Solutions for better sleep

Dr Lianne Tomfohr-Madsen highlights sleep health equity research to inform best practices and policies to improve the sleep of all Canadians

We spend about a third of our lives asleep. Sleep is modifiable, and better sleep contributes to personal and community wellbeing, making optimizing sleep health an urgent public health priority. The demands of a Western lifestyle (urgency, productivity), economic stressors, discrimination, loneliness, and global crises all contribute to poor sleep health, particularly for people who are the most socially and economically vulnerable. ⁽¹⁾ Focusing on prevention and intervention through evidence-informed approaches is essential to enhance health outcomes and quality of life.

Achieving better sleep: What is sleep equity?

Equity is a value-based concept, reflecting notions of fairness, justice, and human rights. ^(2,3) Inequity has multiple implications for health and health systems, and equity considerations underpin examinations of the social determinants of health. ⁽⁴⁾

Sleep inequity can be defined as differences in sleep health between population groups that are systematic in their unequal distribution, avoidable, and unfair. While much attention has been given to disparities in sleep health, a clear model of how these disparities interact across levels of the individual, family, community, and culture is lacking. Having a patient-centred definition of, and priorities related to, sleep equity (reflecting a vision of reducing avoidable and unfair sleep health inequities) is a crucial step in elucidating the contributors to poor sleep health and key step in answering public health questions related to sleep.

The Sleep Equity Team, part of the Canadian Sleep Research Consortium, is dedicated to building national capacity in understanding risk and resilience (protective) factors for sleep health across multiple levels of influence (individual, family, community, culture) and creating a clear intersectional model of sleep health that can be applied to developing therapeutic and public health interventions.

Intersectionality and health

Intersectionality refers to how different aspects of a person’s identity, such as race, gender, sexual orientation, socioeconomic status (SES), and others, interact to shape their experiences and access to resources, opportunities, and social power. ⁽⁵⁾ In the context of health, intersectionality can help to explain how these different factors contribute to health disparities and inequalities and how they can interact to compound or mitigate health risks and outcomes. For example, a person’s race, gender, and SES may all impact their access to quality healthcare, healthy food options, and safe living environments, which in turn can affect all aspects of their physical and mental health, in particular sleep. By recognizing the multiple and interconnected ways in which different aspects of identity can shape insomnia and sleep health, intersectionality offers a nuanced and holistic approach to understanding and addressing health disparities, reducing insomnia and promoting sleep equity.

Considering solutions to better sleep

Sleep problems are an important manifestation of social inequity; however, traditional models of insomnia and sleep health have lacked the nuance of an intersectionality framework, leading to the development of primarily individualist interventions (e.g., CBT-I) based on the culture of Western industrialized nations and often developed without consideration of broader family and cultural systems. Individualist interventions may exclude individuals and groups most needing of intervention. ^(6,7) They may assign a personally focused solution to a systemic problem, one that requires innovative disruption driven by an intersectional understanding. As a prominent example of this phenomenon, parent-child co-sleeping from early infancy through to childhood, which, in many cultures, is normative and culturally appropriate. However, safe sleep guidelines developed to reduce the risk of sudden infant death (SIDS) syndrome discourage this practice. According to our team’s patient engagement data, the impact of this is to foster mistrust between patient and caregiver. Some patients report ‘just lying’ to their care provider when confronted about co-sleeping habits. ⁽⁸⁾ Additionally, in cases where sleep is disrupted due to chronic experiences of discrimination or financial insecurity, applying individually focused sleep interventions such as CBT-I is unlikely to fully address the sleep problem. These are just some examples of what happens when theories, interventions and guidelines are developed: (a) without consultation from individuals with lived experience, (b) without respect for cultural practices and ways of knowing, and (c) without investigation about how intersectional identities lead to practices and policies that exclude and stigmatize.

The Sleep Equity team hypothesizes that (a) people’s identities, location, and access to services interact to affect how well they sleep, and (b) there are cultural and community-based resilience factors that buffer against adversity. Based on this hypothesis and the principles of patient-oriented research, we assert that sleep priorities defined by individuals and communities, including Indigenous communities, will strengthen public health initiatives to improve the sleep of all Canadians.

The most impactful interventions are those that prevent problems before they arise. The Sleep Equity Team, collaborating with diverse stakeholders, aims to reduce the public health burden of poor sleep through evidence-based practices and policies. Through these efforts, we can look forward to a future where everyone has the opportunity for restorative and health-promoting sleep, laying the foundation for healthier lives.

Acknowledgements: The Sleep Equity Team gratefully acknowledges the invaluable support from the Canadian Institute of Health Research. We share a vision for sleep health equity with our funding partners, including the Canadian Institutes of Health Research, the Canada Research Chairs Program, the Canada Foundation for Innovation, and various community organizations. Special appreciation goes to rural and Indigenous communities for their invaluable insights and partnerships that guide our research efforts. We recognize the contributions of individuals and stakeholders committed to promoting sleep health equity, as their collective work helps pave the way for effective interventions and policies aimed at improving sleep outcomes for all.

References

1. Grandner, M.A., Williams, N.J., Knutson, K.L., Roberts, D., Jean-Louis, G. (2016). Sleep disparity, race/ethnicity and socioeconomic position. Sleep Medicine, 18, 7-18. https://www.sciencedirect.com/science/article/abs/pii/S138994571500091X
2. Kahn A. Understanding health equity: Key concepts, debates, and developments in Canada. Health Tomorrow. 2015;3:76-104.
3. CIHR. Government of Canada invests in research to improve sleep for Canadians. Updated 30 June 2022. https://www.canada.ca/en/institutes-health-research/news/2022/06/government-of-canada-invests-in-research-to-improve-sleep-for-canadians.html
4. Public Health Agency of Canada. How to integrate intersectionality theory in quantitative health equity analysis? A rapid review and checklist of promising practices. 2022. September 14. https://www.canada.ca/en/public-health/services/publications/science-research-data/how-integrate-intersectionality-theory-quantitative-health-equity-analysis.html
5. Crenshaw K. On Intersectionality: Essential Writings. The New Press; 2017.
6. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. Feb 1 2021;17(2):255-262. doi:10.5664/jcsm.8986
7. 123. Kalmbach DA, Cheng P, Reffi AN, et al. Racial disparities in treatment engagement and outcomes in digital cognitive behavioral therapy for insomnia among pregnant women. Sleep Health. Nov 28 2022;doi:10.1016/j.sleh.2022.10.010
8. Keys E. Effectiveness of Play2Sleep with Mothers and Fathers of Infants: A Mixed Methods Study. PhD Thesis. University of Calgary; 2019. https://prism.ucalgary.ca/server/api/core/bitstreams/09a7e1d7-c133-4e8b-a149-43e62a43ad75/content