Better Sleep, Better Health: Designing a school-based intervention in Uganda

This project aims to develop a feasible and acceptable intervention to improve sleep and mental health among in-school adolescents in Uganda. Poor sleep is common during adolescence, and is associated with multiple negative health and academic consequences1,2. Globally, trials of sleep interventions for adolescents show preliminary evidence of effectiveness on sleep health3, but more evidence is needed, including to address the evidence gap from low- and middle-income countries (LMICs) and on effectiveness on closely-related outcomes including mental health4-6.

Uganda is an ideal setting to develop a school-based sleep intervention, with an increasingly-recognised problem of poor sleep quality7 and a high proportion of students of all socio-economic backgrounds who board, which increases the potential feasibility and impact of a sleep intervention. We are well-placed to conduct this work due to our experience in developing, delivering and evaluating school health interventions in Uganda, and our strong stakeholder relationships8,9. Our prior work includes a recently completed cluster-randomised trial of the effect of a menstrual health intervention on mental health symptoms among 3844 female students in 60 Ugandan secondary schools9. Overall, 16.2% of participants reported feeling tired or having problems sleeping the previous night at baseline, and these problems were strongly associated with increased mental health symptoms after one year (adjusted for baseline mental health). Preliminary data from 41 teachers showed widespread concern about tiredness in students and willingness to improve sleep health through co-developing and implementing interventions.

This study aims to:

Phase 1: Inform early-stage intervention development by understanding the social, cultural and physical contexts of sleep in Ugandan secondary schools, and the prevalence of different forms of sleep problems among students;

Phase 2: Co-develop a theory-based sleep health intervention to improve sleep health and subsequently mental health in schools;

Phase 3: Disseminate findings and prepare a detailed plan to evaluate the intervention in a future trial.

We will achieve these aims using participatory mixed-methods formative research and stakeholder engagement workshops, specifically:

Phase 1: Qualitative interviews with stakeholders (students, teachers, caregivers and policymakers), a participatory transect walk of school dormitories, and a quantitative survey in 2 secondary schools (N=200 students) to understand the context of sleep, and the prevalence of insomnia, circadian rhythm disturbances, sleep duration, timing and quality, and dysfunctional beliefs and attitudes about sleep.

Phase 2a: Stakeholder workshops to i) review theory about how sleep health interventions improve adolescent sleep and mental health; ii) co-develop a programme theory and intervention for this context based on Phase 1 findings with a whole-school approach to promote sleep health in all students (Step 1) and additional targeted sessions for those with sleep problems (Step 2).

Phase 2b: Feasibility testing in 2 schools to refine the programme theory and intervention, and stakeholder workshop to agree further adaptations based on these findings.

Phase 3: Publications on the findings on sleep health in this population, the intervention development process and revised programme theory, and dissemination to local and national stakeholders. We will prepare a detailed plan for the intervention, and for a future trial to evaluate this.

The study will add to the sparse literature on sleep health in sub-Saharan Africa and in adolescents globally, and provide vital formative evidence needed to inform a rigorous evaluation of a theory-based intervention with the potential to improve sleep and mental health at scale.