Review ArticleSleep disparity, race/ethnicity, and socioeconomic position
Introduction
Despite remarkable improvements in health and health care over the last century, striking and well-documented racial, ethnic, and socioeconomic health disparities persist in inequitably determining the welfare of social groups in the United States [1], [2], [3]. Both non-white and other socioeconomically disadvantaged populations have worse outcomes across a range of health conditions. Cardiovascular disease, diabetes, asthma, HIV/AIDS, and tuberculosis are all significantly more common among Blacks/African Americans and Hispanics than among non-Hispanic Whites [1], [3], [4]. Racial and ethnic disparities persist even after stratification by education or household income [1], [3]. Such pervasive health disparities at the individual and societal level are likely mediated by a combination of structural, physiological, psychological, and behavioral differences across populations [2], [3], [5], [6], [7]. In addition, neighborhood factors play a significant role in perpetuating health disparities. Neighborhoods affect health through differential exposures to social (eg, cultural norms about health behaviors), psychological (eg, neighborhood safety and experience of discrimination), and physical (eg, exposure to toxins, air or noise pollution, access to healthy food) factors [8], [9]. All of these differential neighborhood experiences are shaped by structural/institutional forces that determine both vulnerability to harmful exposures and access to helpful resources. Understanding and reducing health disparities is an important public health goal.
Understanding the population burden of insufficient sleep and poor sleep quality is also an important public health goal. A recent report from the Institute of Medicine identified “sleep deprivation and sleep disorders” as a major unmet public health problem [10]. Another recent Institute of Medicine report, which discussed medical resident duty hours, also identified inadequate sleep as a major risk factor for iatrogenic problems [11]. Adequate sleep has been highlighted as a public health priority by Healthy People 2020, the document that guides federal health-related funding across the US Department of Health and Human Services [12]. In a statement of a joint task force of the American Academy of Sleep Medicine and the Sleep Research Society that identifies the most pressing goals of the sleep research field, the first noted goal was to gain better understanding of the public health implications of insufficient sleep and circadian disruption [13].
Insufficient sleep, operationalized as habitual short sleep duration in epidemiologic studies or enforced sleep restriction in laboratory studies, has been associated with weight gain and obesity [14], hypertension [15], [16], [17], hyperlipidemia [15], [16], inflammation [18], diabetes [15], [19], [20], [21], stroke [16], [22], heart attack [16], [23], and mortality [24], [25], [26], [27], [28]. In addition, relationships with neurocognitive impairment [29], [30], [31] and other systems have been explored [32], [33], [34]. A number of studies have also documented adverse health outcomes associated with poor sleep quality [35]. Sleep is an important domain of health and functioning, and it is possible that sleep represents not only a modifiable risk factor for cardiometabolic disease in general, but also an important moderator in the relationship among minority status, socioeconomic disadvantage, and health.
Section snippets
The problematic definition of “race” in biomedical research
Race has been used as a research variable in the social and biological sciences for centuries [36], [37]. Despite the acceptance of “race” in scientific research, there is no clear, agreed-upon definition of what “race” is [38]. Some researchers define race as a biological category [36], [37]. For example, some definitions of race rely on modern concepts of population genomics to describe groups of humans with shared genetic features. This definition assumes that since race groups are defined
Studies of sleep by race/ethnicity
Traditionally, sleep research did not consider race, ethnicity, or other such social stratifications. Most laboratory-based studies did not report race/ethnicity. In more recent years, laboratory studies still infrequently report the race/ethnicity of subjects. However, many studies, especially those that attempt to generalize to the general population, now attempt to measure race/ethnicity to some degree. There has been a growing recognition that race/ethnicity represents a factor (or set of
Unpacking race/ethnicity findings
Why do race/ethnicity differences exist regarding sleep? Differing social and environmental factors may play a role in different beliefs and attitudes about sleep, or different ways of approaching sleep assessments. Further, these mechanisms may simply be working through (at least partially) other factors that are separate from race/ethnicity as a unique construct but, in our society, they are inexorably linked with race for social reasons. These may include socioeconomic variables, aspects of
The role of socioeconomics
When attempting to model SEP, researchers frequently investigate individual socioeconomic factors. These typically include education level, household income, and occupational status. Previous studies that have examined associations between sleep quality and socioeconomic factors have tended to report that lower SEP is associated with higher rates of sleep disturbance (represented as either general overall sleep disturbance or specific symptoms such as difficulty falling asleep, staying asleep,
Other contextual factors
In addition to race/ethnicity, racism, socioeconomics, knowledge, beliefs and attitudes, the home environment, family factors, occupational factors, neighborhood, and geographic region, other factors have been examined as well. For example, sleep has been described as a component of healthy behavior. Other healthy behaviors have been examined relative to sleep. Those with the healthiest dietary habits also tend to report the best quality sleep [166], [167]. Also, those who are sedentary report
Moving forward
Taken together, there is a relatively small but growing body of literature that casts sleep in a social–environmental context, where factors such as race/ethnicity, as well as socioeconomics, home and family, school and work, neighborhood, culture, and other factors play a role. As sleep is so important to health and functioning, understanding the role of these contextual factors is critically important to improving health. Further, because of the well-documented existence of health
Conclusions
Sleep is an essential pillar of health. Because of the critical significance of sleep, understanding the relationship of race/ethnicity, racism, and socioeconomic disadvantage to sleep is an important part of understanding and eliminating health inequities. This task requires conceptualizing sleep in a social–environmental framework that recognizes that the quantity and quality of sleep, like diet, depend on a set of behaviors that are influenced by the structural, social, and environmental
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2015.01.020.
Acknowledgments
Dr. Grandner is supported by the National Heart, Lung, and Blood Institute (K23HL110216) and the National Institute of Environmental Health Science (R21ES022931). He is also supported by the University of Pennsylvania Clinical and Translational Research Center (UL1RR024134). Dr. Knutson is supported by the National Institute for Diabetes and Digestive and Kidney Diseases (R01DK095207). Dr. Jean-Louis and Dr. Williams are supported by the National Heart, Lung, and Blood Institute (R01HL095799)
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