Student: Feifei Wang, MSc Neptun: GKF8OA
Beginning of the studies in the Doctoral School: February 2018 Form of financing: Stipendium Hungaricum
PhD Programme: Sports and Health Promotion
Name and leader of the programme module: Prof. Dr. György Bárdos Name, status and contact details of the consultant(s):
Prof. Dr. Bárdos György Dr. Szilvia Boros, PhD.
Programme director Associate professor
Email：bardos.gyorgy@ppk.elte.hu Email：szilvia.boros@ppk.elte.hu Name and contact details of the opponents, declaration of authenticity:
Research permit number: _________________________
The relationship between physical activity and sleep quality Doctoral School of Education Science
Institute of Health promotion and Sports Sciences Faculty of Psychology and Pedagogy
2019.02.25
Table of Content
Formulation of the problem ··· 2
The prevalence of sleep disorder ··· 2
Sleep problems and health ··· 2
Poor physical activity ··· 3
Physical health and sleep ··· 4
Theoretical background ··· 4
Physical exercise and health ··· 4
Physical exercise and sleep ··· 5
Walking exercise and health ··· 6
Walking exercise and sleep ··· 7
Research questions/hypothesis ··· 8
Aims of the study ··· 8
Hypotheses ··· 8
Research framework ··· 9
Literature review study ··· 9
Observational study ··· 11
Results of the online study ··· 12
Intervention study ··· 14
Expected results of the intervention study ··· 16
Research outcomes ··· 16
Publication goals ··· 16
Plan of action ··· 17
Overall timeframe for experimental studies ··· 17
Timeframe for intervention study ··· 17
Schedule after the experimental studies ··· 17
Publications ··· 18
References ··· 18
Appendix ··· 26
Formulation of the problem The prevalence of sleep disorder
Given the observable effects of sleep in everyday life, there has been scholarly interest in sleep in scientific research. The term “sleep epidemiology” was appeared in a study of sleep disturbances in 1979 (Bixler, Kales, Soldatos, Kales & Healey, 1979). This issue of IJE included a review, which was the first comprehensive textbook of sleep epidemiology (Kronholm, 2011). A PubMed search for terms “sleep/insomnia” and “epidemiology” shows that the cumulative number of papers on the subject over the past 10 years is already over 10,000. The prevalence of insomnia, poor sleep quality, and daytime sleepiness was significantly high, and even higher in shift workers (Yazdi, Sadeghniiat-Haghighi, Loukzadeh, Elmizadeh & Abbasi, 2014). It is estimated that 4% of males and 2% of females suffer from obstructive sleep apnea and the majority of patients are thought to be under diagnosing. Seventy million Americans (∼23%) are reported to suffer sleep disorder report in 2009 by American Academy of Sleep Medicine. Nevertheless, showed in the most recent study there was not no substantial difference between males and females in different types of sleep disorders, and students with sleep disorders have poorer academic performance at college (Piro, Alhakem, Azzez & Abdulah, 2017).
Sleep problems and health
Sleep deprivation has become a risk factor for mortality. The National Highway Traffic Safety Administration estimates that fatigue is a cause in 100,000 auto crashes and 1,550 crash- related deaths a year in the U.S. The term “sleep health” was defined by Buysse (2014). Sleep problems are assumed to be more common among older adults. Sleep problems were proved to be a risk factor for falls in adults aged above 64 years old. Sleep problems may become an emerging global epidemic, as it was reported that a large number of older adults in low-income settings are currently experiencing sleep problems, which emphasizes the global dimension of
this emerging public health issue (Stranges, Tigbe, Gómez-Olivé, Thorogood & Kandala, 2012).
To our best acknowledge, sleep problems is associated with mental health, diminished work productivity and work quality, which will lead to greater use of health care services (Manocchia, Keller, & Ware, 2001).
Insufficient sleep relates not only to societal impacts, but also diagnostical disorders.
Evidence showed that poor sleep quality related to telomere length in several immune cell types, which may serve as a pathway linking sleep and disease risk (Prather et al., 2015). A longitudinal population-based study indicated that poor sleep predicts symptoms of depression and disability (Paunio et al. 2015). Nevertheless, poor sleep may increase symptoms of depression and anxiety postpartum women (Okun et al., 2018). In general population, a recent study demonstrated that short sleep and evening chronotype related to related to the increased mental health risk (Dickinson, Wolkow, Rajaratnam & Drummond, 2018).
Poor physical activity
The term "physical activity" is not the same with "exercise", which is a subcategory of physical activity that is planned, structured, repetitive, and aims to improve or maintain one or more components of physical fitness (WHO). As reported in 2018 that insufficient physical activity is one of the leading risk factors for death worldwide. Once there was a study
examined the prevalence of physical inactivity during leisure time in a national representative sample of U.S. adults between 1988 and 1994. The prevalence of physical inactivity among U.S. adults was 23%, with more women (28%) than men (17%) reporting being inactive during their leisure time (Crespo et al. 1999). In a recent study, elder population reported having fair to poor physical health (57.7%) (Rosen, Smith, & Reynolds, 2008).
The high prevalence of poor physical health draw attention in scientific research due to its health implications. Postpartum mothers, who will experience certain physical
conditions such as fatigue/physical exhaustion and sleep-related problems, were paid attention
(Cheng & Li, 2008). It was showed that high physical health status associated with better health (Penedo & Dahn, 2005). In addition, the relationship between physical activity and mental health has been widely examined. A population study demonstrated that level of physical activity was positively associated with general well-being, lower levels of anxiety and depression, and positive mood and it also emphasized the psychological benefits of physical activity (Stephens,1988).
Physical health and sleep
Disturbed sleep symptoms are common in the general population, with overall prevalence rates of between 35% and 41% (Staiano, Marker, Martin & Katzmarzyk, 2016).
Early reports suggest that sleep problems are related to lower quality of life as well as poorer mental and physical health (Kripke et al., 2002; Simon & VonKorff, 1996). It was shown that obese adolescents experience less sleep than their non-obese counterparts, however their sleep disturbance appeared to be more closely associated with insufficient physical activity than with obesity (Gupta, Mueller, Chan & Meininger, 2002). Indeed, it was conjectured that increased physical activity could have a positive effect on restoring sleep (Lang et al., 2013). This effect may be ascribed to the actual physical benefits of exercise, as well as to physical activity’s positive impact on the perceived stress, which may further ameliorate one’s sleep quality (Caldwell, Harrison, Adams, Quin & Greeson, 2010).
Theoretical background Physical exercise and health
The benefits of physical exercise to health has been addressed many times. It was widely suggested that exercise can help maintain body weight. Engaging in physical activity, calories burn, which the mechanism of weight loss. Evidence showed that regular exercise helps prevent a wide range of health problems such as stroke, metabolic syndrome, type 2 diabetes, depression, and cancer etc. Nevertheless, physical exercise was revealed to have psychological effects of
well-Being (Hassmén, Koivula & Uutela, 2000). In addition, exercise training provided a vehicle for nonspecific therapeutic processes and aerobic training has now been shown specifically to reduce depression (Salmon, 2001). It is recommended by World Health Organization (WHO) that adults should have at least 150minutes exercise per week to keep health. Walking was suggested as a good exercise to benefit health and walking at an average or brisk/fast pace was recommended than walking at a slow pace (Stamatakis et al., 2018). The benefits of physical exercise showed more significance in populations who are under medical care. There is emerging evidence that physical exercise significantly benefits individuals living with a dementia in nursing homes (Brett, Traynor, & Stapley, 2016). Among patients who are suffering psychological disorders, physical exercise play as therapy in improving mental health (Knapen, Vancampfort, Moriën, & Marchal, 2015).
Physical exercise and sleep
It is conjectured that exercise has sleep-facilitating effects via a downregulation of the body-temperature in the hypothalamus-preoptic area, which is triggered by the exercise- produced increase in the body temperature (Horne & Moore, 1985). Therefore, the effect of physical activity on sleep quality has received substantial attention in the scholastic literature.
Many studies have found that physical activity has positive effect on sleep quality. A metanalytic review reported that regular exercise exerts small effects on sleep time and sleep efficiency, small-to-medium benefits on sleep onset latency, and moderately positive benefits on sleep quality (Pilcher, Lambert & Huffcutt, 2000). Despite the reported connection, an undisputable causal association cannot be established at this time because there were several incongruent findings. For example, an investigation of adults found a positive link between the objectively-measured physical activity and sleep quality (Loprinzi & Cardinal, 2011), while another work with adolescents revealed that the subjectively reported levels of physical activity were better predictors of sleep quality than the objectively gauged levels of exercise. Exercise
intervention research showed that older adults report improved sleep quality after three months of exercise (King, 1997; Reid et al., 2010). Low-intensity physical exercises, such as Pilates, taichi and body mind therapies, which was also associated with subjective reports of ameliorated sleep quality (Caldwell, Harrison, Adams & Travis Triplett, 2009; Hosseini et al., 2011). Moreover, a bidirectional relationship between sleep quality and physical activity was also proposed in that poor sleep may be linked to lower physical activity levels (Kline, 2014).
Evidence from patients with panic disorder and patients with cancer suggested that physical exercise improves sleep (Hovland et al., 2017; Mercier, Savard, & Bernard, 2017).
Walking exercise and health
Many studies have demonstrated that walking is a good way to lose weight and control obesity (Ohtake, 2008; Browning, Kram & Brynes, 2006) and physical activity is good for quality of life (Penedo & Dahn, 2005). However, little study showed the association between walking and mental health functioning among obese people. At present, there is no public acknowledged dose and quantity of walking that is benefit for mental health building even in the most frequently cited multi-study Meta-analysis performed in UK (Barton & Pretty, 2010).
Physical activity is an important component of any weight-management program, particularly for those with depression, for which a substantial body of research indicates both mental and physical health benefits.
In health rehabilitation, walking can be used as training exercise for improving hip osteoarthritis function (Bieler et al, 2017). In addition, it was demonstrated that acute walking exercise has temporal effects on learning and memory function (Sng, Frith, & Loprinzi, 2018).
From broader perspective, walking presented an elegant synthesis of the health benefits, which concisely summarized the extensive physiological, metabolic and other health-related impacts of different patterns of walking across all ages (Bull, & Hardman, 2018).
Walking exercise and sleep
Walking maybe the most feasible way of doing exercise for healthy adults. Previous study showed that exercises improve sleep through physiologic mechanisms that include the regulation of immune-inflammatory response (Besedovsky, Lange, & Born, 2012). The benefits of sleep have been addressed within clinical patients with cancer. It was demonstrated that moderate-intensity walking exercise is effective in improving sleep in individuals with cancer (Chiu et al., 2015). In addition, not only in adult patients, but also in young population, walking exercise is recommended. A 6-week walking exercise conducted in children and adolescents emphasized that walking exercise is a feasible and tolerable intervention that should be considered for children and adolescents with cancer (Su, Wu, Chiou, Lin & Liao, 2018). It was suggested that 12-week exercise intervention was related to better objective measures of sleep duration and sleep quality in obese adolescents (Mendelson et al., 2015).
Sleep and health
Self-reported poor sleep quality has been thought to related to poor health outcome.
Specially, with regard to older community‐dwelling adults, more attention was paid. Even though the elderly people are more vulnerable for health issues compared with young adult population, it is still meaningful to check the mediator effect of sleep quality. It has been hypothesized that sleep is a mediator of the relationship between socioeconomic status and health (VAN CAUTER & SPIEGEL, 1999). Nevertheless, insufficient sleep is associated with health-related quality of life in all domains (Strine & Chapman, 2005). In addition, it reported that sleep problems are common in early infancy across metropolitan socio‐economic levels and are associated with poorer maternal health and well‐being in mothers (Bayer, Hiscock, Hampton & Wake, 2007). Poor sleep quality is a potential risk factor for both physical and mental health according to the current evidence. As reported, sleep fragmentation mediated the effect of social stressors at work on psychosomatic health complaints (Pereira & Elfering, 2013).
Care and attention towards poor sleep should be paid. Throughout the literature, the evidence is weak in addressing the relationship between sleep problems and health effects among healthy young and middle-aged adults, and less to discover the intervention activity for healthy adults.
Research questions/hypothesis Aims of the study
Controversial findings may emerge because other factors might also affect the sleep and exercise relationship, such as perceived stress, therefore, examining these variables in the context of physical activity and sleep quality may be warranted. Sleep quality and life satisfaction are important variables to assess life quality. Thus, in our study, we will include perceived stress and life satisfaction as additional parameters of the research.
The study aims 1) to elaborate comprehensively the relationship between physical activity and sleep quality by systematic review; 2) to figure out the relationships between physical exercise and sleep quality by experimental study; 3) to increase the physical health and sleep health of those who take part in this study; 4) to examine whether walking exercise is good way to keep healthy weight. Broadly, we will try to apply the results of this study in promoting the health status and sleep status of the overall population and encourage the society to behave actively and reduce the health and economic burden caused by poor physical and sleep health.
Hypotheses
According to the evidence above, we hypothesis that:
1. Physical exercise is beneficial to healthy adults.
2. There is a difference in sleep quality, life satisfaction and perceived stress between active and inactive adults.
3. Physical exercise is beneficial to sleep quality.
4. There are significant relationships between physical exercise and sleep quality.
5. Walking exercise benefits sleep quality in adults.
6. Daily walking exercise is good for keeping healthy weight.
Research framework
In order to test the hypothesis, we will organize three sections in the PhD study including literature review, observational study and intervention study. We have already got separate ethical permissions for the online study (completed) and intervention study.
Literature review study
With the purpose of better understand the previous scientific literature results, we will do two sets of literature review: 1) clarifying the risk factors and intervention strategies of sleep quality; 2) to explore the relationship between physical activity and sleep quality. The first review will be conducted by scoping review, and second one will follow the Prisma guideline (Moher et al., 2009).
In this research plan, we list two abstracts of the review articles:
Abstract 1:
Objective To review the various determinants of sleep quality among college students.
Data Source Three databases were searched [PubMed, Web of Science and Cochrane Library] with the following searching string (sleep quality) AND (college students).
Study Inclusion and Exclusion Criteria Studies investigated determinants of sleep quality among college students and published January 2007 to October 2017 were included. Excluded articles were those (1) taken sleep quality as risk factor for other outcomes; (2) involved inpatients or participants under medical care.
Data Extraction Content analysis was used to extract and describe results from each of the included articles.
Data Synthesis Results were classified according to the determinants assessed into four categories: lifestyle, mental health, social and physical factors. Three outcome categories (improve or decrease sleep quality, no effect/not enough data) were made accordingly.
Results A total of 112 eligible studies were identified. Well-organized physical activity, healthy social relations improve, while caffeine intake, stress and irregular sleep-wake pattern decrease sleep quality. Less consistent results were reported regarding to eating habits and sleep knowledge as determinants for sleep quality. In addition, proper napping during the day might strengthen overall sleep quality.
Conclusion College students are vulnerable to sleep risks from both mental and physical aspects. When designing interventions to improve sleep quality among college students the main determinants have to take into consideration.
Abstract 2:
Background: A big amount of research has investigated the effect of physical activity and sleep quality, yet the previous researches have not investigated the physical intensity and sleep quality. Objective: This systematic review examines the effect physical activity intensity on sleep quality in healthy populations. Methods: We conducted a systematic review by searching latest 8 years publications. PubMed and Scopus were used to identify eligible studies with the searching terms, “sleep quality” AND “physical activity”, within the timeframe between Jan 2010 and Jun 2018. All the included articles were systematically reviewed and analyzed. Results: 14 studies were included in the review. Moderate physical activity seems to be effective than vigorous activity to improve sleep quality. The review indicated that moderate physical exercise is beneficial to sleep quality in both young and old people. Vigorous physical activity may not associate with sleep quality. Conclusions:
Moderate exercises showed more promising outcome on sleep quality, however, more
evidence is needed on how vigorous physical activity benefits sleep. Future studies are suggested to identify the relationship between physical intensity and sleep quality.
Observational study Participants
An online questionnaire form by Qualtrics.com was sent to adults above 18 years old.
Instruments
The questionnaire was composed by self-administrated demographic questions followed by a series of questionnaires on physical activity (PA), perceived stress (PS), life satisfaction (LS) and sleep quality (SQ). We collected biophysical data (e.g. age, gender, height, weight), and social characteristic data (e.g. marital status, identity, region). We calculate the exercise volume by asking two questions: 1. How many times do you exercise (minimum 10 minutes each time) each week? 2. On the average, how many minutes you exercise each time?
Physical activity, perceived stress, life satisfaction and sleep quality were assessed by International Physical Activity questionnaire short form (IPAQ-SF) (Craig CL.et al, 2003), Perceived Stress Scale (PSS) (Cohen et al., 1983), Satisfaction With Life Scale (SWLS) (Diener, Emmons, Larsen & Griffin, 1985), Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989), respectively.
International Physical Activity questionnaire (IPAQ) comprises four elements:
vigorous exercise, moderate exercise, waking and sitting. By asking the exercise frequencies and exercise duration per week, vigorous physical activity, moderate physical activity and walking were calculated, the sitting time was evaluated directly by the question: During the last 7 days, how much time did you spend sitting on a weekday? The physical activities were recorded in minutes in last week. High reliability (α >.80) indicated good stability and reliability of the questionnaire, and criterion validity had a median p value of about 0.30, which was comparable to most other self-report validation studies (Craig CL.et al, 2003).
Perceived Stress Scale (PSS-10) is a classic stress assessment instrument with 10 questions. Each item in this scale asks about feelings and thoughts during the last month and is rated on a 5-point scale (0=Never, 1= Almost never, 2=Sometimes, 3=Fairly often, 4=Very often). Individual scores on the PSS can range from 0 to 40 with higher scores indicating higher perceived stress. Scores ranging from 0-13 would be considered low stress; scores ranging from 14-26 would be considered moderate stress and scores ranging from 27-40 would be considered high perceived stress. The PSS-10 showed marginal satisfactory Cronbach’s alpha values (α=0.69) (Andreou, 2011), and Cronbach’s alpha above 0.7 was considered as satisfied.
Satisfaction With Life Scale (SWLS) is a 5-item scale designed to measure global cognitive judgments of one’s life satisfaction. Participants indicate how much they agree or disagree with each of the 5 items (In most ways my life is close to my ideal; The conditions of my life are excellent; I am satisfied with my life; So far I have gotten the important things I want in life; If I could live my life over, I would change almost nothing.) items by using a 7- point scale that ranges from 7 strongly agree to 1 strongly disagree. Higher score indicates better life satisfaction. The SWLS has satisfactory inter-item correlations (0.5<r<0.7), and reliability (α= .82) (Arrindell, Heesink & Feij, 1999).
Pittsburgh Sleep Quality Index (PSQI) is an effective instrument used to measure the quality and patterns of sleep in adults. It differentiates “poor” from “good” sleep quality by measuring seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction over the last month. The global PSQI score > 5 yielded a diagnostic sensitivity of 89.6% and specificity of 86.5% (kappa = 0.75, p ⩽ 0.001) in distinguishing good and poor sleepers (Buysse, 1989).
Results of the online study
Two papers were written based on the online collected data because the results were illustrated from two different perspectives. In this research plan, I added the abstracts of the two papers (the full-texts are under review).
Abstract of paper 1:
Regular physical activity is associated with better sleep, but contradicting findings also exist. Further, it is reported the less sleep is related to reduced physical activity. Such results stem from works that did not consider perceived stress and life satisfaction, which also affect sleep. In this cross-sectional study, we examined the differences in sleep quality, sleep duration, life satisfaction, and perceived stress in 149 physically active- and inactive
participants. Based on a significant correlation, we also studied further the relationship between perceived stress and sleep quality. The results revealed that physically active people report lesser perceived stress and greater life satisfaction, but not better or longer sleep than physically inactive participants. Sleep quality, regardless of the physical activity status, was predicted by the perceived stress, which accounted for 23.6% of variance in the former. The weekly exercise frequency and duration were not related to sleep quality/duration, life
satisfaction, or perceived stress. While these results suggest that physical activity is related to lesser stress and more life satisfaction, they do not reinforce the hypothesis that regular physical activity is associated with better and longer sleep, nor do they support the contention that less sleep is related to decreased physical activity.
Abstract of paper 2:
A body of studies examined physical activity and stress, life satisfaction and sleep quality, but to date no studies investigated the association in between them. Therefore, the aim of this study was 1) to assess the level of physical activity, perceived stress, satisfaction with life, and sleep quality; 2) to present the relationship between demographic factor (e.g.
gender, age) with physical activity, life satisfaction, stress and sleep quality; 3) to explore the
predictive power of these factors on sleep quality. Recruited sample of 292 participants, of whom 63.7% were women, answered a battery of questionnaires on the Qualtrics online research platform. The prevalence of moderate (69.9%) stress was the highest compared with those reporting low (24.7%) and high (5.5%) stress. Stress and life satisfaction were
significantly correlated with sleep quality (p < .05), but only stress significantly associates sleep quality (p<.00, SE=.03, B=.43). In addition, there was neither significant relationship between sleep quality and physical activity. Future studies are suggested to classify the substantial benefits of specific physical activity types on stress and sleep quality.
Intervention study
The details will be introduced for the intervention study of the research plan, which is the main section of the whole PhD study.
It was shown that exercise intensity and/or duration may not affect sleep quality (Myllymäki et al., 2011). However, a follow up study which indicate more scientific evidence, showed that walking duration is a significant predictor for investigating sleep quality (Chen et al., 2018). Based on our literature review, studies were mainly conducted between 4 weeks and 12 weeks, considering our time and study type, we plan to conduct the study by 12 weeks in total. (It is good mention here that the intervention study is part of the whole PhD study, which will be elaborated later in the method section)
The preferred walking speed considering of net metabolic rates (W/kg) were significantly greater for the obese vs. normal-weight people at 1.25m/s to 1.75 m/s (Browning
& Kram, 2005). Thus, the walking distance in one hour is 4.5km to 6.3 km. This study proposed here to test the physical and sleep quality among adult people. Concerning that it is not easy to supervise our participants to carry out walking exercise on scheduled time. We choose to record the steps every day, 10,000 steps (almost equals 4 km) per day is required, the steps will be
tracked by pedometer, in this case, it is will be more efficient to supervise the activities of the participants. The walking speed depends on the participants himself/herself as usual.
In order to test the hypothesis that walking exercise improve sleep quality in general population, we will conduct a randomized, case-control trial by a crossover intervention. Our targeted population is the physically and mentally healthy adults (18+). The health status will be self-reported, we do not organize physical and mental examination for our participants in this study. The call-for-participants advertisement will be distributed through online platforms and by posters.
Participants will be randomly separated into two groups: Group A (GA) and Group B (GB). Both GA and GB will be equipped with pedometers. Walking exercise (10,000 steps) is self-controlled and tracked by daily dairy. All of the participants in the intervention group are obliged to complete 10,000 steps daily between 14:00-20:00 each day and record the start and end time of walking every day. Pedometers will be used for tracking walking steps including heart rate and calories. For the ones who are in the control group, they have to keep sedentary lifestyle, and without regular walking exercise. The participants have the responsibility to carry out the walking exercise every day. Every participant will be counselled to record the activity and submit their report weekly.
The intervention period will last for three months (12 weeks) including three sub- sections (one section each month). In the first four weeks, GA serve as the walking group, and GB serve as control group. There is a wash period in the following 4 weeks. In the third four weeks, GA serve as the control group, and GB serve as the walking group. All participants will be assessed before and after the first four-week and third four-week section. We will assess the sleep quality of our participants by the Pittsburgh Sleep Quality Index (PSQI) and perceived stress (PSS).
Expected results of the intervention study
The study of physical exercise intervention on sleep quality is important because of its effects on global health and quality of life, we expect positive results of this study for all of the hypothesis. In addition, we expect to publish two articles. Details are as follows:
Research outcomes
It is very important that launch the study successfully and get qualified data. All our expectations of the study are based on the successful implementation of the study. There are two hypotheses for this intervention study 1) walking exercise is beneficial to improve sleep quality in adults; 2) walking exercise is effective to reduce stress among adults. We expect positive results of the two hypotheses. The statistical methods (e.g. paired sample t-test, GLM repeated measures, repeated measures ANOVA, MANOVA, and dependent sample t-test, as well as the non-parametric Wilcoxon signed rank test etc.) will be used to help the results analysis.
Publication goals
Two papers are expected to publish based on the data collected in the intervention study.
Since this is a cross-over study, in the first 4 weeks intervention, it is a randomized control trial.
At the beginning and at the end of the first 4 weeks, we will send online formulated questionnaire to all of the participants, which includes the demographic information (e.g.
gender, age, student or not, height, weight, etc.) and the PSQI and PSS.
The first paper will utilize the data collected before and after the intervention of the first 4 weeks. The aim of the paper is to examine the whether the 4 weeks’ walking
intervention benefits to improve sleep quality and decrease perceived stress. The statistical methods will include independent t-test, descriptive statistics etc.
The second paper will utilize the whole database collected at the very beginning and at the end of the intervention. The aim of this paper is to test the effect of walking exercise on
sleep and stress based on a cross-over study design. Repeated measures will be used for the statistical analysis.
Plan of action Overall timeframe for experimental studies
2017/18/1 2017/18/2 2018/19/1 2018/19/2 2019/20/1 Literature
review*
###### ## ###
Observational study*
#### ###
Intervention study
###### ###### ######
# approximately one month
*already completed
Timeframe for intervention study
2018/19/1 2018/19/2 2019/20/1 Preparation ###
Recruitment ### ###
Intervention ### ##
Data analysis ####
Report writing ###
# approximately one month
Schedule after the experimental studies
2019/20/2 2020/21/1 2020/21/2 Dissertation
writing
###### ######
Graduation preparation
######
# approximately one month
Publications
There are three papers submitted to different journals by the time of submitting the research plan.
Paper 1:
Tittle: Quality of Sleep, Life Satisfaction, and Perceived Stress in Physically Active and Inactive Adults
Authors: Feifei Wang, Attila Szabo & Szilvia Boros Journal: Sleep Science
Status: under second round review Paper 2:
Tittle: The relationship between physical activity, stress, life satisfaction and sleep quality Authors: Feifei Wang, Attila Szabo & Szilvia Boros
Journal: Journal of Physical Education and Sport Status: accepted for publication
Paper 3:
Tittle: The determinants of sleep quality among college students Authors: Feifei Wang & Eva Biro
Journal: Community College Review Status: under review
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Appendix Appendix 1
Pittsburgh Sleep Quality Index
The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.
During the past month,
1. When have you usually gone to bed? ____________________________________
2. How long (in minutes) has it taken you to fall asleep each night?
__________________________
3. What time have you usually gotten up in the morning?
__________________________________
4. A. How many hours of actual sleep did you get at night?
________________________________
B. How many hours were you in bed? ____________________________________
5. During the past month, how often have you had trouble sleeping because you
Not during the past month
Less than once a week
Once or twice a week
Three or more times a
A. Cannot get to sleep within 30 minutes B. Wake up in the middle of the night or early morning
C. Have to get up to use the bathroom D. Cannot breathe comfortably E. Cough or snore loudly F. Feel too cold
G. Feel too hot H. Have bad dreams I. Have pain
J. Other reason (s), please describe, including how often you have had trouble sleeping because of this reason (s):
6. During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?
7. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
8. During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done?
9. During the past month, how would you rate your sleep quality overall?
Very good
Fairly good
Fairly bad
Very bad
Appendix 2
Perceived stress scale _ short version
The following questions ask about your feelings and thoughts during THE PAST MONTH. In each question, you will be asked HOW OFTEN you felt or thought a certain way. Although some of the questions are similar, there are small differences between them and you should treat each one as a separate question. The best approach is to answer fairly quickly. That is, don t try to count up the exact number of times you felt a particular way, but tell me the answer that in general seems the best.
Never Almost Never
Sometimes Fairly Often
Very Often
1. In the past month, how often have you been upset because of something that happened unexpectedly?
2. In the past month, how often have you felt unable to control the important things in your life?
3. In the past month, how often have you felt nervous or stressed?
4. In the past month, how often have you felt confident about your ability to handle personal problems?
5. In the past month, how often have you felt that things were going your way?
6. In the past month, how often have you found that you could not cope with all the things you had to do?
7. In the past month, how often have you been able to control irritations in your life?
8. In the past month, how often have you felt that you were on top of things?
9. In the past month, how often have you been angry because of things that happened that were outside of your control?
10. In the past month, how often have you felt that difficulties were piling up so high that you could not overcome them?
Appendix 3
Satisfaction with life scale
Below are five statements that you may agree or disagree with. Using the 1 - 7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding that item. Please be open and honest in your responding.
• 7 - Strongly agree
• 6 - Agree
• 5 - Slightly agree
• 4 - Neither agree nor disagree
• 3 - Slightly disagree
• 2 - Disagree
• 1 - Strongly disagree
____ In most ways my life is close to my ideal.
____ The conditions of my life are excellent.
____ I am satisfied with my life.
____ So far I have gotten the important things I want in life.
____ If I could live my life over, I would change almost nothing.
31-35Extremelysatisfied 26 - 30 Satisfied
20 Neutral
15-19Slightlydissatisfied 10 - 14 Dissatisfied
5 - 9 Extremely dissatisfied
Appendix 4
INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE
We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.
Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.
1. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?
_____ days per week
No vigorous physical activities --- Skip to question 3
2. How much time did you usually spend doing vigorous physical activities on one of those days?
_____ hours per day _____ minutes per day Don’t know/Not sure
Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.
3. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.
_____ days per week
No moderate physical activities --- Skip to question 5
4. How much time did you usually spend doing moderate physical activities on one of those days?
_____ hours per day_____ minutes per day Don’t know/Not sure
Think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you have done solely for recreation, sport, exercise, or leisure.
5. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?
_____ days per week
No walking --- Skip to question 7
6. How much time did you usually spend walking on one of those days?
_____ hours per day_____ minutes per day Don’t know/Not sure
The last question is about the time you spent sitting on weekdays during the last 7 days.
Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.
7. Duringthelast7days, how much time did you spend sitting on a weekday?
_____ hours per day_____ minutes per day Don’t know/Not sure
Appendix 5
CALL FOR VOLUNTEERS TO PARTICIPATE IN A RESEARCH STUDY Title of the Study: “The effects of walking exercise on sleep quality in sedentary healthy adults”
Research Team:
We are from ELTE (a PhD student and two supervisors), and we are conducting a study to improve the sleep quality by a feasible and cost-effective way among people in all age groups in adults.
Why you?
We need you! We feel strongly that it would be very helpful to us if you would help us with our research. Your participation will help identify how daily walking influence sleep quality as well as provide us with a better understanding of how the sleep quality among people who lives in sedentary lifestyle.
What will I need to do?
We are looking for volunteers to participate in four-week walking exercise (10,000 steps) every day.
You will be asked to record the details of your walking everyday (e.g. starting and ending time of your walking, steps, heart rate and calories etc.). During the intervention period, you are not allowed to join any kind of organized or non-organized physical activities.
The whole study will last for 3 month, participants will be randomly assigned to two groups. Below is the structure of the and activity of this study.
Who can volunteer?
To be eligible, you must meet all of the following criteria:
1. An adult over the age of 18 living in a sedentary life style. (you will be test by sedentary behavior questionnaire to see whether you meet the criteria of having a sedentary life style)
2. Have no organized or non-organized physical exercise.
3. Basic English-speaking skills (participants with English as a second language are encouraged to participate)
4. Able to read and understand basic instructions 5. Living in Budapest, Hungary.
Our thank you:
In appreciation for your participation in this study you will have a chance to won a bicycle at the end of intervention. We will also provide you with free course of Yoga.
If you have questions about the study or think you want to volunteer please contact Feifei Wang – either by telephone +36702833412 WhatsApp: +36702833412 or email at feifei.wang@ppk.elte.hu Thank you for your interest and we hope to hear from you soon!
Feifei WANG Institute of Health Promotion and Sport Sciences, Doctoral School of Education, ELTE Eötvös Loránd University, HUNGARY
Dr. Silvia BOROS Institute of Health Promotion and Sport Sciences, ELTE Eötvös Loránd University, HUNGARY
Appendix 6
TERMS AND CONDITIONS TO PARTICIPATE IN RESEARCH
Tittle of study: The effect of daily walking exercise on sleep quality and stress Investigators:
Name: Feifei Wang Dept: PPK ELTE Email: feifei.wang@ppk.elte.hu Name: Dr. Szilvia Boros Dept: PPK ELTE Email: boros.szilvia@ppk.elte.hu Introduction
• You are being asked to be in a research study of walking exercise and sleep quality relations.
• You were selected as a possible participant because you meet the sedentary behavior questionnaire and keep yourself in good health condition.
• We ask that you to read this form and ask any questions that you may have before agreeing to be in the study.
Purpose of Study
• The purpose of the study is whether a daily one-hour walking exercise after dinner benefit sleep quality.
• Ultimately, this research may be published as a scientific paper, or presented in an academic conference etc.
Description of the Study Procedures
• If you agree to be in this study, you will be asked to do the following things: firstly, you need to complete the Sedentary Behavior Questionnaire to examine whether your daily life is sedentary.
• Everyone in the intervention group (Group A) needs to follow the daily walking exercise (10,000steps) and report exercise data to the instructor timely. For those who are in the control group (Group B), what you need to do keep your current life style due, and you are not
allowed to join any other exercise groups or trainings during the study. The study last for one month (four weeks). And, all of the volunteers exchange their role after one-month wash period. All the measurements were repeated. All the volunteers will do pre-post test in each intervention session.
• The tracking equipment are free to use for the volunteers. Walking exercise is self-controlled and tracked by daily dairy. All of the volunteers are obligated to record the start and end time of walking every day. And pedometers will be used for tracking walking steps count including heart rate and calories. You are not allowed to join any other exercise groups or trainings during the study.
• There are no reasonable foreseeable (or expected) risks.
• Important: if you lost the pedometer, you will be fined for 5000HUF.
Benefits of Being in the Study
• First, a free Yoga course is provided for all volunteers after the study.
• Second, you will get a chance to won a bicycle after complete the study.
• In case you are a student in ELTE, you will get 2 credits for participating in the study.
Confidentiality
• The records of this study will be kept strictly confidential. Research records will be kept in a locked file, and all electronic information will be coded and secured using a password protected file. We will not include any information in any report we may publish that would make it possible to identify you.
Payments
• There will be no payment except the benefit mentioned above for the volunteers.
Right to Refuse or Withdraw
• The decision to participate in this study is entirely up to you. You may refuse to take part in the study at any time without affecting your relationship with the investigators of this study.
You have the right to withdraw completely from the study at any point during the process.
Right to Ask Questions and Report Concerns
• You have the right to ask questions about this research study and to have those questions answered before, during or after the research. If you have any further questions about the study, at any time feel free to contact me, Feifei Wang at feifei.wang@ppk.elte.hu or by telephone at +36702833412(WhatApp). If you like, a summary of the results of the study will be sent to you.
• If you have any problems or concerns that occur as a result of your participation, you can report them to Feifei Wang at the contact information above.
Consent
• Your signature below indicates that you have decided to volunteer as a research participant for this study, and that you have read and understood the information provided above. You will be given a signed and dated copy of this form to keep, along with any other printed materials deemed necessary by the study investigators.
Subject’s Name:
Subject’s Signature: Date:
Investigator’s Signature: Date:
Appendix 7
Informed Consent and Description of Research (offline study)
You are about to participate in a research coordinated by Dr. Boros Szilvia. The research is carried out by highly qualified professionals and their assistants. The aim of this study is to investigate the effect of daily walking exercise on sleep quality and stress.
Participation is voluntary. Performing the various tasks and filling out the questionnaires is harmless and it is without any foreseen risks. It is possible to suspend participation so that it should not be tiresome. It is also possible to withdraw consent and terminate participation at any time without any reason and without any consequences. Monetary compensation is due for participation.
During the study recording of the daily walking exercise will also be performed by pedometer attached to the volunteer’s body. The recording has no health hazards, causes no pain. This investigation lasts for about one month for each group.
The results of this study later may be used in publications and will also be presented at scientific conferences. If requested, written or verbal information will be provided on these events.
All information collected during this research will be handled with strict confidentially.
Data obtained during the research is stored as coded information on a secure computer and paper-based material (e.g. questionnaires) is kept in a safe or a locked office also in a coded format. The individual codes are provided by the assistant in charge, and these are accessible and known only to her/him. Data of the research are analyzed statistically during which no personal identification is possible. The document with the rules regulating personal data processing (General Data Protection Regulation, GDPR) is attached with its enclosures.
No medical or laboratory report will be prepared about the results of the study. Verbal account can be provided about the findings upon request.
Please sign the agreement below if you agree with the conditions outlined above and endorse participation in the study. We thank you for your collaboration.
I………(undersigned) declare that I was given thorough information regarding the circumstances of my participation in the present research. I agree with the conditions and to participate in the study. I also give my consent to use the anonymous data collected during this process so that these may be accessible to other researchers. I reserve the right to terminate my participation at any time in which case the data belonging to my person should be erased.
I am not (and have not been) treated for any kind of neurological or mental disease.
ELTE FPP as data processor handles my above personal data confidentially and does not allow access to these for other data processing or data analyzing organizations of any kind. Details of this statement are found in the “Information of Processing of Data (GDPR)“ which I agree with as proven by my signature.
Budapest,……….
date signature
