Advancing adolescent bedtime by using motivational interviewing and text reminders – a randomized controlled trial

ABSTRACT

Introduction: Chronic sleep deprivation is a prevalent sleep prbolem in school-aged adolescents. The natural delay of circadian rhythm combined with early school schedule leading to significant sleep loss during school days. In particular, adolescents in Hong Kong not only sleeping less than their Shanghai counterparts but also having later bedtime. Delaying school start time is an effective strategy but has met numerous constraints. While previous sleep education programs have successfully improved sleep knowledge but failed to increase sleep practice. Intervention with specific focus on late bedtime might be an potential approach to improve adolescent sleep. Current study explores the possibility of advancing adolescent bedtime by group-based motivational enhancement approach and text message reminders. Materials and Methods: Healthy adolescents (12-18 yrs old) with schoolday sleep duration <7 hours and without other sleep disorders such as insomnia and delay sleep phase disorder were randomly allocated to intervention or non-active control group. The intervention consists of four weekly, group-based therapy delivered using motivational interviewing approach and 3 week daily text reminders. Assessments were conducted at baseline, post-intervention, 3-month and 6 -month follow up. The primary outcomes were sleep-wake pattern captured by 7-day sleep dairy. The intervention effect was evaluated by linear mixed model. The trial was registered with the Clinical Trial Registry (NCT03614572). Results: A total of 212 adolescents (mean age 15.8±0.98;female60.1%) were recruited from Aug 2018 to Apr 2021. Approxiamtely 80% of the adolescents attended all the follow up assessments. Adolescents in the intervention group have significantly earlier schoolday bedtime at post-intervention (intervention vs. control(-14 mins vs +19 mins) and 6-month follow up(-14 mins vs + 21 mins) compared to the control group(F=4.6, P = 0.004). They also had a tendency of increased sleep duration throughout the follow up period, but the difference was not significant(F=2.22, P = 0.089). This is explained by the difference in schoolday wakeup time as control group had a significant later wakeup time at post-intervention (intervention vs. control -2 mins vs +23 mins) in relative to the intervention group. It is not common to observe a change in schoolday wakeup time as wakeup time is largely determined by early school schedule. The outbreak of Coronavirus in 2020 has forced schools to close and adopted an online study mode. The online class schedule varied significantly between schools, which might explain the difference in wakeup time at follow up assessment. Despite there is no significant difference in schoolday sleep duration, adolescents in the intervention group reported greater intention to behavioral changes(P=0.043), and lower level of daytime sleepiness(P=0.001). However, there is no difference observed in sleep knowledge, mood symptoms and quality of life. Conclusions: This study supports that motivational interviewing in combined with text reminders are effective approach in advancing adolescent bedtime, improving their motivation and daytime functioning. Adolescents were able to maintain earlier bedtime regardless of the school schedule. We suggest that advancing bedtime protocol should be incorporated at school-level to benefit more adolescents. AcknowledgementsSupported by Health Medical Research Fund (#15163071), Hong Kong SAR, China.