Thursday, June 8, 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.
Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 1.00 ABIM MOC points
This activity is intended for primary care physicians, psychiatrists, and other clinicians who treat and manage adult patients at risk for sleep disturbance.
The goal of this activity is for learners to be better able to evaluate how sleep disturbance might mediate the effects of stress on self-rated health among adults.
Upon completion of this activity, participants will:
Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.
Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0
AMA PRA Category 1 Credit(s)™
. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability
and acceptance of continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the
activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.
Follow these steps to earn CME/CE credit*:
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it.
Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print
out the tally as well as the certificates from the CME/CE Tracker.
*The credit that you receive is based on your user profile.
processing....
Stress is a major contributor to health disparities among racial and ethnic populations in the US. Because of socioeconomic disadvantages and discriminatory experiences linked to historical and continued structural racism, racial and ethnic minority populations are more exposed to and susceptible to stress than are non-Hispanic White people [1,2]. Asian, Black, and Hispanic or Latino populations in the US report higher levels of stress than the US non-Hispanic White population in several domains such as occupation, finances, childhood adversity, racial bias, and neighborhoods [1]. Racial and ethnic differences in stress contribute to disparities in emotional strain, cardiovascular disease, and all-cause mortality [1,3]. Research has focused on some of the pathways linking experiences of stress to health disparities among racial and ethnic minority populations, including allostatic load (cumulative burden of chronic stress) and maladaptive behaviors such as substance use and unhealthy diet [4,5]. Less attention has been paid to the role of disturbed sleep to explain the relationship between stress and poor health.
This study focused on the mediating role of sleep disturbance in the association between stress and self-rated health among a sample of Chinese and Korean immigrants in the US. Self-rated health is a commonly used metric of overall health, and it has been applied in diverse populations, including immigrant Chinese and Korean Americans [6]. Prior research provided empirical evidence that poor sleep mediated the associations between perceived stress and depression [7]. Studies have additionally found disturbed sleep to mediate associations between stress and overall health and well-being among mothers and children experiencing trauma [8,9]. Research suggests that many Asian Americans likely somaticize stressful experiences into physical symptoms such as sleep disturbances [10,11]. Sleep disturbances lead to poor mental and physical functioning, including greater risk of inflammation, chronic diseases, and multimorbidity [12–14].
The current study contributes to this literature by examining the mediating role of sleep in the association between 3 types of stress (acculturative stress, perceived stress, and distress) and health. The sample consisted of Chinese and Korean immigrants, a group prone to experiencing these types of stress. Immigrants may experience acculturative stress — defined as the psychological impact, or stress reaction, of adapting to a new cultural context [15]. Previous research suggests that acculturative stress is significantly associated with sleep disturbance or poor sleep quality among immigrant Chinese and Korean Americans [16]. Furthermore, levels of perceived stress and reported distress may similarly be associated with poor sleep and subsequent poor health among Chinese and Korean immigrants in the US [6]. To our knowledge, this is the first study to examine the role of sleep disturbance to explain the associations between stresses and health among Asians in the US. We first hypothesized that higher levels of acculturative stress, perceived stress, and distress would be associated with worse self-rated health. We also hypothesized that sleep disturbance would partially mediate the associations between stress and self-rated health.
