Efficacy of the Theory-Based Program for Improvement of Sleep Hygiene Behaviors of the Elderly in Hamadan, Iran

¹ Social Development and Health Promotion Research Center, Health Policy and Promotion Research Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

² Sleep Disorders Research Center, Health Policy and Promotion Research Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

*Corresponding author: Farzad Jalilian, Social Development and Health Promotion Research Center, Health Policy and Promotion Research Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran. Email: f_jalilian@yahoo.com

EXTENDED ABSTRACT

Background

Ageing is accompanied by changes in physical and neurocognitive function, and disturbances in sleep quality and quantity are among the most important health challenges of later life [1–4]. Poor sleep has been associated with impaired physical health, pain, depressive symptoms, reduced quality of life, poorer concentration and memory, and limitations in physical performance [5, 6]. More than half of adults older than 60 years may experience some form of sleep disturbance, making sleep problems a common concern in this population [7, 8]. Healthy sleep, characterized by an appropriate duration and satisfactory quality, is therefore an important component of healthy ageing [9, 10]. Although pharmacologic approaches can be effective for sleep disorders, adverse effects and problems associated with prolonged medication use have increased interest in non-pharmacologic strategies [11, 12]. Sleep hygiene is one such strategy and includes behaviors such as maintaining a regular sleep schedule, limiting caffeine and excessive fluids at night, avoiding heavy evening meals, optimizing light and room temperature, and engaging in regular physical activity [13, 14]. Health-behavior theories can strengthen intervention design by clarifying determinants of behavior and linking them to specific educational strategies [15]. The Theory of Planned Behavior proposes that behavioral intention is shaped by attitude, subjective norms, and perceived behavioral control, and it has previously been applied to sleep-hygiene behaviors [16–19]. Earlier work in older adults in Hamadan suggested that participants achieved only about 58% of the maximum obtainable score for sleep-hygiene behaviors, indicating a need for targeted intervention [17]. This study therefore evaluated the efficacy of a theory-based educational program, developed using intervention mapping, for improving determinants and behaviors related to sleep hygiene among older adults in Hamadan, Iran.

Methods

This quasi-experimental efficacy study was conducted in spring 2021 among 60 older adults attending retirement centers in Hamadan. A list of active retirement centers was prepared; two centers were randomly assigned to the intervention condition and two to the control condition. Participants were then selected by simple random sampling, producing 30 individuals in each group. Eligibility criteria included age above 60 years, membership in a retirement center, daily internet access for at least one hour, access to a smartphone, willingness to participate, self-reported absence of an underlying disease, and ability to speak and read Persian. Participants who were unavailable for the post-test or returned incomplete questionnaires were excluded. Because face-to-face group education was restricted during the COVID-19 pandemic, separate WhatsApp groups were established and the educational intervention and final evaluation were conducted virtually. Program development was based on a needs assessment grounded in the Theory of Planned Behavior, while intervention mapping was used to select objectives, theoretical change methods, practical applications, communication channels, and educational materials [20]. The four-week program comprised eight hours of education, with one two-hour session each week. Educational videos, electronic pamphlets, instructional messages, and online discussion were used. Session content addressed sleep quality, sleep-hygiene practices, consequences of sleep disorders, subjective norms, and perceived behavioral control. Data were obtained by self-report before and two months after the program. The study questionnaire included demographic characteristics, Theory of Planned Behavior constructs, and a 12-item sleep-hygiene behavior scale. Attitude was assessed with 7 items, subjective norms with 8 items, perceived behavioral control with 6 items, and behavioral intention with 6 items. Cronbach alpha coefficients were 0.85 for attitude, 0.91 for subjective norms, 0.84 for perceived behavioral control, 0.79 for intention, and 0.72 for sleep-hygiene behaviors. The constructs had been developed with reference to previous theory-based instruments [16–19]. Data were analyzed in SPSS version 16. Baseline comparability was assessed using chi-square and t tests; normality was evaluated with the Kolmogorov-Smirnov test. Paired t tests examined within-group pre-post changes and independent t tests compared the groups. Cohen d was calculated as an effect-size measure [21]. The study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1399.420), and informed consent was obtained from participants.

Results

The intervention and control groups were comparable at baseline with respect to the demographic characteristics assessed, and none of the study constructs differed significantly between groups before the program. In the control group, no construct showed a significant pre-post change. In the intervention group, mean attitude toward sleep-hygiene behaviors increased from 27.50±3.17 before the program to 29.33±2.82 after the program (paired P=0.019), and the post-intervention between-group difference was significant (P=0.008). The estimated Cohen d for attitude was 0.70. Subjective norms increased slightly from 29.43±3.76 to 30.07±4.19, but this change was not significant (P=0.527); the corresponding effect size was 0.16, and the post-intervention comparison with the control group was also not significant (P=0.520). Perceived behavioral control increased from 24.20±3.40 to 25.66±2.77 in the intervention group (P=0.001), whereas the control group changed from 23.37±4.86 to 23.56±4.21 (P=0.455). The between-group post-test difference for perceived behavioral control was significant (P=0.026), with Cohen d=0.60. The strongest effect was observed for behavioral intention: the intervention-group mean increased from 22.50±2.33 to 25.50±2.93 (P<0.001), while the control group remained essentially unchanged from 22.87±2.89 to 22.93±3.25 (P=0.944). The post-intervention between-group difference was significant (P=0.002), and the effect size was 0.83, classified in the study as very large. In contrast, the mean score for actual sleep-hygiene behaviors increased only from 14.83±3.87 to 15.07±3.71 in the intervention group (P=0.802); the control group changed from 15.20±3.91 to 15.33±4.02 (P=0.892). The post-intervention between-group difference in behavior was not significant (P=0.790), and Cohen d was 0.06. Overall, the program significantly improved attitude, perceived behavioral control, and especially intention, but not subjective norms or sleep-hygiene behavior scores.

Table 3. Comparison of study-construct scores in older adults before and after implementation of the program.

Conclusion

The theory-based educational program improved several psychosocial determinants of sleep-hygiene behavior among older adults, particularly behavioral intention, and also increased attitude and perceived behavioral control. However, the intervention did not produce a significant change in subjective norms or in the observed self-reported sleep-hygiene behavior score during the study period. The findings support the Theory of Planned Behavior as a useful framework for developing and evaluating sleep-hygiene promotion programs in older adults, while also indicating that stronger or more sustained strategies may be required to translate improved intention and perceived control into measurable behavior change.

Keywords: Aging, Efficacy, Sleep

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