Original contribution Somnologie DOI 10.1007/s11818-017-0109-5 Received: 12 January 2017 Accepted: 28 March 2017 © Springer Medizin Verlag GmbH 2017

Heidi Danker-Hopfe1 Cornelia Sauter1

· Jens Kowalski2 · Michael Stein2 · Stefan Röttger2 ·

1

Charité Universitätsmedizin, Competence Center of Sleep Medicine Campus Benjamin Franklin, Berlin, Germany 2 German Armed Forces Office, Applied Military Psychology and Research Group, Hamburg, Germany

Development, implementation, and evaluation of a sleep coaching program for the German armed forces An Overview The German armed forces are one of the largest employers in Germany (number of active soldiers in December 2016: 177,308, including 20,087 female soldiers (www.bundeswehr.de) plus 67,000 civilian employees (personal communication, January 2017). The German Federal Ministry of Defense established an occupational health management (OHM) program to improve physiological and psychological health of their employees, and to improve attractiveness of the employer [38]. OHM covered a pilot phase, which was launched on January 1, 2015; altogether 11 sites were selected to participate. A research cooperation with eight universities was established to evaluate the program. The intervention focused specifically on four areas: 1) healthy nutrition, 2) physical activity, 3) stress management, and 4) addiction. Among other aspects, the evaluation of the OHM pilot phase addressed the topics feasibility, acceptance, sustainability, and individual health perception [38].

Background Prevalence of sleep disturbances Sleep disturbances can be due to various underlying mechanisms and/or diseases. The International Classification of Sleep Disorders [3] distinguishes more than 60 conditions. Epidemiological studies

on the prevalence of sleep disorders usually do not consider individuals with hypersomnia, so the prevalence of sleep disorders is often synonymous with prevalence of insomnia. Prevalence data on insomnia suffer from a lack of accepted and consistent definitions and assessment. The large range of prevalence estimates in epidemiological studies reflects this problem. Lichstein et al. [27] summarized insomnia prevalence rates assessed by four definitional categories and three symptom categories. The prevalence rates varied between 4 and 6% when the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria were used to define insomnia and were up to 48% when only insomnia symptoms were assessed. The authors underline the fact that some variants of hyperarousal and psychiatric and medical comorbidity are often associated with insomnia, and are therefore considered as risk factors for its occurrence. The prevalence of heart disease, hypertension, neurological diseases, breathing problems, urinary problems, chronic pain, and gastrointestinal problems is significantly higher in individuals with insomnia than in individuals without (odds ratio [OR] up to 4.64 for neurological diseases, 95% confidence interval [CI] 1.37–15.67). On the other hand, insomnia itself is a significant risk factor for a wide variety of psychological,

psychiatric, and medical disorders. In patients with a neurological disease, the risk of having insomnia is 5.21 (95% CI of the OR 1.22–22.21) [27]. Thus, overall, insomnia is a condition which should be taken seriously, may it be comorbid to another medical or a psychiatric condition, or a condition which constitutes a risk factor for the development of a medical or psychiatric disease. Heinrich et al. (2015) used the Pittsburgh Sleep Quality Index (PSQI, [9]) to assess sleep in 1478 soldiers of the German armed forces 12 months after return from a deployment to Afghanistan and in 880 non-deployed soldiers. These authors found a prevalence of poor sleepers (PSQI score >5) of 41% among the deployed soldiers, and of 38% in the nondeployed group (mean ages ± standard deviation [SD] deployed group 30.8 ± 8.4 years, non-deployed group 30.8 ± 7.7 years) [17]. In the same groups, the Munich Composite International Diagnostic Interview (M-CIDI [50]) revealed prevalence rates of problems falling asleep of 15 and 16%, respectively. The percentage of individuals with sleep maintenance problems was 21% in both groups, and non-restorative sleep was observed in 21% of the deployed sample and in 22% of the non-deployed sample. The German Health Interview and Examination Survey for Adults (DEGS1 Somnologie

Original contribution [40]), which, among other variables, assessed sleep duration, problems falling asleep, and sleep quality as related to the past 4 weeks in a sample of 8152 study participants (18–79 years) revealed that one third of the respondents reported potentially clinically relevant problems initiating or maintaining sleep. A high prevalence of poor sleep, as assessed by the PSQI, was also observed by DankerHopfe et al. [10, 11]. The prevalence of participants with a PSQI >5 at baseline (corresponds to assessment in the preparation phase for deployment) was 35.0% in the deployment group and 28.6% in the non-deployed control group of German soldiers. This prevalence was stable during deployment (t1) and decreased to 17.5% after deployment (t2) in the longitudinal sample. The prevalence of increased daytime sleepiness as assessed with the Epworth Sleepiness Scale (ESS; [23]) was higher in the deployment group than in the control group at all times of measurement. At baseline, i. e., prior to deployment, the percentage of soldiers with a score >10 was 17.8% in the deployment group and 0.0% in the control group. From a longitudinal perspective this percentage increased to 22.2% during deployment and remained stable until after deployment. In the control group, the corresponding prevalence rates of increased sleepiness were 10.6% at t1 and 8.5% at t2. During deployment (combat or humanitarian missions) military personnel is exposed to stressors that might interfere with good sleep, e. g., a disturbed circadian rhythm of sleep and wake due to nighttime operations or witnessing the injury or death of people [48]. Annually performed surveys of the U.S. Army’s Mental Health Advisory Teams (MHATs) revealed that for the surveys 2010, 2012, and 2013, for which data are available, nighttime duties were the primary cause of a disrupted night’s sleep followed by poor sleep environment. The MHAT surveys furthermore underline the fact that during deployment, soldiers suffer from chronic insufficient sleep [48]. Studies from Mysliwiec et al. [30] and Bramoweth and Germain [7] document a high prevalence of sleep disturbances after return from deployment. Germain Somnologie

et al. [14] indicated that 5–20% of soldiers with deployment fulfill the diagnostic criteria of a post-traumatic stress disorder (PTSD), of which sleep disturbances are a core feature. The electronic health records of 2224 U.S. soldiers who had been deployed to Afghanistan or Iraq revealed that 41% reported sleep problems at an initial screen and that sleep problems predict other symptoms of PTSD [29]. A study by Gehrman et al. [13] underlines the fact that not only sleep after and/or during deployment is important for mental health after deployment: based on a prospective study of 15,205 U.S. soldiers, they concluded that sleep duration and insomnia symptoms prior to deployment are independent risk factors for a new onset of mental health disorders such as depression, anxiety disorder, and PTSD. This is of particular interest since Taylor et al. [44] reported a prevalence of insomnia (as assessed by a Insomnia Severity Index [5] score ≥15) of 19.9% in a sample of 4101 U.S. soldiers prior to deployment. However, sleep disturbances are not only a problem in relation to deployment. Given the high prevalence of sleep problems in general, it is increasingly realized that this has implications for public health. Researchers have addressed the importance of implementing strategies against disturbed sleep in public health. McKnight-Eily et al. (p. 236 [28]) claim that “Increased public awareness, expanded surveillance and research, training of health-care professionals, and a multifaceted approach that considers related health, employment, lifestyle, and environmental factors will be needed to improve sleep health [. . . ] and reduce the prevalence of unhealthy sleep-related behaviors and sleep disorders.” Stepped care models should be implemented in public health to help or treat those who suffer from impaired sleep. “Public health workers should educate themselves and their communities on the substantial impact that insufficient sleep and sleep disorders have on health, wellness, and the ability to perform daily activities, such as concentrating and remembering things. Health-care providers can advise patients on lifestyle changes to improve sleep; patients with

more serious sleep problems should be evaluated by a specialist” (p. 241 [49]).

Occupational stress and sleep An early Finnish epidemiological survey by Urponen et al. [47] on factors promoting and disturbing sleep already indicated that in men, work-related pressure was the most important factor (20%) disturbing falling asleep and sleep quality. In women this factor ranked third. For quite some years, insurance companies have faced an increase in stressrelated sick notes [45]. In 2016, the Forsa Institute conducted a survey on stress load and relaxation techniques in everyday life, leisure time, and occupation on behalf of the Techniker Krankenkasse [45]. A representative sample of the German population (≥18 years) weighted by gender, age, education, and region (n = 1200) was interviewed. Six out of 10 felt stressed. Number one in the ranking list of stressors is the job (43%) followed by high self-demands (43%). An agespecific consideration shows that 71% of the 18–29-year-old participants are stressed by their job. This young age group is therefore at a particularly high risk of developing sleep disorders. With increasing age the priority of stressors changes. Of the participants, 30% report irregular working hours and 39% report working ≥41 h/week. Among the job-related stressors, number one is too much work (64%), followed by deadline pressure (59%). Of those who are often stressed, 46% complain of sleep disturbance, as compared to 26% of those who are rarely or never stressed (average 30%). Furthermore, 43% of the participants who cannot detach from work report sleep disturbances. This is also evident from an investigation by Kompier et al. [26], who performed a study with subjective assessments of sleep quality, psychosocial work characteristics, work rumination, fatigue afterwork, and affective wellbeing atwork in a sample of 5210 daytime employees. They concluded that high levels of work rumination constituted the strongest statistical predictor of sleep complaints. In a sample of 60 full-time employees, Pereira and Elfering [32] observed

Abstract · Zusammenfassung Somnologie DOI 10.1007/s11818-017-0109-5 © Springer Medizin Verlag GmbH 2017 H. Danker-Hopfe · J. Kowalski · M. Stein · S. Röttger · C. Sauter

Development, implementation, and evaluation of a sleep coaching program for the German armed forces. An Overview Abstract Background. The prevalence of sleep problems in soldiers is higher than in the general population and impaired sleep prior to deployment increases the risk for developing new mental disorders after return from deployment. To prevent development of sleep disorders and concomitant psychiatric problems, early preventive strategies provided within occupational health management (OHM) programs are needed. Objective. A sleep coaching program was developed and evaluated and is currently implemented as a preventive tool to improve sleep quality in the German armed forces. A four-step approach to development, evaluation, and dissemination of sleep coaching is presented.

Methods. In a first step, a sleep coaching program was developed and offered in a pilot phase of the OHM program of the German armed forces. In a next step, the sleep coaching program was comprehensively evaluated by ambulatory polysomnography and sleeprelated questionnaires in a crossover waiting list study. In a third step, psychologists of the German armed forces will be trained to provide the sleep coaching program within the OHM program. The last step comprises development of an internet-based sleep coaching program to improve accessibility and availability. Results. Sleep coaching is an effective tool for improving sleep quality in military personnel. In a pilot phase, measures of wellbeing,

self-care behavior, and self-care awareness were positively influenced in participants of the sleep coaching program. In a second study, objective and subjective sleep quality improved significantly after participating in the sleep coaching program. Conclusion. Sleep coaching is a preventive intervention method to improve sleep quality and increase health resilience by providing helpful strategies in case of (subjectively) impaired sleep. Keywords Polysomnography · Questionnaires · Occupational health · Mental disorders · Insomnia

Entwicklung, Umsetzung und Bewertung eines Schlaf-Coaching Programms für die Bundeswehr. Eine Übersichtsarbeit Zusammenfassung Hintergrund. Die Prävalenz von Schlafstörungen bei Soldaten ist höher als in der Allgemeinbevölkerung, und ein beeinträchtigter Schlaf vor einem Einsatz erhöht das Risiko für die Entwicklung neu auftretender psychischer Störungen nach der Rückkehr von dem Einsatz. Um die Entstehung von Schlafstörungen und begleitenden psychischen Problemen zu verhüten, sind Frühpräventionsstrategien im Rahmen von Programmen zur Gesundheitsversorgung am Arbeitsplatz („occupational health management“, OHM) erforderlich. Ziel der Arbeit. Ein Schlaf-Coaching Programm wurde entwickelt und evaluiert und wird derzeit als Präventionsinstrument zur Verbesserung der Schlafqualität in der Bundeswehr eingeführt. Hier wird ein 4-Stufen-Ansatz für die Entwicklung,

that enduring social stressors at work was negatively related to psychological detachment on Sunday evening. The inability to detach from work had a negative effect on sleep onset latencies and sleep fragmentation as assessed by actigraphy. This is one of the very few studies where an attempt to objectively assess sleep was made. The study showed that the inability

Bewertung und Verbreitung des SchlafCoaching Programms vorgestellt. Methoden. Im ersten Schritt wurde ein Schlaf-Coaching Modul entwickelt und in einer Pilotphase des OHM-Programms der Bundeswehr angeboten. Im nächsten Schritt wurde das Schlaf-Coaching Programm in einer Crossover-Wartelisten-Studie umfassend mittels ambulanter Polysomnographie und schlafbezogenen Fragebogen evaluiert. Im dritten Schritt werden Psychologen der Bundeswehr darin ausgebildet, das Schlaf-Coaching Modul innerhalb des OHMProgramms anzuwenden. Der letzte Schritt umfasst die Entwicklung eines internetbasierten Schlaf-Coaching Programms, um die Zugänglichkeit und Verfügbarkeit einfacher zu machen. Ergebnisse. Schlaf-Coaching ist ein wirksames Instrument zur Verbesserung der

to detach from work on Sunday evening partially mediated the relationship between social stressors at work and sleep. The results indicate that social stressors at work may have a negative impact on the recovery processes just before the working week starts again. The same research group [33] also found that a daily lack of psychological detachment from work

Schlafqualität bei militärischem Personal. In einer Pilotphase wurden Parameter des Wohlbefindens sowie des Verhaltens und der Achtsamkeit in Bezug auf die Selbstführung bei Teilnehmern des Schlaf-Coaching Moduls positiv beeinflusst. In einer zweiten Studie verbesserten sich objektive und subjektive Schlafqualität signifikant nach Teilnahme an dem Schlaf-Coaching Programm. Schlussfolgerung. Schlaf-Coaching stellt eine präventive Interventionsmaßnahme zur Verbesserung der Schlafqualität und Erhöhung der gesundheitlichen Resilienz durch Vermittlung hilfreicher Strategien für den Fall eines (subjektiv) gestörten Schlafs dar. Schlüsselwörter Polysomnographie · Fragebogen · Arbeitsmedizin · Psychische Störungen · Insomnie

and the related impaired sleep quality is associated with near-accidents when commuting to work next morning. In line with this study, a population-based cohort study (n = 4320 women between 20 and 67 years of age) with a 10-year follow-up period revealed that persistent insomnia symptoms were associated with an increased risk of self-reported occuSomnologie

Original contribution

Step 1 (completed) Development of a sleep coaching program (slides and manual) to be used by psychologists of the German armed forces in the pilot phase of the occupational health management program for military and civil personnel of the German armed forces

Step 2 (completed) Evaluation of the sleep coaching program. Coaching was performed by Dr. Cornelia Sauter, a clinical and health psychologist, somnologist (DGSM), and sleep scientist (ESRS); evaluation was based on objective (polysomnography) and subjective sleep quality assessed in a pre–post waiting list control study

Step 3 (ongoing) Deployment of the sleep coaching program by 4-day group training sessions for psychologists of the German armed forces

Step 4 (in preparation) Development and evaluation of an internet-based version of the sleep coaching program

Fig. 1 8 Phases of development, evaluation, and implementation of a sleep coaching program for the German armed forces. DGSM Deutsche Gesellschaft für Schlafforschung und Schlafmedizin, ESRS European Sleep Research Society

pational accidents but not with occupational accidents, which led to a sick leave as reported in the government register [16]. Buxton et al. [8] could show that independently of other work conditions, as well as household and sociodemographic characteristics, employees’ sleep is associated with demands from work that interfere with one’s family/personal life. Study participants with higher demands reported less sleep sufficiency (feeling rested upon waking), poorer sleep qualSomnologie

ity, more insomnia symptoms, shorter nighttime sleep duration, greater likelihood of napping, and longer nap duration. Results from the Kansas State Employee Wellness Program with more than 11,698 participants revealed that a higher level of subjectively perceived sleep disturbance was a significant predictor of absence from work, lower work performance ratings, and higher healthcare costs. In the longitudinal analysis of the data (n = 5636), more trouble sleep-

ing was significantly related to negative changes in all outcomes [21]. Based on the same data set, Hui and Grandner [20] found that poor sleep quality was associated with an elevated likelihood of contemplating or initiating behavioral change. However, poor sleep was also associated with a decreased likelihood of maintaining healthy behavior. That is why the authors conclude that it is important to consider sleep improvement as an important factor among lifestyle management interventions offered in the employee wellness program [20]. Based on cross-sectional (n = 68,089) and longitudinal (n = 16,503) data from a cohort study of Finnish public sector employees, Salo et al. [37] pointed out thathaving fewopportunities toinfluence the duration and scheduling of worktime may increase the risk of sleep disturbances. However, for study participants with long working hours, very high levels of control were also associated with an increased risk of sleep disturbances. Those with a low worktime control could benefit from gaining more control while those with a high level of control might benefit from some training related to worktime planning to achieve better sleep. One of the few studies that analyzed the relationship of sleep to combined work and home stress from a longitudinal perspective with polysomnographically measured sleep revealed that stress was a significant predictor of non-rapid eye movement (NREM) stage 1 sleep duration and latency in a model that controlled for anxiety and age [1]. Overall, a moderate increase of stress over a 6-week period was related to moderate signs of disturbed sleep, as measured by polysomnography. Akerstedt et al. [2], who summarized the currently available evidence on the relationship betweenstress and sleep, emphasize that little is known about the effects of stress on sleep architecture. They claim that a short stress management course based on cognitive therapy is often effective to reduce subjectively perceived sleep problems. Most of the intervention programs focus on insomnia, applying Cognitive Behavior Therapy for Insomnia (CBT-I) [25, 46]. In recent years other strategies have been intro-

Fig. 2 8 Sleep coaching program in a nutshell:topics of the four sessions

duced, such as sleep coaching for people who do not necessarily suffer from sleep disorders [18], or sleep management programs for specific populations, e. g., patients with Parkinsonism [15], or sleep education programs for, e. g., adolescents [43]. In the occupational setting, without any prior screening, the implementation of a preventive short-term sleep coaching intervention can be an effective tool to improve sleep and health of employees. There are very few studies investigating the effect of intervention programs that include some kind of sleep coaching to improve workers’ health. Riethmeister et al. [34] identified a good working environment, food, as well as sleep and fatigue management as suitable program objectives for a healthy aging at work intervention program. Their program was developed for an offshore working population. Finally, Ammendolia et al. [4] describe a very complex intervention mapping approach to develop a workplace health promotion and wellness program, which specifically aimed at reducing presenteeism. The healthy behavior that was encouraged was regular exercise, proper nutrition, smoking cessation, socialization, work–life balance, and adequate sleep.

Methods Development of a sleep coaching program The high prevalence of sleep disturbances in military personnel and the resultant risks for medical and psychological health, together with attempts to improve the attractiveness of the German armed forces as an employer, led to the development, evaluation, and implementation of a sleep coaching program as part of an OHM program. The aims of the sleep coaching program were to improve sleep and the inextricably linked mental and physical health of military and civil members. The sleep coaching program was realized as a cooperation between the Competence Center of Sleep Medicine at the Charité – University Medicine Berlin and the Applied Military Psychology and Research Group of the German Armed Forces Office. The process of development, evaluation, and implementation is described below (see also . Fig. 1).

Step 1: Development of a sleep coaching program and implementation into the pilot phase of the German armed forces’ OHM program The Competence CenterofSleep Medicine at the Charité – University Medicine Berlin cooperated with the Applied Mil-

itary Psychology and Research Group of the German Armed Forces Office to develop a sleep coaching module to be included in the stress management component of the OHM program. The sleep coaching module consists of four 90–120 min sessions, which were scheduled to be delivered with 1-week intervals between sessions for groups of up to eight participants. The four sessions addressed different sleep-related topics, and were comprised of theoretical parts and practical instructions (. Fig. 2). The latter had to be trained as a sort of “homework”. The Competence Center of Sleep Medicine at the Charité delivered a set of annotated slides for all four sessions and an annotated manual for the psychologists of the German armed forces who performed the sleep coaching within the pilot phase of the OCM program. Two trainings were offered (centrally in Bonn) to advise the psychologists on how to perform the sleep coaching program. Altogether, 113 individuals participated in the sleep coaching module of the OHM program. Complete data for evaluation at t1 (prior to the intervention) and t2 (post intervention) were available for 24 participants. The results of the evaluation indicated a significant improvement in wellbeing, self-care behavior, and self-care awareness [6]. Furthermore, at t2, participants reported a decrease in their irritation score after attending the sleep coaching program [35, 36]. Corresponding changes were not observed in a matched sample of members of the armed forces who did not participate in the sleep coaching module.

Step 2: Evaluation of the sleep coaching program In a second step, the sleep coaching module was evaluated with sleep-specific outcome measures (positive ethics vote from the Charité Ethics Commission: EA4/115/14 and positive vote from the Charité Data Protection Commission). This research project was conducted at four military bases in Germany. Altogether, 57 individuals participated (15 women). All four sessions (basically the same as the ones offered in the OCM, i.e., phase 1; see . Fig. 2) were run by Somnologie

Original contribution

Fig. 3 9 Study design. Schedule for the interventions groups (IG) and the waiting groups (WG)

CS, who is a certified clinical health psychologist, somnologist (Deutsche Gesellschaft für Schlafforschung und Schlafmedizin, DGSM), and sleep scientist (European Sleep Research Society, ESRS). The program was offered to members of the German armed forces who intended to improve their sleep. At each of the four military bases, an information session was held to inform individuals interested in participating about the program, measures, schedule, and necessary time commitment. The study was performed in an intervention–waiting group crossover design. To this end, interested individuals were randomized into one of two groups: an immediate intervention group (IG) and a waiting list control group (WG; . Fig. 3). This procedure was carried out at each participating military base. Prior to any intervention (t0), participants filled out the following questionnaires: 1. Pittsburgh Sleep Quality Index (PSQI [9]) 2. Insomnia Severity Index (ISI [5]) 3. Epworth Sleepiness Scale (ESS [23]) 4. Patient Health Questionnaires [41] (modules depression, PHQ9; and somatic symptoms, PHQ15) 5. RLS Screening Questionnaire [42] 6. Berlin Questionnaire (BF [31]) 7. Morning–Evening Questionnaire (MEQ [19]) Questionnaires 1–4 were again administered in both groups at t1, i. e., after Somnologie

the end of the intervention in IG; at t2, i. e., after the end of the intervention in the WG; and again at a follow-up three months later (t3). Study participants additionally filled in the short version of the sleep logs [12] for a period of 2 × 5 weeks (see . Fig. 3). Subjective sleep quality was also assessed for two nights each at t0, t1, and t2 in both groups by means of the standard version of the sleep logs [12]. The parameters listed in . Table 1 were used for evaluation of intervention effects at the subjective level. Participants gave anonymous feedback on the sleep coaching program by filling in an evaluation questionnaire after they had completed their sleep coaching program (IG: t1, WG: t2). Additionally, the effect of this shortterm intervention was evaluated based on objective sleep quality, which was assessed by ambulatory polysomnography at t0, t1, and t2, conducted and performed according to the American Academy of Sleep Medicine (AASM) standard [22]. The parameters listed in . Table 2 were considered for evaluating effects of the intervention at the level of objective sleep parameters. Out of the 65 participants originally enrolled, eight had to be excluded due to health-related, familial, or time management reasons. The remaining 57 participants (42 males and 15 females) had a mean age of 40.6 ± 10.6 years (range 18–58 years). The groups, i. e., participants who started with the interven-

tion and those who started in the waiting group, were not significantly different with regard to age, gender, or PSQI, ISI, and ESS scores [39]. Both groups showed a significant improvement of sleep quality as assessed by the PSQI (p < 0.001) and the ISI (IG p = 0.004; WG p < 0.001), and a reduction of daytime sleepiness (ESS IG: p = 0.002; WG p = 0.012). After participating in the sleep coaching program, the prevalence rate of individuals with insomnia was significantly lower in the IG than in the WG, who were still waiting to participate (p < 0.05). Polysomnography showed significant improvements in the latency to persistent sleep and sleep efficiency in both groups (p < 0.05). Participants were very content with the sleep coaching program: 98.2% would recommend the program to other affected persons and another 98.2% assumed that the sleep coaching program also affected their quality of life. The results of this study indicate that sleep coaching has a positive effect on subjective (and objective) sleep quality and daytime sleepiness, thus confirming that it is a suitable preventive intervention for OHM.

Step 3: Training of German armed forces’ psychologists and implementation of the sleep coaching program in OHM The aim of the Federal Ministry of Defense is a stepwise implementation (rollout) of the OHM program for all parts of the German Armed Forces by

Table 1 Subjective sleep parameters from the Morning-/Evening protocols Subjective sleep parameters from the morning/evening protocols Time in bed 1, TIB1 (min); calculated from the following questions: “When did you go to bed?” and “When did you finally get up?” Time in bed 2, TIB2 (min); calculated from “lights out” until “lights on” from information received from questions: “When did you go to bed?” “How long had you been in bed, until you tried to fall asleep (lights out)?” “When did you finally get up?”

be considered in the development of an internet-delivered version of the sleep coaching program [51]. The internetbased sleep coaching program will be evaluated throughout the implementation phase and adapted for optimal acceptance.

Subjective total sleep time, sTST (min); question: “How long did you sleep overall?” Sleep latency, SL (min); question: “How long did it take from lights out to sleep?” Wake after sleep onset, WASO (min); question: “Were you awake during the night? How long in total?” Sleep efficiency 1, SE (%) = (TST/TIB1)*100 Sleep efficiency 2, SE (%) = (TST/TIB2)*100 Restoration; “How restorative was your sleep?” 1 = very; 2 = rather; 3 = moderately; 4 = very little; 5 = not at all

Table 2 Sleep parameters from polysomnography.(According to the American Academy of Sleep Medicine standard [22]) Parameters of objective sleep quality Time in bed, TIB (min)

Conclusion The sleep coaching program is a very helpful and efficient tool for persons suffering from impaired sleep. To disseminate the program within the German armed forces, different modes of access are being developed and will be provided in the near future: a face-to-face as well as an internet-delivered sleep coaching program, designed to optimize sleep and health in soldiers and civil members of the German armed forces.

Total sleep time, TST (min) Sleep latency, SL (min); from “lights out” until a first epoch of any stage of sleep Latency to persistent sleep, LPS (min); latency from “lights out” to the occurrence of 10 min uninterrupted sleep Stage R latency, RL (min); from sleep onset to the first epoch of stage R Wake after sleep onset, WASO (min); all wake stages during the recording period minus sleep latency Sleep efficiency, SE (%) = (TST/TIB)*100

Corresponding address Dr. C. Sauter Charité Universitätsmedizin, Competence Center of Sleep Medicine Campus Benjamin Franklin Hindenburgdamm 30, 12200 Berlin, Germany [email protected]

Time in each stage, N1, N2, N3, R (min) Duration of each stage in percent of TST, N1, N2, N3, R (%)

2020. To support this rollout, the Competence Center of Sleep Medicine at the Charité was contracted to train psychologists of the German armed forces (M/SAKE/GA002). The training will be provided to the psychologists of the German armed forces at the Competence Center of Sleep Medicine at the Charité – University Medicine Berlin, in 2017. A maximum of 40 participants will be trained on the sleep coaching program and on all relevant and related topics in sleep medicine in four 4-day courses, to render them able to competently administer the sleep coaching program. The courses will be evaluated according to Donald L. Kirkpatrick’s training evaluation model “the four levels of learning evaluation” [24]. Within the study, the first two levels of the model will be assessed: first level: reaction of the trainees to the training; second level: learning and knowledge achieved by the trainees.

Step 4: Development of an internet-based version of the sleep coaching program Since the measures taken in steps 1 and 2 clearly indicated that a lack of time is a major constraint for face-toface participation in the sleep coaching program, the sleep coaching program will be adapted for an internet-based application in a next step. The aim is to facilitate accessibility and availability for soldiers and civil employees of the German armed forces. The internet version will be comprised of the elements that had been rated to be most helpful by participants in the face-to-face sleep coaching program, such as psychoeducation on healthy and impaired sleep, and techniques to facilitate initiating and maintaining sleep. Furthermore, the exchange of experiences between users and professional support by a sleep expert are essential, and will therefore

Acknowledgements. The study “Guter Schlaf. Ein 4-wöchiges ambulantes Gruppenprogramm für einen erholsamen Schlaf. Durchführung und Evaluation” (M/SAKE/EA002) and the “Sleep-coaching. Train-the-coach” Project (M/SAKE/GA002) are sponsored by the German Federal Ministry of Defense.

Compliance with ethical guidelines Conflict of interest. H. Danker-Hopfe, J. Kowalski, M. Stein, S. Röttger, and C. Sauter declare that they have no competing interests. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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