Table 1.

Characteristic	Total (N = 400)	Sleep disturbance		P value
Characteristic	Total (N = 400)	None/slight	Mild/moderate/severe	P value
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)	.01
Asian subgroup, n (%)
Chinese	200 (50.0)	173 (52.9)	27 (37.0)	.01
Korean	200 (50.0)	154 (47.1)	46 (63.0)	.01
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)	.008
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 stress^b			Perceived stress^c			Distress^d
	Model 1^e	Model 2^f	Model 3^g	Model 1^e	Model 2^f	Model 3^g	Model 1^e	Model 2^f	Model 3^g
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 Health^a 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 2020^a

^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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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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Amanda Jett, PharmD, BCACP

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

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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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

Disclosures

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

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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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From Preventing Chronic Disease

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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Earn Credit CME / ABIM MOC Information

Summary
References

Table 1.

Table 2.

Table 3.

Faculty and Disclosures

Faculty

Brittany N. Morey, PhD, MPH

Soomin Ryu, PhD, MA

Yuxi Shi, MS

Sunmin Lee, ScD, MPH

CME Author

Charles P. Vega, MD

Editor

Rosemarie Perrin

Compliance Reviewer

Amanda Jett, PharmD, BCACP

Peer Reviewer

CME / ABIM MOC

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

Credits Available

You Are Eligible For

Target Audience and Goal Statement

Disclosures

Faculty

Brittany N. Morey, PhD, MPH

Soomin Ryu, PhD, MA

Yuxi Shi, MS

Sunmin Lee, ScD, MPH

CME Author

Charles P. Vega, MD

Editor

Rosemarie Perrin

Compliance Reviewer

Amanda Jett, PharmD, BCACP

Peer Reviewer

Accreditation Statements

For Physicians

Instructions for Participation and Credit

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

References

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