Recommendations to Prevent Sleep Problems

Our review of the literature and sleep policies and practices in the military, discussions with key informants, and working group proceedings found no evidence-based practices to prevent sleep disorders in military or civilian populations, except possibly for weight loss and management strategies that also reduce the risk of OSA. This lack of prevention efforts is consistent with the history of sleep medicine and medicine in general, which has tended to focus on the treatment of manifest physical illnesses or disorders rather than on promoting health—a differing view that has just recently been suggested (Buysse, 2014). However, just as overall health is not merely the absence of disease, sleep health is not merely the absence of sleep disorders. Prevention efforts also have the advantage of reaching a broader audience than what we see in the context of a medical or clinical setting. Changing the military culture's perception of sleep needs is the first step toward developing best practices for sleep prevention. At the individual level, limited understanding or awareness of the effects of sleep deprivation or disturbances on performance may also serve as barriers. Finally, the lack of evidence linking fatigue to suboptimal mission performance is a barrier to demonstrating the importance of sleep and contributes to poor messaging about the importance of sleep. Thus, we provide several recommendations to support prevention efforts, with the ultimate goal of promoting sleep health.

Increase Servicemember and Line Leader Education About Healthy Sleep Behaviors

A key to prevention is self-awareness and knowledge about the factors that inhibit or promote adequate, restful sleep. Many servicemembers are in a high-risk period in life (i.e., ages 18-35) for engaging in a number of behaviors that are counterproductive for achieving high-quality sleep or sufficient sleep duration, including the use of highly caffeinated energy drinks or products, the use of alcohol or other substances, irregular sleep schedules and daily routines, and frequent use of highly stimulating video games. Thus, providing education on factors that facilitate or interfere with healthy sleep is critical. Educational efforts to promote sleep hygiene are necessary, but not sufficient, for treating sleep problems, however. For example, evidence suggests that sleep hygiene treatment alone is not efficacious for insomnia (Moss, Lachowski, and Carney, 2013). Nevertheless, providing sleep hygiene education is a key step to promoting sleep health and preventing sleep disorders from a public health perspective.

There are at least two venues within which to disseminate these educational programs. The first is in operational and training settings. Existing operational and training policies provide guidance to line leaders on what is the sufficient amount of sleep required for servicemembers. However, these policies focus on prescribing rest periods, which do not necessarily translate to adequate, high-quality sleep. As such, these operational and training policies related to sleep must be accompanied by educational programs that remove barriers to achieving sufficient and high-quality sleep. These include programs that increase awareness among line leaders and servicemembers of the need to remove environmental barriers (noise, light) and behavioral barriers (refraining from use of electronics and caffeinated beverages near sleep times) to achieve quality sleep. While sleep hygiene briefings are available for military personnel, few may actually receive these skill-focused briefs. In one study of Army officers, 80 percent reported not receiving sleep management briefings during deployments (Miller, Shattuck, and Mat-sangas, 2011). Expert working group attendees and key informants suggested that the most effective way to disseminate this information is to provide it throughout training and in different operational contexts.

The Army Performance Triad model provides a useful model for incorporating education about healthy sleep in the context of other key health behaviors, such as physical activity and nutrition. Many of our interviewees also stressed that senior leader buy-in is essential to encouraging healthy sleep behaviors and that responsibility should be instilled for enforcing good sleep behavior at all levels, from command down to squad and team leaders and, ultimately, to individual servicemembers. Without leadership education and buy-in, efforts to emphasize the value-added of sleep would be unsuccessful. Leaders are in a unique position to promote sleep health efforts. This can be achieved by modeling healthy sleep behaviors for others, modifying schedules to provide more opportunities for adequate sleep environments without disruption, promoting and encouraging the use of programs for those needing help with sleep problems (either alone or as a symptom of a mental health concern), and counteracting messages that "sticking it out" despite feeling tired is a sign of mental toughness.

The second node to promote and disseminate educational materials is through a centralized repository at the DoD level or, at the very least, the Service-specific level, as some Services have done (Navy and Marine Corps Public Health Center, undated[b]). This repository would store regularly updated and expert-vetted educational materials and resources about sleep and would serve as a readily identifiable source if a service-member has questions about sleep needs, wants tips on how to achieve better sleep in operational or post-deployment settings, or needs guidance on where to go if he or she is experiencing sleep problems.

Ultimately, however, the onus is on the servicemember to ensure the proper amount of sleep when given the opportunity to do so in an appropriate environment and to engage in behaviors that are conducive to healthy sleep. Providing adequate opportunities to sleep, evidence-based prevention and intervention programs, and education on healthy sleep behaviors and having leaders emphasize that sleep health is a priority for one's health and military readiness can help establish the importance of sleep for servicemembers at all phases of the deployment cycle.

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