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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)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • 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.

Editor

  • Rosemarie Perrin

    Editor
    Preventing Chronic Disease
    Atlanta, GA

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

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    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

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This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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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

Authors: Brittany N. Morey, PhD, MPH; Soomin Ryu, PhD, MA; Yuxi Shi, MS; Sunmin Lee, ScD, MPHFaculty and Disclosures

CME / ABIM MOC Released: 1/25/2023

Valid for credit through: 1/25/2024

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Summary

What is already known on this topic?

Racial and ethnic minority populations in the US experience heightened stress, which leads to racial and ethnic disparities in chronic disease.

What is added by this report?

Sleep disturbance is a crucial mediator, explaining part of the associations between stress and poor health among Chinese and Korean immigrants in the US.

What are the implications for public health practice?

Improving sleep health can help to decrease the effects of heightened stress on chronic disease outcomes among racial and ethnic minority populations.

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