains of sleep hygiene are closely associated with sleep quality.[26] Studies have demonstrated a correlation between poorer sleep hygiene practices and experiencing sleep-related issues, suggesting that the closer one adheres to sleep hygiene guidelines, the fewer sleep problems are encountered and better is the overall sleep quality.[27,28] Sleep hygiene encompasses a set of habitual practices aimed at promoting and sustaining high-quality sleep at night.[29] Among all the potential behaviors that can disrupt sleep, present study shows that about 72.1% (708) adolescents engaged in thinking about tasks they need to accomplish, while preparing to sleep, and 62% (616) adolescents tend to replay events of the day in their minds when they went to bed [Table 4]. Additionally, almost 50% of adolescents had irregular sleep on weekdays and weekends in the sleep stability factor, 25%–30% of adolescents did not have a proper sleep environment while falling asleep [Table 4]. Interestingly, use of tobacco, alcohol, or engaging in drinking after 6 p.m. in the evening is an infrequent occurrence among Indian adolescents, as over 90% have never indulged in such activities [Table 4]. A clear relationship has been observed between sleep hygiene practices and sleep quality among adolescents, which is consistent with previous studies.[21,27,30]
Present study shows that 63.6% (625) of adolescents engaged in activities like playing video games, watching TV, or talking on telephone, an hour before bedtime. Moreover, 59.67% (586) of adolescents reported engaging in these activities, while in bed; in addition to reading and doing homework. Such behavioural arousal factors are responsible for making them feel very active an hour preceding bedtime and are observed to be associated with a decline in sleep quality [Table 5].[8] Murugesan et al.[8] reported that 48% (257) of adolescents had heavy meal before bed, and 76% (409) had a gap of less than one hour between dinner and bedtime. 64.1% (345) of adolescents watched TV in bed and 23.2% (125) used their mobile phones in bed.[8] Association between impaired sleep quality and watching television, particularly late at night and in bedroom, has been reported in several studies.[31,32] Letchuman et al.[5] also reported that adolescents, who watched TV late at night experienced excessive daytime sleepiness, indicating poor sleep quality. Use of electronic media and mobile phones has been suggested to impair sleep quality in several research studies.[33,34]
The status of sleep hygiene practices among adolescents is of growing concern and requires attention. While numerous factors contribute to poor sleep hygiene among adolescents, such as academic pressures and electronic device use, it is crucial to understand that good sleep hygiene practices are essential for adolescent’s physical/mental health, and overall well-being.[35] Prevalent unhealthy sleep habits which include irregular sleep-wake schedule on weekdays and weekends, using bedrooms for watching TV, telephone, video games lead to poor sleep hygiene as per the behavioral arousal factor of ASHS and can very well be alleviated through awareness and education of sleep hygiene practices. Sleep hygiene education can be incorporated in school curriculum just as physical education to instill the discipline needed for practicing healthy sleep habits, ultimately enhancing mental and physical health.
In this study, the socioeconomic status of the family and pubertal stage of adolescents were not explored, which could have added to assessing the major hurdles for sleep hygiene practices pertaining to these factors. However, it enrolled many adolescents of varied grades from 6th till 12th from different schools and gave insight on the prevalent sleep hygiene practices, status of sleep quality and its impact on mood of Indian Adolescents. The study very well explored the significant differences in mood and sleep quality of good sleep hygiene followers (good sleepers), which would act as evidence for planning future studies and incorporating sleep education programs for adolescents. Our study has highlighted the important modifiable behaviors prevalent among adolescents which could be corrected on an individual basis for better sleep quality and mood apart from school timings which vary from school to school and need amendments at various external factors.
Conclusion
The study highlights the importance of sleep hygiene in promoting optimal sleep quality and emotional well-being among adolescents. Despite the growing awareness of the importance of sleep hygiene, studies have shown that a significant number of adolescents still struggle with poor sleep habits, such as irregular sleep schedules and excessive screen time before bedtime. It is crucial for parents, educators, and primary healthcare physicians to work together to educate adolescents about the importance of healthy sleep habits. Investing in adolescent sleep health would not only improve their sleep quality but will also upgrade their mood enhancing their mental and psychological well-being.
Compliance with ethical standards
Ethics approval: Approval was obtained from the Institutional Human ethics committee of AIIMS Bhopal, Madhya Pradesh, India. All procedures performed in studies involving human participants were in accordance with the Declaration of Helsinki.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
This work received funding from the Indian Council of Medical Research-Extramural research Grant.
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