IV. Testing of Educational Strategies

BACKGROUND AND PURPOSE
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This research was completed by the Harvard School of Public Health under a cooperative agreement with the National Highway Traffic Safety Administration and in collaboration with Equals Three Communications/Global Exchange, Inc. of Bethesda, MD. The purpose of the project is to (1) identify and provide detailed information about people at risk for fatal fall-asleep motor vehicle crashes and (2) develop educational messages and campaign strategies to help reduce their risk of driving while drowsy, an important contributor to fall-asleep driving deaths.

The present report details the findings of Phase III of this project. A panel of experts was convened by the National Highway Traffic Safety Administration and the National Center for Sleep Disorders Research to summarize the current state of knowledge on the problem of drowsy driving. This panel identified two groups that are likely to be at risk for fall-asleep automobile crashes, (1) young men and (2) shift workers and recommended that both groups be studied further.

In Phase I, qualitative research was conducted with members of each of these two groups. This research revealed that shift workers appeared to be more motivated and ready to change their behavior related to sleep and the conditions that contribute to drowsiness and fatigue compared with young men. Shift workers were judged to be more likely to respond to an intervention, and therefore were selected for further qualitative investigation.

Phase II of this research was conducted to provide detailed information about the environment of shift workers. Target groups interviewed for this project were shift workers, shift work supervisors, and upper-level managers and employers of shift workers. The information gathered in Phase II was used to develop several candidate campaign strategies for further testing.

The aim of Phase III research was to test creative concepts that target the factors that contribute to drowsy driving among shift workers. The reactions to these concepts will be used to develop educational materials..

METHODOLOGY
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We conducted focus group research in Portland, OR on July 27 and 28, 1998 and in Kansas City, MO on July 29 and 30, 1998. The sites were selected according to the following criteria:

  1. Geographic diversity.
  2. High concentration of workers scheduled to be working at night (e.g., health care industry, manufacturing, hospitality industry, airlines, shipping).
  3. High reliance on the automobile for transportation.
  4. Urban, suburban, rural mix.
  5. Existence of quality focus group facilities.

Participants

Shift workers were the target audience for this phase of the research. Two groups of shift workers were interviewed, one group of shift workers under age 30 in each city, and three groups of shift workers between 30 and 50 years of age. The under age thirty group was included to test how these messages would be perceived among young people, since this group was identified by the expert panel as a group at risk for fall asleep crashes and there may be certain overlap between shift workers and young people.

We conducted two groups on each night, for a total of eight. Each group consisted of eight to twelve participants, recruited by field houses at each site. All participants were licensed drivers. Most important, all participants had a history of driving while drowsy, as evidenced by responding "Yes" to at least two of the following statements:

  1. Have you ever fallen asleep or nodded off while driving?
  2. Have you started to drive or continued driving an automobile when you felt very fatigued, drowsy or sleepy three or more times during the past year?
  3. Have you driven an automobile after being awake for a period of eighteen hours or longer three or more times during the past year?

A copy of the telephone screener appears in Appendix F.

Most of the group participants were employed in blue collar labor, service (24 hour customer service), or health care positions.

Procedures

A moderator's guide was prepared to focus the discussion on the topic areas to be covered. The guide included a warm-up and introduction, and evaluation of various potential campaign strategies to reduce the risk of drowsiness and drowsy driving.

Each discussion group lasted approximately ninety to one-hundred twenty minutes.

Subject areas were:

A copy of the moderator's guide appears in Appendix G.

SUMMARY OF MAIN FINDINGS
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  1. Shift workers seem to recognize that drowsy driving is a big problem. However, they do not seem to fully recognize the ways that their lifestyle directly increases the relative risk of a fall-asleep crash or notice what they could change to reduce those risks. They recognize the serious potential consequences, but that knowledge alone does not motivate a change in behavior.
  2. Shift workers have a high level of awareness for the problem of drowsy driving. All have experienced negative outcomes that result from drowsy driving. Despite the high level of awareness of the problem and a stated desire to change their lifestyle, shift workers erect barriers and rationalize their situation to escape the need to take personal responsibility or exert personal control over their situation. To compensate, shift workers actively avoid thinking about the potential for bad outcomes, such as a fall-asleep driving crash.
  3. The family can serve as a very important leverage point for changing the sleep behavior of shift workers. Family members exert a great deal of influence over the sleep behavior of shift workers. The needs of the family take priority over sleep, and shift workers view their sleep as something they must trade-off to spend more time with their family.
  4. Shift workers appear to have a strong ability to conform to the plans and desires of others (e.g., family members, employers/supervisors) while subordinating their own goals. They are very accommodating to others needs. As a result, they fail to get sufficient sleep.
  5. Shift workers do not feel empowered or efficacious to exert control over their environment. They are reactive rather than proactive. They seem to have difficulty solving problems and easily give in to outside influences.
  6. Shift workers have a low level of expectation for the benefits that may result from making changes in their sleep behavior.
  7. Shift workers do not appear to take great pride in doing an outstanding job but rather are satisfied with completing their tasks. The desire to improve their work performance does not seem to be a high priority, nor are they motivated to do a better job at work. Appeals to get better sleep to improve job performance did not seem to have much currency for this group.
  8. Strategies of sleep education, quality of life and the consequences of drowsy driving were very successful in attracting the attention and interest of shift workers to messages about ways to reduce drowsiness. Messages that attempt to portray a concerned management and motivate using improved work performance did not appear to have much currency.
  9. Words such as "tired" or "fatigued" do not seem to have the right connotation in the context of this educational campaign, and shift workers notice this difference. They seemed to respond well to the terms "drowsy" and "sleepy" and these terms appear to more accurately target the risk state of the sleep deprived driver..

DETAILED FINDINGS
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Sleep Habits

The shift workers in the current set of groups described sleep habits consistent with other groups of shift workers we interviewed in previous research. Most group participants suggested that they sleep for a total of 4-6 hours per day on a consistent basis, although much of that sleep is not restful. Many of the respondents indicated that they tend to sleep "when they can." This approach to sleeping usually results in intermittent sleep ranging in duration from 15 minutes to 2 or 3 hours.

Even when shift workers do get to sleep, it does not appear that they are getting quality sleep.

"It's not a sound sleep."

"I'm fatigued even when I get a lot of sleep."

Shift workers frequently exhibit symptoms of this chronic sleep deprivation, such as the ability to fall asleep at any time or in any place.

"I'm falling asleep on the way home from work.."

"I can fall asleep when I want to."

Consistent with previous qualitative research, some group participants indicated that they had a history of sleeping difficulty (e.g., frequently wake up during the night or inability to fall asleep upon going to bed). As a result, many described themselves as being more comfortable in an off-set (from usual night time sleep practices) schedule where they were awake during the night.

"I'm more of a night person anyway."

"I force myself to sleep."

"I'm really nocturnal."

"I know it's daylight out, but my body won't let me sleep."

Distractions in the sleeping environment appear to contribute to poor sleep quality in this group of shift workers. The sources of many of these distractions are family members.

"On the weekend when I'm supposed to be on a normal person's sleep, I have trouble sleeping with someone. I love my husband dearly, but he's not supposed to be there when I'm sleeping."

"I wake up easily. I wonder what the kids are doing."

"I feel guilty if I get too much sleep, like I'm cheating somebody."

"I want to always be available for the kids if they need me."

"My kid's crisis is much more important than my sleep."

The feeling of responsibility for taking care of the children appears to supersede their own need to get the sleep necessary to take care of themselves and their family. Many of the participants refused to turn off the phone ringer or placed it near their bed on the off-chance that they may get a call about their kids. One participant even suggested that she purposely causes herself to get light sleep. She reported leaving the lights on so she could attend to the kids, who were home, awake and otherwise unattended while she was trying to sleep.

Several of the participants in the groups reported that they use certain medications (e.g., anti-histamines) or alcohol to help them sleep.

"I started to take something to go to sleep. I need it now in order to get sleep."

Although the prevalence of this practice among shift workers has not been documented, considering the reports from our group participants it may be widespread. One important communication area for this project to address may be to debunk the myth that these substances promote restful sleep in non-clinical, chronic use situations.

Despite erratic sleep patterns and the seemingly uncontrollable external factors that appear to drive those sleep patterns, many of the participants may be able to adapt to new or off-set (from usual night-time sleep practices) sleep patterns.

"You get programmed to cat napping."

"You get sleep when you can. Whenever I can catch it."

"I'm used to five, so even if I can sleep I'm up."

Although many of the shift workers we interviewed did have difficulty getting sleep, a small minority appear to have made adjustments that allow them to get sufficient sleep. These people recognize their need for sleep and seem to have made it a priority.

"I need my sleep or I don't function."

However, the intent to get sleep is not the only condition for ensuring good sleep habits. Many shift workers wish they could get more sleep, but they do not believe that they can.

"I value sleep. It's a hobby, but I value it."

Given the various constraints that shift workers perceive on their lives, they feel helpless to control the quantity of sleep they get. As a result, they seem to have low expectations for getting a sufficient sleep.

"Six hours I consider good."

"I need eight hours but I don't ever get eight hours."

"If I get five to six hours of sleep, I get too much."

"I need six to eight, I just can't get it."

The Effect of Work on Sleep

In the current interview we asked shift workers if their work affected their sleep. Most of the respondents did believe that their work schedule had a dramatic effect on the amount of sleep and sleep quality.

"If I work the swing or graveyard, I get less sleep. I'm awake at the same time each day."

"I just crash whenever I can. I get two to four hours at a time."

"I get a second wind leaving one job and going to another."

"If I'm on the go, I can keep going. If I stop, I'm worthless."

"It is hard to change (sleep habits) when the work schedule changes."

"I get more sleep if I'm on the evening or day shift."

A split sleeping schedule where the worker sleeps for four hours after coming home from work in the morning and an additional two hours prior to going back to work in the evening is commonly reported.

"I sleep right after work and again right before going to work. I get a total of six or seven hours."

There also appears to be a great variation in the amount of sleep and the time the sleeping occurs. The variation in sleep seems to depend upon factors such as time of the year (summer vs. winter), a rotating work shift schedule which can change monthly, weekly or even daily, and sleep "switching" (i.e., shifting sleep times from day sleep to night sleep over the weekend).

Many respondents indicated that when they had a day or weekend off, they reverted to a "normal" sleep schedule with their sleeping taking place in the night time hours. In a number of cases people indicated that they will stay awake for a period of 24 hours after working a shift in order to sleep during the normal hours. As a result, their body seems confused about when to be awake and when to be asleep.

"I can't get into a regular pattern."

"When I'm changing shifts I get too wound up to go to sleep."

"My sleeps will vary from night to night. It depends on the other things happening in my life."

Some of the apparently well adapted workers did not resort to sleep switching. Instead, they went to sleep at the same time every day, regardless of whether they were going to work.

Another problem that shift workers have is their inability to communicate their needs with other important people in their lives, such as family members and bosses. Many of them seem to be willing to do things for those people even when they have to sacrifice their sleep to do it. They are not confident enough in themselves to assert their own needs. Many of the shift workers in the groups seemed to let things happen to them. They tended to be reactive to their life situations rather than asserting personal control. As a result, many people also felt worn down by their lifestyle and working arrangement.

"I feel like sometimes all I do is sleep and work."

One owner of a small yard care business (his day job) said that competition and business pressure drives him to work and not sleep. His day job seemed to keep him highly motivated to push himself. He viewed his work at night as something that financially allowed him to work his day job.

The Effect of Sleep Deprivation on Job Performance

In previous focus groups, shift workers seemed reluctant to admit that their job performance was affected by their lack of sleep. This was also a consistent theme in the current groups.

"I don't think it (lack of sleep) has a big affect on performance."

Most of the comments we received were complaints about general tiredness. Other suggested that work errors did occur on tasks that require simple math and cognitive energy.

"I'm less efficient. I have to think more about what I have to do."

"You're just really slow."

"For tasks that take more cognitive energy, harder tasks, I try to do those earlier in the shift."

"I have to be extra careful doing dosage counts." (nurse)

"My job is more physical, not as much on mental tasks."

"It seems like I seem to make more mistakes and have to redo it."

Many of the workers did not appear to be concerned about these errors and inefficiency. They believed that as long as "the job gets done" they have done a good, or at least a satisfactory, job.

The other main performance-related problem that arose from this discussion was that many group participants indicated that they had a cranky, grumpy or poor attitude when they were tired.

"If I'm tired, I'm not very nice."

"It affects my attitude."

However, some participants indicated a concern about their safety when working while tired.

"I don't use power tools or sewing machines when I'm tired."

Personal safety on the job may be another leverage point for educational campaigns about sleep. They may also serve to further motivate employers to adopt some of these interventions.

The Effect of Shift Work on Driving

Nearly every person in the groups reported some type of experience with extreme drowsiness or tiredness that effected their driving. These included:

In addition, several of the group participants reported that they had co-workers from the night shift who had been killed or injured in a fall-asleep motor vehicle crash.

As with previous focus group interviews with shift workers, the present group was very concerned about the potential consequences of their sleep deprivation on driving.

"I can see it happening ‘cause it happened to me."

"When I get home I have nightmares of running off the road."

"You do things and you don't remember. You don't remember going from point A to point B."

They recognize drowsy driving as a "big" problem, although they do not seem to understand the relative nature of the risks from other factors (e.g., alcohol-impaired driving accounts for nearly forty percent of all fatal crashes). Many compared the seriousness of the problem to alcohol-impaired driving. Although the consequences may be similar or even worse for fall-asleep crashes (i.e., no attempt at braking in many fall-asleep crashes), it is not clear that the magnitude of drowsy driving crashes is on par with alcohol-impaired driving.

However, they only seem to recognize the risks of drowsy driving when they are forced to think about it. Most of the time they appear to put these thoughts out of their minds or at least try to minimize or compartmentalize their risks.

"Long distances is a problem."

"I didn't have as much trouble in the city."

Some participants had a sense of humor about the tendency to drive on "automatic pilot."

"Don't change vehicles. Your vehicle knows the way home."

They also did not seem to fully recognize that the lifestyle that they lead dramatically increases the relative risk of a fall-asleep crash.

The potential consequences are very serious, but by themselves they do not motivate a change in behavior.

"It was a concern, but I didn't make any adjustments."

They tended to view drowsy driving as something they could not do anything about and had a fatalistic sense of the consequences rather than something they had much control over.

"What can you do? The world is on a day schedule."

"Don't blink. If you blink you could lose it all."

However, they are also more afraid of what the potential consequences could be to others riding in the car. This seems to be a more powerful deterrent than injuring or killing themselves.

Methods Used to Get Restful Sleep

Consistent with our previous research, shift workers indicated that they used a variety of methods or tricks to help them sleep. These included:

The methods listed here are suggestions used by some shift workers to help them improve sleep that appear to have some legitimate basis for promoting sleep. Many other suggestions and techniques were offered by shift workers that appear to be detrimental to their efforts to get quality sleep (e.g., consuming alcohol or night time decongestants and anti-histamines).

A major problem is that most of the shift workers we interviewed do not seem to persist in their attempts to change their sleep habits or use some of the techniques that may help them get better quality sleep.

Shift workers need clear demonstration of the benefits of quality sleep. Many do not seem to recognize that they could be getting better quality sleep.

Encouraging shift workers to persist in methods that will improve their sleep will be a major challenge to any intervention. For each of the potential interventions recommended the communications should consist of the following components:

  1. convince the person that the intervention would be beneficial,
  2. provide explicit directions on what to do,
  3. explain what benefits should be expected as a result
  4. explain how those benefits can be detected, and
  5. describe the length of time needed to persist in those effects in order to notice the benefits.

Motivations for Changing Behavior

Based upon the focus group interviews it has become clear that shift workers do not appear to value sleep or place it as a high priority in relation to other things in their life. They have made choices to sacrifice sleep in order to participate in other activities on which they do place a high priority. Some are even convinced that working at night gives them "free" daylight hours that they otherwise would not have. In some cases the direct trade-off of sleep is not readily recognized.

"I always feel like I have days free. I want to do things."

This lack of recognition may present an opportunity for education or awareness raising in the campaign development.

Shift workers are willing to trade off sleep to achieve some of the other goals that are important to them. This is a decision they feel that they have to make. Many of them believe that consequences are worth the benefits they get from working shifts.

"It's the choice that I make. There are other things that I think are more important (than sleep)."

"I don't have any desire to change my shift. I like the way I work."

However, they seem to believe that the most likely consequences of sleep deprivation are general tiredness and an irritable attitude. They do not believe that other, more serious outcomes are likely to happen to them.

Shift workers appear to be very ingrained into the way that they do things. Their routines are their own and they like being different from other, "normal" people. They tend to see themselves as odd and different from everyone else.

"It's been 18 years since I've been on a regular shift, so I don't remember what it's like to be a regular person."

They identify with this role and erect barriers to making changes that removes that role.

Shift workers make a conscious choice to work overnight, whether due to a lack of ability to get a restful sleep and a preference to be awake at night or a preference to take advantage of the positive aspects of shift work (e.g., no bosses, lowered expectations for work production, ease of parking/light traffic, fewer people awake). They express a preference for working nights and enjoy some parts of night work.

The observation of shift workers that they are not capable of changing or prioritizing their lifestyle contrasts with their stated desire to feel better, be less tired and avoid the other problems related to sleep deprivation and the problems involved with shifting sleep schedules.

Many of the group participants reacted poorly to the suggestion that they "change their sleep." This seemed to be an unrealistic suggestion, since many of them had already made a conscious decision about the benefits of working nights. However, it may be that the message to improve sleep was interpreted as "get more sleep." Most shift workers believe that they cannot get more sleep.

Shift workers need suggestions to improve sleep that do not have a time cost. They need help with improving sleep quality, suggestions that can be done in the same time frame that they sleep now.

Language and Terms

Describing the Problem

In the initial groups in Portland we explored the use of certain language and terminology to determine if shift workers had a special way of communicating about their sleep and driving behaviors that targeted communications or an educational campaign could tap into. However, the results of these discussions were immediately clear so they were dropped for the subsequent groups.

We tested the preferences for the terms (1) sleepy driver, (2) drowsy driver, and (3) fatigued driver. In general, the consensus of the groups was that drowsy driver is the best term to describe the state that the campaign wanted to target. Drowsiness is state with which each of the participants was very familiar.

"I am a drowsy driver."

Most liked the alliteration and said that it "rolled off the tongue the best." They also liked the parallels with drunk driving.

"Dangerous. Drowsy. Driver."

"It tells you, you shouldn't be driving."

"It calls to mind drunk driver. It is something bad."

Some people suggested that each of these presented the stages that you go through, "first fatigued, then drowsy, then sleepy." Drowsy had the right connotation for this program, as one participant accurately summarized,

"When you are drowsy you think you can go further. I think it is more dangerous, because when you are feeling sleepy you know should get off the road."

Some felt that sleepy driver indicated that the driver was "already over the edge" and it was too late to make some type of change. One person said it was "cute" and was like "one of the seven dwarfs."

The term fatigued driver appeared to be the most vague. Some pointed out that you can be fatigued and still alert.

"I'm wide awake, just exhausted."

One of the groups like this term best because they did not want it to be an issue of blaming. However, removing the personal responsibility for behavior precludes a chance of being able to change their behavior or exert any control over it. One challenge of an educational campaign will be to empower people to change without blaming them for their circumstances or making them feel guilty.

The language of sleep & routines

We also explored the words shift workers used to describe their sleep or routines amongst themselves or with their family. In particular we wondered what words replace "a good night sleep" since they are obviously not sleeping at night. This discussion was not particularly insightful. No one seemed to use the terms "good day sleep" or "day sleeper." Their reaction to the proposal of these terms did not indicate much promise for attempting to coin a term that will relate to them.

When asked about the terms they do use they did not have anything to offer. The terms they did use to describe sleep, sleep habits and restful sleep were:

They thought of themselves as night people and seemed to identify with dracula or a night owl.

Shift workers talk with each other about sleep habits, but the focus of the conversations appear to be on talking about the problem and commiserating with each other, rather than about how to get better sleep.

"People don't ask you how you slept. They just complain about how tired they are."

"You either bitch about how much you didn't get, or brag about how much you did."

The talk about sleep deprivation appears to build a sense of camaraderie among shift workers. That tiredness gives them a sense that they belong.

The relationships shift workers have with each other and the ability for them to relate to the shared experience of sleep deprivation provides an excellent way of informally transmitting information through these peer connections. Interventions should take advantage these methods of communication to inform shift workers about how to get better sleep.

In general there does not seem to be any special terminology that shift workers use to describe sleep or talk about sleep with their co-workers..

TESTING OF PROGRAM CONCEPTS AND MESSAGE STRATEGIES
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Five communication strategies were identified as potential means of reaching the shift workers with messages about improving sleep habits. These strategies are designed to draw the attention of the target audience and form the base for the educational campaigns

From each of the various communication strategies a series of specific program messages were developed for testing. Two messages were developed in each of the areas. An art board with the message written in white block letters on a black background was displayed to the group while the copy points were read by the moderator. The boards were designed specifically to draw attention solely to the messages and not to any other aspect of (e.g., color, graphics) that may create an additional factor. The corresponding tag line appeared on the bottom of each board.

Sleep Education

The purpose of the sleep education strategy is to attract the audience with messages about sleep deprivation. The messages identify this common condition of sleep workers and provide information about how to improve their situation by increasing their knowledge about the benefits of sleep, sleep physiology, and how to get better sleep.

IT'S YOU AGAINST THE FORCES OF DARKNESS
Copy Points:
Tag line:

Wake Up And Get Some Sleep.

Focus Group Reaction:

The reaction to this message was mixed. Many of the group participants thought the concept was vague, although for some people it seemed to spark their interest. They indicated that the tag line helped focus attention on sleep. Others did not think it was catchy and said they would not give it a second thought or make the effort to look at it further.

"It doesn't seem to have anything to do with sleep."

"It doesn't say too much to me."

"It tells me I'm going against the norm."

Some of the participants thought that the message was mysterious. That quality was attractive to them and they wanted to learn more about it. Some thought on first glance it might be a religious appeal or a play on superstition or religious fear.

Others suggested that the message might be a turn-off to them because it portrayed darkness as something bad or something to work against. The shift workers we interviewed said they make a choice to work during the night because those work conditions and hours were more attractive to them.

"Darkness is my friend."

"The darkness is our ally.

"Darkness is good."

For this reason, the message seemed to miss the mark with the intended audience. A longtime night worker thought that the message might appeal more to those groups who are not consciously choosing the night shift.

A smaller group thought the message was threatening and expressed common worries about fear and darkness (e.g., worried about being attacked).

"It doesn't remind me of sleep. It reminds me of evil."

Related to that theme, the words "force" and "darkness" appear to evoke strong associations with pop culture. In every single group, there was some mention of the movie "Star Wars" or a character from that movie. One group participant said that the message had a comic book connotation and it might be more appealing to young people working the night shift.

One important feature of this message was that it seemed to place a positive spin on taking personal responsibility for making changes in sleep habits. It did not evoke feelings of defensiveness about the issue of being able to do something about sleep. Instead of blaming management or the individual worker, it transfers the source of the problem to the situation (i.e., working nights). This strategy appears to make it easier to deliver the message. However, as noted above, many workers are sensitive to their preferred work time and any message strategy that challenges that will not be well-received.

BEING TIRED ISN'T SOMETHING YOU CAN CURE OVERNIGHT
Copy Points:
Tagline:

Wake Up And Get Some Sleep.

Focus Group Reaction:

In comparison to the previous message, this message received a more positive reception. The groups seemed to like this concept because it spoke directly to the audience and made sense.

"It's a true statement. Being tired is not something you can cure overnight."

The information compelled the audience to want to know more.

"It makes you wonder what it is that you can do about it."

The message was communicated in a very clear fashion and directly conveyed the appropriate message. They appeared to understand that you cannot catch up on sleep and indicated that this was a message that some of their co-workers may need to hear.

"Just one night of sleep isn't going to do it."

"It means you can't catch up on sleep over the weekend."

"Sleep has to be a priority."

"It has to be a lifestyle change."

"It gives you an indication that it is a long term problem."

However, there was some indication that this message would be met with skepticism, since many shift workers rely on this tactic to make up for inadequate sleep during their work week. This serves as an example of why delivering this message to this target audience is important. Shift workers may be ready to believe that you cannot catch up on sleep all at once, but they may need very direct, convincing evidence.

"That's what I thought. Well can you? Is that true?"

"A lot of my coworkers would swear that is wrong."

"I would believe that I could make it up, but I'd be interested in reading more about it."

Some of the participants suggested that the word "tired" did not fit well in the message and offered to substitute the word "sleep." They felt that the word "tired" had a different connotation and did not specifically speak to the problem of drowsiness and drowsy driving.

"I can be very tired, feet hurt, back hurts. Tired can be tired of it all. But that doesn't mean sleepy."

Evaluation of the Sleep Education Strategy

The sleep education strategy was well-received. Clearly any attempt to alter sleep habits in this population must include some form of education about sleep, and the participants in the groups recognized this fact. This strategy was one of three that the group members endorsed as having potential to effect a change among themselves and their co-workers.

Most members of this group thought that they already knew a great deal about sleep and viewed it as a conscious choice that they make.

"I think most of us know these things. We make the choices."

"They're adults. They know how to regulate their lives."

However, when they were presented with new information, they clearly had the potential to learn much more. Most were very interested in the new information presented to them and did not seem to know even some basic information. Most of the information this group gets appears to come from personal experience or the experience and knowledge of their co-workers.

The negative reaction to this strategy came from the members of the group who already thought they were doing all they could.

The group participants also were sensitive that a message such as this would tend to be condescending and blaming. They tended to take any suggestion to take personal responsibility and control of a situation as blame. These people do not want to be singled out. They do not view themselves as being outside the social norms (a "the other guy is just as bad as me" mentality). Sleep education messages will need to be carefully crafted to emphasize the notion of exerting control over a difficult situation, and minimizing the potential interpretation of blame.

Sleep education will be an important strategy for effecting change in this population of high risk drivers.

Portraying a Concerned Management

In previous qualitative research with shift workers, a strong, recurring theme was that workers wanted their employers and managers to understand their situation and be concerned about the consequences of working night shifts for workers.

The shift workers we interviewed in previous groups were all rather skeptical of the motives of management, mostly feeling that the bottom line mattered more than the health, safety and morale of the night workers. If people on the night shift were going to be exposed to a program that promoted good sleep habits, they wanted their employers to demonstrate an understanding or a concern about the special problems they face in working rotating or night shifts. This appeared to be particularly important if the program was viewed as emanating from the employer.

MANAGEMENT WANTS TO SEE YOU GET TO WORK
Copy Points:
Tagline:

Sleep. Work. Drive. Make sure you're up for all of them.

Focus Group Reaction:

The groups had negative reactions to the strategy of portraying a concerned management. The workers in the current set of groups clearly wanted their employers to show more concern about the effect that work has on their sleep (and in turn their health and well-being) and to take steps to help them to make better adaptations to their night work. However, they take a very cynical view of management and the motives of their employers and upper-level supervisors.

As a result of this cynicism and skepticism, the mere mention of the word management in the concept message draws up their defenses.

"Off duty time is not a concern to them."

"I don't care what management wants to see."

"It sounds like an order."

"I have coworkers that would be offended by it, they feel like they work their butt off and don't want to be told what to do."

Some also suggested that having management tell them what to do would engender the opposite reaction.

"That makes you want to get less sleep just to show them."

Clearly even after being presented with this message, shift workers still believe management does not care about the worker.

"Management is concerned about the result, productivity."

"The word management tells me they are only interested in money."

"I can't imagine management using that sign."

"It seems condescending."

In fact, most of the group participants were not sure anything short of doing it themselves would get management to understand what it is like to work at night.

"They aren't going to have the sensitivity."

This finding contradicts what we found in interviews with upper-level managers. Many of them did have experience working on the night shift and seemed to have a fairly good understanding of the demands required of night workers. This suggests that a high level of communication between management and workers will be necessary for this program to succeed.

Many of the group participants seemed to take the message very literally upon first glance and that caused an immediate negative reaction. No one seemed to understand the meaning of "get to work" as it was presented in this message.

"It makes it sound like you aren't working hard enough."

"I know that. What else do you want from me, some blood?"

"It makes me think that they have a problem."

"They are complaining about your work."

"What? You don't think I'm working? Why don't you come and see me work?"

One change proposed by a participant was to alter the wording to read: "Management Would Like To See You Get Home." This change in tone may be enough to soften the hard tone of the management message. Some others in the group where this suggestion was offered agreed. One person suggested adding the word "safe" at the end.

MANAGEMENT WANTS TO KEEP YOU IN THE DARK
Copy Points:
Tagline:

Sleep. Work. Drive. Make sure you're up for all of them.

Focus Group Reaction:

Many of the same reactions to the previous message apply to this message as well. The concept of a concerned management is totally foreign to these shift workers and appears to contradict other messages that they receive from their employers.

"Rarely does management have our best interest at heart."

"I wouldn't pay attention because it was management."

"My job doesn't really care if I sleep or if I don't. I get bad vibes when I look at it."

For some the message did peak their interest, although again the immediate reaction is one of skepticism.

"It's thought provoking. It gets your attention."

"I'd be curious about what it means. When I found out I'd turn the page."

"It's manipulative. You might read it with your guard up."

Others questioned the lack of a tie-in with sleep and drowsy driving. The message about what to do is not clear.

"I wouldn't necessarily relate it to sleep."

This message, even more than the previous one brings out a very defensive reaction.

"They want to keep us in the dark and then inform us about something?"

"It's a conspiracy."

"They're hiding something."

"What are they trying to pull over our eyes?"

Even for those people who have worked as a manager or a supervisor, the immediate reaction to this concept came from the perspective of the worker.

"As a manager I wouldn't want my people to see that. It would play into what they already think."

Evaluation of the Concerned Management Strategy

The reaction to this strategy was quite negative. Although this group was consistent with previous groups in wanting management to be concerned about their safety and well-being, the execution of this strategy did not elicit a positive reaction. Most were very skeptical and cynical about management and their motivations. Even the word "management" in the message raised suspicions.

The reaction from the current groups probably reflects the difficulty in portraying a concern by management. Many workers perceive that their employers do not care. It may only be a very rare situation where the employer has an established relationship with its employees where a message of this type would work. This message would also have to be part of the context of other changes in the workplace. The message should also be consistent with other management actions.

"They want to see you work. But they're not willing to allocate any benefits toward it."

Portraying the concern of management will be an important strategy. However, shift workers want to see management act to show their concern not simply tell them. Portraying a concerned management will require deeds, not words.

Consequences of Drowsy Driving

The intent of the consequences strategy is to remind viewers of the potential for crashing their vehicle. Most shift workers we interviewed had experience with some type of drowsiness while driving. Many could relate to the potential for a crash, although most said they did not want to think about it. Many felt that they could not change their life in order to be more well-rested. Another important factor for shift workers when they judge the risks of driving while drowsy is that they have a great deal of experience driving under those conditions. In most of those cases they were able to do it without any adverse consequences. In addition, they tend to overestimate their ability to resist falling asleep at the wheel. They seem to feel that they have become conditioned to drive while drowsy and they can do it well.

The purpose of this communication strategy is to expose the shift workers to the potential of a fall-asleep crash and motivate them to seek information about how to change their life to avoid these kinds of crashes.

YOU ARE GETTING SLEEPY. VERY SLEEPY. AT THE COUNT OF THREE, YOU WILL NOT WAKE UP.
Copy Points:
Tagline:

Wake Up And Get Some Sleep.

Focus Group Reaction:

This message seemed to strike a chord with the group participants.

"It's good as a warning. It brings the reality of having a crash."

The message was clear and easily understood.

"It's like death to me."

"The message is that you need sleep."

"If you don't wake up you will get in an accident."

"It reminds me of the drunk driving billboards."

The group participants found the message to be very dramatic and elicit an emotional response. It served to remind people in this target audience of crashes or experiences they had with drowsy driving.

"It gives me a little chill down my spine remembering all the times that I came close."

Others said they liked the idea, but thought it would work best with a picture of a crash in the back to drive the message home.

Some said they did not like it because it was too powerful or because it has the suggestion of being lulled to sleep.

"It's too scary. It's like you're telling them to go to sleep."

This message was frightening to some of the group participants and they turned away from the reality of the situation. They do not want to be forced to examine their choice to work at night or question the way they live their lives.

"It sounds like death and I'd rather not think about that."

"You don't want to feel like you are being careless."

DON'T WAKE UP WITH BAGS UNDER YOUR EYES
icture:

Deploying driver-side and passenger-side airbags in a crashed vehicle shown from the driver's point-of-view.

Copy Points:
Tagline:

Wake Up And Get Some Sleep.

Focus Group Reaction:

As with the previous message, most of the group members liked the message and found it to be very straightforward and "clever." The message conveyed very specific consequences and was clearly aimed at drowsy driving.

"I love it. It's like reality."

"It got my attention."

"You don't want to have an airbag for breakfast."

"That's a little reality check."

It caught the attention of the audience and made them feel that drowsy driving is a serious issue. It seemed to create an awareness and suggest that this was an important problem.

Many of the participants also suggested that both of the "consequences" messages could be targeted to anybody driving, not simply shift workers.

The criticism of this message was that it had too much focus on airbags and not everyone has them in their cars.

"That appeals more to people who drive Volvos and have kids and live in the ‘burbs. I don't have airbags."

Some also wondered if at first glance it may be an anti airbags message.

Others reacted to the part of the message about appearance.

"Gross. I don't want bags under my eyes."

"Vanity would kick in and I would read it."

Women and the younger groups seemed to notice and be more concerned about the connotation of appearance in this message than others in the group.

Evaluation of the Consequences Strategy

The strategy of showing the consequences of drowsy driving received a positive reception among the groups. They indicated that the messages will certainly raise awareness of the problem.

The problem is that shift workers do not want to hear about the consequences of drowsy driving. They already report a high awareness of the problem. In fact, the people who are at increased risk for a fall-asleep crash do not perceive that they can do anything about it. As a result, they spend a great deal of energy trying to avoid thinking about the potential consequences.

"I'm tired of hearing about consequences. I know the consequences, at least in the back of the mind. I don't want to be hit over the head with it."

Messages about consequences will only be effective to the extent that they also provide information about how to change routines and behavior to avoid them.

The younger groups seemed more focused on the consequences compared with older groups. This may be because young people are bombarded with messages about the potential consequences of their risky behavior.

The response to a consequences message may be stronger when focusing on the potential effects of drowsy driving on other people, on family members in particular.

This strategy will be one important component of an overall strategy. However, relying only on messages about consequences will most likely result in the audience ignoring the messages.

Work Performance

The purpose of the work performance strategy was to get workers to be motivated to change their sleep behavior in order to improve their performance on the job.

SO YOU THINK YOU COULD DO THIS JOB WITH YOUR EYES CLOSED
Copy Points:
Tagline:

Wake Up And Get Some Sleep.

Focus Group Reaction:

The general reaction to this message was negative. Among some of the people with relatively unskilled and repetitive jobs, the messages hit a little bit too close to home.

"I can do some of my job with my eyes closed."

"My job I probably could do with my eyes closed."

Consistent with previous observations about members of this target group, they seem to interpret the message or headline in a very narrow or literal sense.

Some participants thought of the message in a humorous way.

"It brought to mind a ‘Homer Simpson.'"

The group participants seemed to like the safety warning and the danger inherent in working while drowsy that the message implied.

"It's scary. It's a safety issue."

"This message should show a picture of a machine shop."

Personal safety does seem to be an important hook for this group, at least while they are on the job where they perceive the risks they take are involuntary (subjected to by their employer). The safety issue is less of a concern to them when they are in their personal vehicles and perceive that they are choosing to assume the risks.

However, there were some negative aspects of this message that the group members perceived. Some thought it might be an attempt to convince employees that they are not performing up to expected levels, and this brought a defensive reaction from the group.

LACK OF SLEEP CAN REALLY AFFECT YOUR PERFORMANCE. NOT TO MENTION YOUR DRIVE.
Copy Points:
Tagline:

Wake Up And Get Some Sleep.

Focus Group Reaction:

This message was also not very well received. The drive to perform on the job does not seem to resonate with this audience. They do not seem to be concerned about or take great pride in their work performance.

"I'm getting the job done so I must be doing ok."

"Lack of sleep can affect your performance? Yeah I know that. I'm too tired to read about it."

A portion of this audience remains unconvinced that lack of sleep really does have an effect on performance.

Although some of the group members seem to like the message and understood the double meaning of the word drive in this context, many did not grasp it. They did not perceive the double meaning and focused their thinking on performance and evaluating their performance. This seemed to make them somewhat defensive.

Evaluation of the Work Performance Strategy

Messages trying to motivate workers to improve their work performance are not going to be successful in promoting changes in sleep behavior. The reaction to the work performance strategy and the specific executions were negative.

Many claimed not to care what the employer wants to see from them. They did not ever see the benefits of better performance so they were not very motivated to perform better.

"If the boss isn't complaining, who cares? You don't need to make any changes."

"There are no promotions, no money, no benefits for performing any better."

They also seemed to take a very narrow view of the relationship between employers and employees.

"They have no loyalty toward us. We have no loyalty toward them."

Most participants did not appear to take pleasure in their job and simply "put in the time" to get the job done. They talked about completing the work or tasks, not about doing a quality job. They seem to have very little to take pride in doing a job well, but simply getting it done.

Quality of Life

A major complaint of shift workers is that they are often tired and have little energy. In addition, their sleep schedules do not permit them to take advantage of the many parts of life that operate on a day schedule. As a result they feel they are missing things (particularly family events) and are not able to enjoy their lives as much as they otherwise might. This reason was often given as a justification for choosing to give up sleep to participate more fully in daylight activities.

The quality of life strategy advances the idea that shift workers would enjoy the time they have and be able to interact with their family, friends, and co-workers in a more positive way if they were able to be sufficiently well-rested.

NOW, IF ONLY YOU COULD GET EVERYONE ELSE ON YOUR SCHEDULE.
Picture:

Rooster crowing at a full-moon.

Copy Points:
Tagline:

Sleep. Work. Drive. Make sure you're up for all of them.

Focus Group Reaction:

The reaction to this message was mixed. The purpose of the message was not clear to many of the group participants.

"We're all on the same schedule? So what? What is the purpose?"

"That's not telling me anything."

"I don't like it. I don't even know my own schedule. I'm not a structured person."

"I'm not sure what the message is."

"I don't get it"

Consistent with previous observations about this target group, they interpreted the meaning of the message in a very literal sense. Therefore, the message did not seem plausible to the shift workers.

"That isn't reality."

The initial reaction from some members of the focus groups was to start smiling and laughing. They thought that the message would be humorous amongst shift workers.

"We would get a laugh about it. Other workers need to have a realization about us."

They thought that other people would have a difficult time working night hours. They know that others are not well adapted to work a night schedule.

For some people, the message spoke to their frustrations with working nights and their sense of isolation.

"I resent that I have to change for everyone else."

"You are the one that is the odd ball. You know you are on the outside and you will stay on the outside."

Conversely, others who interpreted the messages as getting other people to work during the night felt guilty for imposing their schedule on others.

"It sounds selfish. Why would they change for me?"

Some group participants reacted in a negative way to the message. In many cases shift workers work the hours they do in order to avoid the greater contact with people that occurs during the day light hours. The intrusion on their night world is unwelcome.

"We don't want everyone on our schedule."

Some people in the target audience can relate to this message and liked what it was saying. They want people to get a sense of how they lives and to see what life is like "in my shoes." They expressed a need for others in their life to understand the "fatigue that we as night workers experience" and how it affects them.

"My friends don't understand why I don't want to go out."

"People are unsympathetic. They think you're lazy if you sleep during the day."

"There's more to that problem than just us."

"Day people don't think you work as hard as they do."

"People don't know why you are sleeping during the day."

Some thought that this message may work well as a target for the family. They wanted information to bring home for the family to help them understand the problems associated with shift work and daytime sleeping.

TO SEE MORE OF YOUR FAMILY, TRY CLOSING YOUR EYES.
Copy Points:
Tagline:

Sleep. Work. Drive. Make sure you're up for all of them.

Focus Group Reaction:

This message seemed to work very well to catch the attention of the group participants. The family is a very important motivation for many shift workers to work during the night.

"A big reason I work third shift is because I can be home with my family."

"It has a good focus on the family. It's family oriented. That's why I'm out here doing this -- for the family."

However, this motivation also compels them to sacrifice sleep to see their family more.

Some people were very confused by the message because they see the trade-off as either sleep or family.

"That's a contradiction. It doesn't make sense."

"I don't know what that is supposed to mean."

"If you get more sleep, then you see less of your family."

"How do you want me to see my family when I'm sleeping? They are the reason I'm not sleeping."

"If you make the family a priority it takes time from sleeping."

They have consciously made the choice of family over sleep. A challenge of this campaign will be to sell shift workers on the idea that getting better quality sleep will result in increased quality with the time they do have with their family. This fine distinction needs to be clearly communicated so the target audience does not simply reject the message as something they cannot do. It will be important to emphasize getting quality sleep to make the most of awake time rather than thinking about increasing quantity and trading it off against family time.

As one group participant put it…

"If I don't get enough rest, it doesn't benefit my children."

One good point that was made by one participant was to change the wording to "enjoy your family more,..."

However, some people said they were angered by this message because they did not find that it recognized or confirmed the sacrifices they make for their family.

Evaluation of the Quality of Life Strategy

Improving quality of life appears to be a very strong motivation for shift workers. They recognize the problems associated with night work (e.g., sleep deprivation) and would like to minimize these problems. They want to make changes in their life but do not want those changes to compete with their established goals.

Quality of life appears to be an excellent hook for shift workers and may be a good place to start an educational campaign. The message of this strategy is that life beyond work is going to improve. Many shift workers reported that they are always tired and would like to do something to improve their life. The group participants liked the overall approach of changing sleep habits to improve quality of life.

"It gets you thinking about your life as a whole."

Shift workers were concerned about the quality of life outside of work. They feel that they put in the time at work and they want their rewards to come in their personal life.

Tag Lines

WAKE UP AND GET SOME SLEEP.

Many shift workers interviewed for this project liked this tag line and even thought it should take on a more central part of the campaign, in relation to the other messages that were tested.

The message was conveyed in a clear fashion that the audience understood and knew the appropriate action to take. They found it to be a clever word play that demanded their attention, spoke to their situation and gave them a specific course of action.

"It's like, wake up and smell the coffee."

A clear consensus from the groups was that this tag line had the most positive reception.

SLEEP. WORK. DRIVE. MAKE SURE YOU ARE UP FOR ALL OF THEM.

The reaction to this tag line was mixed. Some people seemed to like it, felt it accurately described the topic, and understood what the message wanted them to do. However, many more did not like the message or indicated that it did not speak to them. Some were confused by the message and tended to interpret it in a very literal sense.

"You don't get up for sleep."

This tag also suffered from a negative reaction to the work component. A clear message from many of the shift workers is that they are not motivated by improving their work performance. In fact, they believe they are doing a satisfactory job at work and have little reason to take steps to improve their performance.

In short, this tag did not seem to reach the workers we interviewed or hit key leverage points that are motivating to them.

.

Summary and Recommendations

  1. The motivation for conducting this research program is to reduce fall-asleep motor vehicle crashes. Shift workers clearly are sleep-deprived. This lack of sleep causes them to frequently drive while drowsy and places them at increased risk of fall-asleep crashes. We recommend that an intervention to reduce drowsy driving focus on improving sleep habits in order to reduce drowsiness, rather than focus on how to combat drowsiness while driving.
  2. Sleep is not a high priority for shift workers. They tend to not value sleep or at least place much less value on it compared to other aspects of their life. Although they frequently complain about the effects of sleep deprivation and report that they would like to improve their sleep habits, sleep is something that is sacrificed for other goals. Future strategies should account for this and make suggestions that will help shift workers use their time effectively and highlight the importance of sleep quality to improve the quality of their wakeful hours. An emphasis on sleep quantity will be immediately rejected as something they cannot do, although an increased quantity may be a result of improved sleep quality.
  3. The family is an important leverage point for an intervention with shift workers. Any intervention strategy that is going to be successful must target family members and involve them in the solution. Interventions that target family should emphasize their role in providing motivation for workers to improve their sleep habits. Interventions should also utilize family members in the process of solving problems that arise when sleep and family goals appear to conflict.
  4. Shift workers appear to place a high priority on family and the needs of family members, especially their children. The high priority placed on family was the primary or most often given reason for not getting sufficient sleep among shift workers. The daily routines of shift workers clash with the goals of other people in their environment who operate in a normal wake-sleep cycle (e.g., family members who have needs during the day time when shift workers are able to sleep). In order to effectively accomplish this, the shift worker and family members must be able to agree on common goals (e.g., the strength of the family) and allocate time to activities that promote those goals. When this issue is explicitly re-framed, shift workers may more readily recognize the importance of sleep to function as a contributing member of a family.
  5. Interventions must be presented to shift workers in a manner consistent with their other goals or priorities (e.g., family). The intervention should also result in something they view as desirable (e.g., feel better, more rested, better quality of life), and view as feasible (e.g., increased quality of sleep, not quantity) in order for them to be empowered by the intervention and persist in the changes.
  6. Shift workers appear to have difficulty solving problems that prevent them from getting sleep. One potential strategy that may help shift workers is to provide a model that encounters and successfully solves problems typically encountered by shift workers. This model should possess many of the same characteristics of shift workers, as uncovered in the research, and have goals and priorities that are consistent with the target audience. In addition, it must have clearly specified goals (e.g., increase sleep quality), behavior (e.g., sleep-promoting environment with no distractions) and measurable outcomes (e.g., feel more energetic during waking hours).
  7. Shift workers appear to have difficulty persisting in changes they do make to improve their sleep quality. They may need to be encouraged to alter their expectations about the benefits of improved sleep quality and how long they need to continue the change before they realize those benefits. Educational campaigns should emphasize that the benefits of improved sleep may be difficult to notice in terms of their own attitude/outlook or general level of tiredness in a daily or even weekly time frame. The goals or expectations for a change in sleep behavior should be set at a moderately high level in order for shift workers to be able to perceive a change. They may also require additional feedback (e.g., sleep diary with mood and drowsiness information) in order to see the changes that take place.
  8. Shift workers appear to interpret educational messages in a very literal sense. Messages that are clever or express multiple meanings may not be well understood by this target audience. Future strategies should account for this tendency and develop messages that are straightforward and easy to understand.
  9. The social environment on the workplace may be a fertile ground for intervening in the sleep behavior of shift workers. Co-workers frequently complain about sleep problems amongst themselves and many of the suggestions that people use to improve their sleep they learn from co-workers. Any intervention to improve sleep in shift workers should make use of these informal relationships and sources of information for delivering educational messages about improving sleep. In addition, spokespersons for any campaign message should share personal and environmental characteristics with the target audience. In other words, shift workers want to hear an educational message about sleep from "someone like me."
  10. Shift workers responded well to a comparison of drunk driving and drowsy driving. They recognized the similar danger of operating a motor vehicle while alcohol-impaired and sleep deprived or drowsy. However, any communication that draws this comparison must be careful not to overstate the prevalence of fall-asleep driving crashes or minimize the importance of alcohol as a factor in motor vehicle crashes.
  11. As noted in previous focus group interviews, many workers suggested that the safety meeting they regularly attend would be an ideal method of communicating messages about sleep and drowsy driving. They felt that this forum, more than any other demonstrates that management cares about their safety and well-being. This method may communicate the message of a concerned management in a more effective manner than trying to explicitly say that the management is concerned. This is consistent with the apparent message from shift workers to "show me" that management is concerned about their well-being.
  12. Shift workers may rely on medications (e.g., night time decongestants and anti-histamines) and alcohol in order to fall asleep. These substances are known to disrupt sleep and may increase sleep deprivation on a long-term use basis. One educational intervention should address the use of these substances and encourage the use of alternate methods of sleep promotion.
  13. Although the messages portraying the consequences of drowsy driving received a good response in the groups and appear to be excellent candidates for raising awareness of the issue of drowsy driving, by themselves they will not be successful in changing sleep behaviors in shift workers. Shift workers already appear to have developed a very good understanding of the risks of drowsy driving. All of the participants in these focus groups had experienced a bad outcome from driving while drowsy. (Note: See screening and entry criteria for the interviews.) Shift workers have highly developed cognitive skills for minimizing their own perception of the risks they take. We recommend focusing on what getting better sleep has in common with their other goals and encouraging changes in lifestyles and daily routines to enhance the common pursuit of those goals (e.g., taking care of their family) and sleep.
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[Appendix F]   [Appendix G]
[Contents]