Promoting sleep health in children and youth: application of the population health promotion model

Johnson and Stranges call for comprehensive public health approaches to address sleep health disparities and promote sleep health across the life-course [1]. However, despite recognition of sleep health in national population health objectives, strategic plans, and guidelines (e.g. Healthy People 2030; Advancing our Health: Prevention in the 2020s), children and adolescents continue to experience poor sleep health. Given their inherent vulnerability in society and since sleep health is crucial for children’s and adolescents’ physical, mental, and social health, there is an urgent need to strengthen and broaden public health initiatives within this life-course stage. The Population Health Promotion Model (PHPM) [2] blends population health and health promotion by outlining how a broad set of comprehensive health promotion strategies can be employed to act upon a range of determinants of health at different societal levels. This article showcases how the PHPM can be used to plan the comprehensive public health action called for by Johnson and Stranges [1] to promote sleep health in children, adolescents, and their families by addressing the model’s three critical questions: “What should be done?”, “How should it be done?”, and “With whom should we act?”. Key challenges of sleep health in early childhood are often intertwined with parenting and relate to the notable differences between young children’s sleep compared to adult sleep, as well as the dramatic changes in sleep that occur during early childhood [3]. Parents are often inundated with overwhelming amounts of information on sleep, not to mention the target of many consumer products that promise better sleep; thus, parents as individuals and part of families (the “who”) are a key audience for sleep-related public health interventions. Such interventions could support healthy child development and personal health and practices and coping skills (the “what”) by developing parental knowledge about key sleep health concepts, including what sleep patterns and behaviors are developmentally appropriate, how sleep patterns are established and maintained, and how sleep health is a multidimensional concept—more than just sleep duration (the “how”). Public health sleep-related efforts have historically focused on promoting sleep safety, resulting in significant declines in Sudden Unexpected Infant Deaths. However, broader sleep health in early childhood have yet to be adequately addressed from a public health standpoint. Instead, parental sleep deprivation has often been viewed as a taken-for-granted consequence of parenting young children and parents with concerns about their young child’s sleep are often not sufficiently addressed by health services. Health services that specifically support families of young children who experience sleep difficulties (the “who”) as a means of supporting healthy child development, providing social support networks, and developing personal health and practices and coping skills (the “what”) exist in some countries (e.g. Australia). However, countries without such services could consider reorienting existing health services (the “how”) to better support families in achieving and maintaining sleep health. Finally, given that young children nap during daytime hours, which often occurs in childcare settings, public health action could promote healthy child development (the “what”) by creating supportive environments and developing policies related to protecting and promoting young children’s daytime sleep (the “how”) within the childcare sector (the “who”). For school-aged children, a key sleep health issue that could be addressed via public health action is the interplay between screen time, physical activity, nutrition, and sleep [4] within school communities and the educational sector. For example, since adequate physical activity and nutrition can support sleep health, school communities and districts (the “who”) can build healthy policy and create support environments (the “how”) that promote heathy working conditions (the “what”) within schools that enable children to achieve recommended amounts of physical activity and receive adequate nutrition. This may include adopting minimum daily physical activity requirements and protecting physical education classes, structuring physical, and social environments of schools to promote movement (e.g. safe and interesting outdoor spaces and playgrounds), ensuring students have access to nutritious foods, and limiting access to foods with low nutritional value and/or caffeine. School-age is also a prime time to develop personal skills (the “how”) in children (the “who”), by helping them learn about how sleep is a resource for their personal health and the behaviors that promote sleep health, alongside existing curriculum in physical activity and nutrition (the “how”). Poor sleep health in school-aged children can present as, or exaggerate, behavioral difficulties, which have implications for children’s school performance and trajectories. Reorienting health services (the “how”) to promote collaboration between health and educational sectors (the “who”) to screen for poor sleep health in school-aged children, especially for children who are struggling at school, could result in more appropriate access to health services, support healthy childhood development, and improve educational trajectories (the “what”). Public health strategies directed to support the sleep health of adolescents can address the many transitions that occur during this time period. For example, the educational sector and school communities (the “who”) can implement policies for schools to start at 8:30 am or later (the “how”), which recognize the biological transition that adolescent circadian rhythms undergo [5] and create more appropriate school working conditions (the “what”). Since adolescents are at increased risk of sleep deprivation following the switch to daylight savings time, society (the “who”) could build healthy public policy and strengthening community action (the “how”) to support physical environments (the “what”) of adolescents by permanently adopting standard time and abolishing of the bi-annual time change. Permanent adoption of standard time would support exposure to bright natural light in the morning as part of an adolescent’s physical environment, which helps maintain a circadian rhythm that is aligned with their social (i.e. school) schedules. Finally, given the increasing evidence linking social media use to poor sleep, families, school communities and other youth-serving community organizations (the “who”) could strengthen community action by advocating for improved regulations regarding adolescent’s social media use (the “how”) to support healthy child development and personal health skills (the “what”). Public health initiatives that promote sleep health in children, adolescents, and their families are needed to ensure that children and youth can thrive both physically and mentally, both throughout and beyond childhood and adolescence. Promoting sleep health in children and youth is a critical public health priority that requires a comprehensive and multifaceted approach from the individual level to the policy level. The PHPM provides a robust framework for guiding public health efforts to improve sleep health by considering the full spectrum of health determinants and engaging various societal levels. By employing a suite of comprehensive action strategies, such as developing personal skills, creating supportive environments, building healthy public policies, and reorienting health services, we can promote sleep health in young children and their parents, school-aged children, and adolescents. This approach will create cohesive and effective public health strategies that can be used to holistically promote sleep health across the lifespan, addressing both individual sleep health practices, as well as the social and physical environments within which sleep health occurs. The authors would like to acknowledge support from the Canadian Sleep Research Consortium and the Sleep Health Equity Reimagined CIHR Team. Conflict of interest: None declared. None declared. No new data were generated or analysed in support of this manuscript.

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