A Good Night's Sleep

A GOOD NIGHT’S SLEEP

THE PROBLEM

Sleep is something that all animals need for survival, it is not a choice, rather a biological necessity. Given this common sense statement, it would be reasonable to expect that most people would take the time to get an adequate amount of sleep each night. However, most of us know this is not the case. It is extremely common to hear people saying ‘I didn’t get enough sleep last night’ or ‘I wish I could get more sleep’. It seems that people do understand the importance of sleep and they know they can not go without it, yet so many people still maintain negative sleep related behaviours. We believe that with some small changes, it is possible to maintain a more healthy sleeping pattern while going about our busy lives.

WHY IS IT IMPORTANT?

Because of the prevalence of poor sleep among the general population, sleep has been regarded as a public health issue. Poor sleep has been linked to motor vehicle crashes, industrial disasters, and occupational errors (Institute of Medicine, 2006). Below are some examples of industrial disasters associated with lack of sleep. 

Road accidents are within the top ten causes of death in the world, with a large portion of these accidents being a result of poor sleep maintenance. For example, driving while tired has been thought to be a major explanation of road crashes ending in fatality (Hakkanen & Summala, 2000, 2001; Connor et al., 2002). Sleep-related crashes represent up to 20% of all traffic accidents in industrial societies (Horne & Reyner, 1995; Philip et al., 2001). In the 2002, US National Highway Traffic Safety Administration Survey reported that 37% of the surveyed drivers had fallen asleep while driving at some point in their life (Smolensky et al, 2011, Accident Analysis & Prevention). This is also supported by a 2013 Sleep Poll in America, with 32% of the respondents saying they drive while tired at least once a month, demonstrating that people frequently overlook this issue. We were shocked that such an avoidable issue has been related to such a large percentage of collisions. It seems that a simple change (getting more sleep) could avoid a significant number of these crashes.

A further consequence is that poor sleep management has impacted the work of professionals. On Average, doctors work 72 hours a week, however, full shift rotas in the UK are up to 91 hours. The long working hours cause sleep deprivation which inevitably leads to workplace accidents and errors. It is easy to imagine how dangerous the lack of sleep among medical professionals, such as doctors, can be. The graph below comes from a study showing that extended-duration work shifts were correlated with an increased risk of medical errors, adverse events, and attentional failures in interns across the United States. (Barger L.K. et al., 2006) 

Not only is it dangerous, but the financial costs of sleep deprivation are high too. Results from the America Insomnia Survey show that the average cost of a single insomnia-related accident or error in the workplace is around $32,000. There are estimated to be 274,000 insomnia related incidents a year, with insomnia accounting for 23.7% of the total cost of workplace accidents. The annual costs of these types of incidents amounts to roughly $31.1 billion (Shahly et al., 2012).

Poor sleep has also been correlated with negative impacts on human wellbeing in general. Studies have shown that an individual's mood is particularly affected by poor sleep. For example, it has been shown to decrease emotional intelligence (Killgore et al., 2008), increase psychopathological symptoms such as depression, anxiety and paranoia, as well as somatic symptoms like increased heart rate (Kahn-Greene et al., 2007). Sleep loss has also been associated with intensified negative emotions and fatigue following daytime disruptive events, while positive emotion was mitigated after goal-enhancing events (Zohar et al., 2005).

Sleep is clearly a public issue, but do people know this? We sent out an anonymous survey online that anyone could answer, to see who could benefit from improving their sleep. So many people, including students, parents, full-time working people and even those that had retired, reported that they had trouble with their sleep in some way or another. The data showed that most people considered sleep to be extremely important, yet when asked to rate sleep quality, the responses were mixed. 60% of people also said that they do not think they get enough sleep on average. After considering the information, we confirmed that people in general know how important sleep is, yet do not necessarily get enough. Furthermore, when they do get sleep, the quality is not always high. 

Interestingly, people were very accurate about the effect of sleep on performance and mood. 90% of the respondents thought that there is a change in one’s productivity after a good night’s sleep, and 100% thought that there is a change in one’s mood after a good night’s sleep. This reflects the evidence stated above that although motor and cognitive functioning are affected by lack of sleep, mood is affected the most. It seems that people are very aware of how important sleep is, and in what ways. At the same time, there is a clear issue that people are not getting the quantity or quality of sleep that they believe they should.

TARGET AUDIENCE

Even though a range of people believed sleep was very important (as you can see from our results above), we wanted to change the behaviour of students - firstly, because this is the group that we are most familiar with, and felt most confident that we could find a behaviour change technique that would be beneficial to our kind of lifestyle. Secondly, we acknowledged how poor sleep is having an effect on the mood and performance of students at university specifically. It is clear among university students that poor sleep affects our attendance to lectures and seminars, our motivation to work and even our overall performance scores on coursework and examinations, so this was an issue that we felt was important to us. We believed that our target audience could successfully implement a method to change their behaviour with regards to sleep (unless they had an underlying medical condition).

INTERVENTION

We wanted to find a method to improve sleep that we could get people to implement. We researched various different effective techniques to help sleep onset. We chose to focus on sleep onset because we thought that if we could help people to get off to sleep more easily, then hopefully their sleep in general would improve. Essentially, getting to sleep to begin with is the first step towards getting enough sleep in general. We found three sleeping techniques that were highly rated by the American Academy of Sleep Medicine and the three of us tested out one each ourselves for a week to see if they would work for us. The three sleep techniques we tested were relaxation training, stimulus control and sleep restriction. We decided to do this because we are the target audience demographic, so although different things work for different individuals, the techniques that worked for us were likely to be suited others with a similar age and lifestyle. After the week, we decided that the best technique to use was relaxation, because it is known to be effective (reflecting a high degree of clinical clarity) and seemed easiest to implement everyday out of the three techniques. It also seemed like something that people would be more likely to agree to do, due to its simplicity. From here, our plan was to have a group of people change their behaviour by incorporating this relaxation technique into their everyday bedtime routine, in order to help improve their sleep. If we could get them to change their behaviour for just one week then it would be more likely that they look into improving their sleep long-term. Below is an illustration of the relaxation technique describing how you should perform it. 

After establishing that other people agreed that sleep was a problem with the first public survey, the next step was to gather our participants by specifically asking other students if they would like to participate in our project. Through group messages and in person requests, we got 30 people to agree to take part, of which 27 followed through until the end. We sent out an email to everyone explaining in detail what we wanted them to do. This involved explaining the relaxation technique, and when and how to do it. The instructions were to sit at a chair and complete the steps shown in the picture before sleeping each night for 7 days. They were given details on how many times to do the muscle tensions and breaths, etc. As well as this information, they were sent a link to a questionnaire we created specifically for the participants, asking about their sleeping habits. They were told that there would be another questionnaire at the end of the week to complete once they had tried 7 days of this technique. We asked them to give one anonymous username in both questionnaires so that we could track individual responses if necessary. A week later, we sent them the second questionnaire containing questions to compare with the first one, such as rating sleep quality, so that we could measure any change. There were multiple choice questions asking how the participants found the experience, and whether they noticed a change. In addition, there was a box to write in detail how they found the experience - which was very useful to us in observing the data at the end.

PSYCHOLOGICAL AND PERSUASION TECHNIQUES: HOW DID WE GET PEOPLE TO CHANGE THEIR BEHAVIOUR?

1. JUST ASK

The ‘just ask’ technique is as simple as it sounds. Simply asking someone for something you are more likely to get behaviour change than if you didn’t ask at all. This has been shown in studies including the study of receptivity to sexual offers by Clark and Hatfield (1989). Despite individual differences in age, attractiveness, the presence of romantic music, etc, the effect of ‘just asking’ proves effective at promoting behaviour change. One reason that people agreed to our request to get them to participate in the project was that we simply asked them.

We understood that one of the main reasons that these people complied, was because they were subject to the ‘similarity effect’. This is a tendency for people to be attracted to others who are similar to themselves in important respects. We like people who are more similar to ourselves, thus are more likely to agree with them, or comply with their requests. Collisson and Howell (2014) found that people rated likeable others as more similar to themselves than dislikable others across a variety of domains (e.g., attitudes, personality characteristics, behaviours). Using this ‘just ask’ technique on fellow students was persuasive because we have an obvious similarity in our identities - the fact that we are all students.

‘Just asking’ did work - but we noticed an important difference in the ways that we asked people, and their responses. When we were more vague in our requests, people were less likely to comply. There were times that we casually asked people in person “would you like to participate in my project?”, and were rejected. When we decided to give more information in messages to people, we had much more success. This strategy can be explained as the ‘Pique Technique’ - making requests more specific. Burger et al (2007) asked a passersby for either a common amount of change or 37 cents. They found that the more specific request increased compliance. These results were replicated in our project because more students were willing to take part when we included more information. In our messages to people, we explained in more detail what we wanted them to do. E.g: “Would you be interested in improving your sleep by following a set of instructions to help you relax and help you get off to sleep more quickly?” Just asking is an underrated and extremely useful method, but we acknowledge that other factors such as the similarity effect and the pique technique had an impact on whether people said yes or no.

2. BANDWAGON EFFECT

The phenomenon of the bandwagon effect was beneficial to us when trying to get people to take part in the project. People are very aware of what other people are doing and like to fit in. The bandwagon effect is people doing things that they realise other people are doing - everyone gets on board with the same ‘trend’. The probability of an individual adopting the new behaviour increases with the size of people who have already adopted the behaviour. The bandwagon effect is seen in many different aspects of life and can have such strong effects that it influences the outcome of elections. It has been shown that people want to vote for who or what everyone else seems to be voting for, hoping to be on the winning side (Nadeau, R. et al., 1993). Furthermore, popularity can reduce the need for a credible source. Lin et al (2016) studied the impact of the bandwagon effect on social media compared with authority. They found that the presence of retweets reduced perceptions of source credibility compared to conditions with no retweets. 

Although this phenomenon can often have negative consequences in life, it can be taken advantage of when trying to get people to change an important aspect of their lives. Much of our asking, and the most successful asking, was done through group messages. We found that all that was needed to get a good response, was for one person to start the trend. Much of the time, when one person said yes, almost immediately after, several people quickly got on board.

We found it interesting to see the bandwagon effect occurring right before our eyes, and gathered that group messaging was a very efficient way to get people to participate for this reason. The bandwagon effect is often thought of as a negative side effect of the nature of human social monitoring. However, we found it interesting that such an effect could be used for something that we consider to be positive. Whether or not people knew they were subject to the bandwagon effect when agreeing to participate in the project, it was actually beneficial to them in this situation. Overall, we found it useful that a phenomenon, caused by people wanting to fit in, could be used as an effective persuasion technique.

3. IMPLEMENTATION INTENTIONS 

‘Implementation Intentions’ (Gollwitzer & Sheehan, 2006) is the idea that if people want to achieve a goal, they will have more success if they set out when, where and how the they will do it. We asked the students to follow specific instructions to improve their sleep: when - before bed; where - sitting at your desk, and how - by following the specific instructions on the step-by-step relaxation guide. Implementation intentions also show that a person is more likely to begin something when the stimulus for action is put into the environment - even if it is something you don't particularly want to do. Gollwitzer and Wieber demonstrated that children who were randomly assigned to the "if - then" format of implementation intentions started their homework within 1.5 hours of their intended start time. This was significantly sooner than the 8 hours later for the children with vaguely stated implementation intentions. 

In our project, we made it explicit that if it was time to go to bed, then they would complete the relaxation sleep technique. We thought that this persuasion technique would be the most effective in getting people to stick with the sleep method each night. If we had asked people, for example, to improve their sleep by simply ‘relaxing more’ or ‘meditating’, which is common advice to receive, people would be much less likely to do it, even if they agreed to. Implementation intentions worked especially well for our project as there was no vagueness in how, when or where the action would be completed. There was a simple routine to follow every day to achieve an overall goal. It was easy to incorporate the implementation intentions technique because of the structured nature of what we were asking people to do.

DID IT WORK?

To find out if there was any change in behaviour, we compared the results of the first questionnaire we gave to the participants, to the last. We were able exclude the information of the 3 participants that did not respond a week later, by tracking the usernames. We found that 100% of the 27 people who answered the second questionnaire did change their behaviour all or most nights, with 63% incorporating it into their routine every night. Most of the group rated highly when asked if it helped them to get to sleep, as you can see from the results below. Most excitedly, 71.4% said that they are going to carry on this new behaviour in the future. So we managed to influence long-term behaviour change. As was established earlier, sleep has an important effect on mood and performance, so we think that convincing students to keep up with improving their sleep will have a positive effect on their academic and personal lives.

FUTURE WORK 

There are several areas that could be improved on for future work in this area:

1. We would love if we were able to try out more techniques to see what works for different people, as we acknowledge that one technique will not work for everyone. Perhaps we could have various groups trying out different techniques (not only related to sleep onset), so that we get more information about what works for different people, without overloading individuals with several techniques.

2. We would also be interested to measure sleep more accurately, maybe with the help of technology such as fitbit or a sleep app - this will help with avoiding self-report biases.

3. To further expand the work in this area, we think it would be great if sleep improvement could continue on a wider scale, affecting more people. To make sure sleep improvement happens on a wider and larger scale, we need to be able to contact and persuade different people in different parts of the world. We could use posters and online resources such as videos to try and reach out to people beyond our own social circles, with online resources being able to extend out to different parts of the world.

4.To ensure that effects last, we could research techniques that are known to have long-lasting effects on behaviour change, and catch-up with participants in a few months time to see if these worked.

5. We also think that we could be more persuasive in trying to get people to improve their sleep. In future, we can appeal to personal and emotive experience to help persuade people. This could be done by giving people examples of positive personal experiences with this project, so that they are persuaded to try it themselves. Another way to engage people more would be to appeal to an expert source. We could get advice from a medical professional, and use this information to assure people of the reliability of certain approaches to sleep improvement.

6. Finally, we think that some of the consequences of poor sleep related to collisions, accidents and errors could be so easily avoided if there were better regulations in place to prevent them. Maybe the dangers of tired driving should be taken as seriously as drunk driving, given how disastrous the consequences are. In addition, there could be stricter regulations on the number of hours people can work without breaks. Although we can’t change laws directly, raising awareness can force organisations to face up to these kinds of issues. This could be done through campaigning or petitioning and generally getting more people aware of these issues.

REFERENCES:

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Barger, L. K., et al., (2006) Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures. Plos Medicine.

Clark, R. D., III, & Hatfield, E. (1989). Gender differences in receptivity to sexual offers. Journal of Psychology & Human Sexuality, 2, pp. 39-55. 

Collisson, B. & Howell, J. (2014). The Liking-Similarity Effect: Perceptions of Similarity as a Function of Liking. The Journal of Social Psychology, 154(5), pp. 384-400.

Connor, J., Norton, R., Ameratunga, S., et al., 2002. Driver sleepiness and risk of serious injury to car occupants: population based case control study. Br. Med. J. 324 (7346), pp. 1125.

Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta‐analysis of effects and processes. Advances in experimental social psychology, 38, pp. 69-119.

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