This piece was originally published in University of California (UCI) at Irvine’s Public Health News on February 5, 2023. We publish it here at the start of Black History Month as it coincides this year with our push for equitable health and well-being for all older adults.
UCI professor of environmental and occupational health, Karen Lincoln, PhD, shares her expertise in health disparities affecting African Americans built upon the lived experience as an African American woman and through her interdisciplinary training at the Program for Research on African Americans. Lincoln chairs ASA’s Health and Well-being Advisory Council.
African Americans have been shown to have disproportionately higher rates of sleep disorders (sleep apnea, insomnia, more light and less deep sleep, delayed onset, more daytime sleepiness and shorter sleep duration) compared to any other racial and ethnic groups in the United States. Disparities in sleep patterns are an important, yet underexplored, contributor to racial disparities in health.
There is a strong body of evidence that shows poor sleep quality is associated with Alzheimer’s disease and related dementias (ADRD). Sadly, African Americans are grossly underrepresented in Alzheimer’s disease (AD) clinical trials, therefore most of our understanding of the impact of poor sleep is based on samples of White people. What we know about genetic risks for cognitive decline, neuropathology, decrease in life expectancy and other risk factors is very narrow.
The fact that there is a lack of diversity in AD clinical trials, exacerbated by selection bias, has set researchers back decades. This reality highlights the need for AD studies focused on African Americans, and these studies could also include a wider range of social determinants of health to bring justice and equity to research practices within these communities.
History of How Sleep Became a Luxury for African Americans
Historically, sleep has been elusive for African Americans. From being shackled together en masse in the bowels of a slave ship, lying down, side-by-side, head to foot or even closer, with very little air flow and extremely unsanitary conditions, to living in tight quarters on a plantation, being worked from “sun up to sun down,” fear and terror, to the belief that African people “require less sleep,” African Americans have a long history of sleep deprivation and disruption. Unfortunately, the consequences of a history of structural and systemic racism on sleep and sleep-related health outcomes are relatively unknown.
‘African Americans have a long history of sleep deprivation and disruption.’
Today, African Americans face different circumstances but are still impacted by poor sleep and subsequent health disparities. Sleep tends to be socially patterned—we often observe poor, disrupted and irregular sleep patterns among those in lower socioeconomic positions, including shift work and long hours that contribute to chaotic and irregular sleeping conditions. African Americans are often concentrated in low-skilled and low-paying jobs, with very little control and flexibility in their schedules. The effects of noise, light, traffic, air pollution, crime and discrimination—which are socially patterned by neighborhood—on sleep outcomes have been well documented.
The level of exposure to these conditions is determined by where we live, as are the health-promoting and protective resources available to mitigate the effects of these stressful and unhealthy conditions on our ability to get a good night’s sleep. Because of residential segregation, African Americans have an increased exposure to these adverse neighborhood conditions that contribute to poor sleep health.
However, higher incomes, having a college degree, and living in neighborhoods with more resources doesn’t necessarily protect African Americans from poor sleep quality because they are still subjected to stressors linked to law enforcement, racism, work environments, families and neighborhoods regardless of socioeconomic status. Racism rather than race is a marker of risk for sleep problems.
Racial Disparities in Sleep Is a Public Health Problem
A growing body of research suggests that racial/ethnic differences in sleep deficiency, including extreme sleep duration, sleep-disordered breathing, and insomnia, may help explain disparities in a multitude of diseases like cardiovascular disease, sleep apnea, Alzheimer’s disease and more.
Black Americans are two to four times more likely to be at risk of developing ADRD than non-Hispanic Whites. They are also more likely than Whites to be untreated and undiagnosed with AD, to experience an earlier onset, to have more severe symptoms, and to have less access to information about AD. Research indicates that it takes an average of seven years before Black Americans tell their physicians that they are experiencing memory loss. Although there’s no cure for Alzheimer’s, seven years is a long time to get your affairs in order and enjoy your life.
‘We are exploring the link between poor sleep quality and cognitive impairment in African Americans by using brain imaging.’
A recent study showed that African Americans, and especially men, are much more likely to die from obstructive sleep apnea compared to Whites. Sleep apnea is underdiagnosed in African Americans and, once diagnosed, treatment is less successful compared to the general population. Untreated sleep apnea and poor sleep in general, are associated with hypertension, heart disease, stroke and diabetes—which are all prevalent chronic health conditions in Black Americans.
Interdisciplinary and Community-based Approaches to Address Health Disparities
One of the reasons that African Americans are less likely than Whites to recognize the symptoms of dementia is a lack of access to and education about the disease. To address this problem, I have designed and launched an intervention called “BrainWorks” to increase Alzheimer’s literacy among African Americans by using a talk show format coupled with daily text messages to reinforce culturally tailored AD information. With over 200 African American participants, I and my fellow researchers have been able to improve AD literacy among African Americans after only one month through culturally competent, economically feasible educational formats.
In collaboration with a team of engineers and neurologists, we are exploring the link between poor sleep quality and cognitive impairment in African Americans by using brain imaging. Using a 7T scanner, we examine whether the brain clearance system measured by perivascular spaces is altered by poor sleep quality in African Americans. The data from the brain scans will be analyzed with other sleep quality measures like health conditions, social stress and environmental factors like ambient light and noise.
These studies are all ultimately focused on raising awareness among Black Americans about healthy sleeping habits, ADRD and the risk and protective factors associated with healthy aging. As public health practitioners, we must research and understand how the social environment “gets under the skin” to truly address the health disparities among communities of color.
To move forward, we must listen and address the issues African American residents, communities and organizations have already identified as problems and priorities. We must all acknowledge the past, raise awareness about the current state of affairs, and work together to improve the health and well-being of all communities of color.
Karen Lincoln, PhD, MSW, MA, FGSA, is a professor of Environmental and Occupational Health and director of the Center for Environmental Health Disparities Research at UCI.