Adolescent sleep health in Africa: a scoping review protocol
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* Oluwatosin Eunice Olorunmoteni
* F Xavier Gómez-Olivé
* Biliamin O Popoola
* Adesegun Olayiwola Fatusi
* Karine Scheuermaier

## Abstract

**Introduction** Problematic sleep is a major threat to health and quality of life among adolescents. Hence, to provide directions for research and interventions, there is a need to examine the literature on adolescent sleep health in Africa. However, available studies on adolescent sleep health in Africa have not been properly mapped. Thus, this scoping review aims to investigate the extent and type of available evidence concerning sleep health among adolescents in Africa and to highlight the relationship of adolescent sleep health with adverse mental health outcomes and cardiometabolic risk factors. The review will further highlight areas of agreement and controversies on adolescent sleep health, and identify evidence gaps that require research attention across the continent.

**Methods and analysis** This scoping review will be conducted using Arksey and O’Malley’s six-step procedure. Thus, we have prepared this protocol according to the framework for scoping reviews developed by the Joanna Briggs Institute. To identify eligible studies, we will search MEDLINE, Scopus, PsycINFO, AJOL, JSTOR, HINARI and Google Scholar. The review will include all published articles in English, French, Spanish, Portuguese and Italian languages on adolescent sleep health in Africa from the inception of the databases, while relevant information will be extracted from included studies using an adapted data extraction tool. The results will be presented using tables and charts as appropriate.

**Ethics and dissemination** The scoping review does not require ethical approval because the publications to be used for the review are publicly available and the study does not involve contact with humans or other animals as research participants. Furthermore, clinical records will not be used for the study. Upon completion, findings from the study will be disseminated through presentations at scientific meetings and publication in a relevant peer-reviewed journal.

**Scoping review registration** Open Science Framework ([https://osf.io/5sjwq/](https://osf.io/5sjwq/)).

*   SLEEP MEDICINE
*   PUBLIC HEALTH
*   Paediatric neurology
*   Developmental neurology & neurodisability
*   Child & adolescent psychiatry
*   Adolescent

### STRENGTHS AND LIMITATIONS OF THIS STUDY

*   By interrogating the association of adolescent sleep health with mental health and cardiometabolic risk (CMR) in the wide cultural and geographical context of Africa, the review will provide the needed evidence to elicit action for improved adolescent health in Africa.

*   The scoping review will capture studies published in the major languages spoken on the African continent to ensure inclusivity.

*   As a limitation, the review will not analyse the size of the effects of the relationship between adolescent sleep health, mental health and CMR factors.

## Introduction

Sleep health is an important component of overall health. It was first defined in 2014 by Buysse1 as ‘a multidimensional pattern of sleep-wakefulness, adapted to individual, social, and environmental demands, that promotes physical and mental well-being’. Good sleep health is characterised by subjective satisfaction, appropriate timing, adequate duration, high efficiency and sustained alertness during waking hours.1 Sleep health has since evolved as a concept that explains the role of sleep as a cause or determinant of adverse health outcomes and morbidity rather than just a consequence or symptom of ill health.2–4 Furthermore, the understanding of the concept of sleep health is widening the focus of sleep medicine beyond seeing poor sleep as a cause of sleep disorders to identifying sleep health as a predictor of overall health.1 5 Thus, sleep health has emerged as a holistic view of sleep and its multiple characteristics: duration, quality, alertness, timing and continuity.4 Sleep variability or regularity is being considered as an additional characteristic.4 While earlier studies have focused on the concept of sleep health as it relates to the adult population, there is growing evidence of its applicability to child and adolescent health.4 5 Hence, it is important to investigate the available evidence on the sleep health of adolescents in Africa.

While poor sleep is widely recognised as an important cause of morbidity, research on the subject is lacking both in quantity and quality in Africa.6 7 Studies in high-income countries (HICs) have associated short sleep duration (SD) with increased physical and behavioural problems.4 8 9 Nevertheless, evidence on the role, extent and scope of the various aspects of sleep health characteristics such as SD, sleep quality, sleep chronotype (SC) and bedtime variability (BV) of adolescents in Africa has not been well reviewed or synthesised. Thus, there is a need for a review to examine the available evidence on adolescent sleep health, and the determinants and possible outcomes for adolescent sleep health in Africa.

Furthermore, existing studies have highlighted racial and social disparities in sleep health.10–12 Some disparities have been described among people living in urbanised communities when compared with dwellers of rural communities. This suggests that differences may exist in the sleep health dynamics of adolescents in Africa when compared with adolescents in other low/middle-income countries as well as those in HICs. Similarly, there may be similarities or differences in the sleep health of adolescents dwelling in the various regions of the African continent. The sleep characteristics of adolescents in sub-Saharan Africa may be different from that of their counterparts in North Africa. Conversely, the sleep characteristics of adolescents within the entire African continent may be similar due to similarities and overlap of cultures, including the nomadic culture which cuts across the countries in North and West Africa. Furthermore, there may be disparities in the sleep health of rural-dwelling versus urban-dwelling adolescents in Africa. Thus, a detailed review of existing studies on African adolescents’ sleep patterns and the sleep problems among adolescents residing in all the regions of the continent may help understand the effects of culture, religion, natural light exposures and electricity on adolescent sleep health.

In addition, there is a need to collate the available evidence on the contributory factors and outcomes associated with poor sleep health. The social determinants of sleep problems in adolescents have been well described in HICs using various models, especially the socioecological model.13–15 The leading factors identified by these studies were excessive screen use, early school start times, the burden of homework, caffeine use and parental influences.16–18 However, the available studies on the social determinants of sleep health in Africa have not been well explored among the adolescent population.

Many studies of adolescent sleep are based on SD as the main sleep variable measured. Other variables such as BV, sleep quality and SC have not been well explored.19 20 However, emerging evidence suggests that SC and BV may be more important measures of sleep health.21–23 Thus, there is a need to synthesise the mechanisms by which other sleep health variables such as SC contribute to adolescent sleep problems. This will bring more understanding of the concept of sleep health as it relates to adolescent sleep, particularly in the context of Africa.

Aside from the sociodemographic variables, emerging pieces of evidence have shown links between cardiometabolic diseases and poor sleep.23 24 This suggests a possible association between cardiometabolic risk (CMR) and sleep health. CMR refers to an increased predisposition to cardiovascular disease, diabetes and metabolic syndrome.25 The markers of CMR include cardiovascular risk factors such as weight–height ratio, body mass index, blood pressure, heart rate and measures of adiposity such as waist circumference, waist–hip ratio, body fat percentage and superficial fat thickness.26 27 Others include fasting blood sugar, homeostatic model of insulin resistance, Matsuda index, lipid profile and inflammatory markers, among others.26–28 These factors have been linked to various sleep parameters such as short or long SD, poor sleep quality, SC, bedtime irregularity and intraindividual variability (IIV) in bedtime.13 21 Also, a high CMR in adolescence has been associated with a higher risk of cardiovascular disorders in adulthood, in particular young adulthood.29

However, inconsistencies in findings limit the generalisability of many suggested associations between sleep and CMR. The majority of these studies are cross-sectional in design and suggest a bidirectional relationship between poor sleep and CMR.13 30 Furthermore, a gender disparity was observed between short SD and increased adiposity in females suggesting the need for an improved understanding of the mechanisms of the association.28 31 The postulated mechanisms for the adverse effects of sleep disruption on CMR include inflammation, increased oxidative stress and endothelial dysfunction, elevated ghrelin and leptin levels, etc.24 32 33 However, the types of sleep disruption associated with CMR are mainly those with altered circadian rhythms such as IIV or bedtime irregularity.19 21 28 Thus, the collation of evidence from existing studies is needed to identify research gaps and suggest the direction for future research.

Studies in HICs suggest an association between poor sleep and adverse health outcomes.31 34 35 In some African countries, there is an already worrisome increase in non-communicable diseases (NCDs).36 37 This is mainly due to changes in lifestyles and the consequent increase in the risk factors for NCDs.38 Sleep problems in adolescents, especially circadian misalignment or BV, have been linked with NCDs such as diabetes, cardiovascular diseases and cancers.26 39 40 In addition, the presence of risk factors for the development of NCDs such as obesity has been linked to sleep problems.26 27 31 Furthermore, obesity and poor sleep have been recognised as dual epidemics in adolescents worldwide.26 However, the attention of researchers appears skewed towards obesity, while sleep problems and health outcomes have not been well explored.

The association between sleep health and the mental health of adolescents needs to be well studied. Sleep problems have been reported to result in adverse mental health outcomes such as anxiety, depression and behavioural disorders.41–44 Many mental health disorders have sleep disturbances as a component of their symptomatology.22 In addition, sleep problems can be an early pointer to the existence of a mental health disorder and sleep is a modifiable factor that can be targeted in mental health promotion programmes.44 Furthermore, many of the medications used in treating mental health conditions have significant effects on sleep architecture and quality.45 Thus, the relationship between sleep and mental health is multidimensional. According to the WHO, ‘mental health is more than the absence of mental health disorders’.46 Mental health problems occur for one in seven adolescents.47 Also, many of the determinants of mental health in adolescents contribute to sleep health.44 These determinants would be worth exploring among African adolescents. Thus, this scoping review will include studies on the relationship between sleep health variables and the mental health of African adolescents.

After conducting preliminary searches on MEDLINE, the Cochrane Library of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis, no existing or underway systematic or scoping review on the topic was identified. Thus, the objective of this scoping review will be to assess the extent of the literature on adolescent sleep health in Africa. We present here the methods proposed for this scoping review.

### Review questions

1.  What are the key concepts, beliefs and cultural practices on sleep health in adolescents in Africa?

2.  How have publications in adolescent sleep health evolved in Africa?

3.  What are the geographical distribution, trends, sources and types of evidence available on adolescent sleep health in Africa?

4.  What disparities exist in sleep health among rural versus urban-dwelling African adolescents?

5.  What are the barriers and facilitators to good sleep health among rural and urban-dwelling adolescents in Africa?

6.  What relationship exists between sleep health and mental health among adolescents in Africa?

7.  What relationship exists between sleep health and CMR among adolescents in Africa?

8.  What association exists between sleep health and school schedule among adolescents in Africa?

9.  What interventions have been implemented for improving the sleep health of adolescents in Africa and how effective have they been?

## Methods and analysis

### Study design

This scoping review will be used to map out literature on the topic ‘Adolescent sleep health in Africa’. We will be using the six-step procedure described by Arksey and O’Malley.48 Thus, we have written this protocol according to the framework for scoping reviews developed by the JBI and the proposed scoping review will be conducted following the JBI methodology for scoping reviews.49 The result will be presented following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR).50

### Search strategy

The search strategy will aim to locate published studies. An initial limited search of MEDLINE (via PubMed) and CINAHL will be undertaken to identify articles on the topic. The text words identified in the titles and abstracts of relevant articles, and the index terms used to describe the articles will thereafter be used to develop a full search strategy for MEDLINE (PubMed), Scopus, CINAHL, AJOL, HINARI Summons and PsycINFO. The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. Aside from database searching, a reference snowballing approach will be deployed to identify more studies from the reference lists of screened and eligible articles. The initial search strategy developed for the study is presented in table 1.

View this table:
[Table 1](http://bmjopen.bmj.com/content/13/8/e067373/T1)

Table 1 
Initial search strategy for MEDLINE (via PubMed)

### Planned start and end dates

The study is planned to start in July 2023 and end by August 2023.

### Inclusion criteria

The scoping review will include all published articles on the various sleep characteristics of adolescents, aged 10–19 years living in Africa from the inception of the databases. We will include peer-reviewed publications in English, French, Spanish, Portuguese, Italian and Arabic languages since the official languages in most African countries are anglophone, francophone, lusophone and Arabic. This will enable appropriate inclusion and evaluation of the evolution of publications over the years on adolescent sleep health in Africa.

### Exclusion criteria

Studies published in languages other than English, French, Spanish, Portuguese, Italian and Arabic languages and those based on geographical location outside Africa will not be included in the review. Blogs, web pages, books, conference presentations and other grey literature will also be excluded from the review.

### Types of sources

For comprehensive coverage of available evidence, the scoping review will include analytical observational studies (epidemiological studies) including prospective and retrospective cohort studies, case–control studies and analytical cross-sectional studies. In addition, the review will consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion. In addition, studies from experimental and quasi-experimental study designs including randomised controlled trials, non-randomised controlled trials, before and after studies and interrupted time-series studies will be included. Qualitative studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research will be considered for inclusion. In addition, relevant systematic reviews that meet our inclusion criteria will also be for inclusion in the review. Only studies available in the full text will be included in the review.

### Study/source of evidence selection

Following the search, all identified citations will be collated and uploaded into the Mendeley citation management software for deduplication. Following this, titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion and exclusion criteria for the review. The full text of selected citations will be assessed in detail against the inclusion criteria by two or more independent reviewers. Reasons for the exclusion of studies whose full text does not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a PRISMA-ScR50 flow diagram (figure 1).

![Figure 1](http://bmjopen.bmj.com/http://bmjopenuat.stage.highwire.org/content/bmjopen/13/8/e067373/F1.medium.gif)

[Figure 1](http://bmjopen.bmj.com/content/13/8/e067373/F1)

Figure 1 
Flow chart.50 The PRISMA-ScR flow diagram shown will be used to illustrate the processes involved in conducting this scoping review. These processes are (1) identification: to state the number of articles identified and the respective sources. The number of the duplicates found and removed will also be provided; (2) screening: the total number of articles screened will be provided here; (3) eligibility: the details of the number of full-text articles assessed for eligibility, the number of eligible studies and the number of studies that were excluded; (4) included: this section provided the number of studies included following quality appraisal, data extraction and thematic analysis, respectively. PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review.

### Patient and public involvement

None.

### Data extraction

Data will be extracted from studies included in the scoping review by two independent reviewers using a data extraction tool developed by the team (table 2), adapted from a previous scoping review on adolescent reproductive health in Africa.51 The data extracted will include specific details about the participants, concept, context, study methods and key findings relevant to the review questions. A draft extraction form will be provided in the report of the scoping review. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included evidence source. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with an additional reviewer. Where required, authors of papers will be contacted to request missing or additional data.

View this table:
[Table 2](http://bmjopen.bmj.com/content/13/8/e067373/T2)

Table 2 
Data extraction tool (adapted from a scoping review by Ajayi *et al*51)

### Data analysis and presentation

We intend to map available evidence on adolescent sleep health in Africa. For this, we will characterise sources of evidence through the descriptive presentation of the yearly publication rates of adolescent sleep studies included in the scoping review and the countries of publication of the studies included in the review. Furthermore, extracted data from included publications will be presented according to the study design and sleep themes investigated by performing a basic qualitative content analysis of the publications. By using the thematic content analysis, pertinent qualitative data (texts) extracted from all studies included in the review will be synthesised and descriptively presented under themes that address the review questions.

Specifically, the review will use the three phases of qualitative content analysis described by Pollock *et al*.52 In the preparation phase, the deductive approach will be used to map the data to established frameworks (sleep quality, SD, presence of sleep disorders, sleep as a comorbid condition with mental health) within the literature. The second phase, the organising phase, will involve open coding to allocate concepts or characteristics in the mapped data into overall categories. Thereafter, we will organise the categories of data into themes, based on the review questions, to draw appropriate conclusions from the findings. For these steps, we will use the NVivo V.12 software. Using the NVivo software, the primary author will chart the results obtained from the publications and identify the main themes, while other authors will give feedback and review the synthesised results. These results will include themes and conclusions relating to adolescent sleep in Africa, rural versus urban disparities, the association between sleep and CMR and the association between sleep and mental health. The final results will be validated by the last author who is a specialist in sleep research and the third author who is a librarian. We will conduct the validation of sources using a test set of pre-identified relevant publications that should be captured using the database search. Following the first database search, we will check the identified publications based on our predetermined strategy to ascertain the comprehensiveness of the search. We will use the information obtained to make the appropriate changes to the search strategy if needed. In the reporting phase, the bibliographical characteristics of studies included in the review will be presented through the use of tables and charts. These tables and charts will describe the publication year, country of publication, authorship information, study design and settings, funders, sample size and other available relevant information about the articles. Visual presentation tools such as word clouds, tree graphs and waffle charts will also be used in presenting the results as appropriate. The key findings and gaps will thereafter be presented in a narrative summary within the text of the review.

## Ethics and dissemination

The scoping review does not require ethical approval because the publications to be used for the review are publicly available and the study does not involve contact with humans or other animals as research participants. Furthermore, clinical records will not be used for the study. Upon completion, findings from the study will be disseminated through presentations at scientific meetings and publication in a relevant peer-reviewed journal.

## Ethics statements

### Patient consent for publication

Not required.

## Footnotes

*   Twitter @bilspop

*   Contributors OEO, FXG-O, AF and KS conceived the idea and design for the study. OEO drafted the paper. OEO, KS and BOP developed the protocol and prepared the tables and figures. OEO, FXG-O, AF, BOP and KS all participated in the revision of the manuscript before submission. All authors have seen and given final approval to the final text.

*   Funding OEO is supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (grant no: G-19-57145), Sida (grant no: 54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), by the Wellcome Trust (reference no. 107768/Z/15/Z) and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) Programme.

*   Disclaimer The statements made and views expressed are solely the responsibility of the fellow.

*   Competing interests None declared.

*   Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

*   Provenance and peer review Not commissioned; externally peer reviewed.

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