Cross-cultural Differences In Sleep Patterns And Problems in Asian School-aged Adolescents: The ACROSS Study (ACROSS)

Sleep problems are common in adolescents. Studies have consistently demonstrated that sleep disturbances are prevalent, affecting up to 50% of this population. In this project, the investigators aim to map out sleep patterns, risk factors, and obstacles for sleep in adolescents, capturing the diversity of societal factors that shape the sleeping habits of adolescents. The investigators aim to recruit school-aged adolescents (aged 12-18 years old) in 12 countries across 15 research centres (N = 1000 per centre) to fill in the questionnaire covering sleep-wake patterns, sleep problems, mood, behavioral, daytime functioning and their attitude and perception towards sleep.

Study Overview

• Status: Not yet recruiting
• Conditions: Characterise Sleep Patterns Across Asia; Examine Barriers to Sleep

Detailed Description

Introduction Sleep problems are common in children and adolescents. In particular, extensive evidence consistently demonstrated that sleep disturbance is prevalent affecting up to 30% of this population. The situation is worrying as expanding body of evidence has demonstrated the close relationship between inadequate sleep and daytime impairment, obesity, diabetes, cardiovascular complications, disruptive behaviors, mental health and poor academic performance.

There is a web of interactive factors that contribute to sleep disturbance including biological, social, and cultural factors. For example, during adolescence, teenagers experience a circadian delay in their sleep, leading to a delayed bedtime and this sleep pattern is further exacerbated by increasing technology usage. In addition, cultural influences also play a significant role in their sleep. Mindell and colleagues compared sleep patterns between Asian and Caucasian young children and found that Asian children had significantly later bedtimes and shorter total sleep time as well as different parental perceptions towards their children's sleep problems. A similar trend was also evident among adolescents with Asian teens consistently having later bedtimes, earlier wakeup times and shorter sleep than their Caucasian counterparts. The difference in sleep patterns and sleep habits not only existed between Asian and western countries, but discrepancies were also observed within the Asian countries. A previous study that compared sleep duration between children in Hong Kong and Shanghai revealed that Hong Kong children have later bedtimes and wakeup times as well as shorter sleep than Shanghai children, particularly during weekdays.

Although there is evidence supporting the cultural influence on adolescent sleep-wake patterns, most of the studies are country specific which do not allow adequate cross-cultural comparison. Importantly, substantial cultural, religious, and economic differences exist within and between countries in Asia. A more comprehensive coverage of different countries in Asia will allow for a better understanding of specific sleep patterns in relation to the rich cultural variety across the Asian region.

Moreover, previous studies utilized different inventories, various age groups, and different measurement methods. The variations in methodology make it difficult to make an accurate comparison between different cultures. Identifying the similarities and differences in sleep patterns/problems as well as associated factors across various regions, will allow us to have a more thorough understanding of their sleep, which is an important step in devising countermeasures for mitigating this concerning situation.

In view of the above-mentioned limitations of previous studies and the necessity of multicenter collaboration (15 research centres across 12 countries), the aim of the current study (ACROSS study) is to gather sleep researchers from various Asian countries in order to:

1. To conduct a sleep survey in Asian adolescents
2. To explore the Cultural differences in sleep patterns and problems
3. To evaluate the Risk factors associated with sleep problems
4. To understand the Obstacles to obtain adequate sleep
5. To promote health Sleep in Schools

Methods Participants Participants will be recruited through schools, public advertisement, poster and emails in Asian countries. Adolescents aged 12-18 years old will be invited to complete the questionnaire either in online form or in paper form. The administration of the questionnaire will be conducted during school-term avoiding the exam period.

Participants will be invited to fill in the questionnaire covering the following aspects:

1. Demographics: gender, age, height, weight, education ethnicity, and religion etc. Parental education, employment status and socioeconomic class will be assessed.
2. Sleep patterns and problems: sleep wake patterns, napping habits, various sleep symptoms, chronotype will be covered
3. Mental wellbeing: Mood symptoms will be assessed using Patient Health Questionnarie-2; Anxiety measured by General Anxiety Disorder-2, Stress by Perceived Stress Scale-4, and also overall health status
4. Lifestyle factors: Time spent on different activities such as electronic media use, physical activities, homework, entertainment etc. will be collected
5. Attitude and perception towards sleep: Adolescent's perception towards different sleep conditions will be assessed. Parent and school practice related to sleep measure/issues will also be assessed.

• Study Type: Observational
• Enrollment (Estimated): 15000

Contacts and Locations

• Study Contact: Name: Stijn Massar; Phone Number: +65 66015238; Email: stijn.massar@nus.edu.sg
• Study Contact Backup: Name: Rachel Chan; Email: rachel.chan@cuhk.edu.hk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

School-going adolescents aged 12-18 years old will be invited to participate.

Description

Inclusion Criteria:

• School-going adolescents aged 12-18 years old

Exclusion Criteria:

• Nil.

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Sleep duration	Sleep duration (nocturnal sleep and nap sleep) on weekdays and weekends is probed in the questionnaire.	At enrollment
Sleep timing	Bedtime and wake time on weekdays and weekends is probed in the questionnaire.	At enrollment
Patient Health Questionnarie-2	A 2-item tool used to screen for depression by assessing the frequency of depressed mood and anhedonia over the past two weeks. It includes the first two items of the PHQ-9, with scores ranging from 0 to 6. A score of 3 or more is considered the cut-off point for identifying potential depression.	At enrollment
Generalized Anxiety Disorder-2	A brief, two-item screening tool used to detect generalized anxiety disorder, with a recommended cut-off score of 3 or higher. A score of 3+ indicates a likely anxiety disorder, suggesting the need for further, more comprehensive assessment.	At enrollment
Perceived Stress Scale-4	The Perceived Stress Scale-4 (PSS-4) is a 4-item questionnaire, a shortened version of the PSS-10, designed to measure the degree to which situations in life are appraised as stressful over the past month. Scores range from 0 to 16, with higher scores indicating higher perceived stress.	At enrollment
Time spent on various activities in a day	Lifestyle factors are assessed using a question asking participants to report the amount of time in a day spent on different activities such as electronic media use, physical activity, homework, and leisure time / entertainment. Participants report the amount of time spent in hours and minutes.	At enrollment
Attitude and perception towards sleep	Adolescent's perception towards sleep, as well as parent, peer, and school practice relating to sleep, are probed using questions such as "My parents think finishing my homework is more important than sleep", "My friends encourage me to stay up late to study", "My teachers encourage me to sleep enough", "I believe sacrificing sleep to get more work/study done is necessary". Participants are to indicate how strongly they agree or disagree with these statements.	At enrollment

Collaborators and Investigators

• Sponsor: National University of Singapore
• Collaborators: Shanghai Children's Medical Center; Soonchunhyang University Hospital; All India Institute of Medical Sciences, Rishikesh; Ewha Womans University Seoul Hospital; Brawijaya University, Malang, Indonesia; Li Chiu Kong Family Sleep Assessment Unit; Universitas Kristen Krida Wacana, Jakarta; Hermina Hospital, Manado; Psychology of Traffic, Urban Society, and Psychological Measurement Laboratory, Faculty of Psychology, Universitas Indonesia; Isfahan university of medical sciences, Bamdad respiratory and sleep research center; Department of Psychology, The Center for Psychobiological Research, The Max Stern Academic College of Emek Yezreel; Japanese Society of Sleep Research; The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Psychosomatic Medicine, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China; CHA bundang hospital/university; Yongin Severance Hospital, Yonsei University College of Medicine; Chang Gung Memorial Hospital and University; Sleep Society of Thailand; Vietnam Society of Sleep Medicine

Publications and helpful links

General Publications

• Dahl RE. The impact of inadequate sleep on children's daytime cognitive function. Semin Pediatr Neurol. 1996 Mar;3(1):44-50. doi: 10.1016/s1071-9091(96)80028-3.
• Short MA, Gradisar M, Lack LC, Wright HR, Dewald JF, Wolfson AR, Carskadon MA. A cross-cultural comparison of sleep duration between US And Australian adolescents: the effect of school start time, parent-set bedtimes, and extracurricular load. Health Educ Behav. 2013 Jun;40(3):323-30. doi: 10.1177/1090198112451266. Epub 2012 Sep 14.
• Olds T, Blunden S, Petkov J, Forchino F. The relationships between sex, age, geography and time in bed in adolescents: a meta-analysis of data from 23 countries. Sleep Med Rev. 2010 Dec;14(6):371-8. doi: 10.1016/j.smrv.2009.12.002. Epub 2010 Mar 6.
• Mindell JA, Sadeh A, Kohyama J, How TH. Parental behaviors and sleep outcomes in infants and toddlers: a cross-cultural comparison. Sleep Med. 2010 Apr;11(4):393-9. doi: 10.1016/j.sleep.2009.11.011.
• Zhang J, Li AM, Fok TF, Wing YK. Roles of parental sleep/wake patterns, socioeconomic status, and daytime activities in the sleep/wake patterns of children. J Pediatr. 2010 Apr;156(4):606-12.e5. doi: 10.1016/j.jpeds.2009.10.036. Epub 2009 Dec 21.
• Schmidt RE, Van der Linden M. The Relations Between Sleep, Personality, Behavioral Problems, and School Performance in Adolescents. Sleep Med Clin. 2015 Jun;10(2):117-23. doi: 10.1016/j.jsmc.2015.02.007. Epub 2015 Mar 12.
• Owens J; Adolescent Sleep Working Group; Committee on Adolescence. Insufficient sleep in adolescents and young adults: an update on causes and consequences. Pediatrics. 2014 Sep;134(3):e921-32. doi: 10.1542/peds.2014-1696.
• Biggs SN, Lushington K, van den Heuvel CJ, Martin AJ, Kennedy JD. Inconsistent sleep schedules and daytime behavioral difficulties in school-aged children. Sleep Med. 2011 Sep;12(8):780-6. doi: 10.1016/j.sleep.2011.03.017. Epub 2011 Aug 20.

Study record dates

Study Major Dates

• Study Start (Estimated): May 1, 2026
• Primary Completion (Estimated): December 1, 2026
• Study Completion (Estimated): December 1, 2026

Study Registration Dates

• First Submitted: April 24, 2026
• First Submitted That Met QC Criteria: May 4, 2026
• First Posted (Actual): May 11, 2026

Study Record Updates

• Last Update Posted (Actual): May 11, 2026
• Last Update Submitted That Met QC Criteria: May 4, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Adolescents; Sleep; Cross-cultural
• Other Study ID Numbers: ACROSS study

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No