title: Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work.
abstract: BACKGROUND
  Shift work is often associated with sleepiness and sleep disorders. Person-directed, non-pharmacological interventions may positively influence the impact of shift work on sleep, thereby improving workers' well-being, safety, and health.
  
  
  OBJECTIVE
  To assess the effects of person-directed, non-pharmacological interventions for reducing sleepiness at work and improving the length and quality of sleep between shifts for shift workers.
  
  
  METHODS
  We searched CENTRAL, MEDLINE Ovid, Embase, Web of Knowledge, ProQuest, PsycINFO, OpenGrey, and OSH-UPDATE from inception to August 2015. We also screened reference lists and conference proceedings and searched the World Health Organization (WHO) Trial register. We contacted experts to obtain unpublished data.
  
  
  METHODS
  Randomised controlled trials (RCTs) (including cross-over designs) that investigated the effect of any person-directed, non-pharmacological intervention on sleepiness on-shift or sleep length and sleep quality off-shift in shift workers who also work nights.
  
  
  METHODS
  At least two authors screened titles and abstracts for relevant studies, extracted data, and assessed risk of bias. We contacted authors to obtain missing information. We conducted meta-analyses when pooling of studies was possible.
  
  
  RESULTS
  We included 17 relevant trials (with 556 review-relevant participants) which we categorised into three types of interventions: (1) various exposures to bright light (n = 10); (2) various opportunities for napping (n = 4); and (3) other interventions, such as physical exercise or sleep education (n = 3). In most instances, the studies were too heterogeneous to pool. Most of the comparisons yielded low to very low quality evidence. Only one comparison provided moderate quality evidence. Overall, the included studies' results were inconclusive. We present the results regarding sleepiness below. Bright light Combining two comparable studies (with 184 participants altogether) that investigated the effect of bright light during the night on sleepiness during a shift, revealed a mean reduction 0.83 score points of sleepiness (measured via the Stanford Sleepiness Scale (SSS) (95% confidence interval (CI) -1.3 to -0.36, very low quality evidence). Another trial did not find a significant difference in overall sleepiness on another sleepiness scale (16 participants, low quality evidence).Bright light during the night plus sunglasses at dawn did not significantly influence sleepiness compared to normal light (1 study, 17 participants, assessment via reaction time, very low quality evidence).Bright light during the day shift did not significantly reduce sleepiness during the day compared to normal light (1 trial, 61 participants, subjective assessment, low quality evidence) or compared to normal light plus placebo capsule (1 trial, 12 participants, assessment via reaction time, very low quality evidence). Napping during the night shiftA meta-analysis on a single nap opportunity and the effect on the mean reaction time as a surrogate for sleepiness, resulted in a 11.87 ms reduction (95% CI 31.94 to -8.2, very low quality evidence). Two other studies also reported statistically non-significant decreases in reaction time (1 study seven participants; 1 study 49 participants, very low quality evidence).A two-nap opportunity resulted in a statistically non-significant increase of sleepiness (subjective assessment) in one study (mean difference (MD) 2.32, 95% CI -24.74 to 29.38, 1 study, 15 participants, low quality evidence). Other interventionsPhysical exercise and sleep education interventions showed promise, but sufficient data to draw conclusions are lacking.
  
  
  CONCLUSIONS
  Given the methodological diversity of the included studies, in terms of interventions, settings, and assessment tools, their limited reporting and the very low to low quality of the evidence they present, it is not possible to determine whether shift workers' sleepiness can be reduced or if their sleep length or quality can be improved with these interventions.We need better and adequately powered RCTs of the effect of bright light, and naps, either on their own or together and other non-pharmacological interventions that also consider shift workers' chronobiology on the investigated sleep parameters.
authors.affiliation: Institute and Policlinic for Occupational Medicine, Environmental Medicine and Preventive Research, University of Cologne, Kerpener Str. 62, Cologne, Germany, 50937.
authors.forename: Tracy E
authors.initials: TE
authors.lastname: Slanger
authors.forename: J Valérie
authors.initials: JV
authors.lastname: Gross
authors.forename: Andreas
authors.initials: A
authors.lastname: Pinger
authors.forename: Peter
authors.initials: P
authors.lastname: Morfeld
authors.forename: Miriam
authors.initials: M
authors.lastname: Bellinger
authors.forename: Anna-Lena
authors.initials: AL
authors.lastname: Duhme
authors.forename: Rosalinde Amancay
authors.initials: RA
authors.lastname: Reichardt Ortega
authors.forename: Giovanni
authors.initials: G
authors.lastname: Costa
authors.forename: Tim R
authors.initials: TR
authors.lastname: Driscoll
authors.forename: Russell G
authors.initials: RG
authors.lastname: Foster
authors.forename: Lin
authors.initials: L
authors.lastname: Fritschi
authors.forename: Mikael
authors.initials: M
authors.lastname: Sallinen
authors.forename: Juha
authors.initials: J
authors.lastname: Liira
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Erren
mesh_terms: D001510:Bed Rest; D006970:Disorders of Excessive Somnolence / Q000628:therapy*; D015444:Exercise; D006801:Humans; D010789:Phototherapy / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D020178:Sleep Disorders, Circadian Rhythm / Q000628:therapy*; D013997:Time Factors; D014940:Work Schedule Tolerance