Faculty Bibliography

Sleep represents a set of biological functions necessary for the maintenance of life. Performing these functions, though, requires that an individual engage in behaviors, which are affected by social and environmental factors. Race/ethnicity and socioeconomic position represent categories of factors that likely play a role in the experience of sleep in the community. Previous studies have suggested that racial/ethnic minorities and the socioeconomically disadvantaged may be more likely to experience sleep patterns that are associated with adverse health outcomes. It is possible that disparities in sleep represent a pathway by which larger disparities in health emerge. This review (1) contextualizes the concept of race/ethnicity in biomedical research, (2) summarizes previous studies that describe patterns of sleep attainment across race/ethnicity groups, (3) discusses several pathways by which race/ethnicity may be associated with sleep, (4) introduces the potential role of socioeconomic position in the patterning of sleep, and (5) proposes future research directions to address this issue.

OBJECTIVE: Obstructive sleep apnea (OSA) is a leading sleep disorder that is disproportionately more prevalent in minority populations and is a major risk factor for cardiovascular disease (CVD) morbidity and mortality. OSA is associated with many chronic conditions including hypertension, diabetes, and obesity, all of which are disproportionately more prevalent among blacks (ie, peoples of African American, Caribbean, or African descent). METHODS: This article reviews studies conducted in the United States (US) that investigated sleep screenings and adherence to treatment for OSA among blacks. In addition, guidelines are provided for implementing a practical framework to increase OSA screening and management among blacks. RESULTS: Several studies have documented racial/ethnic disparities in adherence to treatment for OSA. However, despite its public health significance, there is a paucity of studies addressing these disparities. Further, there is a lack of health programs and policies to increase screening and treatment of OSA among blacks and other minority populations. A practical framework to increase the number of blacks who are screened for OSA and treated appropriately is warranted. Such a framework is timely and major importance, as early identification of OSA in this high-risk population could potentially lead to early treatment and prevention of CVD, thereby reducing racial and ethnic disparities in sleep-related CVD morbidity and mortality.

Introduction: Poor adherence to evaluation and treatment of obstructive sleep apnea (OSA) is a public health challenge. Despite higher prevalence of OSA, blacks are less likely to adhere to physician-recommended OSA care than are whites. Methods: Among black patients with metabolic syndrome, we compared, in an RCT, effectiveness of a telephone-delivered culturally and linguistically tailored OSA health messages over 6 months (Intervention) versus standard patient education (Control) in improving adherence to recommended OSA care. We hypothesized that patients randomized to the intervention arm would exhibit greater adherence to OSA consultation, evaluation, and treatment than those in the control arm. We also evaluated the predictive role of baseline sociodemographics, health risks, comorbidity, and psychosocial factors on adherence status using multivariate-adjusted regression analyses. Results: 380 patients (mean age = 59yrs; 71%, women) were enrolled with 80% retention rate (intervention = 160 and control = 143). Of the sample, 69.4% of patients exposed to the intervention attended initial consultations, compared with 36.7% of patients in the control arm (p < .001); 74.7% versus 66.7% of patients in the intervention and control arms, respectively, completed diagnostic evaluations (p = 0.46), while 86.4% versus 88.9% in the intervention and control arm, respectively, adhered to OSA treatment. Based on adjusted logistic regression, patients in the intervention arm were 3.17 times (95% CI = 1.68-5.99, p < 0.001) more likely to have initial consultations, relative to controls. Treatment self-efficacy was the strongest predictor of OSA adherence (OR = 1.11, 95% CI = 1.03-1.20, p < 0.01). Adjusted models revealed no significant differences between the two arms regarding adherence to OSA evaluation and treatment. Conclusion: The culturally and linguistically tailored OSA health messages were successful in improving initial consultation for OSA diagnosis. However, once patients were in treatment, there was no difference in OSA adherence rates between the two groups

Introduction: Health intervention is successful when messages are culturally and linguistically tailored to a specific population. The current study utilized a comprehensive approach involving multiple stakeholders to develop tailored health messages to promote awareness of sleep apnea among Blacks. Methods: We engaged several stakeholders (community-based organizations, patients, and healthcare providers) to develop and implementan online sleep educational inter vention. First round of focus groups were conducted with patients (N = 35; 71% Female, 100% Black, average age 45.2 years). Next, community leaders from churches, barbershops, and other organizations (N = 8, 75% Female, 87% Black, average age 48.1 years). Finally, interviews were conducted with healthcare providers (N = 6, 16% Female, 83% White, average age 51.2 years). All data collection was focused on barriers to awareness, diagnosis and treatment of sleep apnea. This paper presents results of the qualitative analysis conducted to inform the design of this community-engaged, linguistically and culturally tailored online sleep education program. Results: Analysis illuminated key barriers preventing sleep apnea awareness, including 1) low knowledge about the connection between daytime somnolence and associated sleep difficulties, 2) embarrassment about snoring and sleep apnea, and 3) inadequate healthcare access for effective treatments. The educational tool was designed using evidence-based approaches to diagnosis and treatment of sleep apnea, while acknowledging the primary themes identified in the focus groups. The tool was then refined with feedback from stakeholders (community members, sleep medicine doctors, and health communication experts. The TASHE resource included four key components, 1) tailored, population-appropriate reading level, 2) evidence-based tips and suggestions for sleep health and sleep apnea, 3) partnership with community-based organizations, and 4) cultural context. Conclusion: A conceptual model for tailored interventions in sleep medicine has been developed and implemented based on the principles of community-engaged research to ensure acceptability of tailored health messages and sustainability of the online sleep apnea educational program. The model developed can be used to structure the design and implementation of community-based, tailored sleep education programs that aim to promote sleep health at the population level

Introduction: Past research indicates that insomnia symptoms, defined as an inability to initiate or maintain sleep, may be associated with cardiovascular disease (CVD). In many low- and middle-income countries, urbanization and changing lifestyles have contributed to a rapidly growing burden of non-communicable disease, such as CVD. The present study assessed whether insomnia symptoms were associated with CVD in a sample of community-dwelling Ghanaian adults. Methods: Data were collected by structured questionnaires from a community-based sample of 263 participants (> 25 years) in Ghana, randomly selected from among participants in the Research on Obesity and Type 2 Diabetes among African Migrants (RODAM) study. Insomnia symptoms were assessed with three items: 1) having difficulty falling asleep, 2) having difficulty staying asleep, and 3) having problems waking up too early. Insomnia was coded as experiencing one or more of these symptoms. Incident CVD was measured using the Rose questionnaire. We used multiple logistic regression to test the association between insomnia and CVD, adjusting for age and sex. Results: The mean age of the sample was 47.3 years +/- 11.5, 41.1% were men, 44.9% had never been to school or attended only elementary school. Over 59% of the sample reported having one or more insomnia symptoms and 24% had CVD. After adjusting for age and sex, having insomnia symptoms was positively associated with having CVD, and this association approached significance (adjusted OR = 1.78, p = 0.063). This relationship was reduced after adjusting for comorbid conditions (adjusted OR = 1.66, p = 0.110). Conclusion: Our results indicate that insomnia may be related to having incident CVD, and that this relationship may be accounted for by comorbid conditions, which might confound the relationship between sleep and CVD. Nevertheless, assessing and treating insomnia may have important implications for managing CVD. This may be particularly important given the growing burden of chronic diseases in subSaharan Africa

Introduction: The decline in optimal sleep duration among adolescents is well documented. Many factors may contribute to poor sleep duration, so it is important to understand the knowledge, patterns, and behavior about sleep among this population. This study investigated the (1) sleep patterns of adolescents on school days and weekends, (2) sleep knowledge and the extent of knowledge on sleep duration and (3) technology use. Methods: 345 adolescents (age range: 13-18) attending a local high school in grades 9 and 11 were invited to participate in the study. Data collection was conducted from May 2015-June 2015 via an online survey platform. A subset of adolescents participated in a focus group (n = 6). Results: 43% 9th grade males and 57% females and 47% 11th grade males and 53% females completed the survey. Participants completed the knowledge questions with 88% accuracy. Over one-third of 9th and 11th grade adolescents reported engaging in technology use before bed (39% and 36% respectively). 9th and 11th graders reported in short sleep duration during school days (86% and 84% respectively) and long sleep (< 10 hours) during the weekends (53% and 43% respectively). There were no significant differences between 9th and 11th graders. Using a semi-structured interview guide major themes in the focus group revealed that short sleep duration was related to fulfilling school assignments, preparation for college, and social media use. Finally, participants reported that sleep duration declined as they became older. Conclusion: These findings suggest that adolescents engage in both short and long sleep. There is sufficient knowledge about sleep, but poor sleep practices and hygiene are prevalent. Sleep education in schools should take into consideration the varying degrees of sleep practices and hygiene and technology use

BACKGROUND: The National Health Interview Survey (NHIS) was used to ascertain whether increases in inadequate sleep differentially affected black and white Americans. We tested the hypothesis that prevalence estimates of inadequate sleep were consistently greater among blacks, and that temporal changes have affected these two strata differentially. METHODS: NHIS is an ongoing cross-sectional study of non-institutionalized US adults (>/=18 years) providing socio-demographic, health risk, and medical factors. Sleep duration was coded as very short sleep [VSS] (<5 h), short sleep [SS] (5-6 h), or long sleep [LS] (>8 h), referenced to 7-8 h sleepers. Analyses adjusted for NHIS' complex sampling design using SAS-callable SUDAAN. RESULTS: Among whites, the prevalence of VSS increased by 53 % (1.5 % to 2.3 %) from 1977 to 2009 and the prevalence of SS increased by 32 % (19.3 % to 25.4 %); prevalence of LS decreased by 30 % (11.2 % to 7.8 %). Among blacks, the prevalence of VSS increased by 21 % (3.3 % to 4.0 %) and the prevalence of SS increased by 37 % (24.6 % to 33.7 %); prevalence of LS decreased by 42 % (16.1 % to 9.4 %). Adjusted multinomial regression analysis showed that odds of reporting inadequate sleep for whites were: VSS (OR = 1.40, 95 % CI = 1.13-1.74, p < 0.001), SS (OR = 1.34, 95 % CI = 1.25-1.44, p < 0.001), and LS (OR = 0.94, 95 % CI = 0.85-1.05, NS). For blacks, estimates were: VSS (OR = 0.83, 95 % CI = 0.60-1.40, NS), SS (OR = 1.21, 95 % CI = 1.05-1.50, p < 0.001), and LS (OR = 0.84, 95 % CI = 0.64-1.08, NS). CONCLUSIONS: Blacks and whites are characteristically different regarding the prevalence of inadequate sleep over the years. Temporal changes in estimates of inadequate sleep seem dependent upon individuals' race/ethnicity.

BACKGROUND: Exposure to the natural environment may improve health behaviors and mental health outcomes such as increased levels of physical activity and lower levels of depression associated with sleep quality. Little is known about the relationship between insufficient sleep and the natural environment. PURPOSE: To determine whether exposure to attributes of the natural environment (e.g., greenspace) attenuates the likelihood of reporting insufficient sleep among US adults. METHODS: Multiple logistic regression models were used to explore the association between self-reported days of insufficient sleep (in the past 30days) and access to the natural environment in a multi-ethnic, nationally representative sample (n=255,171) of US adults >/=18years of age enrolled in the 2010 Behavioral Risk Factor Surveillance System. RESULTS: Using 1-to-6days of insufficient sleep as the referent group for all analyses, lower odds of exposure to natural amenities were observed for individuals reporting 21-to-29days (OR=0.843, 95% confidence interval (CI)=0.747, 0.951) of insufficient sleep. In stratified analyses, statistically significant lower odds of exposure to natural amenities were found among men reporting 7-to-13-days (OR=0.911, 95% CI=0.857, 0.968), 21-to-29-days (OR=0.838, 95% CI=0.759, 0.924), and 30-days (OR=0.860, 95% CI=0.784, 0.943) of insufficient sleep. Greenspace access was also protective against insufficient sleep for men and individuals aged 65+. CONCLUSIONS: In a representative sample of US adults, access to the natural environment attenuated the likelihood of reporting insufficient sleep, particularly among men. Additional studies are needed to examine the impact of natural environment exposure on sleep insufficiency across various socio-demographic groups.

BACKGROUND: This study ascertained whether individuals of the black race/ethnicity are unequally burdened by sleep-related overweight/obesity. METHODS: Analysis was based on data obtained from Americans (ages, 18-85 years) in the National Health Interview Survey (1977-2009). Sleep duration was coded as either very short sleep (VSS) (8 hours), referenced to 7-8-hour sleepers. Overweight was defined as body mass index (BMI) >/=25.0 and /=30 kg/m2, referenced to normal weight (BMI = 18.5-24.9 kg/m2). RESULTS: Multivariate-adjusted regression analyses indicated that, among whites, VSS was associated with a 10% increased likelihood of being overweight and 51% increased likelihood of being obese, relative to 7-8-hour sleepers. Short sleep was associated with a 13% increased likelihood of being overweight and 45% increased likelihood of being obese. Long sleep was associated with 21% increased likelihood of being obese. Among blacks, VSS was associated with a 76% increased likelihood of being overweight and 81% increased likelihood of being obese. Short sleep was associated with a 16% increased likelihood of being overweight and 32% increased likelihood of being obese. As for the white stratum, long sleep was associated with a 25% increased likelihood of being obese. CONCLUSION: Our investigation demonstrates strong linkages between inadequate sleep and overweight/ obesity among black and white Americans. Although it cannot be said that insufficient sleep causes overweight/obesity, individuals of the black race/ethnicity sleeping