Charge Your Brainzzz: the systematic development of a whole systems action program promoting sleep health in adolescents

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Heemskerk, Vincent Busch, Jessica T. Piotrowski, Carry M. Renders, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5919594/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Inadequate sleep among Dutch adolescents is a complex public health issue with detrimental effects on physical and mental well-being. Previous interventions have shown limited or no lasting effects. While systems approaches help to understand and address such challenges, effective prevention efforts require evidence-based intervention design using behavior change techniques. This study outlines the systematic development of a ‘whole systems action program’ , named Charge Your Brainzzz (CYB), to promote healthy sleep in Dutch adolescents aged 12-15, by integrating theory- and evidence-based behavior change methods using the Intervention Mapping Protocol into a systems science approach, combined with stakeholder engagement Methods The CYB program was developed based on previously identified key system dynamics influencing adolescent sleep and a detailed action plan targeting these dynamics. The development was guided by five steps inspired by the Intervention Mapping protocol: defining the program goal and prioritizing system dynamics outcomes across various interconnected subsystems (step 1), specifying performance objectives (step 2), constructing matrices of change objectives (step 3), developing program components while selecting theoretical methods and practical applications (step 4), and program production and formative testing (step 5). Adolescents, parents, teachers, school boards, school care coordinators, youth healthcare professionals, and Healthy School advisors were actively involved. Results The whole systems action program CYB consists of eight program components and includes: 1) an educational component, 2) a step-by-step guide for implementing school sleep health policies, 3) a parent information evening, 4) an online magazine, 5) Teen Sleep Check, 6) Sleep Guide, 7) Tool for monitoring and early detection for sleep (behavior) problems, and 8) implementation materials including a website. Conclusions The CYB program is the first whole systems action program designed to promote adolescent sleep health. Using a Systems Science approach, the Intervention Mapping (IM) protocol, and stakeholder engagement, the program addresses the complexity of the health issue, the lived experiences of the target groups, and a solid theoretical foundation for behavior change. Beyond presenting the program’s components, this study offers a replicable roadmap for addressing complex public health challenges, paving the way for innovative, system-oriented solutions in health promotion. Adolescent Health behavior Health Promotion Intervention Mapping Sleep Systems Science Approach Teens Whole systems action program Youth Figures Figure 1 Glossary Action Scales Model (ASM) – Framework for understanding and addressing complex problems by distinguishing multiple levels (i.e., events, structures, goals and beliefs) to analyze a system and to intervene within a system to initiate systems change (1). Causal Loop Diagram (CLD) – Visual representation of a system and its dynamics visualizing factors, their interrelationship and feedback loops (2). Charge Your Brainzzz (CYB) – Whole systems action program in the Netherlands aiming to improve the system to promote the sleep health of Dutch adolescents aged 12-15 years. Intervention Mapping (IM) – Systematic framework for developing theory- and evidence-based health promotion interventions and programs. It integrates theoretical knowledge, empirical evidence, and stakeholder input throughout the developmental process (3). Leverage points – Modifiable points within a system. When these points are altered, this could lead to changes in the functioning, and thus the (health)outcome, of the system (4). Whole Systems Approach (WSA) – An approach to address complex problems by considering interconnected factors and relationships within an entire system to develop holistic and sustainable solutions (5). Whole Systems Actions Plan – A plan/strategy that addresses complex problems by integrating and coordinating actions across all system levels and different subsystems and settings to achieve systemic, sustainable systems change (6). Whole Systems Action Program – A program, grounded in theory and evidence-based behavior change methods, designed to address complex problems by integrating and coordinating actions across different system levels and its subsystems. Background Poor adolescent sleep health is an increasingly recognized public health concern in many countries (7). The Netherlands is no exception with over 50% of adolescents aged 14–17 sleeping less than the recommended minimum of 8 hours per night (8) and 24% of adolescents aged 12–16 rating their sleep quality as poor (9). This worrisome trend is further illustrated by the fact that the prevalence of sleep health problems among youngsters aged 12-25 is still increasing. In 2022, 22% percent of Dutch adolescents reported sleep problems compared to 14 percent in 2017 (10). Inadequate sleep health is intricately linked to various aspects of adolescent physical health, mental health and cognitive performance, including for example physical inactivity, decreased emotion regulation, increased risk-seeking behaviors and poor academic performance (11). The increasing prevalence of inadequate sleep health among adolescents and its adverse impacts on adolescent life emphasizes the need for interventions addressing sleep health in this population. Thus far, preventative interventions aimed at promoting healthy adolescent sleep, via e.g., sleep education or relaxation techniques, have shown only minor or no significant, lasting effects (12). A factor that likely hampers the effectiveness of current preventative adolescent sleep health interventions is that most have not taken into account the complexity of sleep health in the intervention design (13, 14). Instead, existing interventions tend to target specific social cognitive determinants, such as knowledge or attitudes, within specific settings like schools (14). However, adolescent sleep health is far more complex, being shaped by the dynamic interplay between many biological, economic-, physical-, sociocultural-, and political factors. Inasmuch, there is a clear need for a comprehensive whole systems approach that embraces and integrates this complexity (15). Systems thinking methodologies can be applied to gain a good understanding of the complex health problem at hand, as well as to develop comprehensive approaches to tackle it (4). A recent study illustrated this by providing insights into the determinants of adolescent sleep health, the system dynamics (e.g., interrelations and feedback loops), and the underlying mechanisms that integrate them into a holistic complex system. It also identified potentially impactful leverage points to focus sleep health promotion efforts on in order to realize effective, durable system changes (15). Subsequently, another study showed how such insights were used to develop a ‘whole systems action plan’ , which outlines a wide range of proposed actions, serving as a guide for strategic planning and implementation of initiatives aimed at driving systemic changes (16). Both studies make clear that no single action or stand-alone intervention can bring about the significant and lasting effects to meaningfully affect adolescent sleep health, but that it will take a comprehensive collection of efforts to do so. However, alongside taking this complexity into account, any successful effort to durably and effectively impact adolescent sleep health should consist of more than a collection of potential actions; such actions should be shaped using evidence-based intervention design techniques, apply appropriate behavior change techniques, and form one coherent whole rather than a collection of parts (12, 16). The previously described whole systems action plan should thus be shaped into a coherent, evidence-based whole systems program. One extensively used approach for developing theory- and evidence-based health promotion programs is the Intervention Mapping (IM) Protocol (Eldredge et al., 2016). IM provides a systematic iterative framework that integrates theoretical knowledge (e.g., appropriate theoretical methods) and scientific evidence with actor participation throughout the developmental process of a health promotion program. A key feature of the IM Protocol is that it guides the selection of appropriate, theory-based behavior change methods to shape health promotion programs (17). It provides a structured approach to choose strategies and techniques (i.e., behavior change methods), based on theoretical and empirical evidence, to influence specific behavioral determinants. As a result, the intervention’s potential impact and sustainability are optimized. However, to date and to the best of the authors knowledge, no whole systems action program exists that has integrated such theory- and evidence-based behavior change methods through a systematic intervention development process like the Intervention Mapping Protocol. To address this notable gap, this study presents the systematic development of a ‘whole systems action program’ promoting healthy sleep in Dutch adolescents aged 12-15, by integrating theory- and evidence-based behavior change methods using the Intervention Mapping Protocol into a systems science approach. With this, the paper offers a guide for both systems scientists and intervention developers on how these approaches can complement and reinforce each other in the development of health promotion programs. Additionally, it provides a detailed description of a whole systems action program promoting adolescent sleep health. Methods Design The current paper presents the development and details of a whole systems action program, named the ‘Charge Your Brainzzz (CYB) program’, to promote the sleep health of Dutch adolescents aged 12-15. It specifically focuses on the development process of the program building upon the whole systems action plan detailed by Heemskerk et al. (15) and incorporating theoretical behavior change methods via the Intervention Mapping (IM) Protocol. Prior to study onset, ethical approval was granted by the institutional medical ethics committee of Amsterdam UMC (VUMC 2021.0783). Procedures To develop the Whole Systems Action Program, a 5-step procedure was conducted inspired by the Intervention Mapping protocol. The procedure was carried out by a planning group consisting of the research team from the University and a researcher of the Public Health Service of Amsterdam (steps 1-3). Later, the group was expanded to include the intended program owner and Healthy School Advisors (step 4). Additionally, a design team from an external organization specialized in youth-related topics collaborated to develop an initial program plan (step 5). Step 1: Formulate Program Goal & Prioritize Key System Dynamics Outcomes Building on the key system dynamics and leverage points shaping adolescent sleep health as identified in Heemskerk, Busch (15) as well as the action plan specifying what needs to happen to impact these system dynamics and which actors need to be involved (16), in the current study, the planning group started by formulating a program goal. In addition, the group prioritized key system dynamics outcomes (i.e., leverage points) that the CYB program should focus on to effectively and sustainably improve adolescent sleep health. As the selected outcomes aligned with the Healthy School Approach (see box 1), which is a preventative infrastructure aimed at promoting health among adolescents in the Netherlands, all consecutive steps were conducted in accordance with this infrastructure, specifically targeting and involving key actors of the Healthy School Approach. [Insert Box 1. The Healthy School Approach - here] Step 2: Specify Performance Objectives As a next step and based on the prioritization of the key system dynamics (step 1) that the CYB program should focus on (e.g., adolescents do their homework in the evening), the planning group defined the desired system dynamics outcomes (e.g., ‘adolescents limit doing homework in the evening’). From that, we specified performance objectives for all actors contributing to the desired system dynamics outcomes (i.e., adolescents, parents, teachers, school boards, school care coordinators, youth healthcare professionals and Healthy School advisors) following the IM Protocol (3). A performance objective describes a specific, observable action or behavior that an actor needs to perform to contribute to a desired outcome. Performance objectives are measurable and are directly linked to the desired outcome. For example, the performance objective for teachers might be: ‘avoid assigning homework for the following day,’ contributing to the broader goal or desired system dynamic outcome: ‘adolescents limit doing evening homework’, thereby positively impacting their sleep health. As input for specifying CYB’s performance objectives, we used the previously developed ‘whole systems action plan’ by Heemskerk et al. (15), which outlined an extensive list of actions that could be taken to change the system dynamics. The complete set of performance objectives outlines all the specific actions that all actors involved could take to achieve the program goal. Step 3: Construct Matrices of Change Objectives Next, the planning group developed change objectives which specify what needs to change in terms of behavioral determinants (e.g., knowledge, attitudes, beliefs or abilities) for all actors to successfully perform the desired performance objectives. While performance objectives outline what needs to be done, change objectives focus on how to achieve that desired behavior by addressing the underlying personal determinants that influence behavior. For example, in the CYB program, a performance objective for teachers is: ‘avoid assigning homework for the following day’ . To support this behavior, change objectives could include that it is necessary to increase teachers’ knowledge about the negative effects of evening homework on adolescents’ sleep health, to raise awareness of their own influence regarding assigning/communicating homework not on time, and to identify barriers for not assigning/communicating homework for the next day on time. These change objectives were organized into matrices to outline the necessary changes in personal determinants required to achieve all performance objectives among all included actors and to achieve the program goals of CYB. Relevant determinants were identified using behavioral models such as the Social Cognitive Theory (18) and Theory of Planned Behavior (19). Key determinants included: knowledge, awareness, attitude/beliefs, self-efficacy/barriers, subjective norms and skills. Step 4: Generate Program Components and select Theoretical Methods and Practical Program Applications Next, the planning group brainstormed on program themes and program components tailored to each actor group for which performance objectives were developed in step 2 (i.e., adolescents, parents, teachers, school boards, school care coordinators, youth healthcare professionals and Healthy School advisors). Thereafter, the research team selected theoretical methods that align with the specified change objectives identified in step 3 (17). Theoretical methods refer to general techniques grounded in behavioral or psychological theories and can be applied to influence behavioral determinants. We used theories such as Theory of Planned Behavior (19), Social Cognitive Theory (18), Health Belief Model (20), and Theory of Goal-Directed Behavior (21). For example, ‘modeling’ is a method derived from the Social Cognitive Theory that can be applied to change a social norm. Each change objective for every actor group was matched to the most appropriate theoretical methods. Thereafter, the planning group translated these methods into practical strategies or applications. For instance, the abstract theoretical concept ‘modeling’ can be translated into a practical application such as creating a video that showcases relatable individuals successfully performing a target behavior. The choice of application depends on the personal determinant(s) that need to be influenced as well as its/their ‘conditions for effectiveness’. These conditions are crucial since theoretical methods are not universally effective; they typically require certain parameters to be met. In the case of ‘modeling’ for example, it is vital to provide an appropriate, i.e., relatable, model performing a desired action or behavior (17). To further ensure that the program components and practical applications were not only theoretically appropriate but also aligned with lived experiences of the target group, active involvement from relevant actor groups was prioritized. This process of co-designing ensured the applications were relevant, feasible and acceptable for implementation. First, to align the program components and practical applications with the Dutch prevention infrastructure promoting health in schools, interviews were conducted with Healthy School Advisors (N=6) who provide support and guidance to schools during implementation of health-promoting practices, policies, and processes (22). Healthy School Advisors were recruited via the network of the consortium’s affiliated municipalities and regional Public Health Services. Second, to design practical applications that aligned with the lived experience of adolescents, we conducted two co-creation sessions with adolescents (N=22). These sessions aimed to explore how adolescents prefer to learn about sleep and to identify suitable practical applications (see Additional File 1 for description of the co-creation structure). We selected adolescents from pre-vocational secondary education (in Dutch: VMBO[1]) (23) aged 12–15 years, as this group experiences the poorest sleep health amongst Dutch adolescents (9). Therefore, these teenagers were the focus for the CYB program. Adolescents were recruited through schools via our Charge Your Brainzzz consortium network and via a youth panel (containing over 7500 members between the ages of 12 and 24). Third, to identify both potential suitable components and practical applications for the school care coordinator – a professional within a school setting responsible for ensuring that students with diverse needs (e.g., academic, social, emotional, or physical) receive appropriate care and interventions – and youth health professionals, a focus group was held (N=4) and additional perspectives of this target group were gathered during a conference for youth healthcare professionals. Fourth, to inform a policy advice for school boards to create a healthy school environment focused on sleep, the research team held (N=6) interviews with school boards and/or teachers about potential implementable school policies (i.e., delaying school starting times, adapting communicating strategies and adjusting exam schedules) and the barriers and facilitators of implementing them. School professionals and youth health professionals were recruited via LinkedIn, schools and the network of the consortium’s affiliated municipalities and regional Public Health Services. Step 5: Program production & formative testing Next, the designed program components and applications led to the actual program production and pretesting. All materials were co-produced and/or formative tested with the planning group, graphical designers, and with those involved with the components, either as recipients (adolescents n=12) and/or as implementers (e.g., school health promotors N=6, youth healthcare professionals N=3, teachers N=5) to ensure their appropriateness and acceptability. This included considerations such as communication channels, methods, messages, materials, protocols, as well as evaluating the program’s appeal, visual design, content, and the clarity of all materials and assignments. Results Step 1: Formulate Program Goal & Prioritize Key System Dynamics Outcomes The program goal of Charge Your Brainzzz is to improve the system to enhance the sleep health of adolescents from pre-vocational education aged 12-15 years. Several key system dynamics outcomes (i.e., leverage points) across the subsystems identified by Heemskerk et al. (2024) – i.e., school environment, digital environment, mental wellbeing, family environment, and personal system – were prioritized as targets for the CYB program. Outcomes included, for example, early school starting times, evening homework, evening school notifications, parenting sleep practices, and evening screen use. An example of how we used the previously identified feedback loops and leverage points from the subsystem ‘school environment’ to form the system dynamics outcomes can be found in Additional file 2. Step 2: Specify Performance Objectives Table 1 specifies the desired system dynamics outcomes and 33 identified performance objectives of the subsystem ‘school environment’. For instance, to address the outcome of ‘ school schedules are aligned with adolescents’ biorhythm’ , a number of performance objectives were formulated for necessary changes to this mechanism. These include, for example, ‘ schools implement a policy that states that school start times are no earlier than 9 AM’ or ‘s chools are provided with tools and guidance (e.g., policy templates) on how to implement changes to their school starting times, end times and exam timetables that allow for a better alignment with students’ biorhythm’ . While all subsystems were approached this way, to facilitate manuscript readability, we only report on the school environment as an example. System dynamics outcomes and performance objectives from the other subsystems are available online at [ will be published on a OSF page after publication]. [Insert Table 1. Desired System Dynamics Outcomes and Performance Objectives – School environment subsystem - here] Step 3: Construct matrices of Change Objectives Table 2 illustrates the change objectives developed to align with the performance objectives for all actors involved with the targeted mechanisms within the subsystem ‘school environment’. It outlines for all actors how specific personal determinants should be changed to achieve their specific performance objective(s). A comprehensive overview of all performance objectives and change objectives related to the other are available online at [ will be published on a OSF page after publication]. [Insert Table 2. Performance Objectives and Change Objectives - School Environment - here] Step 4: Generate program components and select Theoretical Methods and Practical Program applications The practical program components focused on health education, school policies, social and physical environment, and monitoring and screening. As noted earlier, adolescents, parents, teachers, care coordinators, school boards, and Healthy School Advisors were identified as key groups to involve and would serve as CYB’s target audience and implementers. Change objectives were matched to appropriate theoretical methods and thereafter translated into appropriate practical applications. For example, for the change objective that adolescents should not take their phone to bed the theoretical methods that were selected included: ‘planning coping responses’ (based on Relapse Prevention Theory), and ‘implementation intentions’ (based on Theories of Goal-Directed Behavior). The practical applications we selected include individual and class challenges that focus on goal setting and the development of coping strategies. These strategies are then collectively reflected upon in class to reinforce learning and commitment (Table 3). The Charge Your Brainzzz program The described steps resulted in the generation of eight program components that together form the Charge Your Brainzzz whole systems action program. These components are: 1) an educational component for first-year secondary school students comprising of four classes focusing on the themes sleep, stress and screen use; 2) a step-by-step guide for schools and Healthy School Advisors for formulating and implementing school sleep health policies; 3) a parent information evening to be held at school; 4) an online magazine for parents that serves as a reference guide which outlines how parents and caregivers can guide their teenagers toward better sleep; 5) the Teen Sleep Check serving as a tool for parents to find out how well their teenager is sleeping; 6) a Sleep Guide for adolescents and parents including practical tips for specific times of the day to ensure a better night’s sleep; 7) a tool for monitoring sleep health and early detection of sleep (behavior) problems; and 8) several implementation materials including a teachers’ manual for executing the educational program, a manual for Healthy School Advisors to implement the CYB program and an informative website. Table 3 presents an overview of all the Charge Your Brainzzz program components, used methods per intervention component and a description of the practical applications. Table 4 presents an overview of all implementation materials. [Insert Table 3. Overview of the Charge Your Brainzzz program components theoretical methods - here] [Insert Table 4. Overview of the Charge Your Brainzzz implementation materials - here] Figure 1. illustrates the total content, themes and sequence of the Charge Your Brainzzz program. Before the start, schools and/or their Healthy School Advisor receive the CYB manual instructing how to implement the CYB program (e.g., when to start, how and when to implement the school sleep health policies). After that, schools work with the educational program for approximately four weeks, during which about one lesson is taught each week, and commit themselves to a challenge in between lessons. During this period, the parent information evening is also held, and schools can utilize all other components of the CYB program. Aside from the educational program and the parent evening, the other program components can be used flexibly throughout the year. [Insert Figure 1. Charge Your Brainzzz program sequence – here] Discussion This study aimed to describe the systematic development of the whole systems action program ‘Charge Your Brainzzz’ (CYB) designed to promote healthy sleep among Dutch adolescents aged 12-15. For this development the whole systems action plan of Heemskerk et al. (15) was used as input and theory- and evidence-based behavior change methods were integrated using the Intervention Mapping (IM) Protocol. This resulted in a detailed description of a comprehensive, co-created and evidence-based sleep intervention program specifically designed for young Dutch adolescents, with a particular focus on pre-vocational education students. This work provides an empirical example of how to convert a whole systems action plan into a whole systems action program using IM, demonstrating how a Systems Science approach and Intervention Mapping can complement each other in developing health promotion programs. Sleep health interventions for adolescents Recent studies show a growing need to approach adolescent sleep health in a broader, more comprehensive manner to realize more impactful, lasting effects (12, 14, 15, 24). Until now, most preventative sleep interventions have focused narrowly on a single aspect rather than taking a holistic approach to address the complex challenge of promoting adolescent sleep health. To date, such intervention programs usually consist of only an education program (12, 14, 25). While these programs potentially reach large numbers of adolescents, and some have been shown to increase adolescents’ knowledge about sleep, none have shown meaningful, long-term effects on adolescent sleep health (14, 25-27). The reasons for this could be multifaceted. One reason is that sleep education programs often lack a foundation in behavioral theory (12) which is key to achieving significant, sustained health behavior change (3, 28). Another reason could be the lack of actor involvement in program development. Few adolescent sleep health promotion programs have thoroughly engaged stakeholders during program design and development (29). This is likely to limit their appropriateness, acceptance, and feasibility among its recipients and implementers, thereby hampering successful implementation and effectiveness. Moreover, to our knowledge, no intervention program has integrated actions targeting adolescents with parallel efforts directed at c omplementary stakeholders – such as parents and education- and health professionals – who play a key role in influencing and shaping adolescent sleep health (30). Finally, currently existing programs are usually not multi-component programs that also address the environmental and societal factors influencing sleep health alongside the personal behavioral determinants of adolescents (14, 24). In developing the CYB program, we addressed the shortcomings of previous intervention programs by co-developing a whole systems action program targeting system dynamics and consisting of several intervention components beyond traditional educational components. These include, for example, a parent information session at school, an online Teen Sleep Check, a Sleep Guide for parents, a guide to include school sleep health policies and a tool for monitoring and early detection of sleep (behavior) problems for school care coordinators/youth healthcare professionals. The CYB program engages a variety of key stakeholders such as adolescents, parents, teachers, schoolboards, Healthy School Advisors, and school care coordinators/youth healthcare professionals, and it addresses not only personal behavior change but also broader changes in environmental and social determinants shaping sleep health. Furthermore, in order to facilitate the uptake of CYB, we ensured that CYB’s components were aligned with the Dutch Healthy School Approach framework (31). In line with the evidence and call in a recent systematic review on school-based interventions for adolescent sleep health, which emphasizes the importance of developing whole-of-school approaches (14), CYB’s structure emerges as a promising response to this need, instilling considerable confidence it is potential effectiveness. Combining Systems Science with theory -and evidence-based behavior change methods The development of the CYB program illustrates how Systems Science and Intervention Mapping can complement each other in designing evidence-based interventions, particularly for tackling complex or "wicked" problems. Integrating systems thinking into health behavior change programs enhances the ability to account for intricate causal mechanisms and interactions among individual determinants, avoiding overly simplistic "solutions." This approach also improves the capacity to anticipate and manage unexpected or unintended outcomes (32). For example, when delaying school starting times to align with adolescents’ biorhythm, it is essential to consider the potential impacts on school end times, after-school activities and evening homework. However, although these system dynamics illuminate the system mechanisms and actors involved in a particular health issue – in our case sleep health – they do not offer guidance on how to effectively and sustainably generate the necessary behavior changes among those actors within the identified system mechanisms. This is where systematic behavioral change methodologies such as Intervention Mapping prove invaluable. Such behavioral change approaches are needed to understand and change people’s behaviors within the system, given that human behavior drives every system dynamic (i.e., factor, connection, feedback loop, and underlying mechanism). For example, we have created the norm for adolescents to be 24/7 online available for school-related topics. In the absence of theoretically and empirically founded behavioral approaches, the translation of systems thinking into actual systems change becomes challenging. The developers of the IM protocol recognize the complexity of health problems and encourage intervention designers to adapt the protocol to better capture this complexity (33). To the best of the authors knowledge, this study is the first attempt to integrate Systems Science into the evidence-based practice of designing and implementing effective interventions. Using a Causal Loop Diagram as part of the ‘needs assessment’ – in which one aims to understand the health problem and use this information as the foundation for the program – proved to be an effective way to account for the complexity of health issue from the very beginning. This differs from the original more linear ‘logic model of the problem’ used in IM. Although more health problems are considered complex, the challenge thereafter remains: ‘what exactly should we do?’, and ‘how do we ensure that what we develop is effective?’. This study represents a step forward in addressing this gap: combining systems science with theory- and evidence-based methods to develop a more robust framework for tackling complex health issues. Strengths and limitations Our study adopted a distinctive approach by combining participatory methods, systems thinking, and IM, with a primary focus on integrating theory- and evidence-based methods. This makes CYB the first comprehensive adolescent sleep health program built upon a robust theoretical and scientific foundation. By doing so, we advanced academic discourse on adolescent sleep health promotion as well as that on applying systems science and Intervention Mapping in complex health promotion program development. Via our approach we were able to create a program that not only takes into account the complexity of the health problem targeting several system dynamics outcomes influencing sleep health, but also ensures that the components of the program are grounded in theory- and evidence. In addition, the stakeholder engagement (e.g., co-creation, interviews, co-designing) ensures that the program fits the lived experience of the target group of the intervention components (i.e., adolescents, parents and school care coordinators/ youth healthcare professionals) and the implementers and embedders of the program (i.e., program owner, teachers and schoolboard and Healthy School Advisors). We recommend future research to integrate systems thinking and behavioral methodologies to enhance the robustness and effectiveness of interventions. Moreover, another notable strength of the program is its focus on pre-vocational secondary education students, a group that faces the most challenges with sleep compared to their peers in other educational tracks (9). By focusing specifically on pre-vocational students, the program is both adapted to their health literacy and contributes to reducing health disparities. CYB thereby addresses a pressing need in Dutch public health (24, 34). In addition, a system is dynamic, continuously adapting to changes within it (4). Following program evaluation, it is expected that changes within the system will emerge. To address this, we recommend adopting an adapting, learning-oriented approach that allows the program to evolve in response to these observed changes. This approach involves ongoing monitoring and iterative revisions, enabling the program to integrate feedback, new evidence, and emerging needs over time. By remaining responsive and flexible, this strategy supports the program's long-term sustainability and enhances its capacity to deliver sustained outcomes by staying aligned with the system's evolving dynamics. Moreover, the program's current focus is on the school environment, addressing complex and interconnected factors within and across the school subsystem. However, the previously developed whole systems action plan (16) highlights that there are additional actions, settings, and stakeholders outside the school environment that play critical roles in improving adolescent sleep health. To maximize the program's impact, future iterations of the CYB program could be expanded to target other system dynamic outcomes, encompass other key settings and involve a broader array of stakeholders. Conclusions This study introduces Charge Your Brainzzz , the first whole systems action program designed to promote adolescent sleep health. By targeting multiple actor groups and extending beyond traditional education focused solely on adolescents, the program addresses sleep health through a multifaceted lens. Using a Systems Science approach, the Intervention Mapping (IM) protocol, and stakeholder engagement, the program’s development incorporated the complexity of the health issue, the lived experiences of the target groups, and a solid theoretical foundation for behavior change, enhancing its potential effectiveness. This comprehensive approach tackles system dynamics across various interconnected subsystems, such as the school environment, digital landscape, mental wellbeing, family dynamics, and personal behavior, all influencing sleep health. Beyond presenting the program’s components, this study offers a replicable roadmap for addressing complex public health challenges, paving the way for innovative, system-oriented solutions in health promotion. Abbreviations ASM: Action Scales Model CLD: Causal Loop Diagram CYB: Charge Your Brainzzz IM: Intervention Mapping WSA: Whole Systems Approach Declarations Ethics approval and consent to participate This study received approval from the institutional medical ethics committee of Amsterdam UMC (VUMC 2021.0783). No identifying participant information was collected for the purpose of this study, and informed consent was obtained for all participants before study participation. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are available in the OSF repository, [ will be published on a OSF page after publication ] Competing interests The authors declare that they have no competing interests. Funding This work was supported by a grant from The Netherlands Organisation for Health Research and Development (ZonMw); and co-financing from the Dutch Brain Foundation [grant number 555002022]. The funding agency had no role in the design of the study; in the collection, analysis, and interpretation of data; or in the writing of the manuscript. Authors’ contributions The authors confirm contribution to the paper as follows: study conception and design: DH, MvS, VB; data collection: DH, MvS, VB; analysis and interpretation of results: DH, MvS, JP, CR, VB; draft manuscript preparation: DH. All authors provided critical feedback and made critical revisions to the paper for important intellectual contents. All authors reviewed the results and approved the final version of the manuscript. Acknowledgements We would like to acknowledge the adolescents, parents and professionals who participated in this study. In addition, we would like to acknowledge the organization TeamAlert for their help with the data collection. References Nobles JD, Radley D, Mytton OT, team WSOp. The Action Scales Model: A conceptual tool to identify key points for action within complex adaptive systems. 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Adolescent Sleep Patterns and Sociodemographic Differences in 24 European and North American Countries. J Adolesc Health. 2020;66(6):S81–8. Kocevska D, Lysen TS, Dotinga A, Koopman-Verhoeff ME, Luijk MPCM, Antypa N, et al. Sleep characteristics across the lifespan in 1.1 million people from the Netherlands, United Kingdom and United States: a systematic review and meta-analysis. Nat Hum Behav. 2021;5(1):113–22. Stevens G, van Dorsselaer S, Boer M, de Roos S, Duinhof E, ter, Bogt T, van den Eijnden R, Kuyper L, Visser D, Vollebergh W, de Looze. M. HBSC 2017 Gezondheid en welzijn van jongeren in Nederland. Utrecht: University of Utrecht; 2018. Knoops K. Jaarrapport Landelijke Jeugdmonitor 2023: Middelengebruik en psychische gezondheid bij jongeren. 2023. Shochat T, Cohen-Zion M, Tzischinsky O. Functional consequences of inadequate sleep in adolescents: A systematic review. Sleep Med Rev. 2014;18(1):75–87. Albakri U, Drotos E, Meertens R. Sleep Health Promotion Interventions and Their Effectiveness: An Umbrella Review. Int J Environ Res Public Health. 2021;18(11):5533. Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al. The need for a complex systems model of evidence for public health. lancet. 2017;390(10112):2602–4. Gaskin CJ, Venegas Hargous C, Stephens LD, Nyam G, Brown V, Lander N et al. Sleep behavioral outcomes of school-based interventions for promoting sleep health in children and adolescents aged 5 to 18 years: a systematic review. SLEEP Adv. 2024;5(1). Heemskerk DM, Busch V, Piotrowski JT, Waterlander WE, Renders CM, van Stralen MM. A system dynamics approach to understand Dutch adolescents' sleep health using a causal loop diagram. Int J Behav Nutr Phys Act. 2024;21(1):34. Heemskerk DM, van Stralen MM, Piotrowski JT, Waterlander WE, Renders CM, Busch V. Developing a whole systems action plan promoting Dutch adolescents’ sleep health International Journal of Behavioral Nutrition and Physical Activity. In press. Kok G, Gottlieb NH, Peters GJ, Mullen PD, Parcel GS, Ruiter RA, et al. A taxonomy of behaviour change methods: an Intervention Mapping approach. Health Psychol Rev. 2016;10(3):297–312. Bandura A. Health promotion from the perspective of social cognitive theory. Understanding and changing health behaviour. Psychology; 2013. pp. 299–339. Ajzen I. The Theory of planned behavior. Organizational Behavior and Human Decision Processes; 1991. Rosenstock IM. The health belief model and preventive health behavior. Health Educ Monogr. 1974;2(4):354–86. Perugini M, Bagozzi RP. The role of desires and anticipated emotions in goal-directed behaviours: Broadening and deepening the theory of planned behaviour. Br J Soc Psychol. 2001;40(1):79–98. Boot N, van Assema P, Hesdahl B, de Vries N. Professional assistance in implementing school health policies. Health Educ. 2010;110(4):294–308. MECS. Pre-vocational Secondary Education (VMBO). Government of the Netherlands-Ministry of Education Culture and Science; 2020 [Available from: https://www.government.nl/topics/secondary-education/different-types-of-secondary-education/pre-vocational-secondary-education-vmbo Hale L, Troxel W, Buysse DJ. Sleep Health: An Opportunity for Public Health to Address Health Equity. Annu Rev Public Health. 2020;41:81–99. Rigney G, Watson A, Gazmararian J, Blunden S. Update on school-based sleep education programs: how far have we come and what has Australia contributed to the field? Sleep Med. 2021;80:134–57. Blunden SL, Chapman J, Rigney GA. Are sleep education programs successful? The case for improved and consistent research efforts. Sleep Med Rev. 2012;16(4):355–70. Chung KF, Chan MS, Lam YY, Lai CSY, Yeung WF. School-based sleep education programs for Short sleep duration in adolescents: a systematic review and meta‐analysis. J Sch Health. 2017;87(6):401–8. Gruber R. School-based sleep education programs: a knowledge-to-action perspective regarding barriers, proposed solutions, and future directions. Sleep Med Rev. 2017;36:13–28. Vandendriessche A, Deforche B, Dhondt K, Altenburg TM, Verloigne M. Combining participatory action research with intervention mapping to develop and plan the implementation and evaluation of a healthy sleep intervention for adolescents. Health Promot Perspect. 2023;13(4):316–29. Levenson JC, Ford HA, Reyes ZMD, Mukundan A, Patel G, Bahary S, Miller E. Designing adolescent sleep interventions with stakeholder input. Sleep Health. 2021;7(5):581–7. WHO W. Ottawa charter for health promotion. Health Promotion. 1986;1(4):iii–v. Smith L, Curtis J, Bragge P, Kellner P. Systems thinking and behaviour. Inspiring Change: How to Influence Behaviour for a Better World. Monash University Publishing; 2024. Crutzen R. Participatie, systeemdenken en nog een crisis. TSG - Tijdschrift voor gezondheidswetenschappen. 2022;100(3):127–30. Billings ME, Cohen RT, Baldwin CM, Johnson DA, Palen BN, Parthasarathy S, et al. Disparities in Sleep Health and Potential Intervention Models: A Focused Review. Chest. 2021;159(3):1232–40. Footnotes The Dutch education system : Pupils entering secondary education in the Netherlands (usually around 12 years of age) are streamed according to aptitude into one of four forms of schooling: practical education (PrO), pre-vocational education ( vmbo ), senior general secondary education ( havo ), and pre-university education ( vwo ). Tables Tables 1 to 4 are available in the Supplementary Files section. Box Box 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1..docx Table2..docx Table3..docx Table4..docx Box1.TheHealthySchoolApproach.docx Additionalfile1..docx Additionalfile2final.pdf Cite Share Download PDF Status: Published Journal Publication published 17 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 31 Jan, 2025 Editor assigned by journal 29 Jan, 2025 Submission checks completed at journal 29 Jan, 2025 First submitted to journal 28 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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a system and its dynamics visualizing factors, their interrelationship and feedback loops (2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharge Your Brainzzz (CYB) –\u0026nbsp;\u003c/strong\u003eWhole systems action program in the Netherlands aiming to improve the system to promote the sleep health of Dutch adolescents aged 12-15 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention Mapping (IM)\u0026nbsp;\u003c/strong\u003e– Systematic framework for developing theory- and evidence-based health promotion interventions and programs. It integrates theoretical knowledge, empirical evidence, and stakeholder input throughout the developmental process (3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLeverage points –\u0026nbsp;\u003c/strong\u003eModifiable points within a system. When these points are altered, this could lead to changes in the functioning, and thus the (health)outcome, of the system (4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhole Systems Approach (WSA) –\u0026nbsp;\u003c/strong\u003eAn approach to address complex problems by considering interconnected factors and relationships within an entire system to develop holistic and sustainable solutions (5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhole Systems Actions Plan\u0026nbsp;\u003c/strong\u003e– A plan/strategy that addresses complex problems by integrating and coordinating actions across all system levels and different subsystems and settings to achieve systemic, sustainable systems change (6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhole Systems Action Program –\u0026nbsp;\u003c/strong\u003eA program, grounded in theory and evidence-based behavior change methods, designed to address complex problems by integrating and coordinating actions across different system levels and its subsystems.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003ePoor adolescent sleep health is an increasingly recognized public health concern in many countries (7). The Netherlands is no exception with over 50% of adolescents aged 14–17 sleeping less than the recommended minimum of 8 hours per night (8) and 24% of adolescents aged 12–16 rating their sleep quality as poor (9). This worrisome trend is further illustrated by the fact that the prevalence of sleep health problems among youngsters aged 12-25 is still increasing. In 2022, 22% percent of Dutch adolescents reported sleep problems compared to 14 percent in 2017 (10). Inadequate sleep health is intricately linked to various aspects of adolescent physical health, mental health and cognitive performance, including for example physical inactivity, decreased emotion regulation, increased risk-seeking behaviors and poor academic performance (11). The increasing prevalence of inadequate sleep health among adolescents and its adverse impacts on adolescent life emphasizes the need for interventions addressing sleep health in this population. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThus far, preventative interventions aimed at promoting healthy adolescent sleep, via e.g., sleep education or relaxation techniques, have shown only minor or no significant, lasting effects (12). A factor that likely hampers the effectiveness of current preventative adolescent sleep health interventions is that most have not taken into account the complexity of sleep health in the intervention design (13, 14). Instead, existing interventions tend to target specific social cognitive determinants, such as knowledge or attitudes, within specific settings like schools (14). However, adolescent sleep health is far more complex, being shaped by the dynamic interplay between many biological, economic-, physical-, sociocultural-, and political factors. Inasmuch, there is a clear need for a comprehensive whole systems approach that embraces and integrates this complexity (15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSystems thinking methodologies can be applied to gain a good understanding of the complex health problem at hand, as well as to develop comprehensive approaches to tackle it (4). A recent study illustrated this by providing insights into the determinants of adolescent sleep health, the system dynamics (e.g., interrelations and feedback loops), and the underlying mechanisms that integrate them into a holistic complex system. It also identified potentially impactful leverage points to focus sleep health promotion efforts on in order to realize effective, durable system changes (15). Subsequently, another study showed how such insights were used to develop a ‘whole systems action \u003cem\u003eplan’\u003c/em\u003e, which outlines a wide range of proposed actions, serving as a guide for strategic planning and implementation of initiatives aimed at driving systemic changes (16). Both studies make clear that no single action or stand-alone intervention can bring about the significant and lasting effects to meaningfully affect adolescent sleep health, but that it will take a comprehensive collection of efforts to do so.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, alongside taking this complexity into account, any successful effort to durably and effectively impact adolescent sleep health should consist of more than a collection of potential actions; such actions should be shaped using evidence-based intervention design techniques, apply appropriate behavior change techniques, and form one coherent whole rather than a collection of parts (12, 16). The previously described whole systems action \u003cem\u003eplan\u0026nbsp;\u003c/em\u003eshould thus be shaped into a coherent, evidence-based whole systems \u003cem\u003eprogram.\u0026nbsp;\u003c/em\u003eOne extensively used approach for developing theory- and evidence-based health promotion programs is the Intervention Mapping (IM) Protocol (Eldredge et al., 2016). IM provides a systematic iterative framework that integrates theoretical knowledge (e.g., appropriate theoretical methods) and scientific evidence \u003cem\u003ewith\u0026nbsp;\u003c/em\u003eactor participation throughout the developmental process of a health promotion program. A key feature of the IM Protocol is that it guides the selection of appropriate, theory-based behavior change methods to shape health promotion programs (17). It provides a structured approach to choose strategies and techniques (i.e., behavior change methods), based on theoretical and empirical evidence, to influence specific behavioral determinants. As a result, the intervention’s potential impact and sustainability are optimized. However, to date and to the best of the authors knowledge, no whole systems action program exists that has integrated such theory- and evidence-based behavior change methods through a systematic intervention development process like the Intervention Mapping Protocol.\u003c/p\u003e\n\u003cp\u003eTo address this notable gap, this study presents the systematic development of a ‘whole systems action \u003cem\u003eprogram’\u003c/em\u003e promoting healthy sleep in Dutch adolescents aged 12-15, by integrating theory- and evidence-based behavior change methods using the Intervention Mapping Protocol into a systems science approach. With this, the paper offers a guide for both systems scientists and intervention developers on how these approaches can complement and reinforce each other in the development of health promotion programs. Additionally, it provides a detailed description of a whole systems action program promoting adolescent sleep health.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current paper presents the development and details of a whole systems action program, named the \u0026lsquo;Charge Your Brainzzz (CYB) program\u0026rsquo;, to promote the sleep health of Dutch adolescents aged 12-15. It specifically focuses on the development process of the program building upon the whole systems action \u003cem\u003eplan\u003c/em\u003e detailed by Heemskerk et al. (15) and incorporating theoretical behavior change methods via the Intervention Mapping (IM) Protocol. Prior to study onset, ethical approval was granted by the institutional medical ethics committee of Amsterdam UMC (VUMC 2021.0783).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo develop the Whole Systems Action Program, a 5-step procedure was conducted inspired by the Intervention Mapping protocol. The procedure was carried out by a planning group consisting of the research team from the University and a researcher of the Public Health Service of Amsterdam (steps 1-3). Later, the group was expanded to include the intended program owner and Healthy School Advisors (step 4). Additionally, a design team from an external organization specialized in youth-related topics collaborated to develop an initial program plan (step 5).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 1: Formulate Program Goal \u0026amp; Prioritize Key System Dynamics Outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBuilding on the key system dynamics and leverage points shaping adolescent sleep health as identified in Heemskerk, Busch (15) as well as the action \u003cem\u003eplan\u003c/em\u003e specifying what needs to happen to impact these system dynamics and which actors need to be involved (16), in the current study, the planning group started by formulating a program goal. In addition, the group prioritized \u003cem\u003ekey system dynamics\u003c/em\u003e \u003cem\u003eoutcomes \u003c/em\u003e(i.e., leverage points) that the CYB program should focus on to effectively and sustainably improve adolescent sleep health. As the selected outcomes aligned with the Healthy School Approach (see box 1), which is a preventative infrastructure aimed at promoting health among adolescents in the Netherlands, all consecutive steps were conducted in accordance with this infrastructure, specifically targeting and involving key actors of the Healthy School Approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Insert Box 1. The Healthy School Approach - here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 2: Specify Performance Objectives\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs a next step and based on the prioritization of the key system dynamics (step 1) that the CYB program should focus on (e.g., adolescents do their homework in the evening), the planning group defined the \u003cem\u003edesired system dynamics outcomes\u003c/em\u003e (e.g., \u0026lsquo;adolescents limit doing homework in the evening\u0026rsquo;). From that, we specified \u003cem\u003eperformance objectives\u003c/em\u003e for all actors contributing to the desired system dynamics outcomes (i.e., adolescents, parents, teachers, school boards, school care coordinators, youth healthcare professionals and Healthy School advisors) following the IM Protocol (3). A performance objective describes a specific, observable action or behavior that an actor needs to perform to contribute to a desired outcome. Performance objectives are measurable and are directly linked to the desired outcome. For example, the performance objective for teachers might be: \u003cem\u003e\u0026lsquo;avoid assigning homework for the following day,\u0026rsquo;\u003c/em\u003e contributing to the broader goal or desired system dynamic outcome: \u003cem\u003e\u0026lsquo;adolescents limit doing evening homework\u0026rsquo;, \u003c/em\u003ethereby positively impacting their sleep health. As input for specifying CYB\u0026rsquo;s performance objectives, we used the previously developed \u0026lsquo;whole systems action plan\u0026rsquo; by Heemskerk et al. (15), which outlined an extensive list of actions that could be taken to change the system dynamics. The complete set of performance objectives outlines all the specific actions that all actors involved could take to achieve the program goal.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 3: Construct Matrices of Change Objectives\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNext, the planning group developed \u003cem\u003echange objectives \u003c/em\u003ewhich specify what needs to change in terms of behavioral determinants (e.g., knowledge, attitudes, beliefs or abilities) for all actors to successfully perform the desired performance objectives. While performance objectives outline \u003cem\u003ewhat\u003c/em\u003e needs to be done, change objectives focus on \u003cem\u003ehow\u003c/em\u003e to achieve that desired behavior by addressing the underlying personal determinants that influence behavior. For example, in the CYB program, a performance objective for teachers is: \u003cem\u003e\u0026lsquo;avoid assigning homework for the following day\u0026rsquo;\u003c/em\u003e. To support this behavior, change objectives could include that it is necessary to increase teachers\u0026rsquo; \u003cem\u003eknowledge\u003c/em\u003e about the negative effects of evening homework on adolescents\u0026rsquo; sleep health, to raise \u003cem\u003eawareness\u003c/em\u003e of their own influence regarding assigning/communicating homework not on time, and to identify \u003cem\u003ebarriers\u003c/em\u003e for not assigning/communicating homework for the next day on time. \u003c/p\u003e\n\u003cp\u003eThese change objectives were organized into matrices to outline the necessary changes in personal determinants required to achieve all performance objectives among all included actors and to achieve the program goals of CYB. Relevant determinants were identified using behavioral models such as the Social Cognitive Theory (18) and Theory of Planned Behavior (19). Key determinants included: knowledge, awareness, attitude/beliefs, self-efficacy/barriers, subjective norms and skills. \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 4: Generate Program Components and select Theoretical Methods and Practical Program Applications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNext, the planning group brainstormed on program themes and program components tailored to each actor group for which performance objectives were developed in step 2 (i.e., adolescents, parents, teachers, school boards, school care coordinators, youth healthcare professionals and Healthy School advisors). Thereafter, the research team selected theoretical methods that align with the specified change objectives identified in step 3 (17). Theoretical methods refer to general techniques grounded in behavioral or psychological theories and can be applied to influence behavioral determinants. We used theories such as Theory of Planned Behavior (19), Social Cognitive Theory (18), Health Belief Model (20), and Theory of Goal-Directed Behavior (21). For example, \u0026lsquo;modeling\u0026rsquo; is a method derived from the Social Cognitive Theory that can be applied to change a social norm. Each change objective for every actor group was matched to the most appropriate theoretical methods. \u003c/p\u003e\n\u003cp\u003eThereafter, the planning group translated these methods into practical strategies or applications. For instance, the abstract theoretical concept \u0026lsquo;modeling\u0026rsquo; can be translated into a practical application such as creating a video that showcases relatable individuals successfully performing a target behavior. The choice of application depends on the personal determinant(s) that need to be influenced as well as its/their \u0026lsquo;conditions for effectiveness\u0026rsquo;. These conditions are crucial since theoretical methods are not universally effective; they typically require certain parameters to be met. In the case of \u0026lsquo;modeling\u0026rsquo; for example, it is vital to provide an appropriate, i.e., relatable, model performing a desired action or behavior (17). \u003c/p\u003e\n\u003cp\u003eTo further ensure that the program components and practical applications were not only theoretically appropriate but also aligned with lived experiences of the target group, active involvement from relevant actor groups was prioritized. This process of co-designing ensured the applications were relevant, feasible and acceptable for implementation. First, to align the program components and practical applications with the Dutch prevention infrastructure promoting health in schools, interviews were conducted with Healthy School Advisors (N=6) who provide support and guidance to schools during implementation of health-promoting practices, policies, and processes (22). Healthy School Advisors were recruited via the network of the consortium\u0026rsquo;s affiliated municipalities and regional Public Health Services.\u003c/p\u003e\n\u003cp\u003eSecond, to design practical applications that aligned with the lived experience of adolescents, we conducted two co-creation sessions with adolescents (N=22). These sessions aimed to explore how adolescents prefer to learn about sleep and to identify suitable practical applications (see Additional File 1 for description of the co-creation structure). We selected adolescents from pre-vocational secondary education (in Dutch: VMBO[1]) (23) aged 12\u0026ndash;15\u0026thinsp;years, as this group experiences the poorest sleep health amongst Dutch adolescents (9). Therefore, these teenagers were the focus for the CYB program. Adolescents were recruited through schools via our Charge Your Brainzzz consortium network and via a youth panel (containing over 7500 members between the ages of 12 and 24). \u003c/p\u003e\n\u003cp\u003eThird, to identify both potential suitable components and practical applications for the school care coordinator \u0026ndash; a professional within a school setting responsible for ensuring that students with diverse needs (e.g., academic, social, emotional, or physical) receive appropriate care and interventions \u0026ndash; and youth health professionals, a focus group was held (N=4) and additional perspectives of this target group were gathered during a conference for youth healthcare professionals. \u003c/p\u003e\n\u003cp\u003eFourth, to inform a policy advice for \u003cem\u003eschool boards\u003c/em\u003e to create a healthy school environment focused on sleep, the research team held (N=6) interviews with school boards and/or teachers about potential implementable school policies (i.e., delaying school starting times, adapting communicating strategies and adjusting exam schedules) and the barriers and facilitators of implementing them. School professionals and youth health professionals were recruited via LinkedIn, schools and the network of the consortium\u0026rsquo;s affiliated municipalities and regional Public Health Services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 5: Program production \u0026amp; formative testing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNext, the designed program components and applications led to the actual program production and pretesting. All materials were co-produced and/or formative tested with the planning group, graphical designers, and with those involved with the components, either as recipients (adolescents n=12) and/or as implementers (e.g., school health promotors N=6, youth healthcare professionals N=3, teachers N=5) to ensure their appropriateness and acceptability. This included considerations such as communication channels, methods, messages, materials, protocols, as well as evaluating the program\u0026rsquo;s appeal, visual design, content, and the clarity of all materials and assignments. \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eStep 1: Formulate Program Goal \u0026amp; Prioritize Key System Dynamics Outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The program goal of Charge Your Brainzzz is to improve the system to enhance the sleep health of adolescents from pre-vocational education aged 12-15 years. Several key system dynamics outcomes (i.e., leverage points) across the subsystems identified by Heemskerk et al. (2024) – i.e., school environment, digital environment, mental wellbeing, family environment, and personal system – were prioritized as targets for the CYB program. Outcomes included, for example, early school starting times, evening homework, evening school notifications, parenting sleep practices, and evening screen use. An example of how we used the previously identified feedback loops and leverage points from the subsystem ‘school environment’ to form the system dynamics outcomes can be found in Additional file 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 2: Specify Performance Objectives\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Table 1 specifies the desired system dynamics outcomes and 33 identified performance objectives of the subsystem ‘school environment’. For instance, to address the outcome of ‘\u003cem\u003eschool schedules are aligned with adolescents’ biorhythm’\u003c/em\u003e, a number of performance objectives were formulated for necessary changes to this mechanism. These include, for example, ‘\u003cem\u003eschools implement a policy that states that school start times are no earlier than 9 AM’\u0026nbsp;\u003c/em\u003eor ‘s\u003cem\u003echools are provided with tools and guidance (e.g., policy templates) on how to implement changes to their school starting times, end times and exam timetables that allow for a better alignment with students’ biorhythm’\u003c/em\u003e. While all subsystems were approached this way, to facilitate manuscript readability, we only report on the school environment as an example. System dynamics outcomes and performance objectives from the other subsystems are available online at [\u003cu\u003ewill be published on a OSF page after publication].\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Insert Table 1. Desired System Dynamics Outcomes and Performance Objectives – School environment subsystem - here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 3: Construct matrices of Change Objectives\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 illustrates the change objectives developed to align with the performance objectives for all actors involved with the targeted mechanisms within the subsystem ‘school environment’. It outlines for all actors how specific personal determinants should be changed to achieve their specific performance objective(s). A comprehensive overview of all performance objectives and change objectives related to the other are available online at [\u003cu\u003ewill be published on a OSF page after publication].\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Insert Table 2. Performance Objectives and Change Objectives - School Environment - here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStep 4:\u0026nbsp;\u003c/em\u003e\u003cem\u003eGenerate program components and select Theoretical Methods and Practical Program applications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe practical program components focused on health education, school policies, social and physical environment, and monitoring and screening. As noted earlier, adolescents, parents, teachers, care coordinators, school boards, and Healthy School Advisors were identified as key groups to involve and would serve as CYB’s target audience and implementers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChange objectives were matched to appropriate theoretical methods and thereafter translated into appropriate practical applications. For example, for the change objective that \u003cem\u003eadolescents should not take their phone to bed\u003c/em\u003e the theoretical methods that were selected included: ‘planning coping responses’ (based on Relapse Prevention Theory), and ‘implementation intentions’ (based on Theories of Goal-Directed Behavior). The practical applications we selected include individual and class challenges that focus on goal setting and the development of coping strategies. These strategies are then collectively reflected upon in class to reinforce learning and commitment (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Charge Your Brainzzz program\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe described steps resulted in the generation of eight program components that together form the Charge Your Brainzzz whole systems action program. These components are:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1) an educational component for first-year secondary school students comprising of four classes focusing on the themes sleep, stress and screen use; 2) a step-by-step guide for schools and Healthy School Advisors for formulating and implementing school sleep health policies; 3) a parent information evening\u0026nbsp;to be held at school; 4) an online magazine for parents that serves as a reference guide which outlines how parents and caregivers can guide their teenagers toward better sleep; 5) the \u003cem\u003eTeen Sleep Check\u003c/em\u003e serving as a tool for parents to find out how well their teenager is sleeping; 6) a \u003cem\u003eSleep Guide\u003c/em\u003e for adolescents and parents including practical tips for specific times of the day to ensure a better night’s sleep; 7) a tool for monitoring sleep health and early detection of sleep (behavior) problems; and 8) several implementation materials including a teachers’ manual for executing the educational program, a manual for Healthy School Advisors to implement the CYB program and an informative website. Table 3 presents an overview of all the Charge Your Brainzzz program components, used methods per intervention component and a description of the practical applications. Table 4 presents an overview of all implementation materials.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Insert Table 3. Overview of the Charge Your Brainzzz program components theoretical methods - here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Insert Table 4. Overview of the Charge Your Brainzzz implementation materials - here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1. illustrates the total content, themes and sequence of the Charge Your Brainzzz program. Before the start, schools and/or their Healthy School Advisor receive the CYB manual instructing how to implement the CYB program (e.g., when to start, how and when to implement the school sleep health policies). After that, schools work with the educational program for approximately four weeks, during which about one lesson is taught each week, and commit themselves to a challenge in between lessons. During this period, the parent information evening is also held, and schools can utilize all other components of the CYB program. Aside from the educational program and the parent evening, the other program components can be used flexibly throughout the year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Insert Figure 1. Charge Your Brainzzz program sequence – here]\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to describe the systematic development of the whole systems action program ‘Charge Your Brainzzz’ (CYB) designed to promote healthy sleep among Dutch adolescents aged 12-15. For this development the whole systems action \u003cem\u003eplan\u003c/em\u003e of Heemskerk et al. (15) was used as input and theory- and evidence-based behavior change methods were integrated using the Intervention Mapping (IM) Protocol. This resulted in a detailed description of a comprehensive, co-created and evidence-based sleep intervention program specifically designed for young Dutch adolescents, with a particular focus on pre-vocational education students. This work provides an empirical example of how to convert a whole systems action \u003cem\u003eplan\u003c/em\u003e into a whole systems action \u003cem\u003eprogram\u003c/em\u003e using IM, demonstrating how a Systems Science approach and Intervention Mapping can complement each other in developing health promotion programs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSleep health interventions for adolescents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecent studies show a growing need to approach adolescent sleep health in a broader, more comprehensive manner to realize more impactful, lasting effects (12, 14, 15, 24). Until now, most preventative sleep interventions have focused narrowly on a single aspect rather than taking a holistic approach to address the complex challenge of promoting adolescent sleep health. To date, such intervention programs usually consist of only an education program (12, 14, 25). While these programs \u0026nbsp;potentially reach large numbers of adolescents, and some have been shown to increase adolescents’ knowledge about sleep, none have shown meaningful, long-term effects on adolescent sleep health (14, 25-27).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe reasons for this could be multifaceted. One reason is \u0026nbsp;that sleep education programs often lack a foundation in behavioral theory (12) which is key to achieving significant, sustained \u0026nbsp;health behavior change (3, 28). Another reason could be the lack of actor involvement in program development. Few adolescent sleep health promotion programs have thoroughly engaged stakeholders during program design and development (29). This is likely to limit their appropriateness, acceptance, and feasibility among its recipients and implementers, thereby hampering successful implementation and effectiveness. Moreover, to our knowledge, no intervention program has integrated actions targeting adolescents with parallel efforts directed at \u003cem\u003ec\u003c/em\u003e\u003cem\u003eomplementary stakeholders\u003c/em\u003e – such as parents and education- and health professionals – who play a key role in influencing and shaping adolescent sleep health (30). Finally, currently existing programs are usually not multi-component programs that also address the environmental and societal factors influencing sleep health alongside the personal behavioral determinants of adolescents (14, 24).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn developing the CYB program, we addressed the shortcomings of previous intervention programs by co-developing a whole systems action program targeting system dynamics and consisting of several intervention components beyond traditional educational components. These include, for example, a parent information session at school, an online Teen Sleep Check, a Sleep Guide for parents, a guide to include school sleep health policies and a tool for monitoring and early detection of sleep (behavior) problems for school care coordinators/youth healthcare professionals. The CYB program engages a variety of key stakeholders such as adolescents, parents, teachers, schoolboards, Healthy School Advisors, and school care coordinators/youth healthcare professionals, and it addresses not only personal behavior change but also broader changes in environmental and social determinants shaping sleep health. Furthermore, in order to facilitate the uptake of CYB, we ensured that CYB’s components were aligned with the Dutch Healthy School Approach framework (31). In line with the evidence and call in a recent systematic review on school-based interventions for adolescent sleep health, which emphasizes the importance of developing \u0026nbsp;whole-of-school approaches (14), CYB’s structure emerges as a promising response to this need, instilling considerable confidence it is potential effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCombining Systems Science with theory -and evidence-based behavior change methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; The development of the CYB program illustrates how Systems Science and Intervention Mapping can complement each other in designing evidence-based interventions, particularly for tackling complex or \"wicked\" problems. Integrating systems thinking into health behavior change programs enhances the ability to account for intricate causal mechanisms and interactions among individual determinants, avoiding overly simplistic \"solutions.\" This approach also improves the capacity to anticipate and manage unexpected or unintended outcomes (32). For example, when delaying school starting times to align with adolescents’ biorhythm, it is essential to consider the potential impacts on school end times, after-school activities and evening homework. However, although these system dynamics illuminate the system mechanisms and actors involved in a particular health issue – in our case sleep health – they do not offer guidance on how to effectively and sustainably generate the necessary behavior changes among those actors within the identified system mechanisms. This is where systematic behavioral change methodologies such as Intervention Mapping prove invaluable. Such behavioral change approaches are needed to understand and change people’s behaviors within the system, given that human behavior drives every system dynamic (i.e., factor, connection, feedback loop, and underlying mechanism). For example, we have created the norm for adolescents to be 24/7 online available for school-related topics. In the absence of theoretically and empirically founded behavioral approaches, the translation of systems thinking into actual systems change becomes challenging.\u003c/p\u003e\n\u003cp\u003eThe developers of the IM protocol recognize the complexity of health problems and encourage intervention designers to adapt the protocol to better capture this complexity (33). To the best of the authors knowledge, this study is the first attempt to integrate Systems Science into the evidence-based practice of designing and implementing effective interventions. Using a Causal Loop Diagram as part of the ‘needs assessment’ – in which one aims to understand the health problem and use this information as the foundation for the program – proved to be an effective way to account for the complexity of health issue from the very beginning. This differs from the original more linear ‘logic model of the problem’ used in IM. Although more health problems are considered complex, the challenge thereafter remains: ‘what exactly should we do?’, and ‘how do we ensure that what we develop is effective?’. This study represents a step forward in addressing this gap: combining systems science with theory- and evidence-based methods to develop a more robust framework for tackling complex health issues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study adopted a distinctive approach by combining participatory methods, systems thinking, and IM, with a primary focus on integrating theory- and evidence-based methods. This makes CYB the first comprehensive adolescent sleep health program built upon a robust theoretical and scientific foundation. By doing so, we advanced academic discourse on adolescent sleep health promotion as well as that on applying systems science and Intervention Mapping in complex health promotion program development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVia our approach we were able to create a program that not only takes into account the complexity of the health problem targeting several system dynamics outcomes influencing sleep health, but also ensures that the components of the program are grounded in theory- and evidence. In addition, the stakeholder engagement (e.g., co-creation, interviews, co-designing) ensures that the program fits the lived experience of the target group of the intervention components (i.e., adolescents, parents and school care coordinators/ youth healthcare professionals) and the implementers and embedders of the program (i.e., program owner, teachers and schoolboard and Healthy School Advisors). We recommend future research to integrate systems thinking and behavioral methodologies to enhance the robustness and effectiveness of interventions. Moreover, another notable strength of the program is its focus on pre-vocational secondary education students, a group that faces the most challenges with sleep compared to their peers in other educational tracks (9). By focusing specifically on pre-vocational students, the program is both adapted to their health literacy and contributes to reducing health disparities. CYB thereby addresses a pressing need in Dutch public health (24, 34).\u003c/p\u003e\n\u003cp\u003eIn addition, a system is dynamic, continuously adapting to changes within it (4). Following program evaluation, it is expected that changes within the system will emerge. To address this, we recommend adopting an adapting, learning-oriented approach that allows the program to evolve in response to these observed changes. This approach involves ongoing monitoring and iterative revisions, enabling the program to integrate feedback, new evidence, and emerging needs over time. By remaining responsive and flexible, this strategy supports the program's long-term sustainability and enhances its capacity to deliver sustained outcomes by staying aligned with the system's evolving dynamics.\u003c/p\u003e\n\u003cp\u003eMoreover, the program's current focus is on the school environment, addressing complex and interconnected factors within and across the school subsystem. However, the previously developed whole systems action plan (16) highlights that there are additional actions, settings, and stakeholders outside the school environment that play critical roles in improving adolescent sleep health. To maximize the program's impact, future iterations of the CYB program could be expanded to target other system dynamic outcomes, encompass other key settings and involve a broader array of stakeholders.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study introduces \u003cem\u003eCharge Your Brainzzz\u003c/em\u003e, the first whole systems action program designed to promote adolescent sleep health. By targeting multiple actor groups and extending beyond traditional education focused solely on adolescents, the program addresses sleep health through a multifaceted lens. Using a Systems Science approach, the Intervention Mapping (IM) protocol, and stakeholder engagement, the program’s development incorporated the complexity of the health issue, the lived experiences of the target groups, and a solid theoretical foundation for behavior change, enhancing its potential effectiveness. This comprehensive approach tackles system dynamics across various interconnected subsystems, such as the school environment, digital landscape, mental wellbeing, family dynamics, and personal behavior, all influencing sleep health. Beyond presenting the program’s components, this study offers a replicable roadmap for addressing complex public health challenges, paving the way for innovative, system-oriented solutions in health promotion. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eASM:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eAction Scales Model\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCLD:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eCausal Loop Diagram\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCYB:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Charge Your Brainzzz\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIM:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eIntervention Mapping\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWSA:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eWhole Systems Approach\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval from the institutional medical ethics committee of Amsterdam UMC (VUMC 2021.0783). No identifying participant information was collected for the purpose of this study, and informed consent was obtained for all participants before study participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available in the OSF repository, [\u003cu\u003ewill be published on a OSF page after publication\u003c/u\u003e]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by a grant from The Netherlands Organisation for Health Research and Development (ZonMw); and co-financing from the Dutch Brain Foundation [grant number 555002022]. The funding agency had no role in the design of the study; in the collection, analysis, and interpretation of data; or in the writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm contribution to the paper as follows: study conception and design: DH, MvS, VB; data collection: DH, MvS, VB; analysis and interpretation of results: DH, MvS, JP, CR, VB; draft manuscript preparation: DH. All authors provided critical feedback and made critical revisions to the paper for important intellectual contents. All authors reviewed the results and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the adolescents, parents and professionals who participated in this study. In addition, we would like to acknowledge the organization TeamAlert for their help with the data collection.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNobles JD, Radley D, Mytton OT, team WSOp. The Action Scales Model: A conceptual tool to identify key points for action within complex adaptive systems. Perspect public health. 2021;142(6):328\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaugh Littlejohns L, Baum F, Lawless A, Freeman T. The value of a causal loop diagram in exploring the complex interplay of factors that influence health promotion in a multisectoral health system in Australia. Health Res policy Syst. 2018;16:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEldredge LKB, Markham CM, Ruiter RA, Fern\u0026aacute;ndez ME, Kok G, Parcel GS. Planning health promotion programs: an intervention mapping approach. Wiley; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeadows DH. Thinking in systems: A primer: chelsea green publishing; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBagnall A-M, Radley D, Jones R, Gately P, Nobles J, Van Dijk M, et al. Whole systems approaches to obesity and other complex public health challenges: a systematic review. BMC Public Health. 2019;19(1):8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePublic Health England. Whole systems approach to obesity programme: learning from co-producing and testing the guide and resources. London; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGariepy G, Danna S, Gobiņa I, Rasmussen M, Gaspar de Matos M, Tynj\u0026auml;l\u0026auml; J, et al. How Are Adolescents Sleeping? Adolescent Sleep Patterns and Sociodemographic Differences in 24 European and North American Countries. 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SLEEP Adv. 2024;5(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeemskerk DM, Busch V, Piotrowski JT, Waterlander WE, Renders CM, van Stralen MM. A system dynamics approach to understand Dutch adolescents' sleep health using a causal loop diagram. Int J Behav Nutr Phys Act. 2024;21(1):34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeemskerk DM, van Stralen MM, Piotrowski JT, Waterlander WE, Renders CM, Busch V. Developing a whole systems action plan promoting Dutch adolescents\u0026rsquo; sleep health International Journal of Behavioral Nutrition and Physical Activity. In press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKok G, Gottlieb NH, Peters GJ, Mullen PD, Parcel GS, Ruiter RA, et al. A taxonomy of behaviour change methods: an Intervention Mapping approach. Health Psychol Rev. 2016;10(3):297\u0026ndash;312.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBandura A. 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Annu Rev Public Health. 2020;41:81\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRigney G, Watson A, Gazmararian J, Blunden S. Update on school-based sleep education programs: how far have we come and what has Australia contributed to the field? Sleep Med. 2021;80:134\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlunden SL, Chapman J, Rigney GA. Are sleep education programs successful? The case for improved and consistent research efforts. Sleep Med Rev. 2012;16(4):355\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung KF, Chan MS, Lam YY, Lai CSY, Yeung WF. School-based sleep education programs for Short sleep duration in adolescents: a systematic review and meta‐analysis. J Sch Health. 2017;87(6):401\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGruber R. School-based sleep education programs: a knowledge-to-action perspective regarding barriers, proposed solutions, and future directions. Sleep Med Rev. 2017;36:13\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandendriessche A, Deforche B, Dhondt K, Altenburg TM, Verloigne M. Combining participatory action research with intervention mapping to develop and plan the implementation and evaluation of a healthy sleep intervention for adolescents. Health Promot Perspect. 2023;13(4):316\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevenson JC, Ford HA, Reyes ZMD, Mukundan A, Patel G, Bahary S, Miller E. Designing adolescent sleep interventions with stakeholder input. Sleep Health. 2021;7(5):581\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO W. Ottawa charter for health promotion. Health Promotion. 1986;1(4):iii\u0026ndash;v.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith L, Curtis J, Bragge P, Kellner P. Systems thinking and behaviour. Inspiring Change: How to Influence Behaviour for a Better World. Monash University Publishing; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrutzen R. Participatie, systeemdenken en nog een crisis. TSG - Tijdschrift voor gezondheidswetenschappen. 2022;100(3):127\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBillings ME, Cohen RT, Baldwin CM, Johnson DA, Palen BN, Parthasarathy S, et al. Disparities in Sleep Health and Potential Intervention Models: A Focused Review. Chest. 2021;159(3):1232\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e \u003cb\u003eThe Dutch education system\u003c/b\u003e: Pupils entering secondary education in the Netherlands (usually around 12 years of age) are streamed according to aptitude into one of four forms of schooling: practical education (PrO), pre-vocational education (\u003cem\u003evmbo\u003c/em\u003e), senior general secondary education (\u003cem\u003ehavo\u003c/em\u003e), and pre-university education (\u003cem\u003evwo\u003c/em\u003e).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"},{"header":"Box","content":"\u003cp\u003eBox 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, Health behavior, Health Promotion, Intervention Mapping, Sleep, Systems Science Approach, Teens, Whole systems action program, Youth ","lastPublishedDoi":"10.21203/rs.3.rs-5919594/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5919594/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInadequate sleep among Dutch adolescents is a complex public health issue with detrimental effects on physical and mental well-being. Previous interventions have shown limited or no lasting effects. While systems approaches help to understand and address such challenges, effective prevention efforts require evidence-based intervention design using behavior change techniques. This study outlines the systematic development of a ‘whole systems action \u003cem\u003eprogram’\u003c/em\u003e, named Charge Your Brainzzz (CYB),\u003cem\u003e \u003c/em\u003eto promote healthy sleep in Dutch adolescents aged 12-15, by integrating theory- and evidence-based behavior change methods using the Intervention Mapping Protocol into a systems science approach, combined with stakeholder engagement\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CYB program was developed based on previously identified key system dynamics influencing adolescent sleep and a detailed action plan targeting these dynamics. The development was guided by five steps inspired by the Intervention Mapping protocol: defining the program goal and prioritizing system dynamics outcomes across various interconnected subsystems (step 1), specifying performance objectives (step 2), constructing matrices of change objectives (step 3), developing program components while selecting theoretical methods and practical applications (step 4), and program production and formative testing (step 5). Adolescents, parents, teachers, school boards, school care coordinators, youth healthcare professionals, and Healthy School advisors were actively involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe whole systems action program CYB consists of eight program components and includes: 1) an educational component, 2) a step-by-step guide for implementing school sleep health policies, 3) a parent information evening, 4) an online magazine, 5) Teen Sleep Check, 6) Sleep Guide, 7) Tool for monitoring and early detection for sleep (behavior) problems, and 8) implementation materials including a website.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CYB program is the first whole systems action program designed to promote adolescent sleep health. Using a Systems Science approach, the Intervention Mapping (IM) protocol, and stakeholder engagement, the program addresses the complexity of the health issue, the lived experiences of the target groups, and a solid theoretical foundation for behavior change. Beyond presenting the program’s components, this study offers a replicable roadmap for addressing complex public health challenges, paving the way for innovative, system-oriented solutions in health promotion.\u003c/p\u003e","manuscriptTitle":"Charge Your Brainzzz: the systematic development of a whole systems action program promoting sleep health in adolescents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-31 16:03:02","doi":"10.21203/rs.3.rs-5919594/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-31T16:29:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-29T08:16:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-29T08:14:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-01-28T15:37:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a1b80ca-cc9d-4f45-9ccf-3af56faaa076","owner":[],"postedDate":"January 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:07:36+00:00","versionOfRecord":{"articleIdentity":"rs-5919594","link":"https://doi.org/10.1186/s12889-025-23989-2","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-10-17 15:58:17","publishedOnDateReadable":"October 17th, 2025"},"versionCreatedAt":"2025-01-31 16:03:02","video":"","vorDoi":"10.1186/s12889-025-23989-2","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23989-2","workflowStages":[]},"version":"v1","identity":"rs-5919594","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5919594","identity":"rs-5919594","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}