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Table 1.  

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.

Table 2.  

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.

Table 3.  

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.

CME / ABIM MOC

The Mediating Role of Sleep Disturbance on the Association Between Stress and Self-Rated Health Among Chinese and Korean Immigrant Americans

  • Authors: Brittany N. Morey, PhD, MPH; Soomin Ryu, PhD, MA; Yuxi Shi, MS; Sunmin Lee, ScD, MPH
  • CME / ABIM MOC Released: 1/25/2023
  • Valid for credit through: 1/25/2024
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  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

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    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

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:

  • Distinguish the prevalence of sleep disturbance among Korean and Chinese American adults
  • Assess risk factors for sleep disturbance among Korean and Chinese American adults
  • Analyze how different forms of stress contribute to self-rated health
  • Evaluate how sleep disturbance might mediate the effects of stress on self-rated health


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Faculty

  • Brittany N. Morey, PhD, MPH

    Department of Health, Society, and Behavior
    Program in Public Health
    University of California, Irvine
    Irvine, California

  • Soomin Ryu, PhD, MA

    Department of Epidemiology
    School of Public Health
    University of Michigan
    Ann Arbor, Michigan

  • Yuxi Shi, MS

    Department of Medicine
    School of Medicine
    University of California, Irvine
    Irvine, California

  • Sunmin Lee, ScD, MPH

    Department of Medicine
    School of Medicine
    University of California, Irvine
    Irvine, California

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

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  • Rosemarie Perrin

    Editor
    Preventing Chronic Disease
    Atlanta, GA

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    Associate Director, Accreditation and Compliance, Medscape, LLC

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CME / ABIM MOC

The Mediating Role of Sleep Disturbance on the Association Between Stress and Self-Rated Health Among Chinese and Korean Immigrant Americans: Methods

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Methods

Study sample

We used data from a randomized controlled trial to increase colorectal cancer screening among 400 Chinese and Korean Americans (200 Chinese and 200 Korean). Study participants were originally from China or Korea, aged 50 to 75 years, and living in the US for an average of 23 years. Participants were recruited in the Baltimore–Washington, DC, metropolitan area from primary care physicians’ clinics. The baseline survey data were collected from August 2018 through June 2020. Participants completed the survey either in person or by telephone in their preferred language (Mandarin, Korean, or English) after signing informed consent forms. Most (89%) participants completed a self-administered questionnaire in person; 11% of participants completed a research assistant–led telephone survey because of the COVID-19 outbreak in March 2020. This study was approved by the institutional review boards of the University of Maryland, College Park, and the University of California, Irvine.

Measures

Self-rated health was the dependent variable, which was assessed by using the question “Would you say that in general your health is excellent, very good, good, fair, or poor?” Prior studies found self-rated health to be a valid measure of overall physical and mental health among Chinese and Korean populations in their respective languages [17,18]. In this study, we used it as a continuous variable ranging from 1 (excellent) to 5 (poor), with higher scores indicating worse self-rated health.

Our independent variables of interest were 3 types of stress: acculturative stress, perceived stress, and distress. We assessed acculturative stress by using a 9-item scale from the National Latino and Asian American Study intended to measure stressors associated with the experience of being an immigrant in a US cultural and sociopolitical context; this scale has been widely used in the Chinese and Korean languages [15]. Responses to the 9 items were dichotomous (yes = 1; no or not applicable = 0) and included the following: 1) feeling guilty for leaving family or friends in a home country, 2) receiving the same level of respect in the US as in a home country, 3) having limited contact with family or friends outside home country, 4) having difficulty in interactions with others because of English proficiency, 5) being treated badly because of speaking English poorly, 6) having difficulty in finding work because of Asian descent, 7) being questioned about legal status, 8) having concern about being deported if one were to go to a social or government agency, and 9) avoiding seeking health services due to fear of immigration officials. Item 2 was reverse-coded. We calculated acculturative stress as the sum of all 9 items (range, 0–9). Higher scores indicate greater acculturative stress.

We used a modified version of the Perceived Stress Scale to measure perceived stress [19]. The Perceived Stress Scale has been validated in both the Chinese and Korean languages [20,21]. This modified scale included 10 of the 14 items that measured self-reported stress over the past month: 1) how often have you been upset because of something that happened unexpectedly; 2) how often have you felt that you were unable to control the important things in your life; 3) how often have you felt nervous and stressed; 4) how often have you dealt successfully with irritating life hassles; 5) how often have you felt that you were effectively coping with important changes that were occurring in your life; 6) how often have you felt confident about your ability to handle your personal problems; 7) how often have you felt that things were going your way; 8) how often have you found that you could not cope with all the things that you had to do; 9) how often have you been able to control irritations in your life; 10) how often have you felt that you were on top of things. We coded each response on a range from 0 (“never”) to 4 (“very often”). Items 4, 5, 6, 7, 9, and 10 were reverse-coded. We calculated perceived stress as the sum of all 10 items (range, 0–40). Higher scores indicate greater perceived stress.

We measured distress by using a distress “thermometer” numbered from 0 at the bottom (“no distress”) to 10 at the top (“extreme distress”) [22]. Respondents circled the number that best described how much distress they had been experiencing in the past week. Distress was a continuous variable (range, 0–10). Higher scores indicated greater distress.

Sleep disturbance was a potential mediator of the associations between stress and self-rated health. We assessed sleep disturbance by using the short-form version of the Sleep Disturbance Questionnaire from the Patient Reported Outcomes Measurement Information System (PROMIS), a validated and reliable measure of sleep disturbance [23]. It included 8 items to measure self-reported perceptions of sleep quality, depth, and restoration during the past 7 days: 1) my sleep was restless; 2) I was satisfied with my sleep; 3) my sleep was refreshing; 4) I had difficulty falling asleep; 5) I had trouble staying asleep; 6) I had trouble sleeping; 7) I got enough sleep; and 8) my sleep quality was [very poor, poor, fair, good, or very good]. Respondents rated each item on a 5-point Likert scale, and we summed ratings to obtain a total raw score ranging from 8 to 40. Following the PROMIS guidelines for categorizing sleep disturbance, we converted the total raw score to a standardized T-score using conversion tables, with higher scores indicating greater sleep disturbances [23]. Then, we recoded T-scores into a binary variable, with T-scores less than 55 indicating no or slight sleep disturbance and T-scores of 55 or more indicating mild, moderate, or severe sleep disturbance.

Sociodemographic characteristics included age (continuous years), sex (male or female), Asian subgroup (Chinese or Korean), marital status (married or cohabitating, or not currently married or cohabitating), education (less than high school, high school graduate or GED [General Educational Development], business or vocational school or some college, college graduate, or attended graduate or professional school), annual household income (<$20,000, $20,000–$39,999, $40,000–$59,999, $60,000–$79,999, $80,000–$99,999, or ≥$100,000), employment (full time, part time, or not employed), and health insurance status (private health insurance, Medicare or Medicaid, or no health insurance) based on self-report.

Statistical analysis

First, we conducted a descriptive analysis for the sample overall and stratified by risk of sleep disturbance. We calculated means and SDs for all continuous variables, frequencies, and percentages for all categorical variables. To compare the differences between subgroups, we conducted 2-sample t tests for continuous variables and χ2 tests for categorical variables. Second, we used linear regression models to estimate associations between acculturative stress, perceived stress, distress, and self-rated health. We conducted 3 regression models for each exposure: Model 1 included the stress variable, adjusting for age; Model 2 added sex, Asian subgroup, marital status, education, annual household income, employment status, and health insurance status to Model 1; and Model 3 added sleep disturbance to Model 2. We then used the Karlson–Holm–Breen method [24] to conduct mediation analyses to estimate the degree to which sleep disturbance explained the association between stress and self-rated health. Using this method, we decomposed the total effect of stress on self-rated health into the direct (unmediated) effect of stress on self-rated health and indirect (mediated) effect of stress on self-rated health through sleep disturbance. This method also calculates percentages of the total effects of stress on self-rated health caused by sleep disturbance. We also created a simple conceptual model of the mediating role of sleep disturbance between stress and health.

We calculated these effects accounting for all sociodemographic covariates. We conducted analyses using Stata version 14 (StataCorp LLC).