- Email: [email protected]
Sleep health equity
Chapter 35
Sleep health equity Judite Blanca, Jao Nunesb, Natasha Williamsc, Rebecca Robbinsd, Azizi A. Seixasd,e, Girardin Jean-Louisd,e a
NYU Langone Health, Department of Population Health, Center for Healthful Behavior Change, New York, NY, United States, bThe City College of New York, New York, NY, United States, cNYU Langone Health, Division of Health and Behavior, Department of Population Health, Center for Healthful Behavior Change, New York, NY, United States, dNYU Langone Health, Department of Population Health, New York, NY, United States, eNYU Langone Health, Department of Psychiatry, New York, NY, United States
INTRODUCTION: SLEEP AND PUBLIC HEALTH Sleep is the “reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment” [1, p. 15]. Sleep is vital for optimal mental, emotional, and physical well-being, and therefore has emerged as a pillar of health alongside nutrition, exercise, and smoking cessation. Leading scientific, clinical, and governmental organizations in the US and internationally recognize the importance of sleep [2–4]. Despite this wide-scale recognition, schedules in America are inconsistent with healthy sleep habits [5]. For instance, career, social and lifestyle demands represent barriers to adequate sleep that have generated a sleep crisis of significant proportion with impact on individual outcomes (e.g., cognition, mental and physical health) and societal outcomes (e.g., productivity and safety). The Centers for Disease Control and Prevention (CDC) has made specific recommendations to meet daily needs: 9–12 h of sleep for school-aged children, 8–10 h of sleep for adolescents and a minimum of 7 h for adults. However, the 2015 Youth Risk Behavior Surveillance System [6] shows an estimated nationwide prevalence of short sleep duration of 57.8% among middle school students and of 72.7% among high school students. Among adult respondents to the 2009 Behavioral Risk Factor Surveillance System (BRFSS), 41.3% reported 1–13 days of insufficient rest or sleep before the survey [7]. Poor sleep health has significant individual health and societal consequences. Poor sleep is associated with poor mental, emotional (e.g., anxiety, mood disturbance, suicidal ideation) and physical health consequences (e.g., accidents, illness, pain). Additionally, poor sleep health increases the risk for chronic conditions (e.g., high blood pressure, high body mass index (BMI) and obesity) and mortality. Poor sleep health extracts a significant cost in terms of dollars annually in medical expenses such as Sleep and Health. https://doi.org/10.1016/B978-0-12-815373-4.00035-6 © 2019 Elsevier Inc. All rights reserved.
d octor visits, hospital services, prescriptions, and over-thecounter medications [8]. Conversely, research suggests that adequate sleep health has a protective effect for individual health and societal outcomes. Specifically, individuals who consistently report dimensions of sleep health, including good sleep quality, sufficient sleep duration, and absence of sleep disorder, are more likely to have better measures of mental, emotional, and physical health and longevity compared to those who cut their sleep short. But research also documents differences in sleep health along socio-economic lines, sleep health being out of reach for most individuals living in deprived social economic areas. Specifically, minority groups and individuals from disadvantaged economic backgrounds report lower sleep quality. Sleep, a precious resource in our society, this research suggests, may actually constitute a luxury most commonly practiced by majority race/ethnic groups and socio-economically advantaged individuals. In order to tackle the sleep health crisis, the past 10 years has seen a dramatic increase in research that articulates these socio-economic limiting factors that affect sleep. We argue there is a need for a paradigm shift in the way sleep medicine approaches this public health matter. We agree with Buysse [9] that the current focus mainly on sleep disorders should give way to a stronger emphasis on the notion of sleep health. This is crucial to the health of individuals and of the population, and stands to benefit sleep medicine itself.
WHAT IS SLEEP HEALTH? While the body of knowledge on sleep patterns and associated public health outcomes is growing, there is no precise and specific definition of the concept of sleep health for use by sleep researchers and experts. When sleep and health are entered together in databases such as PubMed, and Google Scholar, between 43,714 and 676,000,000 473
474 PART | IX Economic and public policy implications of sleep health
results are identified (September, the 8th of 2018). Authors appear to use “sleep problems” and “sleep health” interchangeably in their titles. Buysse [9] noticed that not even in the 2006 Institute of Medicine Report and in the mission statement for sleep of The Centers for Disease Control and Prevention, an explicit definition of sleep health was included. To fill the gap, in his recently published paper, “Sleep health: can we define it? Does it matter,” Buysse [9] articulated this comprehensive definition: Sleep health is a multidimensional pattern of sleep- wakefulness, adapted to individual, social, and environmental demands, that promotes physical and mental well-being. Good sleep health is characterized by subjective satisfaction, appropriate timing, sufficient duration, high efficiency, and sustained alertness during waking hours. [9, p. 12]
And in contrast to the deficit model, this definition focuses on positive characteristics of sleep health which are physiologically quantifiable. Although adult-centered, it could be easily extrapolated to youth and cannot be conceived outside of its individual, social and environmental components, and offers specific anchors for these five dimensions of sleep health: ● ●
● ● ●
Sleep duration: The number of sleep hours per day Sleep continuity or efficiency: The ability of falling asleep and staying asleep Timing: The placement of sleep within the 24-h day Alertness/sleepiness: The capacity of staying awake Satisfaction/Quality: The individual perception of “good” or “poor” sleep.
The following are questions of interest in the context of the present analysis: What is the relationship between the sleep health dimensions and physical and mental well-being? What are the mechanisms that influence sleep dimensions and related health outcomes? Overall, does the presence of sleep impairment affect all groups at the same level?
SOCIAL DETERMINANTS OF SLEEP HEALTH DIMENSIONS AND ASSOCIATED HEALTH OUTCOMES During the last decades, factors affecting the five dimensions of sleep health, including age, sex, body mass index (BMI), race/ethnicity, education, environment, workplace and economic position have been widely documented [7, 10–12]. In Table 35.1, we present a list of problems related to patients, providers and the healthcare system that potentially undermine optimal sleep in disadvantaged communities. As described in Table 35.1, there is a growing body of studies that show similar findings, not all categories are equally impacted by the sleep health crisis. How does this sleep deficiency vary across racial and ethnic groups? Are other individual, social and environmental components
contributing to this variation of sleep patterns among different social groups? These are valid questions that current research findings cannot yet answer in full. At this point, we intend to explore another valid question: Can any role be attributed to the historical context, specifically to the race-based slavery system that underpins the birth of the American society?
HEALTH DIFFERENCES AND THE HISTORICAL SLEEP GAP BETWEEN BLACKS AND WHITES Identifying determinants of health differences The debate is not a new one about the origin of historically ubiquitous health disparities/inequities and of the elusive health equity, but the tools of the debate remain faulty. Until now, there is little consensus regarding the meaning of the terms “health disparities/inequities” and “health equity.” An early articulated and widespread conceptualization of these notions is attributed to Margaret Whitehead in her famous article, “The concepts and principles of equity and health” [13]. She stated: “inequality in health is a term commonly used in some countries to indicate systematic, avoidable and important differences.” In her discussion, she described seven critical determinants of health differentials: (1) Natural, biological variation; (2) Health-damaging behavior if freely chosen, such as participation in certain sports and pastimes; (3) The transient health advantage of one group over another when that group is first to adopt a health-promoting behavior (as long as other groups have the means to catch up fairly soon); (4) Health-damaging behavior where the degree of choice of lifestyles is severely restricted; (5) Exposure to unhealthy, stressful living and working conditions; (6) Inadequate access to essential health and other public services; and (7) Natural selection or health-related social mobility involving the tendency for sick people to move down the social scale. According to Whitehead, these seven determinants of health differences are all interacting. Although the impact of biological factors and the effects of sick people moving down the social scale have been demonstrated, she underlined that the major role is to be attributed to socioeconomic and environmental factors, including lifestyles. Consequently, how may this fact hold explanations for the actual sleep health disparities?
History behind the black–white “sleep gap” Biological imperatives to maintain homeostatic processes and social factors determine sleep in humans. The National Heart Lung and Blood Institute (NHLBI) of the National Institutes of Health (NIH) describes sleep as a fundamental requirement of living. Yet extensive scientific evidence revealed
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TABLE 35.1 Summary of social determinants of sleep health and potential health outcomes. Dimensions of sleep measured Duration
Population studied
Social determinants/ risk factors
Health outcomes
Source
BRFSS 2014 N = 444,306 American men and women aged ≤18 from 50 states and the District of Columbia
Location, employment status, education, Black race, Hawaiians or other non-White/ Hispanic ethnicities
N/A
Liu et al. [14]
N = 474,684 participants of multiple studies from USA, Japan, UK, Sweden, Germany, Singapore, Israel, and Taiwan
N/A
Mortality of Coronary Heart Disease, Stroke CVD,
Cappuccio et al. [14a]
N = 29,818, aged 18–85 Cross-sectional household interview survey 2005 National Health Interview Survey (NHIS)
Black race
Obesity
Donat et al. [14b]
N = 578 Chicago residents, aged 33–45 Wrist Actigraphy for three consecutive days from 2003 to 2005
Black race
Incident hypertension difference in diastolic and systolic blood pressure
Knutson et al. [14c]
Sleep continuity/ efficiency
N = 812 participants (36% African American; 67% female) Longitudinal and cross-sectional
Black race, sedentary life
Metabolic syndrome (increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels)
Troxel et al. [14d]
Timing (shift work)
37 African American women and 62 women of other races. Day shift (n = 61), evening shift (n = 11), and night shift (n = 27)
Black race, evening and night shift
Nondipping blood pressure
Yamasaki et al. [14e]
Alertness/ sleepiness
N = 84,003 Multi-ethnic female registered nurses aged 37–54 in 14 US states. Longitudinal analyses of data from the Nurses' Health Study II
Shift work
Hypertension, diabetes, hypercholesterolemia, obesity, and depression
Gangwisch et al. [14f]
Satisfaction/ quality
N = 1139 including 520 whites, 586 African Americans, and 33 of Asian, Native American, or Hispanic ethnicity
Female gender, age, education, income
Overall self-reported physical health
Moore et al. [14g]
that social categories such as racial/ethnic minorities and socioeconomically disadvantaged groups do not attain the adequate and recommended amount, quality and consistency of sleep. The associations between sleep quantity/quality and both demographic and socioeconomic factors have been widely reported in the literature [12, 14, 15]. Also, similar observations have been made for race/ethnicity that emerged as a significant determinant of individual v ariation in sleep phenotype. For instance, African Americans are more burdened with sleep health disparities [16]. White youth generally have better sleep than minority youth, Hispanics have more than Blacks, and there is inconclusive evidence for Asians and other minorities [17]. Depending on the definition adopted, sleep-disorder-breathing (SDB) was 4–6 times more likely in 8- to 11-year-old black children compared with white children, and almost 3–5 times more likely in those born preterm
than term children [18]. Moreover, on average, African– American adults report shorter sleep duration compared to other racial/ethnic groups [14]. This critical prevalence of suboptimal sleep in communities of African descent compared to those of European descent is of interest to this chapter. Traditionally and according to historians and national archives, people of African descent were the most affected compared to nativeAmericans and Hispanics by the slave trade and chattel enslavement in the US. Sleep health disparities require to be investigated from a historical perspective, considering the birth context of this nation. The roots of the “blacks and whites sleep gap” is suspected by some historians to stretch back to the history of chattel enslavement and colonization in the United States. During this period, after people were kidnapped from the African continent and considered
476 PART | IX Economic and public policy implications of sleep health
as chattel slaves by white European settlers, resting time control became an efficient weapon in the hands of the European masters to strengthen the race-based slavery system and allowed the maximum exploitation of the enslaved workforce [19, 20]. Report on the sleep condition by the former enslaved abolitionist leader, Frederick Douglas echoes historian Benjamin Reiss's analysis:
that contribute to health and health care disparities [21], particularly cardiovascular health in the United States [22]. This idea of a mediating effect of sleep on health disparities can be analyzed based on the conceptual framework proposed by Jackson et al. [22], in their review of the multilevel determinants of sleep-cardiovascular health disparities via proximal, intermediate and distal pathways.
There were no beds given the slaves unless one coarse blanket be considered such, and none but the men and women had these. This, however, is not considered a very great privation. They find less difficulty from the want of beds, than from the want of time to sleep; for when their day's work in the field is done, the most of them having their washing, mending, and cooking to do, and having few or none of the ordinary facilities for doing either of these, very many of their sleeping hours are consumed in preparing for the field the coming day; and when this is done, old and young, male and female, married and single, drop down side by side, on one common bed,—the cold, damp floor,—each covering himself or herself with their miserable blankets; and here they sleep till they are summoned to the field by the driver's horn. At the sound of this, all must rise, and be off to the field. There must be no halting; everyone must be at his or her post, and woe betides them who hear not this morning summons to the field; for if they are not awakened by the sense of hearing, they are by the sense of feeling: no age nor sex finds any favor. [19, pp. 8–9]
(1) Proximal factors include individual risks behaviors, biological/genetic pathways, and biological responses, personal demographics such as acculturation, age, and sex that are recognized risks factors for Cardiovascular Diseases and impact sleep quality and quantity. (2) Intermediate factors comprise physical context, built environments, neighborhood and housing disadvantages, social relationships through family influences and social context such as racism. Data from the 2014 Census estimate the portion of Racial/ ethnic minorities of US population at 37.8% [22a]. Approximately, ¼ of Blacks (mostly descendants of the former enslaved Africans, Africans, and Afro-Caribbean immigrants) (21.2%) and Hispanic persons (18.3%) lived in Poverty compared with non-Hispanic white (7.8%) (Descendants of the settlers and European immigrants) and Asian (10%) [22b]. Research has demonstrated that people living in disadvantaged neighborhoods have increased exposure to sleep disturbance risk factors such as inappropriate light, noise, allergens, tobacco or air pollution. In addition to the higher rate of poverty, racial/ethnic minorities report more frequently objective and perceived discrimination. Results reported by Jackson et al. [22] have shown that experiences of racial discrimination and internalization of negative racial bias contribute to the acceleration of vascular aging in Black males. (3) Distal factors are occupational patterns, treatment access, and adherence, social conditions, and policies. For example, shift work is more current in African– Americans workers compared to their white counterparts and was reported to play a role in racial differences in sleep quantity. The proportion of job-related stress, low-wage jobs, and discrimination experiences was higher in black workers compared to whites ones.
Reiss's conception of the structure, ideology, practices, and policies that governed slave plantations and therefore enslaved people and their sleep phenotype might be very relevant for investigating sleep health disparities over a century later. All in all, socio-historical context has always been a significant determinant of who gets the best sleep, for: If slaves helped build the modern world, they were never afforded sufficient rest from the toils involved. Nor were they afforded the privacy that, according to the sociologist Norbert Elias, was becoming a hallmark of Western bourgeois sleep. Once they were excluded from normal sleep, they were punished for failures to maintain alertness and productivity and branded as constitutionally lazy for any sign of exhaustion. Their supposedly different sleep patterns- those that marked them as belonging to an inferior race- were actually taken as a justification for race-based slavery by medical authorities and slavery propagandists [20, p. 122].
Sleep health as a contributor to health disparities in modern days Regarding health differences in our contemporary society, sleep may play an important role among the factors
FROM SLEEP HEALTH DISPARITIES TOWARD SLEEP HEALTH EQUITY The CDC's Health Report from 1999 to 2014 indicates that trends in health were generally progressive for the overall population in the US. Differences in life expectancy, infant mortality, cigarette smoking among women, influenza vaccinations among those aged 65 and over,
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and health insurance coverage narrowed among the racial and ethnic groups. Nonetheless, during 1980–2014, life expectancy at birth for males and females was longest for white persons and shortest for black persons. For both males and females, racial differences in life expectancy at birth lessened, but persisted during 1980–2014. Furthermore, disparities by racial and ethnic group in the rate of high blood pressure and smoking among adult men persisted throughout the study period, with non-Hispanic black adults more likely to have high blood pressure than adults in other racial and ethnic groups throughout the period, and non-Hispanic black and non-Hispanic white males more likely to be current smokers than Hispanic and non-Hispanic Asian men. In summary, the authors of the report concluded that: Despite improvements over time in many of the health measures presented in this Special Feature, disparities by race and ethnicity were found in the most recent year for all 10 measures,a indicating that although progress has been made in the 30 years since the Heckler Report, elimination of disparities in health and access to health care has yet to be achieved. [23, p. 21]
Meanwhile, in the field of sleep medicine, although extensive efforts are being deployed by concerned clinicians and sleep researchers along with recommendations to develop research agenda and implement programs to decrease disparities in sleep health, the data presented previously suggest that there are still miles to go until society de facto attains sleep health equity [24]. Therefore we conclude the chapter proposing a conceptual framework intended as a roadmap toward sleep health which incorporates findings from our group's research initiatives in the field of behavioral sleep-research. At the beginning of this chapter we adopted Buysse's [9] definition of sleep health as a multidimensional pattern of sleep-wakefulness, adapted to the individual, social, and environmental demands, that promotes physical and mental well-being. Moreover, equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification [13]. Pursuing Equity in Health implies pursuing the elimination of health disparities/inequities [25]. To effectively move toward sleep equity, we believe a first step would be to define such a concept. Thus borrowing from the definitions of sleep health and health equity, we define sleep health equity as:
a. Measures of mortality, natality, health conditions, health behaviors, and health care access and utilization, by race, race and ethnicity, or by detailed Hispanic origin.
Equal opportunities that are given to each individual and/or communities based on their need, no matter their age, sex, race/ethnicity, geographic location, and socio-economic status, to obtain recommended, satisfactory, efficient amount of sleep with appropriate timing that promotes physical and mental well-being.
Similarly to the analogy of sacred circle that has the power to generate unity and to heal, we propose that sleep health equity practice is the constant effort to provide adequate sleep health resources to each group and individual, and to avoid sleep health disparities inherent to socio-economic and environmental factors. Thus, moving toward sleep health equity implies to pay close attention to the importance of contextual factors such as culture, education, policies, funding, governance, institution, historic events, historic collaboration, community capacity and readiness, university capacity and readiness and the dynamic between them. Additionally, the question of mutual respect and trust, cultural relevance and sustained partnerships should receive as much attention in the process (Fig. 35.1). We identify a list of problems related to patients, providers and the health-care-system that are undermining optimal sleep in disadvantaged communities, and then propose scientifically-informed potential policy examples that may contribute to decrease sleep health disparities [5, 22, 24, 26, 27]. See Table 35.2.
CONCLUSION Although sleep is fundamental to general health, the American lifestyle and societal schedule are not consistent with healthy sleep patterns. Unfortunately, racial/ethnic minorities are the most affected by the sleep health crisis, which, for Blacks echoes of the historical context of the birth of America. Sleep medicine experts, specialists, practitioners, representatives and policymakers have an ethical responsibility to help to eliminate sleep health inequities. Although recent data demonstrated that in general there was improvement in sleep health parameters in both privileged groups and disadvantaged ones, there is still a lot to be accomplished in order to eliminate health disparities. Youth and adults from disadvantaged communities would benefit if sleep medicine emphasizes the definition of sleep health dimensions and encourages the changes in practice they embody, in addition to identifying and treating sleep disorders. The positive aspect of sleep health as defined previously, and the ideal of equity in health comprise the anchors for our proposed definition of sleep health equity, and its associated conceptual framework toward the elimination of sleep health inequities.
478 PART | IX Economic and public policy implications of sleep health
1. Requirement for schools at all levels to include module on sleep health in their curriculum and refer at-risk youth to sleep health centers
10. Allocate funding to advance research on sleep health resilience
9. Allocate funding to advance epigenetic studies on factors associated with sleep health
8. Implementation of training programs from high-school level till faculty level to increase minority in sleep medicine
2. Limitations or suppression of all sources of inadequate light, noise, allergen, irritants and air pollution during the sleep time in target communities
Sleep Health Equity is equal opportunities that are given to each individual and/or communities based on their need, no matter their age, sex, race/ethnicity, geographic location, and socioeconomic status, to obtain recommended, satisfactory, efficient amount of sleep with appropriate timing that promotes physical and mental well-being.
7. Requirement for cultural competence training in sleep medicine programs
6. Establishment of sleep centers with multi-ethnic and multi-lingual staff in target communities
FIG. 35.1 Roadmap of policies toward the implementation of sleep health equity practices.
3. Tax incentives to corporate wellness programs that promote sleep and population health in disadvantaged communities
4. National campaign to raise awareness on the deleterious effect on health of racial bias, racial profiling, and discrimination
5. Limitations of shift length, regulation of time between shifts, regulation of degree of circadian phase change in consecutive workdays
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TABLE 35.2 Barriers to sleep health equity and policy solutions for reducing health disparities and advancing sleep health equity. Sleep health equity barrier
Solution advancing sleep health equity
1. Higher prevalence of Sleep-DisorderedBreathing (SBD) among African–American children
Implementation of programs for sleep health literacy, early screening and treatment for sleep disorders since elementary schools. Requirement for schools at all levels to include module on sleep health in their curriculum and refer at-risk youth to sleep health centers
2. Greater exposure to environmental risk factors for poor sleep among racial/ ethnic minorities living in disadvantaged neighborhoods
Implementation of a multilevel approach to reducing environmental factors that disturb sleep such as inadequate light, noise, allergen and irritants, and air pollution. Limitations or suppression of all sources of inadequate light, noise, allergen, irritants and air pollution during the sleep time in identified communities
3. A higher rate of short sleep duration that increases cardiovascular risk among individuals of African-descents and other minorities
Adopt a multilevel community-oriented sleep health and promotion education campaign (Ex: PEERS-ED, TASHE, and MetSO). Provide incentives to corporate wellness programs that promote sleep and population health among racial/ethnic communities
4. Racial/ethnic minorities, particularly Blacks are exposed to higher racial discrimination, which induces stress that undermines sleep
National campaign to raise awareness on the deleterious effects of racial bias, racial profiling, and discrimination on health. Increase severity of sanctions against racial discrimination nationwide
5. Blacks are disproportionately concerned with effects of shift work. Need stronger work schedule regulations
Limitations of shift length, regulation of time between shifts, regulation of degree of circadian phase changes in consecutive workdays
6. Culture and language barriers limit access to sleep health literacy among racial/ethnic minorities
Establishment of sleep centers with multi-ethnic and multi-lingual staff in vulnerable communities. Requirement for healthcare facilities in vulnerable communities to have a multi-ethnic and multi-lingual staff
7. Poor adherence to treatment of sleep disorders among minorities, particularly Blacks at risk for Obstructive Sleep Apnea (OSA)
A tailored behavioral intervention to increase adherence to physician recommendation (Ex: MetSO and PEERS-ED studies). Requirement for cultural competency training in sleep medicine programs
8. Lack of minority in the field of sleep medicine
Implementation of training programs from the high-school to faculty level to increase minority representation in sleep medicine (Ex: PRIDE and COMRADE programs). Requirement for a specific quota of racial/ethnic minorities in the recruitment of future sleep specialists
9. Lack of research on epigenetic factors associated with sleep problems among children and adults
Implementation of multi-level research that explores links of individual and household/neighborhood factors with poor sleep. Allocate funding to advance epigenetic studies on factors associated with poor sleep health
10. Lack of research on psychological resilience factors that are protective against factors that negatively affect sleep and CVD
Implementation of multi-level research that explores links among, stress exposure, individual, social, cultural and physical factors that affect sleep. Allocate funding to advance research on sleep health resilience
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[16] Petrov ME, Lichstein KL. Differences in sleep between black and white adults: An update and future directions. Sleep Med 2016; https://doi.org/10.1016/j.sleep.2015.01.011. Elsevier. [17] Guglielmo D, Gazmararian JA, Chung J, Rogers AE, Hale L. Racial/ethnic sleep disparities in US school-aged children and adolescents: a review of the literature. Sleep Health 2018; https://doi. org/10.1016/j.sleh.2017.09.005. Elsevier Inc. [18] Rosen GM, Bendel AE, Neglia JP, Moertel CL, Mahowald M. Sleep in children with neoplasms of the central nervous system: case review of 14 children. Pediatrics 2003;112(1 Pt 1):e46–54. https:// doi.org/10.1542/peds.112.1.e46. [19] Douglas F. Narrative of the life of Frederick Douglass, an American Slave. New York: Penguin Classics; 1845. [20] Reiss B. Wild nights: how taming sleep created our restless world. Basic Books; 2017. [21] Williams NJ, Grandner MA, Snipes A, Rogers A, Williams O, Airhihenbuwa C, Jean-Louis G. Racial/ethnic disparities in sleep health and health care: Importance of the sociocultural context. Sleep Health 2015;1(1):28–35. [22] Jackson C, Redline S, Emmons KM. Sleep as a potential fundamental contributor to disparities in cardiovascular health. SSRN; 2015 https://doi.org/10.1146/annurev-publhealth-031914-122838. [22a] Colby SL, Ortman JM. Projections of the size and composition of the U.S. population: 2014 to 2060. Current Population Reports, P25-1143. Washington, DC: US Census Bureau; 2014. https://doi. org/P25-1143. [22b] US Census Bureau. Historical poverty tables: people and families—1959 to 2017; 2018. Available at: https://www.census.gov/ data/tables/time-series/demo/income-poverty/historical-povertypeople.html. [23] National Center for Health Statistics. Health, United States, 2015: with special feature on racial and ethnic health disparities. Hyattsville, MD: National Center for Health Statistics; 2016. [24] Jean-Louis G, Grandner M. Importance of recognizing sleep health disparities and implementing innovative interventions to reduce these disparities. Sleep Med 2016;18:1–2. https://doi.org/10.1016/j. sleep.2015.08.001. [25] Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health 2006;27(1):167–94. https:// doi.org/10.1146/annurev.publhealth.27.021405.102103. [26] Jean-Louis G, Newsome V, Williams NJ, Zizi F, Ravenell J, Ogedegbe G. Tailored behavioral intervention among blacks with metabolic syndrome and sleep apnea: results of the MetSO trial. Sleep 2017;40(1):https://doi.org/10.1093/sleep/zsw008. [27] Williams NJ, Robbins R, Rapoport D, Allegrante JP, Cohall A, Ogedgebe G, Jean-Louis G. Tailored approach to sleep health education (TASHE): study protocol for a web-based randomized controlled trial. Trials 2016;17(1):585. https://doi.org/10.1186/ s13063-016-1701-x.
Sleep health equity Judite Blanca, Jao Nunesb, Natasha Williamsc, Rebecca Robbinsd, Azizi A. Seixasd,e, Girardin Jean-Louisd,e a
NYU Langone Health, Department of Population Health, Center for Healthful Behavior Change, New York, NY, United States, bThe City College of New York, New York, NY, United States, cNYU Langone Health, Division of Health and Behavior, Department of Population Health, Center for Healthful Behavior Change, New York, NY, United States, dNYU Langone Health, Department of Population Health, New York, NY, United States, eNYU Langone Health, Department of Psychiatry, New York, NY, United States
INTRODUCTION: SLEEP AND PUBLIC HEALTH Sleep is the “reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment” [1, p. 15]. Sleep is vital for optimal mental, emotional, and physical well-being, and therefore has emerged as a pillar of health alongside nutrition, exercise, and smoking cessation. Leading scientific, clinical, and governmental organizations in the US and internationally recognize the importance of sleep [2–4]. Despite this wide-scale recognition, schedules in America are inconsistent with healthy sleep habits [5]. For instance, career, social and lifestyle demands represent barriers to adequate sleep that have generated a sleep crisis of significant proportion with impact on individual outcomes (e.g., cognition, mental and physical health) and societal outcomes (e.g., productivity and safety). The Centers for Disease Control and Prevention (CDC) has made specific recommendations to meet daily needs: 9–12 h of sleep for school-aged children, 8–10 h of sleep for adolescents and a minimum of 7 h for adults. However, the 2015 Youth Risk Behavior Surveillance System [6] shows an estimated nationwide prevalence of short sleep duration of 57.8% among middle school students and of 72.7% among high school students. Among adult respondents to the 2009 Behavioral Risk Factor Surveillance System (BRFSS), 41.3% reported 1–13 days of insufficient rest or sleep before the survey [7]. Poor sleep health has significant individual health and societal consequences. Poor sleep is associated with poor mental, emotional (e.g., anxiety, mood disturbance, suicidal ideation) and physical health consequences (e.g., accidents, illness, pain). Additionally, poor sleep health increases the risk for chronic conditions (e.g., high blood pressure, high body mass index (BMI) and obesity) and mortality. Poor sleep health extracts a significant cost in terms of dollars annually in medical expenses such as Sleep and Health. https://doi.org/10.1016/B978-0-12-815373-4.00035-6 © 2019 Elsevier Inc. All rights reserved.
d octor visits, hospital services, prescriptions, and over-thecounter medications [8]. Conversely, research suggests that adequate sleep health has a protective effect for individual health and societal outcomes. Specifically, individuals who consistently report dimensions of sleep health, including good sleep quality, sufficient sleep duration, and absence of sleep disorder, are more likely to have better measures of mental, emotional, and physical health and longevity compared to those who cut their sleep short. But research also documents differences in sleep health along socio-economic lines, sleep health being out of reach for most individuals living in deprived social economic areas. Specifically, minority groups and individuals from disadvantaged economic backgrounds report lower sleep quality. Sleep, a precious resource in our society, this research suggests, may actually constitute a luxury most commonly practiced by majority race/ethnic groups and socio-economically advantaged individuals. In order to tackle the sleep health crisis, the past 10 years has seen a dramatic increase in research that articulates these socio-economic limiting factors that affect sleep. We argue there is a need for a paradigm shift in the way sleep medicine approaches this public health matter. We agree with Buysse [9] that the current focus mainly on sleep disorders should give way to a stronger emphasis on the notion of sleep health. This is crucial to the health of individuals and of the population, and stands to benefit sleep medicine itself.
WHAT IS SLEEP HEALTH? While the body of knowledge on sleep patterns and associated public health outcomes is growing, there is no precise and specific definition of the concept of sleep health for use by sleep researchers and experts. When sleep and health are entered together in databases such as PubMed, and Google Scholar, between 43,714 and 676,000,000 473
474 PART | IX Economic and public policy implications of sleep health
results are identified (September, the 8th of 2018). Authors appear to use “sleep problems” and “sleep health” interchangeably in their titles. Buysse [9] noticed that not even in the 2006 Institute of Medicine Report and in the mission statement for sleep of The Centers for Disease Control and Prevention, an explicit definition of sleep health was included. To fill the gap, in his recently published paper, “Sleep health: can we define it? Does it matter,” Buysse [9] articulated this comprehensive definition: Sleep health is a multidimensional pattern of sleep- wakefulness, adapted to individual, social, and environmental demands, that promotes physical and mental well-being. Good sleep health is characterized by subjective satisfaction, appropriate timing, sufficient duration, high efficiency, and sustained alertness during waking hours. [9, p. 12]
And in contrast to the deficit model, this definition focuses on positive characteristics of sleep health which are physiologically quantifiable. Although adult-centered, it could be easily extrapolated to youth and cannot be conceived outside of its individual, social and environmental components, and offers specific anchors for these five dimensions of sleep health: ● ●
● ● ●
Sleep duration: The number of sleep hours per day Sleep continuity or efficiency: The ability of falling asleep and staying asleep Timing: The placement of sleep within the 24-h day Alertness/sleepiness: The capacity of staying awake Satisfaction/Quality: The individual perception of “good” or “poor” sleep.
The following are questions of interest in the context of the present analysis: What is the relationship between the sleep health dimensions and physical and mental well-being? What are the mechanisms that influence sleep dimensions and related health outcomes? Overall, does the presence of sleep impairment affect all groups at the same level?
SOCIAL DETERMINANTS OF SLEEP HEALTH DIMENSIONS AND ASSOCIATED HEALTH OUTCOMES During the last decades, factors affecting the five dimensions of sleep health, including age, sex, body mass index (BMI), race/ethnicity, education, environment, workplace and economic position have been widely documented [7, 10–12]. In Table 35.1, we present a list of problems related to patients, providers and the healthcare system that potentially undermine optimal sleep in disadvantaged communities. As described in Table 35.1, there is a growing body of studies that show similar findings, not all categories are equally impacted by the sleep health crisis. How does this sleep deficiency vary across racial and ethnic groups? Are other individual, social and environmental components
contributing to this variation of sleep patterns among different social groups? These are valid questions that current research findings cannot yet answer in full. At this point, we intend to explore another valid question: Can any role be attributed to the historical context, specifically to the race-based slavery system that underpins the birth of the American society?
HEALTH DIFFERENCES AND THE HISTORICAL SLEEP GAP BETWEEN BLACKS AND WHITES Identifying determinants of health differences The debate is not a new one about the origin of historically ubiquitous health disparities/inequities and of the elusive health equity, but the tools of the debate remain faulty. Until now, there is little consensus regarding the meaning of the terms “health disparities/inequities” and “health equity.” An early articulated and widespread conceptualization of these notions is attributed to Margaret Whitehead in her famous article, “The concepts and principles of equity and health” [13]. She stated: “inequality in health is a term commonly used in some countries to indicate systematic, avoidable and important differences.” In her discussion, she described seven critical determinants of health differentials: (1) Natural, biological variation; (2) Health-damaging behavior if freely chosen, such as participation in certain sports and pastimes; (3) The transient health advantage of one group over another when that group is first to adopt a health-promoting behavior (as long as other groups have the means to catch up fairly soon); (4) Health-damaging behavior where the degree of choice of lifestyles is severely restricted; (5) Exposure to unhealthy, stressful living and working conditions; (6) Inadequate access to essential health and other public services; and (7) Natural selection or health-related social mobility involving the tendency for sick people to move down the social scale. According to Whitehead, these seven determinants of health differences are all interacting. Although the impact of biological factors and the effects of sick people moving down the social scale have been demonstrated, she underlined that the major role is to be attributed to socioeconomic and environmental factors, including lifestyles. Consequently, how may this fact hold explanations for the actual sleep health disparities?
History behind the black–white “sleep gap” Biological imperatives to maintain homeostatic processes and social factors determine sleep in humans. The National Heart Lung and Blood Institute (NHLBI) of the National Institutes of Health (NIH) describes sleep as a fundamental requirement of living. Yet extensive scientific evidence revealed
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TABLE 35.1 Summary of social determinants of sleep health and potential health outcomes. Dimensions of sleep measured Duration
Population studied
Social determinants/ risk factors
Health outcomes
Source
BRFSS 2014 N = 444,306 American men and women aged ≤18 from 50 states and the District of Columbia
Location, employment status, education, Black race, Hawaiians or other non-White/ Hispanic ethnicities
N/A
Liu et al. [14]
N = 474,684 participants of multiple studies from USA, Japan, UK, Sweden, Germany, Singapore, Israel, and Taiwan
N/A
Mortality of Coronary Heart Disease, Stroke CVD,
Cappuccio et al. [14a]
N = 29,818, aged 18–85 Cross-sectional household interview survey 2005 National Health Interview Survey (NHIS)
Black race
Obesity
Donat et al. [14b]
N = 578 Chicago residents, aged 33–45 Wrist Actigraphy for three consecutive days from 2003 to 2005
Black race
Incident hypertension difference in diastolic and systolic blood pressure
Knutson et al. [14c]
Sleep continuity/ efficiency
N = 812 participants (36% African American; 67% female) Longitudinal and cross-sectional
Black race, sedentary life
Metabolic syndrome (increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels)
Troxel et al. [14d]
Timing (shift work)
37 African American women and 62 women of other races. Day shift (n = 61), evening shift (n = 11), and night shift (n = 27)
Black race, evening and night shift
Nondipping blood pressure
Yamasaki et al. [14e]
Alertness/ sleepiness
N = 84,003 Multi-ethnic female registered nurses aged 37–54 in 14 US states. Longitudinal analyses of data from the Nurses' Health Study II
Shift work
Hypertension, diabetes, hypercholesterolemia, obesity, and depression
Gangwisch et al. [14f]
Satisfaction/ quality
N = 1139 including 520 whites, 586 African Americans, and 33 of Asian, Native American, or Hispanic ethnicity
Female gender, age, education, income
Overall self-reported physical health
Moore et al. [14g]
that social categories such as racial/ethnic minorities and socioeconomically disadvantaged groups do not attain the adequate and recommended amount, quality and consistency of sleep. The associations between sleep quantity/quality and both demographic and socioeconomic factors have been widely reported in the literature [12, 14, 15]. Also, similar observations have been made for race/ethnicity that emerged as a significant determinant of individual v ariation in sleep phenotype. For instance, African Americans are more burdened with sleep health disparities [16]. White youth generally have better sleep than minority youth, Hispanics have more than Blacks, and there is inconclusive evidence for Asians and other minorities [17]. Depending on the definition adopted, sleep-disorder-breathing (SDB) was 4–6 times more likely in 8- to 11-year-old black children compared with white children, and almost 3–5 times more likely in those born preterm
than term children [18]. Moreover, on average, African– American adults report shorter sleep duration compared to other racial/ethnic groups [14]. This critical prevalence of suboptimal sleep in communities of African descent compared to those of European descent is of interest to this chapter. Traditionally and according to historians and national archives, people of African descent were the most affected compared to nativeAmericans and Hispanics by the slave trade and chattel enslavement in the US. Sleep health disparities require to be investigated from a historical perspective, considering the birth context of this nation. The roots of the “blacks and whites sleep gap” is suspected by some historians to stretch back to the history of chattel enslavement and colonization in the United States. During this period, after people were kidnapped from the African continent and considered
476 PART | IX Economic and public policy implications of sleep health
as chattel slaves by white European settlers, resting time control became an efficient weapon in the hands of the European masters to strengthen the race-based slavery system and allowed the maximum exploitation of the enslaved workforce [19, 20]. Report on the sleep condition by the former enslaved abolitionist leader, Frederick Douglas echoes historian Benjamin Reiss's analysis:
that contribute to health and health care disparities [21], particularly cardiovascular health in the United States [22]. This idea of a mediating effect of sleep on health disparities can be analyzed based on the conceptual framework proposed by Jackson et al. [22], in their review of the multilevel determinants of sleep-cardiovascular health disparities via proximal, intermediate and distal pathways.
There were no beds given the slaves unless one coarse blanket be considered such, and none but the men and women had these. This, however, is not considered a very great privation. They find less difficulty from the want of beds, than from the want of time to sleep; for when their day's work in the field is done, the most of them having their washing, mending, and cooking to do, and having few or none of the ordinary facilities for doing either of these, very many of their sleeping hours are consumed in preparing for the field the coming day; and when this is done, old and young, male and female, married and single, drop down side by side, on one common bed,—the cold, damp floor,—each covering himself or herself with their miserable blankets; and here they sleep till they are summoned to the field by the driver's horn. At the sound of this, all must rise, and be off to the field. There must be no halting; everyone must be at his or her post, and woe betides them who hear not this morning summons to the field; for if they are not awakened by the sense of hearing, they are by the sense of feeling: no age nor sex finds any favor. [19, pp. 8–9]
(1) Proximal factors include individual risks behaviors, biological/genetic pathways, and biological responses, personal demographics such as acculturation, age, and sex that are recognized risks factors for Cardiovascular Diseases and impact sleep quality and quantity. (2) Intermediate factors comprise physical context, built environments, neighborhood and housing disadvantages, social relationships through family influences and social context such as racism. Data from the 2014 Census estimate the portion of Racial/ ethnic minorities of US population at 37.8% [22a]. Approximately, ¼ of Blacks (mostly descendants of the former enslaved Africans, Africans, and Afro-Caribbean immigrants) (21.2%) and Hispanic persons (18.3%) lived in Poverty compared with non-Hispanic white (7.8%) (Descendants of the settlers and European immigrants) and Asian (10%) [22b]. Research has demonstrated that people living in disadvantaged neighborhoods have increased exposure to sleep disturbance risk factors such as inappropriate light, noise, allergens, tobacco or air pollution. In addition to the higher rate of poverty, racial/ethnic minorities report more frequently objective and perceived discrimination. Results reported by Jackson et al. [22] have shown that experiences of racial discrimination and internalization of negative racial bias contribute to the acceleration of vascular aging in Black males. (3) Distal factors are occupational patterns, treatment access, and adherence, social conditions, and policies. For example, shift work is more current in African– Americans workers compared to their white counterparts and was reported to play a role in racial differences in sleep quantity. The proportion of job-related stress, low-wage jobs, and discrimination experiences was higher in black workers compared to whites ones.
Reiss's conception of the structure, ideology, practices, and policies that governed slave plantations and therefore enslaved people and their sleep phenotype might be very relevant for investigating sleep health disparities over a century later. All in all, socio-historical context has always been a significant determinant of who gets the best sleep, for: If slaves helped build the modern world, they were never afforded sufficient rest from the toils involved. Nor were they afforded the privacy that, according to the sociologist Norbert Elias, was becoming a hallmark of Western bourgeois sleep. Once they were excluded from normal sleep, they were punished for failures to maintain alertness and productivity and branded as constitutionally lazy for any sign of exhaustion. Their supposedly different sleep patterns- those that marked them as belonging to an inferior race- were actually taken as a justification for race-based slavery by medical authorities and slavery propagandists [20, p. 122].
Sleep health as a contributor to health disparities in modern days Regarding health differences in our contemporary society, sleep may play an important role among the factors
FROM SLEEP HEALTH DISPARITIES TOWARD SLEEP HEALTH EQUITY The CDC's Health Report from 1999 to 2014 indicates that trends in health were generally progressive for the overall population in the US. Differences in life expectancy, infant mortality, cigarette smoking among women, influenza vaccinations among those aged 65 and over,
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and health insurance coverage narrowed among the racial and ethnic groups. Nonetheless, during 1980–2014, life expectancy at birth for males and females was longest for white persons and shortest for black persons. For both males and females, racial differences in life expectancy at birth lessened, but persisted during 1980–2014. Furthermore, disparities by racial and ethnic group in the rate of high blood pressure and smoking among adult men persisted throughout the study period, with non-Hispanic black adults more likely to have high blood pressure than adults in other racial and ethnic groups throughout the period, and non-Hispanic black and non-Hispanic white males more likely to be current smokers than Hispanic and non-Hispanic Asian men. In summary, the authors of the report concluded that: Despite improvements over time in many of the health measures presented in this Special Feature, disparities by race and ethnicity were found in the most recent year for all 10 measures,a indicating that although progress has been made in the 30 years since the Heckler Report, elimination of disparities in health and access to health care has yet to be achieved. [23, p. 21]
Meanwhile, in the field of sleep medicine, although extensive efforts are being deployed by concerned clinicians and sleep researchers along with recommendations to develop research agenda and implement programs to decrease disparities in sleep health, the data presented previously suggest that there are still miles to go until society de facto attains sleep health equity [24]. Therefore we conclude the chapter proposing a conceptual framework intended as a roadmap toward sleep health which incorporates findings from our group's research initiatives in the field of behavioral sleep-research. At the beginning of this chapter we adopted Buysse's [9] definition of sleep health as a multidimensional pattern of sleep-wakefulness, adapted to the individual, social, and environmental demands, that promotes physical and mental well-being. Moreover, equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification [13]. Pursuing Equity in Health implies pursuing the elimination of health disparities/inequities [25]. To effectively move toward sleep equity, we believe a first step would be to define such a concept. Thus borrowing from the definitions of sleep health and health equity, we define sleep health equity as:
a. Measures of mortality, natality, health conditions, health behaviors, and health care access and utilization, by race, race and ethnicity, or by detailed Hispanic origin.
Equal opportunities that are given to each individual and/or communities based on their need, no matter their age, sex, race/ethnicity, geographic location, and socio-economic status, to obtain recommended, satisfactory, efficient amount of sleep with appropriate timing that promotes physical and mental well-being.
Similarly to the analogy of sacred circle that has the power to generate unity and to heal, we propose that sleep health equity practice is the constant effort to provide adequate sleep health resources to each group and individual, and to avoid sleep health disparities inherent to socio-economic and environmental factors. Thus, moving toward sleep health equity implies to pay close attention to the importance of contextual factors such as culture, education, policies, funding, governance, institution, historic events, historic collaboration, community capacity and readiness, university capacity and readiness and the dynamic between them. Additionally, the question of mutual respect and trust, cultural relevance and sustained partnerships should receive as much attention in the process (Fig. 35.1). We identify a list of problems related to patients, providers and the health-care-system that are undermining optimal sleep in disadvantaged communities, and then propose scientifically-informed potential policy examples that may contribute to decrease sleep health disparities [5, 22, 24, 26, 27]. See Table 35.2.
CONCLUSION Although sleep is fundamental to general health, the American lifestyle and societal schedule are not consistent with healthy sleep patterns. Unfortunately, racial/ethnic minorities are the most affected by the sleep health crisis, which, for Blacks echoes of the historical context of the birth of America. Sleep medicine experts, specialists, practitioners, representatives and policymakers have an ethical responsibility to help to eliminate sleep health inequities. Although recent data demonstrated that in general there was improvement in sleep health parameters in both privileged groups and disadvantaged ones, there is still a lot to be accomplished in order to eliminate health disparities. Youth and adults from disadvantaged communities would benefit if sleep medicine emphasizes the definition of sleep health dimensions and encourages the changes in practice they embody, in addition to identifying and treating sleep disorders. The positive aspect of sleep health as defined previously, and the ideal of equity in health comprise the anchors for our proposed definition of sleep health equity, and its associated conceptual framework toward the elimination of sleep health inequities.
478 PART | IX Economic and public policy implications of sleep health
1. Requirement for schools at all levels to include module on sleep health in their curriculum and refer at-risk youth to sleep health centers
10. Allocate funding to advance research on sleep health resilience
9. Allocate funding to advance epigenetic studies on factors associated with sleep health
8. Implementation of training programs from high-school level till faculty level to increase minority in sleep medicine
2. Limitations or suppression of all sources of inadequate light, noise, allergen, irritants and air pollution during the sleep time in target communities
Sleep Health Equity is equal opportunities that are given to each individual and/or communities based on their need, no matter their age, sex, race/ethnicity, geographic location, and socioeconomic status, to obtain recommended, satisfactory, efficient amount of sleep with appropriate timing that promotes physical and mental well-being.
7. Requirement for cultural competence training in sleep medicine programs
6. Establishment of sleep centers with multi-ethnic and multi-lingual staff in target communities
FIG. 35.1 Roadmap of policies toward the implementation of sleep health equity practices.
3. Tax incentives to corporate wellness programs that promote sleep and population health in disadvantaged communities
4. National campaign to raise awareness on the deleterious effect on health of racial bias, racial profiling, and discrimination
5. Limitations of shift length, regulation of time between shifts, regulation of degree of circadian phase change in consecutive workdays
Sleep health equity Chapter | 35 479
TABLE 35.2 Barriers to sleep health equity and policy solutions for reducing health disparities and advancing sleep health equity. Sleep health equity barrier
Solution advancing sleep health equity
1. Higher prevalence of Sleep-DisorderedBreathing (SBD) among African–American children
Implementation of programs for sleep health literacy, early screening and treatment for sleep disorders since elementary schools. Requirement for schools at all levels to include module on sleep health in their curriculum and refer at-risk youth to sleep health centers
2. Greater exposure to environmental risk factors for poor sleep among racial/ ethnic minorities living in disadvantaged neighborhoods
Implementation of a multilevel approach to reducing environmental factors that disturb sleep such as inadequate light, noise, allergen and irritants, and air pollution. Limitations or suppression of all sources of inadequate light, noise, allergen, irritants and air pollution during the sleep time in identified communities
3. A higher rate of short sleep duration that increases cardiovascular risk among individuals of African-descents and other minorities
Adopt a multilevel community-oriented sleep health and promotion education campaign (Ex: PEERS-ED, TASHE, and MetSO). Provide incentives to corporate wellness programs that promote sleep and population health among racial/ethnic communities
4. Racial/ethnic minorities, particularly Blacks are exposed to higher racial discrimination, which induces stress that undermines sleep
National campaign to raise awareness on the deleterious effects of racial bias, racial profiling, and discrimination on health. Increase severity of sanctions against racial discrimination nationwide
5. Blacks are disproportionately concerned with effects of shift work. Need stronger work schedule regulations
Limitations of shift length, regulation of time between shifts, regulation of degree of circadian phase changes in consecutive workdays
6. Culture and language barriers limit access to sleep health literacy among racial/ethnic minorities
Establishment of sleep centers with multi-ethnic and multi-lingual staff in vulnerable communities. Requirement for healthcare facilities in vulnerable communities to have a multi-ethnic and multi-lingual staff
7. Poor adherence to treatment of sleep disorders among minorities, particularly Blacks at risk for Obstructive Sleep Apnea (OSA)
A tailored behavioral intervention to increase adherence to physician recommendation (Ex: MetSO and PEERS-ED studies). Requirement for cultural competency training in sleep medicine programs
8. Lack of minority in the field of sleep medicine
Implementation of training programs from the high-school to faculty level to increase minority representation in sleep medicine (Ex: PRIDE and COMRADE programs). Requirement for a specific quota of racial/ethnic minorities in the recruitment of future sleep specialists
9. Lack of research on epigenetic factors associated with sleep problems among children and adults
Implementation of multi-level research that explores links of individual and household/neighborhood factors with poor sleep. Allocate funding to advance epigenetic studies on factors associated with poor sleep health
10. Lack of research on psychological resilience factors that are protective against factors that negatively affect sleep and CVD
Implementation of multi-level research that explores links among, stress exposure, individual, social, cultural and physical factors that affect sleep. Allocate funding to advance research on sleep health resilience
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480 PART | IX Economic and public policy implications of sleep health
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