The '5 principles' of good sleep health.

The '5 Principles of good sleep health' are proposed (a) to facilitate improved public health engagement with the importance of looking after your sleep; and (b) to offer a first line intervention for people with poor sleep and mild insomnia symptoms, that goes beyond the scope of what is traditionally known as 'sleep hygiene'. The '5 Principles' were developed by the author for the UK National Health Service (NHS) campaign 'Every Mind Matters', initiated in 2020 by Public Health England, and supported by the Mental Health Foundation. The author served as the campaign spokesperson for sleep as a critical ingredient in mental wellbeing. The '5 Principles' encourage people to Value, Prioritise, Personalise, Trust, and Protect their sleep. They are intended to educate about sleep health and to support evidence-based self-management of sleep, and not as an alternative to cognitive behavioural therapy (CBT) which is the guideline treatment for chronic insomnia disorder. However, they may bridge an important gap in self-care practices for many people. The '5 Principles' would benefit from formal research evaluation.

INTRODUCTION

Like many others in the field of behavioural sleep medicine I have frequently been asked to provide my ‘top tips’ for getting a good night's sleep. Requests of this kind have come from diverse sources – newspapers and magazines, radio and television stations, social media, and also from health care, social care, and third sector (charitable) organisations. Having worked in the sleep field for several decades, my experience is that public interest in sleep has never been greater than it is now. Indeed, at times the demand feels almost insatiable. There also appears to be no shortage of folks who are ‘passionate about sleep’ (variously sleep gurus and evangelists; wellbeing champions; app and device developers), and they always seem willing to venture an opinion or a solution. Don't misunderstand me, I don't think that this is necessarily a bad thing. Sleep is one of the most accessible and least stigmatised topics in the health conversation, and sleep belongs to the people, not to the professionals. Rather, I think we have a duty of care, from an evidence‐based clinical perspective, to contribute actively to public engagement with the science of sleep. So, what then should I say, when it comes to offering the ubiquitous ‘sound bites’ about why society has a poor relationship with sleep or about how to overcome sleepless nights? What do I have to say that's different or new? Does it really just boil down to ‘sleep hygiene’?

Almost 30 years ago, I wrote The Good Sleep Guide which formed part of a National Medical Advisory Committee report, published by the Crown Office in Scotland (National Medical Advisory Committee, 1994). Although I have written self‐help books and other similar materials during the interim period, my work has been more in the research domain, and I am rather ashamed to admit that it wasn't until early in 2020 that my attention again turned to what I could usefully say within just a couple of pages. Although the ‘patient handout’ may be a dated concept, and there are more contemporary ways of distributing a leaflet's worth of content, there seems to be enduring need and demand for summarised sleep wisdom. An opportunity arose that gave me more focus than usual to consider what a revised version of my sleep guide would look like.

I was approached by Public Health England (PHE) which is part of the UK National Health Service (NHS) to work with them on their mental health campaign Every Mind Matters. This was to be an online and social media campaign with the call to action “Feeling stressed, anxious, low or struggling to sleep? Every Mind Matters can help with expert advice, practical tips and personalised actions to help stay on top of your wellbeing”. It was very gratifying that PHE wanted to make sleep a core element of this national effort, and I was delighted to be asked to serve as the ‘face’ of the campaign. So, I began to ask myself what were the most important things to include?

We agreed the brief. The content was to be salient to everyone, not just to poor sleepers or those with insomnia. The focus, therefore, was not on treatment but on universal insights and practical advice. The NHS team involved recognised that there are gaps in clinical assessment and treatment services for people with sleep disorders, but this was a public health campaign. The intention was to position sleep as central to emotional health and mental wellbeing, as something that everyone should and could look after, much in the same way that diet and exercise are core to behavioural health. I was very pleased that the Mental Health Foundation, a UK charity dedicated to advocacy and improving mental health in the community, were also involved and in an associated development they approached me about contributing to their report, Taking Sleep Seriously: Sleep and our Mental Health (Mental Health Foundation, 2020).

My thoughts inevitably turned to ‘sleep hygiene’; so often the subject matter of the sleep tips that I mentioned earlier. Although Dr Nathaniel Kleitman first referred to the ‘hygiene of sleep and wakefulness’ as a chapter heading his early book (Kleitman, 1939), we owe a huge debt of gratitude to the late Dr Peter Hauri, who developed the concept, and in 1977 he operationalised it as follows:

Sleep Hygiene Education is intended to provide information about lifestyle (diet, exercise, substance use) and environmental factors (light, noise, temperature) that may interfere with or promote better sleep. Sleep hygiene also may include general sleep facilitating recommendations, such as allowing enough time to relax before bedtime, and information about the benefits of maintaining a regular sleep schedule (Hauri, 1977).

It is quite remarkable how much traction sleep hygiene has had over the past 45 years! Although it is not a sufficient standalone intervention for chronic insomnia, and would not qualify as the entry level treatment in a stepped‐care service model (Espie, 2009; Chung et al., 2018), sleep hygiene is typically integrated within evidence‐based CBT programmes and is referenced in clinical guidelines throughout the world as a contributing factor to sleep education and sleep improvement (Edinger et al., 2021; Qaseem et al., 2016; Riemann et al., 2017; Sateia et al., 2017; Wilson et al., 2019). Undoubtedly, therefore, sleep hygiene has served as a building block of the behavioural sleep medicine approach, because it addresses the question ‘what can I do?’ and it channels people's thinking into self‐care as the answer. It has also I think proven to be an alluring catchphrase.

It is important to note, however, that Peter Hauri did not intend sleep hygiene to be thoughtlessly distributed. In fact, he lamented the practice that “many mental health professionals hand their patients little pamphlets filled with ‘sleep hygiene’ rules” and suggested that this would be “no more effective … than handing a neurotic patient a list of ten ‘rules for healthy emotional living’” (Hauri, 1991, p. 66). Rather, Hauri's focus was upon summarising research evidence “accumulated to scientifically support a set of rules on how to get to better sleep” (op. cit., p. 65), and it is likely for this reason that we see iteration of sleep hygiene content across Hauri's writings. For him sleep hygiene was not intended to become static or rigid, and the term itself was not sacrosanct. Indeed, as he put it, “… the name stuck, although I never liked it” (op. cit., p. 65). What he did like, and was relentlessly positive about, was the probability of there being one or two ‘rules’ that, once discovered for a given individual, would unlock better sleep for them. Peter Hauri embodied sleep wisdom, and we still miss him.

Reflecting on his encouragement to iterate led me to a set of 5 key principles that underpin good sleep health, each of which I think reflect scientific truth and practical value. I am sure that others would suggest additions to my list; or may prefer other synonyms. Any omissions or confusions are mine. However, I trust there is reasonable consensus that, as principles, they are fundamental and incontrovertible, and that they are salient to everyone and should stand the test of time. The ‘5 Principles’ of good sleep health that I came up with were that we should encourage people to Value, Prioritise, Personalise, Trust, and Protect their sleep (https://www.youtube.com/watch?v=OvQTjAlIvI8).

The target audience for the ‘5 Principles’ was the population at large, rather than a subsection of the general public; and, it should be noted, this does present certain challenges. Some people reading the principles will be good sleepers already, whilst others will not, and some of these poor sleepers will have sleep disorders. Likewise, there will be personal, situational, and occupational factors, as well as medical and psychological factors, that contribute to an individual's sleep opportunity, sleep pattern and sleep quality at any given point in time. For these reasons I have tried to frame the principles in a way that is somewhat generic but still, I trust, compelling, and with an emphasis on being supportive and encouraging rather than perplexing or even anxiety‐provoking. The principles are by no means intended as a panacea and I do not wish to oversimplify the journey to good sleep health, or back to good sleep health in the case of those with chronic sleep problems. However, when one thinks of what can be safely said to be salient to everyone I do believe that we would all do well to value, prioritise, personalise, trust and protect our sleep.

The starting point for the ‘5 Principles’ lies in valuing sleep. This is because there is a fundamental problem for achieving and sustaining sleep health if a person does not regard sleep as a ‘need to have’, compared with a ‘nice to have’. It is absolutely crucial not to cut corners where sleep is concerned. Logically, valuing something means that it merits a priority place in our lives. So often we can take important things (and people too!) for granted. This is why the second principle is to encourage people to actively prioritise sleep in behavioural terms, not just in their intentions. Next, I emphasise the discovery of your own sleep pattern and timing. I believe this personalisation through trial‐and‐error learning is very important. Understanding the likely range, within which your sleep need is likely to fall, is a helpful range‐finding exercise (c.f. National Sleep Foundation: Hirshkowitz et al., 2015), but the fine tuning is conducted by experimentation. This is why, having a ‘trusting sleep mindset’ is the fourth principle that I see as key to sleep health. We don't ever become good at sleeping, though we can become good sleepers. The power of the sleep system primarily rests in the regulatory properties of the homeostatic and circadian system reliably delivering sleep to us. Finally, and this takes us full circle to a set of both ‘traditional’ (e.g. caffeine) and contemporary (e.g. smart phones) sleep hygiene factors, I suggest we need to protect our sleep. Of course, addressing sleep hygiene may at times also promote healthy sleep, but in the main this is by mitigating factors that interfere with sleep initiation or maintenance. In the section on protective factors, you will see that I have dovetailed some cognitive behavioural strategies with sleep hygiene. I do not intend this to be CBT, or even ‘CBT light’, so I do encourage people who have established sleep problems to seek professional advice.

In Appendix 1, I have shared with you the detailed content of the ‘5 Principles’ material that was used in the NHS Every Mind Matters, and the Mental Health Foundation (UK) campaigns in 2020. My hope is that you may find it useful, and that you will feel free to share it also through your channels to support your public engagement with sleep health. I also hope that this paper will stimulate research, acknowledging that the material has not been evaluated formally for impact at this point.

CONFLICT OF INTEREST

CAE is the Co‐Founder and Chief Scientist of Big Health Inc. and is a shareholder in the company. Unrelated to this work.

AUTHOR CONTRIBUTION

CAE developed the concepts underlying this work and wrote the paper.