Friday, March 24, 2023
| Characteristic | Total (N = 400) | Sleep disturbance | P value | |
|---|---|---|---|---|
| None/slight | Mild/moderate/severe | |||
| No. (%) of participants | 400 (100.0) | 327 (81.8) | 73 (18.2) | — |
| Self-rated health, mean (SD)a | 3.1 (1.0) | 3.0 (1.0) | 3.8 (0.9) | <.001 |
| Acculturative stress, mean (SD)b | 1.6 (1.5) | 1.5 (1.5) | 2.2 (1.8) | .002 |
| Perceived stress, mean (SD)c | 15.6 (4.3) | 15.2 (4.3) | 17.5 (3.9) | <.001 |
| Distress, mean (SD)d | 3.6 (2.4) | 3.3 (2.3) | 5.0 (2.4) | <.001 |
| Age, mean (SD), y | 58.4 (6.4) | 58.4 (6.5) | 58.4 (5.7) | .93 |
| Sex, n (%) | ||||
| Female | 211 (52.8) | 163 (49.8) | 48 (65.8) | .01 |
| Male | 189 (47.3) | 164 (50.2) | 25 (34.2) | |
| Asian subgroup, n (%) | ||||
| Chinese | 200 (50.0) | 173 (52.9) | 27 (37.0) | .01 |
| Korean | 200 (50.0) | 154 (47.1) | 46 (63.0) | |
| Marital status, n (%) | ||||
| Not currently married or cohabitating | 59 (14.8) | 41 (12.5) | 18 (24.7) | .008 |
| Married/cohabiting | 341 (85.3) | 286 (87.5) | 55 (75.3) | |
| Education, n (%) | ||||
| Less than high school | 43 (10.8) | 35 (10.7) | 8 (11.0) | .22 |
| High school graduate or GED | 91 (22.8) | 73 (22.3) | 18 (24.7) | |
| Business/vocational school/some college | 68 (17.0) | 59 (18.0) | 9 (12.3) | |
| College graduate | 101 (25.3) | 76 (23.2) | 25 (34.2) | |
| Attended graduate/professional school | 97 (24.3) | 84 (25.7) | 13 (17.8) | |
| Household income, n (%), $ | ||||
| <20,000 | 62 (15.5) | 46 (14.1) | 16 (21.9) | .52 |
| 20,000–39,999 | 64 (16.0) | 54 (16.5) | 10 (13.7) | |
| 40,000–59,999 | 85 (21.3) | 68 (20.8) | 17 (23.3) | |
| 60,000–79,999 | 49 (12.3) | 40 (12.2) | 9 (12.3) | |
| 80,000–99,999 | 32 (8.0) | 26 (8.0) | 6 (8.2) | |
| ≥100,000 | 108 (27.0) | 93 (28.4) | 15 (20.5) | |
| Employment status, n (%) | ||||
| Working full time | 231 (57.8) | 190 (58.1) | 41 (56.2) | .67 |
| Working part time | 84 (21.0) | 66 (20.2) | 18 (24.7) | |
| Not currently working | 85 (21.3) | 71 (21.7) | 14 (19.2) | |
| Health insurance status, n (%) | ||||
| Private health insurance | 243 (60.8) | 200 (61.2) | 43 (58.9) | .94 |
| Medicare/Medicaid | 74 (18.5) | 60 (18.3) | 14 (19.2) | |
| No health insurance | 83 (20.8) | 67 (20.5) | 16 (21.9) | |
Table 1. Characteristics of 400 Chinese and Korean Immigrants Aged 50 to 75 Years Recruited From Physicians’ Clinics in the Baltimore–Washington, DC, Metropolitan Area, August 2018–June 2020
Abbreviations: —, does not apply; GED, General Educational Development.
a Scale for self-rated health ranged from 1 (excellent) to 5 (poor).
b Scale consisted of 9 dichotomous (yes = 1; no or not applicable = 0) items. Scale ranged from 0 to 9, with higher scores indicating greater acculturative stress.
c A 10-item modified version of the Perceived Stress Scale (19) was used; scale ranged from 0 to 40, with higher scores indicating greater perceived stress.
d Measured by a distress “thermometer” numbered from 0 at the bottom (no distress) to 10 at the top (extreme distress). Respondents circled their response; scale ranged from 0 to 10, with higher scores indicating greater distress.
| Variable | Self-rated health to β (95% CI) | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Acculturative stressb | Perceived stressc | Distressd | |||||||
| Model 1e | Model 2f | Model 3g | Model 1e | Model 2f | Model 3g | Model 1e | Model 2f | Model 3g | |
| Stress | 0.14 (0.07 to 0.20) | 0.10 (0.03 to 0.16) | 0.08 (0.01 to 0.14) | 0.08 (0.06 to 0.10) | 0.06 (0.04 to 0.09) | 0.05 (0.03 to 0.08) | 0.10 (0.06 to 0.14) | 0.11 (0.07 to 0.15) | 0.09 (0.05 to 0.13) |
| Age | 0.01 (–0.01 to 0.03) | –0.01 (–0.03 to 0.01) | –0.01 (–0.02 to 0.01) | 0.01 (–0.01 to 0.03) | 0 (–0.02 to 0.02) | 0 (–0.02 to 0.02) | 0.01 (0 to 0.03) | 0 (–0.02 to 0.01) | 0 (–0.02 to 0.02) |
| Sex | |||||||||
| Female | — | 0.22 (0.01 to 0.43) | 0.16 (–0.04 to 0.37) | — | 0.21 (0.01 to 0.42) | 0.16 (–0.04 to 0.36) | — | 0.19 (–0.01 to 0.40) | 0.15 (–0.05 to 0.35) |
| Male | — | Reference | Reference | — | Reference | Reference | — | Reference | Reference |
| Asian subgroup | |||||||||
| Chinese | — | –0.21 (–0.43 to 0.02) | –0.14 (–0.36 to 0.07) | — | –0.14 (–0.36 to 0.08) | –0.09 (–0.31 to 0.12) | — | –0.21 (–0.43 to 0.01) | –0.16 (–0.38 to 0.05) |
| Korean | — | Reference | Reference | — | Reference | Reference | — | Reference | Reference |
| Marital status | |||||||||
| Not currently married | — | 0.13 (–0.15 to 0.42) | 0.07 (–0.21 to 0.34) | — | 0.13 (–0.14 to 0.41) | 0.07 (–0.20 to 0.34) | — | 0.12 (–0.15 to 0.40) | 0.07 (–0.20 to 0.34) |
| Married or cohabiting | — | Reference | Reference | — | Reference | Reference | — | Reference | Reference |
| Education | |||||||||
| Less than high school graduate | — | 0.18 (–0.23 to 0.59) | 0.19 (–0.21 to 0.59) | — | 0.17 (–0.23 to 0.57) | 0.18 (–0.21 to 0.57) | — | 0.37 (–0.03 to 0.76) | 0.34 (–0.06 to 0.73) |
| High school graduate or GED | — | 0.35 (0.01 to 0.69) | 0.36 (0.03 to 0.69) | — | 0.35 (0.02 to 0.69) | 0.36 (0.04 to 0.68) | — | 0.51 (0.18 to 0.84) | 0.49 (0.16 to 0.81) |
| Business/vocational school/some college | — | 0.40 (0.06 to 0.74) | 0.42 (0.09 to 0.76) | — | 0.41 (0.08 to 0.75) | 0.43 (0.11 to 0.76) | — | 0.49 (0.15 to 0.82) | 0.49 (0.16 to 0.82) |
| College graduate | — | 0.35 (0.04 to 0.67) | 0.32 (0.01 to 0.62) | — | 0.33 (0.02 to 0.64) | 0.30 (0 to 0.60) | — | 0.42 (0.11 to 0.73) | 0.38 (0.07 to 0.68) |
| Attended graduate/professional school | — | Reference | Reference | — | Reference | Reference | — | Reference | Reference |
| Annual household income, $ | |||||||||
| <20,000 | — | 0.57 (0.17 to 0.98) | 0.49 (0.09 to 0.88) | — | 0.44 (0.04 to 0.84) | 0.38 (–0.01 to 0.77) | — | 0.57 (0.18 to 0.96) | 0.50 (0.11 to 0.89) |
| 20,000–39,999 | — | 0.44 (0.07 to 0.81) | 0.46 (0.10 to 0.81) | — | 0.28 (–0.09 to 0.64) | 0.31 (–0.04 to 0.67) | — | 0.40 (0.04 to 0.76) | 0.42 (0.07 to 0.77) |
| 40,000–59,999 | — | 0.22 (–0.11 to 0.55) | 0.22 (–0.10 to 0.54) | — | 0.17 (–0.16 to 0.49) | 0.17 (–0.15 to 0.48) | — | 0.18 (–0.14 to 0.50) | 0.18 (–0.13 to 0.50) |
| 60,000–79,999 | — | 0.08 (–0.30 to 0.46) | 0.08 (–0.29 to 0.45) | — | 0.01 (–0.37 to 0.38) | 0.01 (–0.35 to 0.38) | — | 0.01 (–0.36 to 0.38) | 0.02 (–0.35 to 0.38) |
| 80,000–99,999 | — | –0.10 (–0.52 to 0.32) | –0.10 (–0.51 to 0.30) | — | –0.23 (–0.64 to 0.19) | –0.21 (–0.62 to 0.19) | — | –0.19 (–0.59 to 0.22) | –0.17 (–0.57 to 0.23) |
| ≥100,000 | — | Reference | Reference | — | Reference | Reference | — | Reference | Reference |
| Employment status | |||||||||
| Working part time | — | –0.01 (–0.28 to 0.26) | 0 (–0.26 to 0.26) | — | 0.07 (–0.20 to 0.33) | 0.07 (–0.19 to 0.32) | — | 0.07 (–0.19 to 0.33) | 0.06 (–0.19 to 0.32) |
| Not currently working | — | 0.05 (–0.24 to 0.34) | 0.09 (–0.19 to 0.37) | — | 0.06 (–0.22 to 0.34) | 0.09 (–0.18 to 0.37) | — | 0.11 (–0.17 to 0.39) | 0.13 (–0.15 to 0.40) |
| Working full time | — | Reference | Reference | — | Reference | Reference | — | Reference | Reference |
| Health insurance status | |||||||||
| Medicare/Medicaid | — | –0.05 (–0.37 to 0.26) | –0.04 (–0.35 to 0.26) | — | –0.10 (–0.40 to 0.21) | –0.08 (–0.38 to 0.22) | — | –0.13 (–0.44 to 0.18) | –0.11 (–0.41 to 0.19) |
| No health insurance | — | 0.11 (–0.16 to 0.37) | 0.11 (–0.15 to 0.37) | — | 0.10 (–0.16 to 0.37) | 0.10 (–0.15 to 0.36) | — | 0.12 (–0.13 to 0.38) | 0.12 (–0.13 to 0.38) |
| Private health insurance | — | Reference | Reference | — | Reference | Reference | — | Reference | Reference |
| Sleep disturbance | |||||||||
| Mild, moderate, or severe | — | — | 0.61 (0.36 to 0.86) | — | — | 0.55 (0.30 to 0.80) | — | — | 0.49 (0.24 to 0.75) |
| None to slight | — | — | Reference | — | — | Reference | — | — | Reference |
Table 2. Associations of Acculturative Stress, Perceived Stress, and Distress With Self-Rated Healtha in Linear Regression Analysis of Data From 400 Chinese and Korean Immigrants Aged 50 to 75 Years Recruited From Physicians’ Clinics in the Baltimore–Washington, DC, Metropolitan Area, August 2018–June 2020
a Scale for self-rated health ranged from 1 (excellent) to 5 (poor).
b Scale consisted of 9 dichotomous (yes = 1; no or not applicable = 0) items. Scale ranged from 0 to 9, with higher scores indicating greater acculturative stress.
c A 10-item modified version of the Perceived Stress Scale (19) was used; scale ranged from 0 to 40, with higher scores indicating greater perceived stress.
d Measured by a distress “thermometer” numbered from 0 at the bottom (no distress) to 10 at the top (extreme distress). Respondents circled their response; scale ranged from 0 to 10, with higher scores indicating greater distress.
e Model 1: Stress + age.
f Model 2: Model 1 + sex, Asian subgroup, marital status, education, household income, employment status, health insurance status.
g Model 3: Model 2 + sleep disturbance.
| Decomposition of effects | β (SE) | P value | Percentage of total effect due to sleep disturbance |
|---|---|---|---|
| Total effect of acculturative stress on self-rated health | 0.10 (0.03) | .002 | 21.6 |
| Direct (unmediated) effect of acculturative stress on self-rated health | 0.08 (0.03) | .02 | |
| Indirect (mediated) effect of acculturative stress on self-rated health through sleep disturbance | 0.02 (0.01) | .02 | |
| Total effect of perceived stress on self-rated health | 0.06 (0.01) | <.001 | 14.9 |
| Direct (unmediated) effect of perceived stress on self-rated health | 0.05 (0.01) | <.001 | |
| Indirect (mediated) effect of perceived stress on self-rated health through sleep disturbance | 0.01 (0) | .005 | |
| Total effect of distress on self-rated health | 0.11 (0.02) | <.001 | 18.7 |
| Direct (unmediated) effect of distress on self-rated health | 0.09 (0.02) | <.001 | |
| Indirect (mediated) effect of distress on self-rated health through sleep disturbance | 0.02 (0.01) | .002 |
Table 3. Sleep Disturbance Mediating the Association Between Stresses and Self-Rated Health Among 400 Chinese and Korean Immigrants Aged 50 to 75 Years Recruited From Physicians’ Clinics in the Baltimore–Washington, DC, Metropolitan Area, August 2018–June 2020a
a All effects were calculated by accounting for the following covariates: age, sex, Asian subgroup, marital status, education, household income, employment status, and health insurance status.
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Disturbed sleep may be a factor that links stress with poor health, especially among groups experiencing high levels of stress caused by racial and ethnic minority and nativity status. The objective of this study was to describe the potential mediating role of sleep disturbance in the associations between various types of stress and self-rated health among Chinese and Korean Americans.
Our cross-sectional study consisted of 400 Chinese and Korean immigrants aged 50 to 75 years recruited from August 2018 through June 2020 from physicians’ clinics in the Baltimore–Washington, DC, metropolitan area. We used the Patient Reported Outcomes Measurement Information System (PROMIS) short-form questionnaire to measure sleep disturbance. Linear regression analyses examined associations between 3 types of stress (acculturative stress, perceived stress, and distress) and self-rated health, accounting for demographic, socioeconomic, and health insurance factors. The Karlson–Holm–Breen method was used to estimate the total and direct effects of stresses on self-rated health and the indirect effects of stresses on health through sleep disturbance.
Greater acculturative stress (β = 0.08; 95% CI, 0.01–0.14), perceived stress (β = 0.05; 95% CI, 0.03–0.08), and distress (β = 0.09; 95% CI, 0.05–0.13) were all associated with poorer self-rated health. Sleep disturbance was a partial mediator, with sleep disturbance accounting for 21.7%, 14.9%, and 18.7% of the associations between acculturative stress, perceived stress, and distress and self-rated health, respectively.
Because sleep disturbance partially mediates the associations between stress and poor self-rated health, future interventions and research may consider mitigating sleep disturbances and stress among racial and ethnic minority populations to address health disparities.
