Sleep Medicine Reviews 36 (2017) 13e28

Contents lists available at ScienceDirect

Sleep Medicine Reviews

journal homepage: www.elsevier.com/locate/smrv

CLINICAL REVIEW

School-based sleep education programs: A knowledge-to-action

perspective regarding barriers, proposed solutions, and future
directions
Reut Gruber a, b, *
a
Department of Psychiatry, Faculty of Medicine, McGill University, Canada
b
Attention Behavior and Sleep Lab, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Montr

eal, QC H4H 1R3, Canada

a r t i c l e i n f o s u m m a r y

Article history: Sleep is associated with an array of physical and mental health outcomes that are essential for healthy
Received 13 January 2016 adjustment in children. Unfortunately, transfer of this knowledge into action has been slow and largely
Received in revised form ineffective. There are only 15 published school-based sleep health promotion programs, and findings are
28 September 2016
mixed in terms of their impact on sleep behavior, knowledge and health outcomes. This paper applies a
Accepted 3 October 2016
Available online 11 October 2016
knowledge-to-action (KTA) framework to assess the strengths and weaknesses of such programs and to
identify strategies that can be used to enhance the translation of empirical evidence in pediatric sleep to
effective action. It is proposed that effectiveness of interventions may be increased by defining specific
Keywords:
Sleep education
targets for change, identifying prospectively the gap between current sleep practice or knowledge and
Children intervention goals, assessing and addressing barriers and facilitators for program implementation,
Adolescents adapting the program for local use, tailoring it to the developmental needs of the target users, using
Knowledge translation rigorous designs to evaluate outcomes and improving sustainability by engaging multiple stakeholders
Knowledge-to-action throughout the KTA process. Collectively it is proposed that integrating a KTA framework and related
strategies will enhance the effectiveness of these programs in translating empirical evidence in pediatric
sleep to effective and sustained action.
© 2016 Elsevier Ltd. All rights reserved.

Sleep in children is not merely a “break” or leisure period, but
rather an essential component of healthy growth and development
from infancy through an individual's lifespan. While the idea that
“sleep is important for children” seems axiomatic, it has proven
difficult to translate this notion into actions that may actually in-
fluence health. Since 1905, some 5815 articles [1] have examined
the associations between sleep duration and an array of key
physical and mental health outcomes that are essential for optimal
productivity and adjustment in children. Considerable resources
have been devoted to these studies, which have improved our
understanding of the impact of short sleep duration on multiple
outcomes, and have emphasized that we must help children obtain
adequate sleep. However, such evidence cannot change children's
health outcomes unless it is applied in practice and policy [2,3].
Abbreviations: CBPR, community based participatory research; KTA, knowledge
to action; KT, knowledge translation.
* Department of Psychiatry, Faculty of Medicine, McGill University, Canada.
E-mail address: reut.gruber@douglas.mcgill.ca.
Unfortunately, transfer of knowledge in pediatric sleep into action
has been slow and ineffective. In sharp contrast to the large number
of studies documenting the association between short sleep dura-
tion and negative health outcomes, only 15 published studies have
described school-based health promotion interventions aimed at
optimizing the sleep duration of children or adolescents. At the
present time, no educational policy has been formulated regarding
sleep and very few sleep-health promotion programs have been
integrated into school curricula. This is problematic, because until
the necessary information is widely applied and disseminated, we
will be missing an important opportunity to significantly improve
health and well-being among our youth, and to prevent mental and
physical sickness in this population.
A “knowledge-to-action (KTA) gap [4]” is described as a gap that
exists between research-derived knowledge and its use by key
stakeholders. The US Institute of Medicine has declared such gaps to
be problematic, as the failure to move new knowledge into effective
action is a major barrier that prevents humans from benefiting from
advances in biomedical sciences [5]. The identified gap between our
knowledge regarding the biology of sleep and its translation into

http://dx.doi.org/10.1016/j.smrv.2016.10.001
1087-0792/© 2016 Elsevier Ltd. All rights reserved.
14 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28
child-focused public health interventions is herein called the “KTA
gap in pediatric sleep.” Growing awareness that research findings in
pediatric sleep are not applied in a timely fashion, coupled with the
current emphasis on evidence-based, cost-effective and accountable
preventative interventions, has spurred new interest in minimizing
the KTA gap in pediatric sleep [6,7]. An attempt to overcome the KTA
gap in pediatric sleep should address multiple theoretical and
practical barriers that exist at the individual, family and societal
levels, while also taking into account theoretical models of behav-
ioral change (for a comprehensive discussion, see [8]). This paper
focuses on one of the many factors that need to be further investi-
gated, namely, KTA model and related strategies that could be used
to improve mobilization of pediatric sleep research data into effec-
tive action. Improving such efforts will not solve all of the challenges
or answer all of the open questions pertaining to the desire to
improve sleep health promotion programs. It seems, however, that
improving KTA practices could facilitate the successful uptake of
sleep health promotion programs, regardless of their theoretical
orientation and/or behavioral model.
This goal of this review is to highlight a formal process of
knowledge transfer that has not yet made its way into the field of
pediatric sleep research. The author proposes that if pediatric sleep
researchers consciously address key issues that have been shown to
affect the KT process, they will greatly improve the effectiveness of
their interventions. First, key terms will be defined. Next, Graham's
KTA framework will be introduced and used to assess the strengths
and weaknesses of the existing school-based sleep health promo-
tion programs. This framework was chosen because it has been
shown to positively impact the ability of researchers to translate
evidence into effective action in multiple domains of health. This
does not mean it is the only relevant framework, or that it should
have been used in the past. It is used here to demonstrate how a
framework known to be effective in related fields could have been
applied in the past, thereby showing how we can improve future
efforts to develop school-based sleep health-promotion programs.
Finally, recommended KTA strategies will be assessed for their
potential to enhance the translation of empirical evidence in pe-
diatric sleep to effective action.
Methodological issues, such as objective versus subjective
measures of sleep, the strengths and weaknesses of different
experimental designs, and the selection of particular measures of
sleep knowledge, are all important and can modify the quality of
the results obtained in the reviewed studies. However, this paper
will not address such issues. For a discussion of these aspects of
sleep health-promotion programs, please see [9,10].
KTA-related terminology
Knowledge translation is the synthesis, dissemination, exchange,
and ethically sound application of knowledge to improve health,
provide more effective health services and products, and strengthen
the health care system [11]. The process of KTA, which entails the
transfer of high-quality evidence from research into effective
changes in health and/or products, includes two key aspects: 1)
purposeful activities undertaken to produce knowledge; and 2) the
application of this knowledge for the benefit of people in the real
world. Integral to this process is the gap between new research-
generated knowledge and its acceptance by end-users. Contempo-
rary models of KT [12e18] emphasize: 1) that we need to move
beyond simply disseminating knowledge to actually using it effec-
tively; 2) that KTA encompasses the processes of both creating and
applying knowledge; 3) that the process should be taken as a whole,
with knowledge producers (researchers) and knowledge imple-
menters (users) working collaboratively; and 4) that it should be
viewed as a bi-directional flow of knowledge and action.
KTA in pediatric sleep: school-based sleep education
interventions
The integration of sleep-promotion programs into schools has
been proposed as a way to move knowledge in pediatric sleep into
effective action. Among young people, such programs are expected
to increase knowledge regarding the importance of sleep and to
significantly improve their sleep health and related outcomes (e.g.,
mental health and academic performance). Schools have been
identified as an ideal formalized setting for health-promoting
programs because they can reach large segments of the youth
population, provide a platform for health education and promotion
[19], and actively encourage children to adopt and maintain a
healthy lifestyle. In addition, it has been shown that using the
existing infrastructure of the educational system can be a cost-
effective route for delivering health-promoting programs [20,21].
A number of published studies worldwide have examined how
school-based sleep education programs can impact sleep and
sleep-related outcomes. Unfortunately, although there is
convincing rationale for school-based sleep education, most of the
findings in this area have not provided evidence of successful
intervention (Table 1).
Of the 15 published studies [22e37] examining sleep education
programs throughout the world, findings are mixed regarding the
impact of these programs on sleep behavior, knowledge and health
outcomes. Moreover, there are no published reports of a researcher
successfully sustaining a sleep education program in a partner
school beyond the study period.
It is not clear why the school-based sleep education programs
have not been successful in improving sleep and related daytime
outcomes. Previous relevant reviews have noted that the published
school-based sleep intervention programs have suffered from
numerous methodological issues, see [6,7,9,10] for review. The
existing reviews, however, have not addressed the limitations of
these programs from the perspective of KTA. This is an important
omission, given that the ultimate goal of such programs (and one
way in which their success is measured) is their ability to take
knowledge regarding the positive impact of sleep and move it to
effective action. To date, no work has sought to develop a mecha-
nism to ensure that a sleep education program can successfully
move information related to sleep to effect change, be acceptable to
the target community, and be sustainable beyond the study period.
A framework for moving knowledge to action in pediatric sleep
Graham et al. [4] created a framework to guide researchers and
implementers in planning how to move their created knowledge
into action. The authors presented a systematic series of activities
that collectively encompassed the process through which research
evidence is translated into effective action. Their framework divides
the entire KTA process into two main concepts: knowledge creation
and the action cycle (Fig. 1).
Knowledge creation encompasses the phases of conducting
research and refining it into a usable format. At the center of the
KTA cycle, we can imagine a knowledge-creation funnel [4]. As
knowledge moves through the funnel, it is refined to (ideally)
become more useful to its end-users.
Knowledge creation may be separated into three categories,
called generations, as follows:
1) In first-generation knowledge creation, a multitude of studies
generate information about a topic of interest. In the context of
KTA in pediatric sleep, all of the sleep education programs that
have been employed to date have been based on the scientific
evidence that has accumulated based on first-generation
Table 1
Summary of published sleep education studies.

Reference Objectives Intervention description Evidence based Design Measures Participants Results
strategy for behavioral (sample size, age)
change

Azevedo et al., 2008 1) To increase awareness about Study 1: NA Study 1: Study 1: Study 1: Study 1:
[22] the importance of sleep for 12 daily 50-min activities Pre- and post- -Sleep habits N ¼ 25 -Improved sleep
school performance; delivered during class assessment -Sleep knowledge M ¼ 16 ± 1.2 y knowledge
2) To encourage students, Study 2: Teachers' workshop -No change in sleep
teachers, and parents to Study 3, 4: not relevant behavior
prioritize sleep hygiene -Decreased frequency of
naps
-Decreased sleep
irregularity
Bakotic et al., 2009 To evaluate the impact of Distribution of sleep education NA Pre- and post- Sleep knowledge test N ¼ 1209 Improved percentage of
[23] exposure to educational leaflet leaflet that contains assessment Age range ¼ 15e18 y correct answers
on sleep knowledge information regarding:
1) Recommended sleep
practices and duration
2) Consequences of sleep
deprivation

R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28

Beijamini and To evaluate the impact of sleep Duration: four consecutive NA Randomized control -Actigraphy and sleep logs N ¼ 21 No significant outcomes
Louzada, 2012 education program on sleep days, 50 min daily classes trial -Reported daytime Age range ¼ 13e14 y
[24] patterns, daytime sleepiness, sleepiness
sleep duration and -Psychomotor performance
psychomotor performance
Blunden et al., 2012 -To increase parents' and -PowerPoint presentations NA Pre-post cross- -Sleep knowledge N ¼ 98 -Increased sleep knowledge
[25] students' sleep knowledge -Student workbook sectional uncontrolled questionnaires M ¼ 15 y -No change in sleep
-To change sleep behavior -Teacher's manual design -Self-reported sleep Age range ¼ 13.3 duration
-To assess feasibility of delivery -Parent booklet duration e16.9 y
and acceptability of content in -3 to 4 sessions of 45 min
New Zeeland
Bonnar et al., 2015 -To increase sleep knowledge Duration: 50 min, once per -Motivational Randomized control -Sleep knowledge N ¼ 193 -Improved sleep
[26] and motivation-to-change week, for four weeks interviewing trial, pre, post and six -Self-reported sleep M ¼ 16.3 ± 0.4 y knowledge
sleep behaviors Groups: -Bright light therapy weeks follow up patterns, mood, motivation, -Increased motivation to
-To improve adolescents' sleep 1) Sleep education program use of bright light change
-To improve mood (SEP) -Number of videos views by -Improved sleep onset
2) SEP þ parental involvement parents latency
(PI) -Increased 27 min of
3) SEP þ bright light (BL) reported sleep time
4) SEP þ PI þ BL -Improved mood
5) Controls
Cain et al., 2011 -To provide information about 4  50 min session  four Motivational Non-randomized -Reported sleep patterns, N ¼ 104 -Increased sleep knowledge
[27] sleep weeks interviewing controlled before-and- daytime sleepiness, M ¼ 16.2 ± 0.4 y -Increased motivation to
-To motivate students to after study and six depression, anxiety, and regularize sleep schedule
change sleep behaviors weeks follow up behavioral intention to -No changes in sleep or
change sleep behavior daytime functioning
-Sleep knowledge -No permanent behavior
changes at six week follow-
up
Cortesi et al., 2004 To increase sleep knowledge 2 h lesson (slides) NA Randomized controlled Sleep knowledge N ¼ 425 Improved sleep knowledge
[28] before-and-after study M ¼ 17.9 y
and three months Age range ¼ 17e19 y
follow up
Diaz-Moralez et al., To change sleep beliefs 1 h course (slides) NA Pre- and post- program Sleep Beliefs Scale N ¼ 386 Increased accuracy of
2012 [29] assessment M ¼ 13.78 ± 1.17 y responses on the sleep
Age range ¼ 12e16 y beliefs scale
(continued on next page)

15
 16
Table 1 (continued )

Reference Objectives Intervention description Evidence based Design Measures Participants Results
strategy for behavioral (sample size, age)
change

Kira et al., 2014 Increase sleep duration 4 50-min classroom-based NA Parallel, two-arm Sleep knowledge N ¼ 29 Increased weekend sleep
[37] education sessions with randomized controlled questionnaires duration
interactive groups pilot trial with 10 Self-reported sleep No change in sleep duration
weeks follow up duration during week nights
Moseley and To improve sleep knowledge, 4 50-min lessons Cognitive behavior Randomized controlled -Sleep N ¼ 81 -No change in sleep
Gradisar, 2009 sleep behavior, daytime therapy trial with six weeks knowledge M ¼ 15.6 ± 0.6 y patterns
[30] sleepiness and mood follow up -Self-reported sleep -Students with delayed
patterns, sleep reduced discrepancy
daytime sleepiness, between school week and
depression, anxiety and weekend out of bed times
intentions -Sleep knowledge
increased
-No change sleepiness or
mood
Rigney et al., 2015 To improve sleep behavior, See Blunden S et al., 2012 [25] Theory of planned Cluster randomized -Actigraphy N ¼ 296 -10 min delay in wake time
[31] sleep knowledge and sleep behavior controlled trial with -Self-reported sleep M ¼ 12.2 ± 0.6 y immediately after the
hygiene two groups and three duration and patterns Age range ¼ 11e13 y intervention

R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28

Souza et al., 2007 To improve sleepewake cycle,
[32] sleep quality and sleepiness
Souza et al., 2013 To increase sleep knowledge
[33] and improve sleep habits
Vollmer et al., 2014 To increase sleep knowledge
[34] and improve sleep hygiene
practices
Wing et al., 2015 To increase sleep knowledge,
[35] and sleep duration, improve
sleep hygiene and patterns,
improve mental health and
behavior
One week, daily 50 min class
Duration: Five 45 min sessions
held during usual class time
-Intervention group: 1.5 h sleep
education program
-Control group: 1.5 h dream
education program
-1 h town hall seminar by sleep Time and stress
physicians
-Two 40 min class workshops
once per month, 30e40
students per class (two months)
-Brochure, sleep education
leaflets
-Slogan competition
-Sleep education seminar for
teachers and parents
assessment points (pre, -Sleep knowledge
immediately after, six questionnaire carriage
and 18 weeks post return-Sleep hygiene index
intervention)
NA Pre-post program -Sleep habits questionnaire N ¼ 58
assessment -Epworth sleepiness scale
-Morningness-eveningness
inventory
Meaningful learning Pre- and post- program -Chronotype
approach assessment -Sleep knowledge
-Reported sleep habits and
sleep diaries
-Daytime sleepiness
Pre- and post- design -Sleep knowledge
with a control group, questionnaire
and six weeks follow up -Intended/actual sleep
practices
-Chronotype
Cluster randomized -Insomnia symptoms
management trial -Reported sleep-wake
patterns
-Daytime sleepiness
-Sleep knowledge
-Daytime behavior
-No changes in sleep
knowledge/hygiene
-Reduction in index of sleep
M ¼ 15.98 ± 0.93 y irregularity
-Sleep latency decreased
-Nap-wake up schedule
advanced
N ¼ 34 -Increase in sleep
M ¼ 16.8 ± 0.6 y knowledge
-18 min advanced bedtime
on weekdays
-1 h 19 min advanced
bedtime and 1h56 min
advanced wake up time on
weekends
-Decreased irregularity of
sleep schedule
N ¼ 279 -Increased sleep knowledge
M ¼ 12.51 ± 0.46 y -Improved sleep practices
immediately after the
intervention, but not
sustained at follow up
N ¼ 3713 -Improved sleep
M ¼ 14.72 ± 1.53 y knowledge
Age range ¼ 12e18 y -Decreased energy drinks
consumption
-Sleep duration shortened
-Improved behavior and
mental health
 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28 17

knowledge showing that: 1) there is a high prevalence of sleep

deterioration in the control

hygiene, increased time in

deprivation among young people, particularly adolescents (e.g.,

efficacy, improved sleep

bed, advanced bedtime

[38]); 2) sleep deprivation impairs the mental and physical

-Increased sleep self-

health of young people, and is detrimental to academic perfor-

-Stable academic

mance (e.g., [39,40]); 3) adolescents are sleep deprived due to

performance vs

the combined effects of biological and socio-environmental

pressures, decreased parental supervision regarding bedtime,
group

and poor sleep hygiene (e.g., [39]). This provides a strong

justification for the need to prevent sleep deprivation in youth.
2) In second-generation knowledge creation, explicit and repro-
M ¼ 12.54 ± 0.27 y

ducible methods are used to identify, appraise, and synthesize

studies or information relevant to specific questions, in an effort
to consolidate the relevant knowledge. Such work takes the
N ¼ 143

form of systematic reviews, including meta-analyses and meta-

syntheses, and is often found in high-quality and up-to-date
databases such as the Cochrane collaboration, Ovid's evidence-
based medicine reviews (EBMR), and BMJ clinical evidence. In
the case of pediatric sleep research, however, these databases
hygiene scale

currently lack any information regarding sleep health promo-

efficacy scale

tion programs. Several meta-analyses and reviews have sum-

marized the available evidence regarding the impact of sleep on
habits
diary

cognition and health (e.g., [39,41]). However, this second-

generation knowledge is based on weak scientific evidence,
-Sleep
-Sleep
-Sleep
-Sleep

BL ¼ bright light; M ¼ mean age; N ¼ number of participants; NA ¼ non-applicable; PI ¼ parental involvement; SEP ¼ sleep education program.

such as that from correlational studies that do not account for

causality and use mostly subjective sleep measures. Therefore,
sessions and two follow
trial with two booster

the efforts to develop sleep education programs have lacked the

Randomized control

empirically sound second-generation knowledge needed to

move first-generation knowledge into effective action in the
public realm.
3) In third-generation knowledge creation, knowledge-related
tools or products are generated to provide explicit recom-
ups

mendations that will meet the stakeholders' informational

-Social learning theory

needs and facilitate the uptake and application of knowledge.

-Skill training model

Examples of third-generation knowledge include synopses that

present knowledge in a clear, concise, and user-friendly format,
practice guidelines, or decision aids and tools [42]. In the
context of sleep health promotion programs, third-generation
knowledge could include evidence-based tools for: designing
and conducting pragmatic sleep health promotion programs;
evaluating such programs and identifying the most effective
-Small groups facilitated by two
-Eight sessions, twice a week,

options; and assessing the implementability of sleep health

promotion programs (i.e., predicting potential challenges to
effective implementation) in different contexts, such as within
high/low SES situations, different cultures/subcultures, and the
BA-level leaders

guidelines of different school systems. For examples in other

40 min each

health domains, see http://www.unicef.org/evaluation/files/

Advocacy_Toolkit.pdf. Currently several sleep education pro-
grams have been shown to succeed in increasing sleep
knowledge. These could constitute third-generation knowl-
edge that could be effectively disseminated using the steps
sleep hygiene, academic and

described in the action cycle. However, there is no evidence

Wolfson et al., 2015 To improve sleep patterns,

regarding what information should be included for these pro-

behavioral well being

grams to be effective in achieving goals such as improved sleep

hygiene or behavior, nor is there any indication that the in-
clusion (or lack) of any particular topic is associated with
achieving or not achieving the program objectives. This is a
problem, because it means that at this point we do not yet have
valid tools for changes of youth's sleep health that can be
disseminated to improve sleep health youth.

Additional aspects of the knowledge creation cycle, according to

the KTA model, is that given that the ultimate goal of health
research-related knowledge production is to improve health out-
[36]

comes the desired outcome/s should be considered during each

phase of knowledge creation, rather than solely at the end of it. In
18 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28
Fig. 1. The knowledge to action cycle. Knowledge Translation in Health Care: Moving from Evidence to Practice, 2nd Edition Sharon Straus (Editor), Jacqueline Tetroe (Editor), Ian D.
Graham (Editor) ISBN: 978-1-118-41354-8, [11], reproduced with permission.
other words, from a KTA perspective, knowledge production should
be driven by the gaps that are the most relevant to the health-
related goal at hand. In the context of pediatric sleep, a key KTA
gap is the question of how much sleep is required for the optimal
health, growth, and performance of children at different ages.
Recently, a panel of experts appointed by the National Sleep
Foundation produced sleep guidelines that attempted to provide
such recommendations [43,44]. However, the panel members
acknowledged that the recommendations were not based on strong
empirical evidence, but instead came from weak scientific evidence
and, at times, their own experiences and/or opinions. This critical
gap of the first-generation knowledge needed to empirically
determine the appropriate sleep durations for different ages could
be used to guide the creation of additional knowledge. Such KTA-
driven “first-generation knowledge inquiry” would be expected
to include studies that could provide the empirical evidence
needed to determine the age-sensitive doses of sleep extension that
would be sufficient to improve cognitive, physiological, emotional,
and safety outcomes while decreasing sleep deprivation, which is
detrimental to such outcomes. This first-level knowledge would
inform the creation of critical second-generation knowledge (e.g.,
evidence-based guidelines for recommended sleep durations) that
we currently lack in the absence of the necessary first-generation
knowledge.
Finally, the knowledge creation cycle is bi-directional. In the
context of pediatric sleep, the existing first-level knowledge has
been used to produce evidence-based guidelines for recommended
sleep durations (i.e., second-generation knowledge). Given the lack
of sufficient evidence, however, the process must circle back to the
production of first-generation knowledge that will fill the gap (e.g.,
the amount of sleep needed for optimal health and cognition at
different ages), thereby enabling the production of second-
generation knowledge (e.g., evidence-based guidelines) and even-
tually third-generation knowledge (e.g., tools that allow the
 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28
effective implementation of evidence based guidelines such as
school-based sleep health promotion programs). Thus, the first-
generation knowledge produced to fill the identified gaps would
be used to inform the subsequent phases in the KTA cycle and
contribute to closing the KTA gap in pediatric sleep.
Action cycle
The knowledge-creation cycle is followed by the action cycle of
knowledge implementation, which includes the following phases/
activities: identifying the problem; identifying the knowledge that
is needed; identifying, reviewing, and selecting the knowledge
that is to be implemented; adapting that knowledge to the local
context; assessing the barriers and facilitators; selecting, tailoring,
implementing, and monitoring KT interventions; evaluating out-
comes; and determining strategies that will ensure the sustained
use of the transferred knowledge. These action phases can occur
sequentially or simultaneously, and they may be influenced by the
knowledge-creation phases. Table 2 presents a summary of the
existing and missing steps in the KTA cycle as they related to pe-
diatric sleep.
Assessing sleep health promotion programs from a KTA
perspective (see Table 3)
Although no existing pediatric sleep study has explicitly used
the KTA framework, the next section will define each of the action
phases more specifically while using the KTA framework to
examine the reports that have described the implementation of
school-based sleep health promotion programs.
Identifying the problem
All such programs have aimed to improve sleep health or sleep
knowledge, and have been based on the general idea that sleep is
essential for physical and mental health. However, not all of them
have targeted the same number or type of sleep-related goals.
Some studies aimed only to increase knowledge regarding sleep
[23,28,29]; some studies only aimed at improving sleep behavior
[24,37]; some studies targeted both increasing knowledge and
improving sleep behavior [25,32e34,45]; and several studies aimed
at changing sleep behavior, decreasing daytime sleepiness, and
improving functional outcomes (mood, performance, and behavior)
[26,27,30,31,35,36]; and increasing awareness regarding the
importance of sleep and prioritize sleep hygiene [22].
Although all of the existing studies have generally sought to
address the high prevalence of poor sleep health/habits among
youth, these reports have generally not evaluated or specified the
magnitude or nature of these problems in students of the specific
schools or communities in which the interventions were imple-
mented. According to the KTA model, these issues should be spe-
cifically determined via a “needs assessment,” which is a systematic
process for determining the size and nature of the actual gap be-
tween the existing and desired knowledge, skills, attitudes, be-
haviors, and outcomes in the target community. For a sleep health
promotion program, the needs assessment would consist of sub-
jecting the members of the target community to a pre-intervention
scan aimed at determining the amount of sleep they obtain, their
level of sleep knowledge, the presence/absence of skills needed to
implement proper sleep hygiene, their attitudes towards sleep, and
their sleep habits. The health curriculum of the target school would
also be assessed to determine whether sleep education appears in
any of the existing modules and, if so, what information is included.
In the existing literature, only one study conducted a needs
assessment to determine the sleep knowledge level, actual sleep
habits, and sleep duration of the students targeted by the
19
intervention [33]. Sousa et al. [33] adapted their program so that it
includes only the most relevant information for their participating
students.
Identifying, reviewing and selecting knowledge for implementation
The range of topics that have been covered by the previously
reported interventions are presented in Table 4. At face value, all of
the information appears generally relevant to sleep. However,
most of the programs did not include justification for why the
selected information was chosen, examine whether potential users
lacked particular knowledge, or test whether the included
knowledge was related to the program's desired change. When
such considerations are omitted, the designed intervention may
not add to the users' existing knowledge base, as seen in the work
of Rigney et al. [31], who reported a ceiling effect at baseline, and
therefore were not able to observe any post-intervention change
in knowledge. Conversely, the intervention could assume that the
users have a higher initial level of knowledge, with the end result
that the users might be unable to fully grasp or benefit from the
information.
Adapting the knowledge to the local context
The goal of this phase of the action cycle is to ensure that the
presented knowledge is relevant, enhance its applicability, improve
its acceptance, and increase the likelihood that users will adhere to
the interventions. For example, although many sleep health pro-
motion programs encourage children to keep their bedrooms quiet
and peaceful, this might not possible in some environments, such
as when numerous family members share the same bed/bedroom
or the child sleeps in the living room.
Of the 15 published studies, only two programs included steps
to adapt the identified knowledge to the local context [33,37]. Kira
et al. collaborated to adapt the language and the teaching method
used in ACES program which was developed in Australia [45], for
implementation in New Zealand (NZ) [37]. However, nothing was
reported regarding the value or usefulness of any particular
knowledge to the new setting.
Assessment of barriers and facilitators to disseminating or using the
knowledge
There is evidence that the success of an intervention is increased
when implementation strategies address prospectively specific
setting-related barriers or facilitators [46]. An assessment of such
factors can help researchers prioritize the desired changes and
select appropriate methods for implementing interventions.
None of the reports described assessment of potential barriers
that could limit the uptake of sleep related knowledge, nor did the
program designers make the effort to diminish barriers or make
use of facilitators. Several of the programs requested post-
intervention feedback, and their analyses uncovered multiple
barriers for the successful implementation of their sleep education
programs in retrospect (See Table 3). Whereas some of these issues
could only have been identified following the intervention, mul-
tiple issues such as school timetables and the method of delivery
could have been identified early and taken into consideration
during the design phase, potentially increasing the chance of
success.
Selecting, tailoring and implementing interventions
This phase of the action cycle seeks to overcome specific barriers
to change on a theory-driven basis. In the context of pediatric sleep,
20 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28

Table 2
Knowledge to action cycle in pediatric sleep.

Knowledge to action cycle Existing activities/data sources Missing activities/data sources Potential strategies to mitigate missing
steps activities/data sources

Knowledge creation
Knowledge creation
Knowledge products and
tools (3rd generation
studies)
Studies showing associations between sleep Experimental studies assessing causality and Experimental studies that use objective
duration and an array of physical and determining optimal sleep duration for sleep measures and are age and outcome
mental health outcomes different outcomes at different ages; minimal specific
amounts of sleep extension/restriction affecting
specific outcomes
Reviews/meta-analyses based on low-level Meta-analyses that will be based on high-level Knowledge syntheses that will be based on
evidence evidence regarding sleep duration and relevant stronger studies
Consensus based recommended sleep outcomes
duration for children Evidence based recommended sleep duration
NA Tool-Kits for the adaptation of evidence based Develop tool kits and evidence based
sleep health promotion programs to different practice guideline
communities and contexts
Practice guidelines for effective sleep health
promotion programs

Steps in the knowledge to action cycle as they relate to pediatric sleep

Action cycle Existing Missing Strategies that could be used to accomplish

this goal

Identifying the problem General evidence that children do not get Easily accessible tools to conduct needs Conduct ”environmental scan” to
optimal/sufficient sleep and/or do not have assessment to produce local evidence about the determine existing sleep habits, duration
enough information regarding sleep magnitude of the problem in the specific and knowledge
school(s) that are targeted
Adapting knowledge to NA Tools to guide adaptation of knowledge to the Create a pool of potential factors that could
local context local context be examined prior to program
implementation to assist with program
adaptation
Assessing barriers to NA Tools to guide assessment of barriers prior to Use focus group, interviews, or survey
knowledge use program implementation before the implementation
Selecting, tailoring and Use of integrated motivational interviewing Tailor programs to students' developmental Integrate neuroscientific understanding of
implementing and interactive activities characteristics in different ages students learning style and needs
interventions to promote Optimizing intervention methods or theory to Use the wheel of change to identify and
knowledge use the particular knowledge users and select behavioral intervention strategies
circumstances
Monitoring knowledge use NA Long-term monitoring of knowledge use
Evaluating outcomes Multiple designs have been Table used to Outcomes evaluation beyond the intervention
assess outcomes (See Table 1) period;
Use of objective measures to assess sleep
outcomes
Sustaining knowledge use NA Strategies to sustain the knowledge use Collaborate with stakeholders through the
KTA process; develop a training manual for
the program implementation

KTA ¼ knowledge to action; NA ¼ non-applicable.

most of the school-based sleep health promotion programs re-
ported to date have targeted adolescents. However, only a few of
them have tailored the intervention to the developmental charac-
teristics of this population. Bonnar et al. [26] and Cain et al. [27]
tailored their interventions to the developmental needs of adoles-
cents by using a motivational approach, while Wolfson et al. [36]
used interactive sessions to increase the interest and involvement
of the participating adolescents. These programs were found to be
effective in increasing knowledge [26,27,36], improving motivation
[26,27], and changing sleep behavior [26,36].
Monitoring knowledge use
During program implementation, it is critical to monitor
changes in the sleep knowledge level, the understanding and atti-
tude towards sleep, and sleep behaviors/practices. Changes in at-
titudes related to sleep were found in the following studies:
Azevedo et al. [22] reported changes among students in terms of
understanding the importance of sleep and the habits that influ-
ence it. Bonnar et al. [26] and Cain et al. [27] reported improved
motivation to get up at the same time every day, and Wolfson et al.
[36] reported improved self-efficacy in managing sleep. Instru-
mental use of knowledge has also been described, such as in studies
showing improved sleep hygiene [22,32,36], increased time in bed
[26,31,33,36], improved mood [26], and improved behavior [36].
Whereas knowledge use has been observed immediately
following the various interventions only a few studies have
assessed knowledge use at a follow-up intervention and only
limited long term changes in sleep knowledge use have been
observed. Of the handful of studies that assessed knowledge use at
3e6 months following intervention [26,28,31,34] only one study
reported sustained improvement in mood [26], but none of the
changes in conceptual or instrumental knowledge use were sus-
tained at follow up.
Evaluating outcomes
According to the action cycle, programs should be evaluated
using rigorous strategies that include both qualitative and quanti-
tative methodologies (for a detailed discussion of the topic see [6,9]).
As presented in Table 1, all of the published studies have evaluated
outcomes. Several reported post-intervention increases in sleep
knowledge [20,26,28,30,33,34]. In addition, four studies found
changes in sleep behavior: Bonnar's et al. intervention increased the
total sleep time by 27 min and advanced the nap waking schedule
[26]; Sousa's et al. (2013) study advanced bedtime by 18 min on
Table 3
Published sleep health promotion studies from a KTA perspective.

Integration of KT strategies/theories? Knowledge to action cycle

Community/ Community/ Explicit Identify, review, and Adaptation of the identified knowledge or Reported barriers Reported facilitators
stakeholders stakeholders theory select the knowledge research to the local context
involvement prior to involvement after informed or research relevant to
and during the the intervention? approaches the problem
intervention? to KT?
Level 1 Level 2 Level 3 Adaptation to the Mechanisms Strategies to Barrier KT related? Facilitator KT
knowledge users? by which the sustain related?
local change ongoing
is facilitated? knowledge
use?

Azevedo et al., No Parents and No Yes No No Study 1 (of 4)- No No Vacation time No N/A
2008 [22] teachers sleep measure was
education adapted to Brazilian
workshops students
Bakotic et al., No No Exposure to Yes Yes No Test was adapted to No No Celling effect in Yes e Did not N/A
2009 [23] leaflets as a adolescents' level of knowledge tailor the
public understanding intervention to
health the baseline

R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28

campaign levels of sleep
knowledge
Beijamini and Yes e Program No No Yes No No No No No N/A N/A
Louzada, developed with
2012 [24] school's pedagogical
team
Blunden et al., No Post intervention No Yes No No Yes e Adapt the No No 29% of students found Yes N/A
2007 [26] feedback program for the program boring
delivery in New Training and delivery Yes
Zealand schools were time consuming
Program was time No
intensive
Insufficient salience Yes
attributed to sleep
education
Bonnar et al., Yes e Modified Post intervention No Yes No Yes No Yes No School timetable Yes NA
2015 [25] previously developed feedback Method of delivery (not Yes
program based on interactive)
feedback from Insufficient information No
stakeholders about the light devices
Insufficient parental Yes
involvement
Cain et al., 2011 Yes Post intervention No Yes No Yes No No No N/A NA
[27] feedback
Cortesi et al., No No No Yes No No No No No NA NA
2004 [28]
Diaz-Moralez No No No Yes No No No No No N/A N/A
et al., 2012
[29]
Kira et al., 2014 No No No No No No No No No Some participants Yes N/A No
[37] found the program
difficult to understand,
boring, and not
entertaining
Yes
(continued on next page)

21
Table 3 (continued )

22
Integration of KT strategies/theories? Knowledge to action cycle

Community/ Community/ Explicit Identify, review, and Adaptation of the identified knowledge or Reported barriers Reported facilitators
stakeholders stakeholders theory select the knowledge research to the local context
involvement prior to involvement after informed or research relevant to
and during the the intervention? approaches the problem
intervention? to KT?
Level 1 Level 2 Level 3 Adaptation to the Mechanisms Strategies to Barrier KT related? Facilitator KT
knowledge users? by which the sustain related?
local change ongoing
is facilitated? knowledge
use?

Facilitator and
participants lack
enthusiasm
Subjective sleep No
measures
School principal Yes
skeptical regarding the
impact of sleep on
performance

R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28

Difficulty engaging Yes
teachers
Inadequate knowledge Yes N/A
of sleep benefits by
school staff
Sleep program is not Yes
compatible with
curriculum
requirements
Moseley and Yes e Determined prior No No Yes No Yes Yes No Method of delivery (not Yes
Gradisar, knowledge re sleep interactive)
2009 [30] Low students' Yes
motivation
Rigney et al., No No No Yes No Yes Teachers do not have Yes
2015 [31] enough sleep
knowledge
Ceiling effect on Yes
student's knowledge
measure
Souza et al., Yes, school declares No No Yes No No No No No 66.48% of the subjects Yes N/A
2007 [32] “sleep hygiene week” dropped out of the
and activities are study
carried out in this
context
Not addressing beliefs, Yes
habits and norms
regarding sleep
Program duration too No Yes
short
Souza et al., Yes Yes Yes No Yes Yes Yes Significant drop out Yes Engaging students
2013 [33] in the initial survey
 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28 23

weekdays, advanced bedtime by 1 h 19 min on weekends, advanced

the wake-up time by 1 h 56 min on weekends, and decreased the
Yes

Yes

Yes
irregularity of sleep schedule [33]; Wolfson's et al. intervention was
associated with 13- and 42-min increases in time-in-bed on school

Interactive teaching
and to their needs;

knowledge to pre-
students daily life

intervention level
knowledge to the

nights and weekends, respectively, whereas comparison-group

regarding sleep;
of knowledge

peers reported decreases of 12 and 17 min, respectively, in these

Small classes
Tailoring the

Tailoring the

parameters [36]; and Rigney et al. found that students slept 10 min
longer immediately after their program [31].
style
N/A

N/A
Sustaining knowledge use

Finally, if all of the previous steps have been accomplished

successfully, it is important to sustain ongoing knowledge use by
Yes

Yes
No

No
No

No
continued implementation of evidence over time. At this point,
none of the existing studies report on an attempt to sustain ongoing
other school employees
members, teachers and

Low Cronbach alpha of

Poor sleep self efficacy

Lack of motivation to

Self report measures

Not including family

knowledge use.
sleep questionnaire

No objective sleep

In addition, the KTA model emphasizes the importance of using

integrated knowledge translation. Integrated KT refers to a process
change sleep

in which stakeholders or potential knowledge users are engaged

measure

throughout the entire research process. In integrated KT, re-

searchers and research users shape the research process by
collaborating to determine the research questions, decide on the
methodology, collect data, develop tools, interpret the findings, and
disseminate the research results. This process produces research
findings that are relevant to and applied by the end users.
No

No

No

Unfortunately, previous studies that developed and imple-

mented school-based sleep education programs have generally not
attempted or succeeded with involving knowledge users in their
research. Only two of these programs involved community stake-
Yes
No

No

holders prior to and/or during the intervention. Bonnar et al. inter-

acted with the school staff and relied on pre-existing relationships
with schools that allowed sleep interventions to be integrated into
their classes [26]. Cain et al. adjusted and modified previously
developed program based on feedback from stakeholders [27].
No

Discussion
Yes

Yes

Yes

The present review offers the first examination of the existing

sleep-education programs from the perspective of KTA, and iden-
tifies KT strategies that may help narrow the gap between knowl-
Yes
No

No

edge and action in pediatric sleep, especially in terms of developing

effective school-based sleep-education programs. The contribution
Yes

Yes

Yes

of this review is that it presents a framework that can be used to

interactive

increase the success of researchers who seek to embark on KT in

sessions

pediatric sleep.
Yes-

This paper discusses previous studies, highlights a set of factors

No

No

that may have contributed to the translational gap, and maps out a
practical framework that can be used to improve the future effec-
tive translation of empirical evidence and the integration of
evidence-based sleep education into school curricula. Unlike pre-
KT ¼ knowledge translation; NA ¼ non-applicable.

vious reviews, the present paper walks the reader through existing
studies and identifies what could be done differently, how it could
No

No

No

be accomplished, and why it would be useful.

Assessing the existing interventional efforts in the field of pe-
diatric sleep from a KTA perspective reveals that although no such
study has explicitly used a KTA perspective, the studies that ach-
ieved the most measureable improvements in sleep behavior took
several steps that are consistent with the KTA perspective
[26,33,36]. These studies tailored the intervention to the develop-
No

No

No

mental needs of the participants [26,33,36], incorporated feedback

Wolfson et al.,
Vollmer et al.,

from the knowledge users [26,33], and one program adapted the
2014 [34]

2015 [35]

2015 [36]
Wing et al.,

transferred information to the users' initial level of knowledge [33].

Although this should not be taken as a full and detailed examina-
tion of how integrating the KTA model could impact the develop-
ment and implementation of school-based sleep health promotion
 24
Table 4
Sleep related information covered by sleep education program.

Authors, Reference number Importance What is Why do Causes of sleep Consequences of Sleep needs Developmental Sleep duration Sleep physiology Sleep phase Role of light
of sleep sleep we sleep deprivation sleep deprivation changes in sleep recommendations and regulation delay exposure in
sleep regulation

Azevedo et al., 2008 [22] X X X X X X X

Bakotic et al., 2009 [23]
Beijamini and Louzada, 2012 [24]
Blunden et al., 2015 [26]
Bonnar et al., 2015 [25]
Cain et al., 2011 [27]
Cortesi et al., 2004 [28]
X X X X
X X X X X X
X X X X X X
X X X X X X
X X X X X
X X X X X

R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28

Diaz-Moralez et al., 2012 [29]
Kira et al., 2014 [37]
Moseley and Gradisar, 2009 [30]
Rigney et al., 2015 [31]
Souza et al., 2007 [32]
Souza et al., 2013 [33]
Vollmer et al., 2014 [34]
Wing et al., 2015 [35]
Wolson et al., 2015 [36]
X X X
X X X X X X
X X X X X X
X X X
X X X X X
X X X X
X
X X X
X X X X X X

Authors, Reference number Causes of sleep Sleep General sleep Sleep hygiene - Sleep hygiene - Use of sleep diary and Pros and cons of Relaxation/Stress Well-being Parental
problems disorders hygiene controlled screen time no caffeine self-monitoring of getting up early management involvement
sleep duration

Azevedo et al., 2008 [22] X

Bakotic et al., 2009 [23]
Beijamini and Louzada, 2012 [24]
Blunden et al., 2015 [26]
Bonnar et al., 2015 [25]
Cain et al., 2011 [27]
Cortesi et al., 2004 [28]
Diaz-Moralez et al., 2012 [29]
Kira et al., 2014 [37]
Moseley and Gradisar, 2009 [30]
Rigney et al., 2015 [31]
Souza et al., 2007 [32]
Souza et al., 2013 [33]
Vollmer et al., 2014 [34]
Wing et al., 2015 [35]
Wolson et al., 2015 [36]
X X
X X X
X X X X X X
X X X X X X
X X X X X
X X
X
X X X X X X
X
X X X X X
X
X X X
X
X X X X
X X X X
 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28
programs, it supports the need for further investigation and
implementation of this concept.
A key barrier to successfully implementing the KTA process in
pediatric sleep is the absence of valid evidence-based recommen-
dations regarding the amount of sleep needed to achieve specific
outcomes at different ages. This bottleneck is currently preventing
the field from closing the KTA gap in pediatric sleep. We thus need
to create first-generation knowledge, such as by empirically
determining how much sleep is needed for optimal cognitive
functioning and optimal health at different ages, whether there is a
threshold below which insufficient sleep becomes detrimental to
children, and how much more sleep is needed to yield improve-
ments in health outcomes. This will then inform the creation of
second-generation knowledge in the form of evidence-based
guidelines and meta-analyses, which will provide a scientifically
sound basis for the creation of third-generation knowledge such as
effective tools for transforming the gathered knowledge to effective
action.
It could be argued that it is premature to push for a KTA
framework, given the knowledge gaps in pediatric sleep. Indeed,
this paper contains a great deal of related discussion. In the end, it
seems that moving knowledge to action using the best available
evidence, while being transparent about the quality of the evidence
base, is the prudent approach. This will allow children to benefit
from the knowledge we have already accumulated, while at the
same time encouraging researchers to produce additional infor-
mation that will be essential for effective KTA. It has been proposed
that it is more important to help push this approach than wait for it
to be pulled by more and higher-quality research evidence, and that
public and population health has more to gain than lose from such
an approach [47]. Obviously, there will be individuals and juris-
dictions that disagree. The author further proposes that the evi-
dence supports all school-based sleep health-promotion programs,
and that even where the evidence is weakest, there is still potential
for benefits with little or no likelihood of harm. A change of para-
digm to one that considers the whole KTA cycle has shown benefits
in other domains of health, and such benefits have far exceeded the
risks associated with using this approach [47]. Challenges to these
recommendations are encouraged and will enable us to develop
more refined and informed studies in the future.
Among the existing reports, no group described conducting a
full needs assessment prior to the implementation of the program,
perhaps explaining why so few studies observed significant post-
intervention changes in the studied outcomes. The goal of a
needs assessment is to understand the health needs of the target
population to ensure that the intervention responds to these
particular needs and directs resources and action at the most
important priorities. Only one program invested in selecting rele-
vant targets based on the participants' knowledge level. Notably,
this program was successful [33]. This indicates that study de-
velopers should devote effort to selecting information that serves
the purpose(s) of the intervention. If the goal is to increase
knowledge regarding sleep, an intervention would benefit from the
identification of what the target audience already knows at base-
line, followed by the selection of information that will expand this
knowledge base.
Evidence-based sleep information should be used to develop a
sleep-knowledge questionnaire aimed at determining the knowl-
edge level of the target audience. Ideally, this measure should be
developmentally appropriate for different age groups, and should
offer parent and teacher versions.
Most of the reported programs did not make an effort to adapt
the presented knowledge to the local context, examine which as-
pects of the content were unknown to the students, or consider
what information is the most relevant to the intervention goal(s).
25
The actual content included should be both necessary to achieve
the goals of the program and selected with reference to the baseline
knowledge level and environment of the target audience. This
would adapt the program to the knowledge level and the reality of
the target audience. For example, if the goal of an intervention is to
inform young drivers regarding the potential impact of sleep
deprivation on driving, it might be critical to provide statistical
information on sleep-deprivation-related deaths and injuries. In
contrast, this information might be less relevant to an intervention
that aims to optimize sleep in order to prevent obesity. Another
example of taking the context into consideration could be to
identify the SES level of the participants, and then examine
whether there are related contextual factors that should be
addressed. There could be barriers to sleep related to living in a
poor, noisy, and/or dangerous neighborhood, such as the need for
several family members to sleep in the same room, noise from the
street, or concern regarding crime during the night. These would
differ from the barriers to sleep experienced in a middle-upper
class neighborhood, where teens would be more likely to worry
about how long they can stay online during the evening hours. In
both cases, sleep deprivation will contribute to negative health,
emotional, and cognitive consequences. However, to help children
in the poor neighborhood, it could be more valuable to address
creating a safe space for them at night than encouraging them to
deposit their electronic devices with parents.
Future research should seek to: establish what knowledge is
essential, recommended, or optional for achieving specific goals;
validate a measure that can be used to determine the initial
knowledge level of the intervention group; and develop a strategy
for adapting an intervention to the needs/situation of the target
audience.
The published post-intervention feedback indicates that the
barriers for potential adopters of sleep education programs include:
practical barriers, such as lack of time among teachers and stu-
dents, difficulties in recruiting schools and students, difficulties in
obtaining parental involvement, and a lack of curricular time given
to the integration of sleep education; attitude-related barriers, such
as students and administrations giving low priority to sleep edu-
cation, teachers and students lacking interest in the topic, and
students having low motivation to change their sleep behavior; and
skill-related barriers, such as a lack of the expertise required to
successfully deliver the program, a lack of the self-efficacy needed
for students to implement changes in their daily lives, and a lack of
evidence-based strategies for effective behavioral change. Unfor-
tunately, the authors of the existing studies did not assess the
relevant barriers prior to developing or implementing their school-
based sleep education programs, nor did they work with the
knowledge users on findings strategies to avoid or overcome these
barriers and facilitate success. Future work should seek to develop
methods for identifying common barriers related to the imple-
mentation of school-based sleep health promotion programs and
recommending interventions to address them. Moreover, re-
searchers should consider using standardized, valid and reliable
instruments to assess the barriers and facilitators to knowledge use
prior to implementing the intervention [48,49].
The reported programs applied different evidence based stra-
tegies derived from multiple models of behavioral change (Table 1)
and there is no clarity regarding the underlying mechanism(s) of
change. Additional research is needed to formulate strategies for
choosing the right intervention to address a specific barrier and/or
facilitator. Although this critical topic is beyond the scope of the
present paper, the work initiated by the behavior change wheel
may provide an interesting avenue for further discussion [8].
Three of the reported programs tailored [26,27,36] their in-
terventions to their adolescent participants by addressing the
26 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28
interplay of sleep determinants and other developmental charac-
teristics. Notably, these programs were successful in increasing
motivation and eventually facilitating changes in sleep behavior
[33,36]. Although it is not possible to determine if the success of
these programs was due to the tailored nature of the intervention,
the apparent correlation should not be ignored. Thus, the effec-
tiveness of an intervention may be increased by tailoring it to the
developmental needs of adolescents, for example by addressing
their increased need for autonomy, social stimulation, and excite-
ment, their low threshold for boredom, and their inclination to
respond emotionally rather than relying on their rational side when
making decisions.
Collectively, the findings indicate that although some sleep
education programs have been successful in increasing the level of
sleep-related knowledge for short periods of time, several pro-
grams have changed knowledge without successfully stimulating
any behavioral change, and no program has been successful in
facilitating knowledge use beyond the immediate post-
implementation assessment. In most of the studies, the knowl-
edge use was lower than expected and desired. Thus, it is important
to explore further with the knowledge users regarding their
intention to use the knowledge in the future. The answers to this
question could clarify whether the lack of change reflects that po-
tential adopters lack any desire to change the behavior, that they
are facing known barriers beyond their control, and/or that new
barriers have emerged after the initial introduction of the adapted
knowledge. However, even when no change was reported imme-
diately after the intervention or at a later measurement of out-
comes, it remains possible that the program-provided information
could contribute to a positive change in the knowledge level or
behavior at some future time point. Future studies should be con-
ducted to determine the long-term impact of exposure to a sleep
health promotion program on health outcomes in the years beyond
those of the intervention, in order to fully assess the preventative
potential of such programs.
It is vitally important that investigators consider ways to sustain
ongoing knowledge use. Sustainability planning is recommended
early in the KTA cycle [11,50], such as when interventions are being
designed. It has been shown that engaging local decision-makers
from the beginning of the KTA process can help enhance their
understanding of how the interventions relate to their system and
help support a positive attitude towards the topic. For example,
school principals or school-board decision-makers who are inter-
ested in improving academic performance or encouraging healthy
active living should be engaged in the process of creation/tailoring
the intervention. This will increase their understanding of the
process, help ensure that the intervention is relevant to their
goal(s), and increase their interest in integrating the program into
the school system. Ideally, such partners would have leadership
skills and local influence, and could thus help facilitate changes in
the school system, such as by integrating the sleep education pro-
gram into the school's health curriculum. In addition, the de-
velopers of the interventions should create a training module that
could be used by the local knowledge users to train additional
partners and sustain the intervention beyond the study period. In
the context of sustaining the changes gained from the intervention
over time, booster session(s) could be offered, A pre-requisite for
success is that the partnership that created the intervention must
be sustained and the knowledge users must stay engaged and
involved.
Strategies for effective KTA
Despite the obstacles and challenges that have hampered sleep
education for children and youth to date, education holds promise
as an effective public health strategy. The findings of the present
review show how the integration of evidence-based KTA frame-
works and strategies into the design and implementation of sleep
education programs could help overcome some of the barriers to
success in the field, facilitate the development of effective school-
based programs aimed at improving youth sleep, and promote
the integration of these programs into schools. This would signifi-
cantly contribute to narrowing the KTA gap in pediatric sleep.
Recommended KTA strategies
Prepare
Determine whether you have secured sufficient stakeholder
interest and involvement.
Select the gap
Define clear goals and targets for change. Be specific about the
goal of the change and what/how/when you will measure whether
it has been achieved.
Conduct a needs assessment
Determine the existing sleep knowledge level, sleep behavior,
and sleep attitude. Compare your findings to pre-established
criteria, determine whether a need exists in a particular commu-
nity, and identify the specific needs in terms of sleep knowledge,
attitude, skill, behavior, existing curricula. Measure the gap be-
tween the current practice and your target. Decide which recom-
mendations are “mandatory” and which are “negotiable.”
Adapt the program for local use prior to program implementation
During this adaptation, ask the intended knowledge users to
judge the value, usefulness, and appropriateness of particular
pieces of knowledge in light of their local setting, circumstances
and needs.
Assess barriers and facilitators
Establish why the identified gap exists. Use brief surveys or one-
on-one and/or focus group interviews with students, parents, ed-
ucators to identify the perceived barriers/facilitators/motivators for
the proposed program, and refer to this information when choosing
implementation strategies.
Evaluate
Randomized controlled trials provide the highest degree of in-
ternal validity, whereas non-randomized designs provide less in-
ternal validity but may be easier to execute. Qualitative methods
should be used alongside quantitative strategies, to provide a
clearer understanding of how the context may affect the outcomes
and how the intervention achieves (or fails to achieve) its effects,
thus improving our understanding of the theory of change.
Improve sustainability
1) involve multiple stakeholders and engage them throughout
the KTA process; 2) partner with these stakeholders and let them
share in the success; 3) disseminate the gains/improvements in
outcomes, especially those that matter most to the stakeholders,
such as academic success, or class behavior; 4) emphasize how the
new knowledge fits into the existing policies; and 5) develop a
 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28
training program that can be sustained beyond the intervention
period [11,50].
Use an integrated KT such as community based participatory
research [51e53]. This is expected to enhance the relevance of the
research data for all partners involved and to help overcome many
of the barriers described in the existing studies. For example,
working collaboratively with the teachers ahead of time to deal
with practical issues related to curricular time could enhance the
practicality of the research. When decision-makers of the school
system are engaged in the research process, their interest will be
increased, which is expected to increase their assignment of pri-
ority to the integration of sleep education into their curricula.
Finally, collaborative work could facilitate researchers' ability to
select the best practices for the local needs and circumstances.
Reporting
Clear and comprehensive reporting of interventions is essential
to our ability to translate research findings into effective action.
Research syntheses and reviews can only accurately evaluate the
features of an intervention if they are described clearly and
comprehensively enough to allow them to be accurately catego-
rized. Similarly, the ability of other researchers to replicate and
faithfully implement an intervention requires that all of its char-
acteristics be accurately described. Researchers should report each
and every aspect of the scientific process that has contributed to
achieving their goal, could have influenced the results, and/or
would be required to replicate their intervention or study. Reports
that do not to include all such information create an ambiguity that
can impede accurate replication and/or obscure the reasons un-
derlying between-study heterogeneity.
Taken together, these steps are expected to yield significant
improvements in the success of school-based sleep education
programs.
Limitations
Although this paper provides a detailed examination of the KTA
gap in pediatric sleep, it does not address all of the critical factors
that could affect this process, nor does it answer the many
remaining open questions. Future studies should further investi-
gate: which theoretical models of change should be applied in sleep
health promotion programs; whether and how we should address
the array of personal, family, and societal factors that influence the
uptake of such programs; and how we can effectively integrate KTA
strategies to improve the success of these programs. Another lim-
itation of this study is that its summary is based solely on what was
stated in the paper descriptions. It is theoretically possible that the
authors performed additional research activities they did not
describe in the published work. Pediatric sleep researchers are fully
committed to the highest standard of scientific reporting, particu-
larly with respect to the transparency and completeness of the
reporting of information that could affect their results. Thus, it is
likely that the authors of the cited works would mention all aspects
of the procedure, methods, or design that might have impacted the
success of the program. Thus, it seems that the reported informa-
tion may be taken at face value for the purpose of this review, as has
been done in many prior meta-analyses and reviews.
Conclusion
In conclusion, this review recommends the integration of
evidence-based KTA frameworks and strategies into the design and
27
implementation of sleep education programs as a way to facilitate
the development of effective school-based sleep health education
programs and their integration into schools. These frameworks and
strategies will help ensure that the developed sleep education
program would successfully use sleep-related information to effect
change and useful action, while being acceptable to the target
community and sustainable beyond the study period. This is ex-
pected to significantly contribute to narrowing the KTA gap in pe-
diatric sleep.
Practice points
1. Considerable resources have been devoted to studies
showing the impact of short sleep duration on children's
health and daytime function.
2. The transfer of this knowledge into preventative action
has been slow and ineffective.
3. School-based sleep education programs have been used
as a means to move this knowledge into action but have
limited success.
4. A possible limitation to the success of these programs is
that they do not adequately integrate evidence based
knowledge transfer strategies.
5. Knowledge to action (KTA) refers to an evidence based
framework for knowledge transfer that has been suc-
cessfully used to transfer other health related behaviors.
6. Integration of KTA framework and practice into the
design and implementation of school-based sleep health
promotion program is warranted.
Research agenda
1. Future research should empirically determine how much
sleep is needed for optimal cognitive functioning and
optimal health at different ages, whether there is a
threshold below which insufficient sleep becomes detri-
mental to children, and how much more sleep would
yield improvements in health outcomes.
2. Future research should examine what information
should be included in sleep education programs in order
to achieve specific outcomes, such as changing sleep
knowledge, attitudes, behavior and related daytime and
health outcomes.
3. Future studies should be conducted to test whether
involving community members (knowledge users) in all
stages of research and adapting the intervention to the
local context would overcome existing barriers and
improve the outcomes of school-based sleep education
programs.
Conflicts of interest
The authors do not have any conflicts of interest to disclose.
28 R. Gruber / Sleep Medicine Reviews 36 (2017) 13e28

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