Addressing Equity in Sleep Health Is a Work in Progress

Gaps in knowledge about sleep in Black children and families permeate research in sleep health. Panelists at a session hosted during SLEEP 2023 in Indianapolis are aiming to close some of those knowledge gaps and improve sleep health in this population. They presented on preliminary results from studies in progress.

Racial Disparities in Sleep Health

Sleep is important for mental health, cognition, immune response, and cardio-metabolic health, according to Alicia Chung, EdD, MPH, assistant professor at New York University Langone Health. However, Black children are 50% more likely to experience sleep problems compared with their White peers, with the biggest pediatric sleep problems including bedtime resistance, poor sleep quality, insomnia, short sleep duration, and night wakings.

The prevalence of short sleep duration varied by state, according to Chung, ranging from 25.2% to 52.5% across the United States. Up to 7 out of 10 high schools do not get enough sleep, and these issues were further exacerbated during the pandemic.

Chung said that bedtime routines are the gold standard in addressing behavioral sleep problems. Getting into a routine for each night—starting at least 1 to 2 hours prior to the intended bedtime—could be the key to addressing lack of sleep. However, sleep interventions that address these routines have been largely developed and tested in White children and their families, and they lack culturally tailored behavioral sleep interventions that consider socioecological factors.

The other speakers at this panel aimed to provide ongoing evidence of addressing these areas of sleep intervention research.

Interventions Aimed at Black Children and Families

Ariel A. Williamson, PhD, DBSM, a psychologist in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children's Hospital of Philadelphia, presented on the pilot of a sleep navigation program to increase access to specialty care in sleep medicine.

The pilot aimed to transform the management of sleep disordered breathing (SDB) in primary care by incorporating universal snoring and sleep screening, giving clinical decision support to patients with SDB, and using sleep navigation to address care disparities. The present study focused most on the sleep navigation aspect, with someone helping families to navigate their sleep treatment.

The program was developed by reviewing local data for care of SDB, consulting with family advisors and primary care clinicians, and reviewing previous evidence for patient/family navigation with a community navigator.

The program was delivered in 1 to 3 sessions over video or telephone with a follow-up communication of texting. The care was documented and routed to the referring provider. The sleep navigation addressed providing psychoeducation on SDB and its effects, and using motivational interviewing to promote health literacy and engagement in care.

To manage referrals, the researchers scheduled the referral and reminded family about the visit before they offered resources to the family. This was aimed at increasing specialty care referral completion and reducing disparities in the access to care.

There are 33 families in this present study, 100% of whom identify as Black or African American and 6% who identify as Hispanic. Williamson emphasized that this population was specific to western Philadelphia, which means the population of this study may be more monolithic than the general Black population.

A total of 56% of the participants went to 1 session via telephone or video; however 32% did not go to a session at all. The sessions provided content on SDB education, sleep education, and referral scheduling. Early referral outcomes have seen similar results with 69% of participants having a SDB visit scheduled through sleep navigation compared with 59% who had an SDB visit scheduled through usual care.

The sleep navigation was received positively by the participants, with 100% strongly agreeing or agreeing that navigation was a program that they would participate in again, and 100% of participants felt that the navigator was respectful, accepting of family values, and understanding of their culture.

Williamson, however, was hesitant to say that this method was feasible, despite its promising initial results.

“So is it feasible? I don’t know, I don’t really think so. I think it’s a really important type of program, it’s worked for a lot of other issues, but I think it might be at the wrong point in the care continuum,” she said.

Acceptability of Infant Sleep Guidance

Sarah M. Honaker, PhD, associate professor of pediatrics at Indiana University School of Medicine, also presented her work on interventions for Black families when it came to sleep health. She noted that most studies on the efficacy of interventions have been conducted with participants who were primarily White and college educated, which has led to underrepresentation of how interventions could benefit Black families.

A recent study from this year found that there was a sleep duration increase of 73 minutes when Black families used an intervention for infant sleep. However, only 24.7% retained a bedtime of 8 pm or earlier after the intervention was over; though a regular use of the bedtime routine was maintained by the majority (88.5%).

Honaker’s team is leading the SLUMBER study, which is assessing parent perspectives on behavior sleep interventions (BSI) in Black families through virtual interviews. The study is preliminary and is still recruiting, leaving the initial population at only 8 participants. These participants all completed the interview; 50% of them were married and 50% said that this was their first child.

The preliminary results found that the participants had an interest in joining an intervention due to addressing problems in sleep with their baby, learning new things, and having social support. However, time and uncertainty about the source kept others from wanting to join such an intervention.

Sleep training received mixed reactions, with some seeing it as a benefit to their child for future independence and sleep habits whereas others couldn’t tolerate their child crying. Others had family or cultural influences that steered their baby’s sleep.

“We are starting to get some ideas about potential adaptations that might help with acceptability,” concluded Honaker. “Parents are really open to trying things that will help their child now and in the future. I think it may in some sense be generational but there seems to be more of a focus on what works for our family rather than specific cultural or ideological philosophy.”

Although sleep interventions are under-researched in Black families, current researchers are taking the time to determine how effective these meetings can be for families who are underrepresented in other studies. Future research on this is important in addressing sleep in Black children and families.