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Discussion

Even with the best evidenced-based practices and programs to prevent and treat sleep problems among servicemembers and with codified policies related to sleep in place, cultural, operational, and individual (knowledge-related) barriers may impede efforts to promote sleep health in servicemember populations. Barriers associated with military medical and treatment systems also pose a potential challenge to identifying and treating servicemembers experiencing sleep problems.

Military cultural attitudes have historically tended to prioritize mission requirements over healthy sleep practices, particularly in deployed settings. Furthermore, the stigma associated with expressing a greater need for sleep may deter servicemembers from self-identifying or seeking help before a sleep problem becomes chronic and debilitating. Screening for sleep disturbances is limited, but it is difficult to determine the respective extent to which military culture, gaps during the transition period following a deployment, and a shortage of sleep specialists contribute to this trend.

In operational contexts, the military emphasizes mission first, with the need for sleep perceived as a sign of weakness. Manpower limitations can compound the operational demands faced by military leaders and servicemembers; even where sleep policies are in place, leaders may not have sufficient manpower to accommodate the guidance for proper sleep—a consideration that is particularly salient given the high OPTEMPO of recent years. Above and beyond these operational barriers, operational settings are often uncomfortable, noisy, and otherwise challenging environments. Although the ability to deviate from a sleep policy may be extremely important for a unit's operational effectiveness, doing so produces an inherent tension or trade-off: Efforts to improve or enforce healthy sleep behaviors must be carefully balanced against the realities of the military environment. However, our interviews and working group discussions indicated that recent initiatives to promote healthy sleep by optimizing crew shift schedules have been largely successful. Thus, perceived trade-offs may be balanced by improvements in servicemember performance and overall satisfaction. New policies must account for servicemembers' need to prioritize among multiple responsibilities and a fear of punitive consequences (for servicemembers or commanders), however.

We asked our interviewees and expert working group participants whether new sleep-related policies were needed. In general, they felt that introducing new policies would create a confusing exercise in prioritization for servicemembers and expressed concern that new sleep policies could be established independent of—or perhaps even in competition with—other, more operationally focused policies or guidance. Such a change could require servicemembers to decide which policies and regulations to follow and could raise concerns about the punitive consequences of not following a new policy that conflicts with an existing policy or mission requirements. Instead, interviewees suggested that better enforcement of existing policies and more education to address knowledge barriers would be more welcome than new policies.

A lack of knowledge about the importance of sleep behaviors may also act as a barrier to recognizing and addressing sleep problems. Our interviews and working group discussions suggested that this lack of knowledge or awareness is due, at least in part, to limited education and training among leadership about the importance of sleep and a lack of a centralized DoD-wide resource on how to identify or manage sleep problems or develop and implement a sleep plan, though some Service-specific websites do provide sleep resources and tips on sleep promotion and disturbances.4 One particular area in which interviewees and working group participants noted a possible deficit was knowledge of the risks of chronic sleep medication use.

Finally, medical and treatment system challenges also pose barriers. A common theme pointed to a lack of adequate screening tools, procedures, and systems for the detection of sleep problems in military contexts. In addition, both continuity of care and sleep provider and clinic shortages were noted as barriers to promoting sleep health in servicemember populations.

Understanding these barriers is critical to making well-informed and robust policy recommendations related to the prevention, identification, and clinical management of sleep problems and to promoting sleep health in both operational and training settings.

 
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