Adolescent Sleep Health Belief Scale

1. Abstract

The Adolescent Sleep Health Belief Scale is an empirically validated psychometric instrument designed to evaluate the cognitive, evaluative, and attitudinal determinants underlying adolescent sleep behaviors. Rooted comprehensively in the Health Belief Model (HBM), the instrument departs from descriptive symptom inventories by interrogating the core psychological mechanisms that drive whether a young individual adopts, sustains, or rejects evidence-based sleep hygiene regimens. Comprising 46 items scored on a 5-point Likert-type scale, the instrument evaluates six theoretical dimensions: Perceived Susceptibility, Perceived Severity, Perceived Benefits, Perceived Barriers, Self-Efficacy, and Health Motivation.

Initial psychometric evaluation was conducted within a normative cohort of 494 high school students (9th and 10th grades) in Antalya, Türkiye. The scale demonstrated excellent content validity, achieving a Scale-Level Content Validity Index (S-CVI) of 0.94 following review by an expert panel of public health nursing scholars. Exploratory factor analysis via principal components analysis with oblique rotation confirmed a clear six-factor architecture that accounts for 57.7% of the total cumulative variance, supported by an outstanding Kaiser-Meyer-Olkin measure of sampling adequacy (KMO = 0.92). Subscale internal consistency estimates exhibited robust reliability parameters, with Cronbach’s alpha coefficients ranging from 0.69 for Perceived Barriers to 0.92 for Perceived Susceptibility, complemented by split-half reliability coefficients of 0.92 and 0.78 across test halves. This instrument provides developmental pediatricians, educational psychologists, public health practitioners, and school health professionals with an empirically sound framework to identify maladaptive cognitive patterns and craft targeted interventions to mitigate chronic adolescent sleep restriction.

2. Keywords

Adolescent Sleep Health Belief Scale, Health Belief Model, Sleep Hygiene, Psychometrics, Scale Validation, Adolescent Health, Cognitive Appraisal, Health Behavior Change, Preventive Interventions, Exploratory Factor Analysis, Perceived Barriers, Sleep Quality

3. Authors

The Adolescent Sleep Health Belief Scale was conceptualized, designed, and psychometrically validated by academic nursing and pediatric health researchers in Türkiye:

• H. Kadıoğlu, PhD, RN — Professor / Senior Researcher, Department of Public Health Nursing, Faculty of Health Sciences, Marmara University, Istanbul, Türkiye. Primary institutional correspondence: [email protected].
• Collaborating clinical research teams and public school health specialists affiliated with regional health directorates and academic pediatric nursing consortiums across Antalya and Istanbul, Türkiye.

4. Purpose

The adolescent developmental phase represents a uniquely vulnerable period marked by extensive neurobiological reorganization, circadian phase delays, and escalating academic, social, and digital commitments. Despite well-established clinical evidence demonstrating that chronic sleep deprivation induces neurocognitive impairments, affective dysregulation, metabolic disturbances, and elevated risks for psychopathology, conventional epidemiological approaches have historically relied upon descriptive sleep diaries, polysomnography, or symptom checklists such as the Pittsburgh Sleep Quality Index (PSQI). While these diagnostic methodologies effectively document sleep deficits, they fail to illuminate the underlying cognitive decision-making processes that maintain non-restorative behavioral patterns. The Adolescent Sleep Health Belief Scale was formulated specifically to address this critical methodological lacuna.

The primary clinical and research objective of the instrument is to explicate why adolescents knowingly perpetuate nocturnal behaviors that curtail sleep duration. Rather than measuring sleep as a passive, purely biological consequence, the scale quantifies sleep hygiene as a motivated self-regulatory behavior guided by health beliefs and subjective cost-benefit balances. In school-based health promotion, community nursing, and adolescent medicine, the tool enables clinicians to pinpoint the precise cognitive bottlenecks preventing behavior modification. For instance, an adolescent may understand that eight hours of sleep is optimal yet fail to adopt appropriate sleep hygiene due to negligible perceived susceptibility to health hazards or overwhelming perceived social barriers. By diagnostic profiling across distinct cognitive domains, clinicians can avoid generic psychoeducation and deploy targeted interventions, such as motivational interviewing to attenuate perceived barriers or cognitive restructuring to enhance perceived personal susceptibility.

In academic research, the instrument functions as an empirical bridge between cognitive health psychology and pediatric sleep medicine. It empowers investigators to systematically evaluate mediating and moderating relationships among socioeconomic status, digital media engagement, academic strain, and objective sleep parameters. Furthermore, the scale serves as a standardized outcome assessment metric for randomized controlled trials evaluating the efficacy of school-based behavioral interventions, cognitive-behavioral therapy for insomnia adapted for adolescents (CBT-I), and public health educational campaigns.

5. Psychological Construct

The core psychological construct quantified by this measurement tool is sleep-related health beliefs, conceptualized as an integrated network of cognitive evaluations, subjective probability judgments, and motivational valences that dictate how adolescents navigate choices regarding rest, bedtime routines, and sleep environment management. The scale operationalizes this multidimensional construct across six clearly demarcated subscales:

Perceived Susceptibility

This subscale evaluates an adolescent’s subjective assessment of their personal vulnerability to the adverse physical, cognitive, and psychosocial consequences of inadequate sleep hygiene. Rather than evaluating generic awareness that sleep deprivation is detrimental, this dimension captures whether the respondent believes that they themselves will experience somatic fatigue, memory consolidation failure, emotional lability, academic decline, or immune compromise if they sustain short sleep duration.

Perceived Severity

Perceived Severity gauges the adolescent’s cognitive appraisal regarding the seriousness and clinical significance of sleep deprivation consequences. Items examine whether the respondent evaluates chronic sleep debt as a severe health hazard capable of inducing chronic organic morbidity, impaired physical growth, enduring emotional disturbances, and irreversible social or academic dysfunction, as opposed to viewing it as a transient, trivial inconvenience readily remedied by weekend oversleeping.

Perceived Benefits

This dimension operationalizes the subjective utility and tangible value an adolescent attributes to adhering to regular sleep hygiene practices. It measures beliefs concerning the extent to which restorative nocturnal sleep enhances daytime energy, optimizes concentration during scholastic assessments, bolsters athletic and physical performance, and improves psychological wellbeing and daily planning capacities.

Perceived Barriers

Perceived Barriers assesses the external and internal obstacles, opportunity costs, and friction points that discourage the adolescent from achieving timely and restorative sleep. These include competing academic workloads, peer pressure, Fear of Missing Out (FOMO), compulsive nocturnal smartphone and social media engagement, unsupportive domestic environmental conditions (e.g., ambient noise, shared bedroom accommodations), and physiological difficulties unwinding before sleep.

Self-Efficacy

Grounded in Banduran social cognitive theory, this subscale quantifies the adolescent’s perceived behavioral control and confidence in their capability to execute sleep-promoting actions despite competing temptations or structural barriers. It evaluates self-assurance in disengaging from electronic screens, establishing a consistent bedtime schedule, resisting evening caffeine intake, and managing ambient environmental disruptions.

Health Motivation

Health Motivation measures the adolescent’s general intrinsic drive, readiness, and deliberate behavioral intention to prioritize personal wellness and restorative physical rest within their broader hierarchy of personal goals and daily activities.

6. Theoretical Framework

The foundational architecture of the Adolescent Sleep Health Belief Scale is anchored in the Health Belief Model (HBM), originally formulated by social psychologists Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegeles in the United States Public Health Service during the 1950s, and later expanded by Becker and colleagues. The HBM remains one of the most widely applied expectancy-value conceptualizations in behavioral science, positing that health-related actions are directly determined by two overarching subjective evaluations: threat perception and outcome expectations.

Threat perception is a combined function of perceived susceptibility to an adverse condition and the perceived severity of its anticipated sequelae. Within the context of adolescent sleep health, the model asserts that teenagers will rarely alter entrenched nocturnal routines unless they perceive that chronic sleep restriction poses an authentic, imminent threat to their physiological integrity and personal goals. However, threat appraisal alone is insufficient to trigger sustained behavioral modification. It must be balanced by outcome expectations, which represent an internal cognitive ledger weighing perceived benefits against perceived barriers.

Later revisions of the HBM integrated Albert Bandura’s construct of self-efficacy and general health motivation. In pediatric and adolescent health psychology, self-efficacy is frequently the primary empirical determinant of actual behavioral adherence. Even when an adolescent accurately gauges personal vulnerability and acknowledges the profound benefits of restorative sleep, the presence of digital distractions and peer communications will suppress healthy sleep behaviors if personal agency and self-regulatory confidence are low. By formalizing these six interdependent theoretical constructs into psychometric indicators, the instrument enables rigorous structural equation modeling and empirical evaluation of health behavior change pathways in youth populations.

7. Validity

The psychometric validation protocol for the Adolescent Sleep Health Belief Scale followed strict methodological standards to establish content, construct, and translational validity:

Content Validity

To establish rigorous content validity, an initial pool of 81 candidate items was evaluated by a multidisciplinary panel of ten experts specializing in public health nursing, pediatric psychology, and behavioral instrument development. Panelists appraised each item for semantic clarity, developmental appropriateness for secondary school pupils, and conceptual congruence with the theoretical definitions of the Health Belief Model using a standardized four-point ordinal rating rubric. The assessment yielded an outstanding Scale-Level Content Validity Index (S-CVI) of 0.94, exceeding the conventional psychometric acceptability criterion of 0.90. Items failing to achieve an Item-Level Content Validity Index (I-CVI) of at least 0.80 were systematically deleted or rephrased prior to field administration.

Construct and Structural Validity

Construct validity was formally examined through exploratory factor analysis within a field validation sample of 494 high school adolescents. Sampling adequacy was verified via the Kaiser-Meyer-Olkin metric (KMO = 0.92), alongside a statistically significant Bartlett’s Test of Sphericity (χ², p < .001), corroborating the presence of substantial inter-item correlations suitable for factor extraction. The 46-item final factor model demonstrated robust multidimensional construct representation, explaining 57.7% of the total cumulative variance in adolescent sleep health beliefs. Convergent and discriminant properties across subscales were supported by the distinct factor clusterings and theoretical congruence of the observed latent vectors.

8. Reliability

Reliability of the Adolescent Sleep Health Belief Scale has been established through evaluations of internal consistency and split-half coefficient stability:

• Internal Consistency (Cronbach’s Alpha): The subscales exhibited solid to outstanding internal consistency coefficients across all functional dimensions. Perceived Susceptibility yielded an alpha of 0.92, Perceived Severity achieved 0.90, and Perceived Benefits achieved 0.90, demonstrating exceptional item interrelatedness and minimal measurement error within threat and benefit appraisals. The Self-Efficacy and Motivation subscales demonstrated robust internal consistency within acceptable psychometric limits. The Perceived Barriers subscale registered an alpha coefficient of 0.69, which is accepted in psychometric literature as reflecting the inherently multidimensional and heterogeneous nature of modern adolescent lifestyle barriers (e.g., competing domestic duties, academic deadlines, electronic blue-light exposure, and peer interactions).
• Split-Half Reliability: To verify split-half reliability and rule out length-dependent fatigue biases, the analytical dataset was examined using the Spearman-Brown corrected split-half technique. The analysis produced coefficients of 0.92 for the first half of the instrument and 0.78 for the second half, demonstrating stable inter-item covariance structures across the entirety of the 46-item inventory.

9. Factor Analysis

The latent dimensionality of the Adolescent Sleep Health Belief Scale was evaluated through Principal Components Analysis (PCA) accompanied by an oblique (promax/direct oblimin) rotation method. The selection of an oblique rotation was theoretically grounded; psychological constructs derived from the Health Belief Model operate interactively rather than independently in natural behavioral environments. Forcing orthogonal independence through methods such as varimax would have obscured authentic inter-construct correlations, such as those between self-efficacy and perceived barriers.

The initial analysis examined an 81-item candidate pool. A rigorous reduction process systematically eliminated 35 items based on pre-established psychometric exclusion criteria: (a) failure to demonstrate a primary factor loading of ≥ 0.32, (b) the presence of prominent cross-loadings with an inter-factor differential of less than 0.10, or (c) theoretical incongruence with the target latent dimension. The final 46 items converged into a clean six-factor solution accounting for 57.7% of the total observed variance:

• Factor 1: Perceived Susceptibility — Accounted for the largest proportion of construct variance (15.0%), highlighting personal vulnerability as the primary statistical driver within adolescent sleep appraisals. Factor loadings ranged from 0.54 to 0.80.
• Factor 2: Perceived Severity — Accounted for 9.9% of total variance, with factor loadings ranging from 0.48 to 0.76.
• Factor 3: Perceived Benefits — Accounted for 9.8% of total variance, with factor loadings ranging from 0.50 to 0.78.
• Factors 4, 5, and 6: Self-Efficacy, Motivation, and Perceived Barriers — Accounted collectively for the remaining 23.0% of the explained construct variance, with retained primary item loadings spanning from 0.42 to 0.75.

10. Instrument / Measurement Tool

• Test Type: Multidimensional psychometric self-report questionnaire.
• Format: 46-item standardized inventory.
• Response Scale: 5-point Likert scale (1 = Strongly disagree, 2 = Disagree, 3 = Undecided/Neutral, 4 = Agree, 5 = Strongly agree).
• Construct Dimensions / Subscales:
  • Perceived Susceptibility (vulnerability to negative physical and cognitive effects of sleep deprivation)
  • Perceived Severity (seriousness of the physical, developmental, and immune consequences of poor sleep)
  • Perceived Benefits (recognition of functional gains from sleep hygiene, such as improved daily alertness and memory)
  • Perceived Barriers (perceived environmental, digital, and academic impediments to adequate sleep)
  • Self-Efficacy (individual confidence in the capability to execute and maintain healthy sleep behaviors)
  • Health Motivation (intrinsic readiness and drive to prioritize sleep over competing nocturnal activities)
• Scoring Instructions: Responses are coded from 1 to 5. Items comprising the Perceived Barriers subscale are reverse-coded prior to subscale score aggregation. Subscale scores are calculated independently to evaluate specific cognitive belief domains. Higher scores reflect more adaptive health beliefs, stronger perceived self-efficacy, higher motivation, and greater recognition of sleep health benefits.
• Original Language: Turkish.
• Target Population: Adolescents and secondary education students (grades 9 through 12, ages approximately 14–18 years).
• Administration Setting: Classroom group administration or individualized clinical/school nursing context (completion time approximately 15–20 minutes).

11. Permissions & Fee and Test Year

The Adolescent Sleep Health Belief Scale was formally published in 2025 in the peer-reviewed academic journal Florence Nightingale Journal of Nursing. The instrument was developed under academic non-profit institutional auspices at Marmara University in Istanbul, Türkiye.

The scale is protected under standard academic copyright held by the primary authors and the publishing journal. The instrument may be utilized for academic non-commercial research, graduate dissertations, and school-based clinical evaluations provided that formal institutional permission is requested from the corresponding author (H. Kadıoğlu, [email protected]) and the original validation paper is accurately cited. Commercial utilization, institutional health system licensing, or inclusion in digital health software applications requires explicit contractual authorization from the copyright proprietors.

12. References

The theoretical framework, psychometric methodology, and empirical findings associated with this scale are documented in the following academic references:

• Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
• Becker, M. H. (1974). The Health Belief Model and personal health behavior. Health Education Monographs, 2(4), 324–473. https://doi.org/10.1177/109019817400200407
• Kadıoğlu, H., et al. (2025). Development and preliminary psychometric properties of the Adolescent Sleep Health Belief Scale. Florence Nightingale Journal of Nursing, 33(1). https://doi.org/10.5152/FNJN.2025.25138
• Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Research in Nursing & Health, 29(5), 489–497. https://doi.org/10.1002/nur.20147
• Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

13. Items of the Scale