Designing Adolescent Sleep Interventions with Stakeholder Input

Abstract

Objective:

Few sleep promotion programs for adolescents have involved stakeholders as part of the intervention development, which may contribute to their limited accessibility, scalability, acceptability, and feasibility. Specifically asking stakeholders for their input on how to modify factors impacting sleep is critical, as is identifying strategies for motivating sleep behavior change. We report qualitative feedback from stakeholders interested in improving adolescent sleep, data collected specifically to inform the development of an adolescent sleep promotion program.

Participants:

We conducted 9 focus groups (3 each for young adults (n=8, ages 21–25), parents of adolescents (n=12), and healthcare providers working with adolescents (n=29)) following a semi-structured approach.

Design:

Participants reported on contributors to good and poor sleep; motivators for improving sleep; strategies for promoting and sustaining behavior change; and feasibility of a proposed sleep promotion program. We coded and thematically analyzed focus group transcripts using inductive and deductive approaches.

Results:

Moderate engagement in activities (e.g., a job, sports) was seen as a contributor to good sleep, while having too many or too few activities was thought to contribute to poor sleep. Linking improved sleep with personalized outcomes of interest can enhance motivation for changing sleep. Strategies for behavior change should rely on increasing internal motivation, personalizing intervention content, and having parents model desired behaviors.

Conclusions:

Key stakeholders are critical to the development of acceptable interventions that can be implemented effectively in real-world settings. Future work should test whether the identified themes contribute to increased feasibility, scalability, and effectiveness of sleep programs.

Introduction

Adolescence is characterized by insufficient sleep, poorly timed sleep, and daytime sleepiness.^1–5 Though insufficient sleep is highly common among youth,^{6, 7} sleep extension is feasible and has been associated with meaningful improvements in various areas of functioning.^8–13 Accordingly, sleep promotion programs for adolescents have been developed, some of which have demonstrated success in changing sleep behaviors among adolescents.^14–17 Yet, many programs involve multiple face-to-face sessions delivered in specialty care settings, which may limit their accessibility, scalability, acceptability, and feasibility among youth, their parents, and the providers delivering the program.

One potential reason for poor implementation of research-informed programs in real-world settings is limited input from key stakeholders. Interventions that have been developed and tested in the laboratory may have less relevance and reduced effectiveness in ‘real-world’ settings,¹⁸ whereas stakeholder-engaged research increases sustainability and effectiveness by tailoring programs to the community context.^{19, 20} Limited stakeholder involvement in most existing sleep promotion programs may contribute to limited impact, scalability, and accessibility.^21–25

One area that has benefitted from stakeholder involvement is in elucidating adolescent perspectives on barriers and facilitators to sleep.^26–30 Commonly reported barriers include electronic media use; aspects of the physical environment (e.g., bedroom temperature); worry and stress; demands on time; and socialization. Commonly reported sleep promoters include relaxing activities at bedtime and limiting social media/technology at night. Still, inconsistencies in these findings exist;³¹ for example, some youth report that physical activity promotes sleep, though evidence shows physical activity too close to bedtime can impede sleep. Further understanding of these contributors and obtaining input from young people on strategies for modifying these factors is a critical gap in the literature and may inform the development, adaptation, and delivery of evidence-based sleep interventions.

Further, there is scant evidence on adolescents’ intrinsic motivations for improving sleep, which could inform interventions. While well-known models of behavior change (e.g., the Theory of Planned Behavior,³² the Transtheoretical Model³³) describe the importance of internal motivation to change a behavior, the identification of successful strategies for sleep behavior change reported by individuals with lived experience remains an important scientific gap. These strategies may exemplify and complement identified theoretical models while supporting long-term change in sleep and other health behaviors.

Moreover, no qualitative studies have considered the perspectives of complementary stakeholders, i.e., parents and health care providers, who have a clear stake in improving adolescent sleep. The inclusion of additional stakeholders is imperative in providing highly relevant but understudied perspectives on the sleep of adolescents, especially as these stakeholders may be key implementers of adolescent sleep interventions.

The aim of this study is to report and synthesize qualitative feedback from a heterogeneous group of community stakeholders who are interested in improving adolescent sleep. By design, we examined stakeholders’ perspectives based on their own experience and beliefs, rather than on their knowledge of the published literature. To our knowledge, ours is the first study to use qualitative methods to describe the perspectives of multiple stakeholder groups: young adults reporting on their experience as adolescents, parents of adolescents, and healthcare providers who work with adolescents. We selected community stakeholders, as opposed to sleep experts, to understand perspectives from community settings. Here, we further explore contributors to good and poor adolescent sleep and report on stakeholder perspectives regarding motivations for changing sleep; effective strategies for behavior change; and methods of sustaining behavior change. We also describe stakeholder perspectives on the feasibility of a proposed sleep promotion program.

Method

Participants

Participants were young adults, parents of adolescents, and healthcare providers working with adolescents. Young adult stakeholders were members of the Youth Research Advisory Board (YRAB) of UPMC Children’s Hospital of Pittsburgh, a standing body of 15–26 year-olds who provide input on adolescent research. YRAB focus groups occurred during three of YRAB’s established meetings at UPMC Children’s Hospital of Pittsburgh. YRAB members attending on those dates were invited to participate. While our YRAB focus groups could have included adolescents, only young adults were in attendance at the meetings when our focus groups were held. These stakeholders reported on their experiences as an adolescent. This perspective is highly relevant for designing adolescent-centered interventions as YRAB attendees work exclusively on adolescent research and intervention development and are accustomed to providing perspectives on what works for different stages of adolescence. Some YRAB members participated in more than one focus group, with 8 participating in total (3 attended all meetings, 3 attended two meetings, and 2 attended only one meeting.).

Parents of adolescents were recruited via advertisements in community primary care practices, local schools, coffee shops, and online. Parents had at least one child age 12–18. We also recruited parents through the University of Pittsburgh Clinical and Translational Science Institute Research Participant Registry. Parent and young adult stakeholders were not related, to our knowledge. We intentionally did not recruit parent-young adult dyads to increase the heterogeneity of our findings. Twelve parents participated, with 6 of 12 attending more than one meeting. Parent groups lasted 2 hours and were held on the University of Pittsburgh campus. Parents were asked to report on their experience when their child was a young adolescent (which may have reflected the present, based on the age of their child).

Providers were any healthcare professional working in a pediatric primary care practice who interacts with adolescents (e.g., physicians, nurses, social workers). We defined this group broadly, since anyone interacting with an adolescent and/or their family in that setting may have a valuable contribution to our understanding of adolescent sleep. Three pediatric practices within the University of Pittsburgh Pediatric PittNet practice network were selected for diversity of location and patient background, including an academic-affiliated practice in a large city, a suburban practice, and a rural practice. Each practice focus group met once during a scheduled practice meeting for 60 minutes. Providers participated in only the focus group held at his/her practice, with 29 providers in total.

All participants provided informed consent (age 18+). Though we had obtained a waiver of parental consent for minors, this was not utilized as the YRAB members in attendance happened to be over age 18. Participants were compensated $25 for each focus group in which they participated. This study was approved by the University of Pittsburgh Human Research Protection Office.

Procedures

Focus groups were audio recorded and followed a semi-structured approach. After obtaining consent, stakeholders were oriented to the focus group proceedings and provided an overview of the proposed sleep promotion program (see below). Participants shared their views on adolescent sleep, barriers and facilitators to good sleep, motivators for improving sleep, and strategies for promoting and sustaining behavior change, particularly as related to the proposed program. They also provided perspectives on the feasibility of the proposed intervention program. Follow-up questions were asked to clarify participants’ points and to guide discussion.

Audio recordings were professionally transcribed and edited to exclude identifying information.

Data Collection Instruments

A focus group guide (see Supplement) was developed for each stakeholder group, though all focused on the same themes. The guide shown in the Supplement includes only the a priori questions relevant to this paper. Stakeholders were invited to complete an optional demographic information form.

Proposed Intervention Program

The sleep intervention program was described as a clinic-based, sleep-focused intervention for 13- to 15-year old adolescents identified from a pediatric clinic. Parents and youth participants receive brief psychoeducation about sleep. Youth then complete a smartphone-based sleep diary for one week, which informs the content of the face-to-face session with a clinic-based provider. The session focuses on the nature of the youth’s sleep, strategies for improving sleep, and building motivation for change. Following this session, youth continue the daily diary to track their sleep for one month. Using a smartphone-based system, they receive a summary of their sleep twice per week and are invited to set updated goals based on recent sleep patterns.

Data Analysis

Table 1 lists the thematic codes relevant to this paper and their descriptions. De-identified focus group transcripts were analyzed using a combination of inductive and deductive approaches.^{34, 35} Questions listed in the guide formed the basis of the codes identified a priori. Transcripts were reviewed multiple times to identify additional codes from spontaneous discussion among stakeholders. For example, Reasons for Changing Sleep was identified a priori based on our guide, while Sustaining Behavior Change arose in subsequent discussions (see Table 1, Supplement). The codebook was reviewed iteratively to increase clarity and to eliminate redundancy. One transcript from each of the young adult, parent, and provider transcripts was coded by two authors (JCL and HAF). Coding discrepancies were resolved through discussion.

Table 1.

Thematic codes and descriptions

Code	Meaning	Examples
Contributors to good sleep	Anything that contributes to good sleep among teens	Teens participating in sports may have more daytime regularity to their schedule, perhaps contributing to better sleep; things parents do to help teens get good sleep
Contributors to poor sleep	Anything that contributes to poor sleep among teens	Teens sleeping in on weekends sufficiently that it disrupts their sleep schedule heading into the school week
Reasons for changing sleep	Motivation or reasons that the teen has (or could imagine having) to make changes to their sleep habits; could also include broader motivation discussion that could be applicable to sleep; internal feelings or thoughts that might contribute to increased motivation; any outcome that a teen believes would be better if sleep was improved	Teens participating in sports may be more motivated to follow sleep strategies if they believe better sleep would improve their performance; when teens feel more empowered or more in control of themselves, they may be more motivated to make changes to their sleep
Strategies for behavior change	How parents/providers have been involved in eliciting behavior change from kids in the past that has/has not worked; OR how they imagine their involvement in eliciting behavior change from youth would be helpful or not helpful; can relate to sleep or other non-sleep behaviors	Parents to model the desired behavior; view a tailored feedback report of progress on changing the desired behavior
Sustaining behavior change	How to create long-term change in child sleep habits	How the child utilizes healthy sleep habits to have good sleep in the future
Incentives for participation	Things teens need to feel more inclined to participate in the program components (e.g., completing assessments, coming to in-person session, paying attention to video); things to enhance participation and engagement in study components	Providing the teen with payments at the end of the program completion

The three coded transcripts served as training transcripts to train the coders (ZR, AM, and GP). Once all coders exhibited sufficient reliability, one author (ZR) coded the six remaining transcripts, serving as the gold-standard coder for those. AM and GP each coded three of those six transcripts, and codes were compared to ZR’s codes. Discrepancies were discussed with, and resolved by, JCL. We then distilled the most salient and common underlying themes for each code, described below. To be stakeholder-centered and to demonstrate potential misperceptions among stakeholders, quotes were fit to codes based on the stakeholder’s perspective, even if that perspective did not accurately reflect the literature. For example, identifying alcohol as a contributor to easily falling asleep was coded as Contributor to Good Sleep, even though the literature may not support that statement.

Results

Participants included 8 young adults (21–25y), 12 parents (32–68y; n=2 parents did not report), and 29 healthcare providers (32–64y; n=3 did not report). Of those completing the optional questionnaire, 43% of young adults were female (n=2 did not report), 82% of parents were female (n=1 did not report), and 75% of healthcare providers were female (n=5 did not report). Regarding race, 38% of young adults identified as White/Caucasian (n=1 did not report); 75% of parents identified as White/Caucasian (all parents reported race), and 93% of providers identified as White/Caucasian (n=1 did not report). No young adults or parents identified as Hispanic or Latino (n=1 young adult and n=3 did not report), though two providers identified as Hispanic or Latino (n=4 did not report). Over half (58%) of parents were working, and eight reporting having one child ages 12–18 (n=4 reported 2 or 3 children ages 12–18). Among providers, 19 were medical doctors (with 7 nurses, 1 medical assistant, and 2 physician’s assistants), and 5 reported that they deliver psychotherapy as part of their work. Table 2 shows shared and unique stakeholder perspectives for all themes.

Table 2.

Shared and unique stakeholder perspectives^*

Code	Theme	YRAB	Parent	Provider	Representative Quote
Contributors to good sleep	Healthy technology use		X		“You need a break, period. You know? So when it comes to bedtime, that’s your break. And it’s unfortunate, because I take the phone, the tablet, there’s no TVs in her room anyway, you know.”
	Being occupied after school (e.g., sports, a job)			X	“The kids, though, I think the kids that are in sports are actually really tired. They have the best sleep schedules […].”
Contributors to poor sleep	Being overscheduled, too much homework	X	X	X	“[…] I just didn’t have that much time to sleep, I guess, due to assignments and other commitments.” (young adult)
	Use of substances	X	X	X	“I think whatever you’re doing, the substance will affect, from a physiological standpoint, […] it’ll make you either more prone to fall asleep or more prone to stay up.” (youne adult)
	Social impacts on sleep		X		“I think it’s kind of a badge of honor among students, like they kind of brag about how little sleep they get.”
	Poor time management		X		“So if she […] re-figured out her evening schedule so that she’s getting it all done by 9:00—I don’t think she’d fall asleep at 9:00—but 9:30 would be great. She would learn something. She’d be like, ‘Hey, you know what? You can do it. You can reorganize.’”
	Use of electronics		X	X	“A lot of kids, when you actually ask, have TVs right…” “In the room.” “Absolutely.” “Often with gaming systems.” (providers)
	Mental health problems		X	X	“I have some patients who are—have always been innately bad sleepers, particularly kids with ADHD who their brain is just going a mile a minute, and they have no brakes to slow it down.” (providers)
	Lack of structure at home, too few activities		X	X	“What I see is just kids that are just up, because they don’t have structure at home” (providers)
	Inconsistent place to sleep			X	“I guess some of them don’t have, you know, a consistent place to sleep […]”
Reasons for changing sleep	Link sleep with outcomes of interest	X	X	X	“So like kids who are having lots of headaches, I can get them to buy into the fact that sleeping better will help their headaches.” (providers) “Not just to show them how much sleep they get, but to help them see the impact. ‘Cause you were talking about “they see the impact,” well the more we can spell that out and present that to them.” (parent)
	Sleep as something in youth’s own control	X	X		“I think in high school, I thought that there were so many things out of my control […] so I think if I could make that connection of, sleep is something you can control […]” (young adult)
	Observe personalized information about sleep	X			“I think having that intervention be personalized to each different person would be important, ‘cause everybody’s gonna care about different bullet points there.”
Strategies for behavior change	Parents to model desired behavior, otherwise avoid involvement	X	X		“And when I look at my relationship between my daughter and myself, in connecting with that parent being the role model and recognizing that I’m not perfect and I’m trying to make changes.” (parent)
	Youth to teach strategies for behavior change to someone else	X	X		“[…] wouldn’t it be cool if you could get them to teach other kids? The best way to learn something is to teach it […]” (parent)
	Avoid extrinsic rewards	X	X		“Extrinsic motivation just don’t work for her. Whatever she wants to do she is bound and determined to do it.”
	Receive individualized information on behavior change	X		X	“Yeah, I tend to look at my Fitbit sleep app sometimes, and if I see like, “Oh, I only got 5 hours last night,” I try to sleep a bit more the next day.” (young adult)
	Someone to keep youth accountable	X			“I’m thinking of a life coach, but sleep coach. I don’t know, just a person that you communicate with, that is there to help you set those goals.”
	Receive reminders on phone for behavior change			X	“[…] you get a reminder on Friday that’s the goal that you set, and give them the offer to change [their sleep behavior] if they would like to.”
Sustaining behavior change	Increase internal motivation for change	X	X		“If it’s your own internal motivation rather than a competition, it might have longer-lasting effects.” (young adult)
	Make new sleep behaviors habitual		X		“You want to try to make it so it’s a habit so that you carry on with it, and they can see the rewards themselves[…]”

^*If multiple stakeholders share the same perspective, the representative quote indicates in parentheses which stakeholder group the quote comes from.

Contributors to Good Sleep

Young adults focused primarily on substances, though there was disagreement about whether using substances before bed promotes or inhibits falling asleep. One person commented that the social aspect of drinking has relevance to sleep, as drinking alone makes one more likely to fall asleep, while drinking with a group contributes to staying awake longer due to socializing.

Providers focused on identifying characteristics of good sleepers, noting that youth in sports tend to be the most tired and have the best sleep schedules, perhaps because they follow a schedule and have good time management. Providers reported that keeping youth busy with activities and responsibilities (e.g., working at a job) was beneficial to limiting afternoon naps and helping youth feel tired at bedtime.

Parents focused on technology, though they varied on whether using or removing technology prior to bedtime contributes to good sleep. Other reported contributors to good sleep included teaching youth to self-monitor technology use and encouraging youth to eat something as bedtime approaches.

Contributors to Poor Sleep

Young adults stated that being too busy with many commitments during early adolescence contributes to poor sleep, as do environmental disturbances like excessive activity in their home. Variability in sleep duration from night to night was attributed to staying up late to study for exams or evening extracurricular activities. Most young adults reported that use of caffeine, alcohol, and smoking, contributes to poor sleep.

Among providers and parents, commonly cited contributors to poor sleep were having too many commitments or being overscheduled; use of electronics; lack of structure or rules about sleep at home; and being high achieving with lots of homework. Less commonly reported contributors included caffeine, and mental health conditions as well as effects of the medications to treat them.

Providers uniquely stated that room sharing or not having a consistent place to sleep contributes to poor adolescent sleep, as can having too few activities, and a lack of exercise. Parents uniquely identified poor time management and procrastination as contributors to poor sleep, as well as school stress and worries about sleep itself. Parents also identified social contributors to poor sleep, such as youth bragging to friends about how little they sleep or feeling obligated to respond to communication from friends.

Reasons for changing sleep

Young adults reported that linking sleep with outcomes of interest (e.g., weight, physical health, academic performance, social interactions, stress) would have motivated them to change their sleep when they were adolescents. Some reported experiencing limited autonomy over many aspects of their lives as adolescents, so perceiving sleep as an area within their control would have motivated them to change their sleep. They also reported interest in personalized information about their sleep behaviors; for example, observing the number of times they hit the snooze button would have motivated them to get up with their first alarm. Finally, some young adults stated they would have wanted to understand the problems with a lack of sleep, rather than the benefits of getting more sleep. This perspective was shared by parent stakeholders.

Consistent with adolescents, providers and parents reported that linking better sleep with improved outcomes (e.g., academic achievement, sports performance, improved daytime energy and reduced daytime sleepiness, having fewer somatic problems) would motivate youth to change their sleep habits. One provider stated that linking sleep with mood and anxiety would motivate changes to sleep, but another disagreed. Interestingly, some providers perceive that older adolescents have little desire to change their sleep, even though they believe these teens are interested in talking or learning about sleep generally.

Parents highlighted their belief that teens will change their sleep based on their own priorities, not because they are convinced by parents. Parents also emphasized the importance of focusing on adolescents’ personalized goals and reasons for changing sleep. While some parents felt it was important for youth to compare their sleep to the recommended amount for their age, others worried their children would feel hopeless at learning they were obtaining less than the recommendation.

Strategies for behavior change

Pertaining to strategies for bringing about behavior change, young adults highlighted the importance of accountability and having someone with whom they could communicate about their goals when they were adolescents. They reported that tracking their sleep and receiving individualized strategies for improving sleep would promote behavior change. Some highlighted the role of personal choice in motivating behavior change, while others reported that they would have been motivated by competition with peers or financial incentives as adolescents. Young adults felt that as adolescents they would not have wanted behavior change to be dictated by an adult, nor would they have wanted their parents involved in the behavior change process, except to model the desired behavior. Last, they thought it would be helpful for adolescents to teach the behavior change strategies to someone else.

Providers were divided on whether they believed behavior change in general is plausible among adolescents, especially for older teenagers. Providers noted that external factors could motivate youth to change their sleep, such as a parental system of rewards and discipline for certain behaviors, and receiving reminders on their phones about bedtime. Last, providers suggested delivering individualized reports to adolescents on the progress of their behavior change and relating this change to outcomes of interest to youth.

Parents felt that some extrinsic motivators (e.g., financial compensation) are not an effective strategy for sustained behavior change, but that praise may be useful. Like adolescents, several parents felt they should model desired behavior(s) for their children. While some parents stated that their children would not want parents to be heavily involved in the behavior change process, others felt it would be useful for an adult to share strategies for behavior change and to discuss with teens how parents can support them. Consistent with youth, parents suggested that teens teach their peers how to change the desired behavior to successfully bring about change themselves. Last, parents were divided on the utility of teens comparing their performance on behavior change to their peers.

Sustaining Behavior Change

Young adults and parents stated that sustained behavior change needs to rely on building intrinsic motivation for youth to make changes, as the power of extrinsic rewards (e.g., monetary incentives, competitions) would fade over time. Parents suggested that youth receive information about sleep so that they would choose healthy sleep practices in the long-term; others suggested that youth learn to make new behaviors ‘habitual’ and facilitate first-hand experience of the benefits of improved sleep. Providers did not comment on this theme.

Intervention Feasibility and Acceptability

As above, young adults reported on their perspectives as adolescents. Related to the feasibility of the proposed program, young adults and providers commented that a short video presenting sleep psychoeducation would be preferred over a written format, which would be too burdensome to read. Young adults and providers also emphasized that using technology to deliver intervention components would increase study feasibility, if the functionality was fast, easy to use on mobile platforms, available using WIFI rather than a data plan, and if use of technology as part of the program did not negatively impact their sleep.

Young adults reported that a 30–45 minute face-to-face session would be feasible. Some providers were concerned about the feasibility of in-person sessions and they inquired about the possibility of phone or videoconference sessions, as well as evening and weekend appointments to suit adolescent schedules. All groups agreed on the need to tailor the study components, such as individually-set reminder times for sleep diary completion and separate weekday and weekend goal setting.

Parents focused on how their involvement in the study could be helpful and would avoid unintentionally derailing progress. They preferred to view the sleep psychoeducation video with their child but wanted to wait to view their child’s progress on set goals until the end of the program. Parents felt it would be acceptable for them to join a portion of the clinician session with their child, but that the majority should be individual to empower their child to make changes on their own. Young adults also preferred that their parents not receive the mobile intervention components.

Discussion

This study described qualitative feedback from young adults, parents, and healthcare providers interested in improving adolescent sleep, collected to inform the development of a sleep promotion program for adolescents. We encouraged stakeholders to comment on their personal experiences and then coded responses according to stakeholders’ own perceptions, rather than forcing responses into codes based on the evidence base. This strategy allowed us to identify stakeholder beliefs and experiences that may not align with the literature, which can be helpful in developing effective interventions. Young adults reported on their perspectives as adolescents, to reflect the population for which the intervention is intended. Feedback emphasized 1) building motivation for changing sleep by linking improved sleep with outcomes of interest; 2) the need to balance internal motivation for changing sleep with input from external sources; and 3) modifiable contributors to good and poor sleep that can be targeted through such programs.

Consistent with previous reports from adolescents,^{28, 36} all stakeholder groups reported that some level of activity and responsibilities (e.g., extracurricular activities, homework) is helpful to sleep, while too much is detrimental. Young adults corroborated previous reports²⁷ that environmental disturbances can be harmful to sleep, a perspective shared by our provider stakeholders. Sleep environment in the home is just one of various contexts that are important to sleep, including neighborhood (e.g., violence exposure), school (e.g., school start time), and culture (e.g., napping as a cultural norm).³⁷ Future work should consider how it may be possible to modify these factors as part of adolescent sleep interventions.³⁷ Young adults also emphasized substance use as a contributor to sleep, with some reporting that substance use aids sleep, a perspective that does not align with much of the evidence base and may reflect misinformation.³⁸ As young adults may have more experience with alcohol than early adolescents, teenagers may report different perceptions of substance use and its impact on sleep than the perspectives reported here.

Parents and providers noted that appropriate time management promotes good sleep, in line with previous adolescent reports that procrastination contributes to poor sleep.³⁶ Supporting previously reported adolescent perspectives,²⁷ some parents and providers identified technology as a sleep promoter, while parents identified stress, worries, social pressures, limited structure at home, and lack of parent-set bedtime as contributors to poor sleep.²⁶

In future work, sleep interventions should increase sleep health literacy, including the impact of substances on sleep, as several of our stakeholders endorsed beliefs about sleep that do not align with the literature. Sleep promotion programs should also integrate management of social pressures and extracurricular obligations. This might include a discussion on how social interactions after bedtime impact sleep, strategies for setting boundaries around sleep, and identifying the appropriate level of activity and regularity in adolescents’ weekly schedule. Last, future work should elucidate the situations in which technology use aids sleep and those in which it is an impediment.

Our work also focused on strategies for enhancing motivation, a critical aspect of sleep behavior change^{22, 23} that has received minimal attention in the qualitative literature.³⁹ Our stakeholders emphasized that sleep promotion programs should explicitly link poor sleep with negative outcomes that are relevant to each youth (e.g., “when you sleep poorly, you don’t have as much energy during sports”), and, consistent with previous research,^{40, 41} offer personalized feedback about sleep, extracted from a sleep diary or wearable technology, to support sleep behavior change.

Consistent with theoretical models of behavior change,^{32, 33} many stakeholders agreed that increasing internal motivation is more likely to bring about sustainable behavior change than external reward. Sleep promotion programs should use a motivational interviewing framework,⁴² as some previous programs have done.⁴³ Still, some viewed external influences as helpful, like asking parents to model the desired behavior, having a system of accountability for behavior change, or offering financial incentives. Though stakeholders did not want parents heavily involved in the behavior change process, published evidence suggests parental involvement in sleep contributes to positive outcomes.^{44, 45} Needed are strategies for balancing the increasing autonomy of adolescence with the important role of parents in promoting healthy sleep. Further, some youth may benefit from provision of external rewards for behavior change to spur motivation at the start of the program, which may be replaced by intrinsic motivation over time. Future work should test such a model of sleep behavior change.

Stakeholder feedback on the feasibility of the proposed sleep promotion program helped refine the development of the web-based intervention components, including a 2-minute sleep psychoeducation video; the timing of the sleep diary assessments to be tailored for each adolescent; the setting and structure of the clinician session; and the nature of parental involvement in the intervention program.

Our findings should be interpreted in light of several limitations. By design, we did not aim for systematic agreement from participants on all themes, though our coding methods helped to ensure the reliability of the themes identified. Focus groups were not designed to be representative of the general population, stakeholders self-selected to participate, and our young adult group included only 8 individuals. Not all focus groups discussed the same themes, some stakeholders participated in multiple focus groups, which may have reduced the heterogeneity of our findings, and not all participants expressed opinions on all issues. Though we intended to include adolescents in our focus group, only YRAB members ages 21–25y attended meetings when focus groups were held. These individuals shared perspectives based on how they felt when they were teenagers, which may have introduced recall bias in our data. Sleep during the teenage years (13–19) is developmentally patterned³⁷ and related to puberty,⁴⁶ and we do not know which period of this developmental stage YRAB participants were reflecting on; further, the sleep of adolescents differs from the sleep of young adults in meaningful ways (e.g., recommended sleep duration becomes shorter in young adulthood; chronotype becomes later during adolescence, reaches its peak ‘lateness’ around ages 18–19y, and then begins to advance in the 20s),^{6, 47, 48} and it is possible that YRAB members inadvertently commented on their more recent sleep patterns. Thus, findings should be interpreted cautiously, and any application to adolescent sleep should consider developmental stage and pubertal development. Additional input from youth ages 13–15 could inform future refinements to this intervention as the program is tested for efficacy and effectiveness.

Conclusions

Translating research findings into real-world settings has been a challenge for researchers across disciplines. As many sleep interventions have not shown significant changes in sleep behaviors, it is essential that researchers consider the perspectives of key stakeholders who would be involved in an intervention. Our results provide valuable insight into the content of future interventions, as well as feasible, acceptable, and potentially effective methods of increasing motivation for behavior change and for sustaining such change. Future work should focus on evaluating whether the inclusion of these identified approaches improves effectiveness, feasibility, and scalability of sleep promotion programs.

Abbreviations:

YRAB

Youth Research Advisory Board