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JBI Database of Systematic Reviews & Implementation Reports
2015;13(9) 72 - 83
The effectiveness of sleep education programs in improving
sleep hygiene knowledge, sleep behavior practices and/or sleep
quality of college students: a systematic review protocol
Shellene K Dietrich1
Coleen M Francis-Jimenez1
Melida Delcina Knibbs1
Ismael L Umali1
Marie Truglio-Londrigan1,2
1. College of Health Professions, Pace University, New York, NY, USA
2. The Northeast Institute for Evidence Synthesis and Translation (NEST): a Collaborating
Center of the Joanna Briggs Institute
Corresponding author:
Marie Truglio-Londrigan
mlondrigan@pace.edu
Review question/objective
What is the effectiveness of sleep education programs in improving sleep hygiene knowledge,
sleep behavior practices and/or sleep quality of college students?
The review objective is to identify, appraise and synthesize the best available evidence on the
effectiveness of sleep education programs in improving sleep hygiene knowledge, sleep behavior
practices, and/or sleep quality versus traditional strategies.
Background
Sleep is a physiological state occurring in alternation with wakefulness, and its duration and
quality are equally important for the quality of life of an individual.1 The World Health Organization
(WHO) along with other organizations have realized the importance of sleep and its direct
correlation to health.2 According to WHO, one-third of the lifespan is spent asleep, a state that is
crucial for physical, mental and emotional well-being.2 The WHO and the National Sleep
Foundation, a nonprofit organization dedicated to improve sleep via sleep education based in the
United States (US), recommend that adults should be receiving an average of seven to nine
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hours of sleep per night.1,3 A reduction in sleep hours and sleep quality has a direct effect on
lifestyle.1,3
Poor sleep health can have severe consequences for the individual as well as society.3,4 Sleep
health is essential for overall health, quality of life and safety. The Institute of Medicine (IOM), an
independent nonprofit organization dedicated to provide advice and answers about health in the
U.S., reports that approximately 20% of automobile accidents are caused by drivers' drowsiness.5
Healthy People 2020, a US based initiative aimed at improving the nation's health, recognize that
drowsy driving causes vehicular crashes and its objective is to reduce the rate of vehicular
crashes per 100 million miles traveled that are due to drowsy driving.3,4 Sleepiness from any
cause can compromise memory, grades, perception of effort and driving performance.6,7,8 The
individual can experience a poorly functioning immune system, emotional instability, memory
deficits and poor concentration.3 Approximately half of the world's population is at risk for some
kind of sleep disorder and the cost to society is over $18 billion from a loss in productivity and
mass transportation accidents.2 The National Center on Sleep Disorder Research (NCSDR)
estimates that 70 million Americans suffer from sleep problems, and nearly 60 percent have a
chronic disorder.9 Satisfactory sleep is comprised of numerous aspects, such as sleep quality and
quantity.6 These factors are affected by, but are not limited to, the following: consumption of
alcohol, caffeine and drugs, establishing a regular relaxing bedtime routine, reducing lighting, the
use of technology and being aware of environmental noise.6
For the past 20 years, researchers have found a reduction in the average number of hours of
sleep among college students.10 College students are notorious for sacrificing sleep to study,
socializing during the week, and then sleeping long hours on weekends along with the
consumption of alcohol, drugs and caffeine.5,7,10,11 Many of these behaviors are not reflective of
sleep hygiene practices that facilitate sleep health.7 Sleep hygiene is "...a variety of different
practices that are necessary to have normal, quality nighttime sleep and full daytime alertness".12
(p1) Sleep practices are behaviors that an individual carries out to facilitate sleep health. These
practices include: maintaining regular sleep wake times, limited alcohol, caffeine and nicotine use
prior to bed time, regular sleep wake schedules, and sleep environments conducive to sleep.3 In
2000, a study found that 68.3% of college students reported poor sleep health as a result of
inappropriate sleep behaviors that do not reflect sleep hygiene practices.7,8 Among college
students, 50% reported daytime sleepiness while 70% experienced insufficient sleep.6
Poor
sleep has been ranked the third most common impediment among college students and has been
associated with deficit in attention, reduction in academic performance, impaired driving, risk-
taking behavior, depression, impaired social relationships and poorer health.8,11,13 College
students may have limited knowledge about sleep health and sleep hygiene practices that
supports sleep health. This limited knowledge may lead to poor sleep behavior practices
ultimately leading to poor sleep health resulting in diminished quantity and quality of sleep.
Efforts to improve the overall health status of college students in the United States (US) began
with Healthy Campuses in 2007.  Healthy Campuses is closely aligned with Healthy People 2020
using Healthy People as a guiding framework.14 Healthy Campus 2020 is an initiative that reflects
the work of higher education professionals representing numerous organizations and disciplines.
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The vision of Healthy Campus 2020 is to promote campus communities in which all members live
long, healthy lives.15 Overarching goals guide the work of the Healthy Campus initiative15 and
specific health objectives have been developed to track and measure successful attainment of
these goals.16 One of the major student objectives pertaining to sleep health is Health
Impediments to Academic Performance.17 Under this objective there is a series of sub-objectives.
Sub-objective 1.2 states: "reduce the proportion of students who report that their academic
17(p1)
performance was adversely affected by sleep difficulties in the past 12 months".
Sleep health is important not only for health, quality of life and safety but also for optimal
academic performance in college students.10 Gilbert and Weaver described how sleep deprived
college students performed poorly academically. These students had poor concentration, often
missed classes due to sleepiness and as a result had lower grade point averages, and more
course incompletes, drops and withdrawals than participants with little sleep deprivation and good
sleep quality.10 Furthermore, without interventions that promote sleep hygiene practices and
sleep health, there is the  potential for later diagnosis of  sleep disorders such as delayed sleep
phase disorder and insomnia, both common to the population of college students.8 Hershner and
Chervin6 found that there was a significant link between lack of sleep and academic performance.
They hypothesized that effective interventions which focus on improving sleep behavior and
disseminating sleep knowledge could help to improve academic performance among this
population.5-8,10,11,18,19
Studies that have looked at sleep education programs have demonstrated positive outcomes. For
example, a sleep 101 program for college students described improved sleep hygiene
knowledge, reduced maladaptive beliefs about sleep, and a decrease in sleep disturbances.20
Other studies have also revealed the potential benefits of formal sleep education with a
curriculum based on sleep hygiene practices versus informal advice delivered via verbal  prompts
from school staff and professionals.5,7,8,16,17 Formal sleep education programs on sleep, sleep
health, and sleep hygiene practices developed for the college student population may increase
this population's knowledge on sleep and sleep hygiene practices.17 The implementation of formal
health promoting sleep education programs that focus on sleep hygiene practices is a strategy
that has the potential to facilitate sleep health.7,10,13,16,20-24
A search of the Cochrane Library of Systematic Reviews, Medline, CINAHL and the Joanna
Briggs Institute Database of Systematic Reviews and Implementation Reports found no
systematic review on the effectiveness of sleep education programs on sleep hygiene knowledge,
sleep behavior practices, and/or sleep quality in college students or in any other specific
population. A systematic review on sleep education is necessary in providing valuable, evidenced
based information concerning the impact of sleep education on college students.
Keywords
sleep; sleep education; sleep hygiene; sleep hygiene knowledge; sleep quality; sleep behavior
practices; Healthy People 2020; Healthy Campus 2020
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Inclusion criteria
Types of participants
This review will consider studies that include all undergraduate or graduate college students,
male or female, and of all ages, cultures and ethnicities. All undergraduate and graduate college
students will be considered for inclusion due to pre-existing behaviors and circumstances that
occur when a student enters into the college environment, for example, late night sleep patterns
due to studies and socializing as previously discussed in Background. Pre-existing knowledge on
sleep hygiene practices, diagnoses and treatments are not considered in this systematic review
as confounding variables as the entire population is exposed to the contexts and risks for poor
sleep health.
Types of intervention(s)
This review will consider studies that evaluate formal sleep education programs that include a
curriculum on sleep hygiene practices that is designed to facilitate sleep health including but not
limited to: maintaining regular sleep wake times, limited alcohol, caffeine and nicotine use prior to
bed time, regular sleep wake schedules, and sleep environments conducive to sleep.3 Formal
educational delivery will include, for example: college courses/seminars that are delivered face
to-face, web-based computer programs, and/or a combination of these delivery methods. The
formal sleep education program may be delivered any time throughout the participants' college
experience.
Comparator intervention
This review will consider as a comparator no sleep hygiene education as an intervention.
Types of outcomes
This review will consider studies that include the following primary outcome measures:
Sleep hygiene knowledge - measured by tools such as the Sleep Hygiene Awareness and
Practices Scale (SHAPS). The SHAPS contains three sections: sleep hygiene awareness and
knowledge, sleep hygiene practices and caffeine. The first section has 13 items to measure
participants' knowledge of activities that disrupt sleep. The second section assesses caffeine
knowledge and has 19 items to measure participants' awareness of food, beverages or drugs that
disrupt sleep. The final practice section of this instrument contains an additional 19 items asking
participants how many nights per week where they engage in activities that promote or inhibit
sleep.7,20,25
Sleep hygiene behavior - measured by tools such as the Sleep Hygiene Awareness and
Practices Scale (SHAPS) and the Sleep Habits Surveys (SHS). The Sleep Habits Surveys
consists of 10 fill-in-the-blank items that ask for estimates of respondents' sleep habits, such as
bed times, rise times and total sleep times for both weeknights and weekends.25
Sleep quality - measured by tools such as the Pittsburg Sleep Quality Index (PSQI). The
Pittsburg Sleep Quality Index (PSQI) measures and assesses sleep patterns. It is a self-rated
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instrument with 19 items designed to assess sleep and sleep disturbances over a period of one
month.7,10,11,20,25
Types of studies
This review will consider both experimental and epidemiological study designs including
randomized controlled trials, non-randomized controlled trials and quasi-experimental studies. In
the absence of the above other designs will be considered for inclusion, including before and after
studies, prospective and retrospective cohort studies, case control studies and analytical cross
sectional studies.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search
strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be
undertaken followed by an analysis of the text words contained in the title and abstract, and of the
index terms used to describe the article. A second search using all identified keywords and index
terms will then be undertaken across all included databases. Thirdly, the reference list of all
identified reports and articles will be searched for additional studies. Studies published in English
will be considered for inclusion in this review. Non-English studies will be excluded due to limited
language proficiency of the review team. Studies published from the year 1980 will be considered
for inclusion in this review. This year was identified as the target start date as it has been noted
that the trend of poor sleep among college students began in the 1980s. Hicks, Fernandez and
Pellegrini conducted surveys and noted a trend of reported sleep problems beginning in the late
70s and 80's in which "24% of the respondents were dissatisfied with their sleep and in 1988,
23(p660)
53% were dissatisfied with their sleep".
The databases to be searched include:
CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Academic
Search Complete, PsycINFO, Healthsource Nursing/Academic edition, ProQuest Central, and
PubMed and ERIC.
The search for unpublished studies will include:
New York Academy of Medicine, ProQuest Dissertations and Thesis, Google Scholar Advance,
Virginia Henderson Library of Sigma Theta Tau, Robert Wood Johnson Institute
Initial keywords to be used will be:
college students, sleep, sleep education programs, sleep hygiene, sleep practices, sleep quality
Assessment of methodological quality
Quantitative papers selected for retrieval will be assessed by two independent reviewers for
methodological validity prior to inclusion in the review using standardized critical appraisal
instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review
Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will
be resolved through discussion until consensus is reached, or with a third reviewer.
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Data extraction
Data will be extracted from papers included in the review using the standardized data extraction
tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the
interventions, populations, study methods and outcomes of significance to the review question
and specific objectives. Additionally, attempts will be made to obtain data missing from the study
report(s) by contacting the appropriate author(s).
Data synthesis
Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI.
All results will be subject to double data entry. Effect sizes expressed as weighted mean
differences (for continuous data) and their 95% confidence intervals will be calculated for
analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also
explored using subgroup analyses based on the different study designs included in this review.
Where statistical pooling is not possible the findings will be presented in narrative form including
tables and figures to aid in data presentation where appropriate.
Conflicts of interest
The authors have no conflict of interest to declare.
Acknowledgements
We would like to thank Jennifer Rosenstein MLS, MA for her input and guidance with the
construction of this protocol.
We would like to thank Noreen McGuire MLS, MA, Assistant University Librarian for Collection
Development, for her guidance and extensive assistance with literature searches and databases.
This review will partially fulfill degree requirements for successful completion of the Doctor of
Nursing Practice Program at Pace University, College of Health Professions, New York, NY, for
SD, CF-J, MK and IU.
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References
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18. Pilcher JJ, Huffcutt  AJ. Effects of sleep deprivation on performance. A meta-analysis.
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Appendix I: Appraisal instruments
MAStARI appraisal instrument
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Appendix II: Data extraction instruments
MAStARI data extraction instrument
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