ABSTRACT
The present study was conducted to investigate the sleep habits of primary school children and identify factors affecting it.
This cross-sectional, descriptive study comprised 1876 school-aged children (ages 6-11 years). The Sociodemographic Characteristics questionnaire and Children’s Sleep Habits questionnaire were used as data-gathering tools. Before the study was started, ethical approval was obtained from the ethics committee. All statistical data were analyzed using the SPSS program. In descriptive statistics, mean, standard deviation, frequency, and percentages were used. Sleep habits and related variables were analyzed using the student’s t-test and One-Way ANOVA test. Statistical significance was determined as p<0.05.
The study comprised 1876 students, with ages ranging from 6 to 11 years (mean 8.52±1.21 years). Of these, 51.5% (n=966) were girls, 48.5% (n=910) were boys, and 71.2% had a sleep disorder. The mean bedtime was 10:01 p.m. ±0:49 min, the mean wake-up time was 07:35 a.m. ±0:55 min, and the mean sleep duration was 9.33±1.13 hours. Significant differences were observed among the participants’ sleeping habits in terms of variables, such as parental education level, family structure, family income, chronic diseases, computer game addiction, and dietary pattern (p<0.05).
It is recommended that school nurses be more careful when evaluating the sleep characteristics of school-aged children. Moreover, school nurses should inform parents and children of any sleep problems.
Keywords: Affecting factors, sleep habits, primary school children
Introduction
Sleep is essential to good health. Sleep significantly affects the quality of life and well-being of an individual. A good sleep plays a key role in disease resistance, injury prevention, clarity of thought, and stability of mood (1). Twenty-five percent of children experience sleep problems during childhood, and night waking/bedtime resistance is reported most commonly (2,3).
Healthy sleep habits for children are important. However, some factors may adversely affect children’s sleep habits. In studies conducted on children’s sleep habits, the following factors have been reported to affect their sleep health: obesity (4,5), dietary habits (6-8), consumption of junk food and high-calorie drinks (9), family factors (10-14), sleep routines, time spent watching television or using computer or smart phones (15-19), and the presence of a chronic disease (20-22).
It is well known that sleep has a significant impact on the growth and development of children. The average sleep time for school-age children is recommended to be more than 10 hours (23,24). The American Academy of Pediatrics recommends that children 6 to 12 years of age should sleep 9 to 12 hours per 24 hours on a regular basis to promote optimal health (25). Inadequate sleep health is adversely affected. In order to prevent the adverse health effects of sleep problems on children, they should be provided with opportunities to sleep and rest well. Inadequate sleep is an important public health problem affecting children’s health seriously (26). For this reason, it is important to determine the sleeping habits in children, to define the sleep problems well and to determine the factors affecting the sleep health and to make appropriate interventions.
The aim of the present study was to assess the sleep habits of schoolchildren and factors affecting of the sleep habits of school children in Turkish population.
Materials and Methods
The study was designed as a cross-sectional one. The study population of this cross-sectional research covered 46 primary schools. Four primary schools were selected by the simple random technique. The sample consisted of 1876 students (ages 6-11) in these schools.
Data collection was performed during March 2015 and June 2015. The Sociodemographic Characteristics questionnaire and Dietary Pattern index (DPI) were filled in by students. Body Mass index (BMI) was measured by the researchers. The Children’s Sleep Habits questionnaire (CSHQ) was filled in by the parents of students.
The Sociodemographic Characteristics questionnaire, BMI, DPI and the CSHQ were used as data gathering instruments.
The Sociodemographic Characteristics Questionnaire
This form was prepared by the researchers and included questions to gather data about sociodemographic characteristics of the children such as, age, gender, education level of parents, mothers’ employment status, family income, playing computer games and watching television.
Body Mass Index
Anthropometrics were measured by the researchers following the standard procedures. BMI was defined as weight in kilograms divided by height in meters squared. Children and adolescents who measure between the 85th to <95th percentiles are considered overweight, and those at the ≥95th percentile are considered obese (27).
Dietary Pattern Index
The DPI developed by Demirezen and Caşansu (28) includes 6 items questioning the respondents’ eating habits (e.g., eating vegetables, fruits, fatty and sugary foods and drinking tea, coffee, salt consumption). The responses are measured using a 4-point Likert-type scale (0= never to 4= always). One of the items is reverse scored. The total score ranges from 0 to 24, with higher scores representing unhealthier eating habits. Total score was categorized as no risk (0 points), low risk (1-6 points), intermediate risk (7-12 points), high risk (13-18 points), very high risk (19-24 points). The internal consistency of the scale is 0.68.
The Children’s Sleep Habits Questionnaire
The CSHQ was developed by Owens et al (29). The CSHQ is a retrospective, 41-item parent questionnaire that has been used in a number of studies to examine sleep behavior in young children. The CSHQ includes items relating to a number of key sleep domains that encompass the major presenting clinical sleep complaints in this age group: bedtime behavior and sleep onset, sleep duration, anxiety around sleep, behavior occurring during sleep and night waking, sleep-disordered breathing, parasomnias, and morning waking/daytime sleepiness. Parents are asked to recall sleep behaviors occurring over a “typical” recent week. Items are rated on a three-point scale: (i) “usually” if the sleep behavior occurred five to seven times/week; (ii) “sometimes” for two to four times/week; and (iii) “rarely” for zero to one time/week. Some items are reversed in order to consistently make a higher score indicative of more disturbed sleep. A total score of over 41 indicates sleep problem. The internal consistency of the scale is 0.68-0.78 (29). The index was adapted into Turkish by Perdahlı Fiş et al. (30) The internal consistency of the Turkish version is 0.78. In the present study, the internal consistency of the Turkish version of the scale is 0.61.
Human Subjects Approval Statement
The study was approved by the Pamukkale University Ethics Committee (approval number: 60116787-020/3517). Ethical permissions were obtained from the Pamukkale University Ethics Committee, and provincial Directorate of National Education. Written consent was obtained from the parents and children by sending a letter explaining the aim and the procedures of the study, and a guarantee was given that the gathered data would not be used other than the aim of the study (they were ensured that the study data would be used within the scope of the study and would not be disclosed to third parties). All procedures were performed in accordance with the Declaration of Helsinki.
Statistical Analysis
The data were analyzed with the IBM Predictive Analytics SoftWare Statistical Product and Service Solutions version 22.0 (31). P values of <0.05 were considered statistically significant. Frequencies and percentages were used to describe the descriptive data and the characteristics of the primary school children. The data were analyzed using the Independent samples t-test and One-Way ANOVA test.
Results
Sleep habits of the participating primary school children are shown in Table 1. The mean bedtime was 10:01 p.m. ±0:49 min., the mean wake up time was 07:35 a.m. ±0:55 min., the mean sleep duration was 9.33±1.13 hours. The mean CSHQ score was 45.99±7.36.
The study included 1876 students. The age of the children ranged from 6 to 12 years (mean 8.52±1.21). Of the students who participated in the study, 51.5% were girls, 38.1% had primary school graduate mothers, 32.6% had primary school graduate fathers, 47.5% had mothers working at a paid job, 8.4% had a chronic disease, and 62.2% had families with moderate income.
There were statistically significant differences between the scores obtained from the CSHQ in terms of the variables such as the maternal educational level, paternal educational level, family structure, family income, chronic diseases, playing computer games and dietary pattern. No relationship was found between sleep problems and the variables such as age, gender, mother’s employment, BMI, watching television (Table 2).
Discussion
The present study provides information on the sleep habits of Turkish children who participated in the study. The children’s sleep habits were assessed in terms of bedtime, wake up time, sleep duration and CSHQ scores.
In Amschler and McKenzie’s study, the bedtime of the children was determined to range between 9:00 p.m. and 9:30 p.m. (1). In other studies, the bedtime was reported as 10:00 p.m. or later (32-34) In the present study, similar to other studies, the mean bedtime of the participating, students was 10:00 p.m.
While the mean wake up time was 7:51 a.m. in Canet’s study and 7:00 a.m. in Bharti et al. (35) study, it was before 8 a.m. in Koçoğlu et al. study (32,33,35). On the other hand, in Amschler and McKenzie’s study, the majority of the students woke up after 7:00 a.m (1). In the present study, the mean wake time was 7:35 a.m. which was consistent with the findings in the literature.
Given sleep duration, children in the 5-10 age group are categorized into 3 groups: normal sleepers (≥10 h), short sleepers (8-9 h) and shortest sleepers (<8 h) (23). The mean sleep duration of the students was 9.26 hours in Canet’s study, 8.30 hours in Firouzi et al. (34) study, 8.77 hours in Bharti et al. (35) study, 9.20 hours in Li et al. (37) study and 8.42 hours in Park’s study (32,34-37). In the present study, the mean sleep time of the students whose mean age was 8.52 years was 9.33 hours which was consistent with the findings of Canet’s and Li et al. (37) studies (32). The mean sleep time of the students in the present study indicates that they were normal sleepers.
Studies show that sleep problems are a common health problem among students (1,32,38). In Surani et al. (39) study, while the overall mean score for the CSHQ was 44.09 for the elementary school students and 44.18 for the middle school students, it ranged between 49.3 and 54.9 in Firouzi et al. (34) study. In the present study, the mean score the participating students obtained from the CSHQ was 45.99. Considering that the cut-off point of the scale was 41, it can be said that the students had sleep problems. Their sleep patterns and sleep habits are distorted due to irregular sleep hours on school days, changes in sleep hours and spending more time in front of a computer and television on weekends (32).
This research, which attempted to identify factors associated with sleep habits among school-age children in Turkey, found a significant association between their sleep habits and variables such as maternal educational level, paternal educational level, family structure, family income, chronic diseases, playing computer and dietary pattern.
In the present study, the participants’ parents educational status affected the participants’ sleep habits. Of the participants, those whose parents’ education level was low had more sleep problems than did those whose parents’ education level was high. In the literature, there are studies indicating that there is a relationship between educational status of parents and sleep problems (10-12). As parents’ education level increases, so do their socioeconomic levels and awareness of their children’s sleep health, which affects children’s sleep health positively.
In the present study, family structure and family income were the factors that affected the sleep habits of school age children. Of the participating children, those having a single-parent family had a higher mean CSHQ score than did those having a two-parent family. These children had more sleep problems. In a study of Troxel et al. (14), children having a single-parent family were reported to have more sleep problems than did children having a two-parent family. In single-parent families, the parent’s having to take on more responsibility because of being alone (the other parent’s responsibility is laid on him/her too), and differences in parental control and family routines may cause children to have more sleep problems. In the present study, of the participants, those having families with low income had more sleep problems than did the others. In the literature, there are studies whose results are consistent with those of the present study (40,41) On the other hand, in their study, Smaldone et al. reported that children in high-income families had more sleep problems.
Children with chronic diseases not only try to overcome the symptoms of the disease, but also suffer from physical, social, psychological, developmental and environmental problems due to their diseases. Having a chronic disease is among the factors leading to decreases in sleep time in children (25). In the present study, the mean CSHQ score of the children with a chronic disease was higher than was that of the children without a chronic disease, suggesting that they had more sleep problems. Studies have shown that sleep problems increase in children with chronic diseases (20-22). Chronic diseases can affect sleep due to symptoms getting worse at night, disease-related pain, hospitalization, side effects of drugs, etc.
In the present study, the children who played computer games 1 hour and more had more sleep problems than did those who played computer games less than 1 hour. In several studies, it was reported that there was a relationship between the duration of computer use and sleep problems and that spending more than 2 hours a day on the computer caused difficulty in falling asleep and waking up (15-18). In their systematic review and meta-analysis, Mei et al. (19) determined that overuse of computers (excessive computer usage) caused sleep problems.
There are many studies indicating the effect of dietary habits on sleep problems in children. Several studies have demonstrated that there is a relationship between unhealthy eating habits and sleep habits, between the way food is consumed and sleep habits, and positive relationship between sleep duration and dietary habits including fruits and vegetables (6-8). Another finding indicates that while carbohydrate-based diet increases sleep time, fat-based diet reduces it (9). In the present study, it was found that of the participating children, those who were at high risk in terms of diet habits had more sleep problems.
Conclusion
In the present study, it was found that parents’ education level, family structure, family income level, presence of a chronic disease, playing computer games and dietary habits affected the participants’ sleeping habits. Of the participants, those who had parents with low levels of education, single-parent family, low family income and a chronic disease, who played computer games 1 hour and more per day and children and/or who were at high risk of inappropriate dietary habits had more sleep problems. It could be recommended that school nurses be more careful and questioning while evaluating the sleep characteristics of school-aged children. School nurses should also inform parents and children about sleep problems.
