Last week, we dove deep into existing research and revealed profound racial disparities in the amount of sleep that adults in the United States get on a regular basis. This week, we follow up with a Special Feature that tackles the reasons behind these disparities, featuring comments from experienced healthcare providers.
Studies reveal that Black Americans are twice as likely to be sleep-deprived, compared with their white counterparts.
Also, Black and Hispanic adults who live in inner-city areas, in particular, are more likely to sleep for shorter periods.
In addition, Black and Latinx individuals tend to work less conventional hours and more inconvenient shifts, which can derail circadian rhythms and interfere with regular sleep schedules.
In this context, we asked three healthcare professionals about broader disparities in sleep: What are the roles of socioeconomic inequalities? How does racial discrimination come into play? And how can doctors’ guidance about sleep better reflect and account for these disparities?
To find out, we spoke with Dr. Harshil Matta, DO, a family medicine physician at Loyola Medicine, in Chicago, IL; Dr. Emelia “Mimi” Arquilla, DO, an assistant professor of clinical family medicine at the University of Illinois, in Chicago; and Cynthia Taylor Chavoustie, MPAS, PA-C, a physician assistant practicing family medicine in Parker, CO.
MNT: Numerous studies have pointed to lower sleep quality among people of color, compared with their white counterparts. What are some of the reasons behind these disparities?
Taylor Chavoustie, MPAS, PA-C: Compared to their white counterparts, Black Americans are more likely to work night shifts or multiple shifts, live in noisy or crowded environments, not have assistance with childcare, live in unsafe neighborhoods, work in physically demanding and hazardous jobs, and have to get up earlier to take public transportation to their jobs — all of which can significantly interfere with sleep.
They are also less likely to seek or have access to medical care, such as evaluations for sleep apnea, which is a condition that, in addition to the environmental factors, can interfere with sleep. Unfortunately, sleep cannot always take priority for most Black Americans.
Dr. Matta: I think there are many factors which point to this disparity. I think it starts with mental and physical health and how socioeconomic status [SES] ties into that it. SES plays an integral role in an individual’s heath.
In my opinion, SES is more complex than just occupation or high income level; you have to explore how SES affects all [the other aspects] in one’s life.
Higher SES provides you with job security, access to healthcare, food security, and a safer place of residence. These variables, when shifted in the other direction, greatly affect quality of sleep. Shift work, food insecurity, concern over the home environment, and financial stress all lead to lower sleep quality.
– Dr. Harshil Matta
[To sum up,] lower SES greatly increases stress [for some individuals], which in turn affects their sleep quality. The stress increase leads to chronic disease, and the use of stress relief methods, such as tobacco, alcohol, or taking on too much work to make ends meet, all lead back to poor sleep habits.
I think my bigger point is that we, as a society, don’t do enough to aid minority groups to ease these challenges.
Dr. Matta: Better food options, safer neighborhoods, more access to physical activity, equal financial opportunity — these changes would reduce the sleep disparity, in my opinion.
Dr. Arquilla: Sleep disparities are often related to the degree of control one has over their life. Oftentimes, those with lower [SES] will work multiple jobs or do shift work and cannot afford to work less in order to sleep more.
It’s also important to consider the environment that people live in. Is it an unsafe or a busy neighborhood? If so, they may be more hypervigilant or not want to leave their home as often, even to get groceries or exercise.
These issues are often consequences of institutionalized racism that places people of color at a disadvantage [and] ultimately contributes to healthcare inequalities.
– Dr. Emelia Arquilla
MNT: You mentioned shift work, urban residence, job strain, and discrimination as just some of the factors that may explain these race-related disparities in sleep. Should the lifestyle and sleep advice that healthcare professionals give their patients reflect these specificities?
Taylor Chavoustie, MPAS, PA-C: Absolutely, but there’s no easy answer as to how. Most importantly, we [as healthcare professionals] need to ask about these factors and show that we understand that it’s not easy for some to make sleep a priority and that uninterrupted sleep or sleeping [for more than] just a few hours may not even be a possibility because of their living and work environments.
We definitely shouldn’t just assume everyone has 8 hours of undisturbed sleep time, but we can help patients realize that sleep is important for their health and overall wellbeing and explore some ways they can improve their sleep.
Dr. Matta: Absolutely! Physicians need to take into account each patient’s entire picture. If a patient is working in a job with shift work or working overnight shifts or changing shifts every 2–3 weeks, that already will not let that individual practice the norms of what we consider good sleep hygiene. We need to tailor our approach to fit what people need to better help them.
Healthcare advice needs to be better tailored to different populations and to do that we need to understand the depth of challenges that different groups face. Everyone says, ‘Go eat healthily,’ but people don’t realize that in some areas, food insecurity prevents that.
– Dr. Harshil Matta
We need to recognize these challenges and find other ways — for example, okay, how can we eat healthier with the options that we do have?
Health advice shouldn’t just be tailored for the general, it needs to include everyone, and everyone faces different barriers to healthcare.
Dr. Arquilla: Absolutely, all healthcare advice should be tailored with the whole person in mind.
It’s important to remember that people are more than a symptom and that they exist within a community, with multiple variables impacting their day-to-day lives. To know these variables, you have to ask about them, which may seem intrusive but is necessary to provide quality care. For instance, if someone’s neighborhood is not safe to go for a run in, consider providing ideas for home-based exercises that still get their heart pumping.
– Dr. Emelia Arquilla
Thanks to COVID, there are many resources for free guided workouts online that don’t need any special equipment.
MNT: Are there any other examples of sleep or self-care advice that is tailored for one sociodemographic group and excludes others?
Taylor Chavoustie, MPAS, PA-C: “Try to go to sleep and wake up at the same time” is difficult for shift workers; “Exercise is good for sleep” is another one that may be difficult for some who work multiple shifts, or live in unsafe urban environments, or can’t afford gym memberships, etc.
Dr. Arquilla: Part of good sleep hygiene includes making your bed a place that is only used for sleep or sex and to also make it as comfortable as possible. For those living in small apartments, it may not be feasible to only use one’s bed for those two activities.
In addition, the cost alone is often prohibitive — to get a new mattress, pillows, bedding, blackout curtains, or noise machines. These socioeconomic hurdles place patients at a further disadvantage for establishing a healthy sleep cycle.
MNT: Can you tell us more about the role that discrimination plays in these race-related sleep disparities?
Taylor Chavoustie, MPAS, PA-C: Racial discrimination has been shown to increase job and personal stress, triggering emotions like fear, anger, and sadness, all of which naturally make life and sleep more difficult.
Racial discrimination also shapes the environment that people live in: crowded, unsafe, noisy [homes that may be] full of allergens, etc. It can also make it difficult for minorities to get the education and consideration they deserve for higher-paying jobs — often the jobs that provide health benefits or childcare, or jobs that are closer to where they live. All of this can make sleep more difficult for an individual.
Dr. Matta: I think racial discrimination plays a substantial role in sleep disparities. It goes back to my point in the first question: It raises stress levels and increases worry over home environment and safety. When any individual is stressed, it leads to insomnia. Think about a time you were very angry or upset — it takes a while to become calm and go back to your routine.
Racial discrimination prevents that from happening, it stimulates constant stress, constant worry that disrupts everyday life, and it leads to sleep disparity. Lack of sleep is associated with fatigue, depression, and anxiety, [and] racial discrimination in society harms individuals’ growth in that society.
Healthcare providers need to do a better job of becoming more aware of these challenges that minorities face day in and day out — truly understand what your patients go through and then you will be better able to help them.
– Dr. Harshil Matta
Dr. Arquilla: Systemic racism has created inequalities that impact every aspect of life for a person of color. It has created a healthcare system that limits accessibility and quality of care, contributing further to health inequalities.
Because of this structure, people of color are [also] less likely to get diagnosed with sleep-related conditions, including sleep apnea, which can place a person at increased risk for uncontrolled high blood pressure, cardiovascular disease, and even death.
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