"It's Not All About My Baby's Sleep": A Qualitative Study of Factors Influencing Low-Income African American Mothers' Sleep Quality

Effects of contextual stress on Black mothers' self-reported and actigraph-estimated postpartum sleep

STUDY OBJECTIVES

To evaluate the impact of contextual stressors on postpartum sleep among Black mothers.

METHODS

This prospective observational study examined associations of racial discrimination and financial strain (measured at 1 week postpartum) with self-reported maternal sleep difficulties at 1, 8, and 16 weeks postpartum and actigraph-estimated maternal sleep at 8 weeks postpartum.

RESULTS

Mothers (N = 212) were Black/African American (100%) and non-Hispanic (98.6%) and averaged 22.7 (SD = 4.5) years of age. Multivariate regression models found unique associations between racial discrimination and financial strain and mothers' postpartum sleep, even after controlling for covariates expected to predict mothers' sleep (including infant sleep). Specifically, past year racial discrimination measured at 1 week postpartum was associated with poorer concurrent self-reported sleep (b = 1.24, p < .001) as well as greater actigraph-estimated night-to-night variability in total sleep time at 8 weeks postpartum (b = 12.89, p = .005). Financial strain reported at 1 week postpartum was prospectively associated with more self-reported sleep difficulties at 16 weeks postpartum (b = .52, p = .007) and with more actigraph-estimated sleep timing variability at 8 weeks postpartum (b = 9.77, p = .02).

CONCLUSION

Experiences of racial discrimination and financial strain may negatively impact Black mothers' sleep in the postpartum period, beyond the effects of their infant's sleep.

Examination of Social Determinants of Health Characteristics Influencing Maternal Postpartum Symptom Experiences

Postpartum women experience multiple, co-occurring postpartum symptoms. It is unknown if social determinants of health (SDOH) influence postpartum symptom typologies. This secondary analysis used the Community and Child Health Network study data. Participants included for analysis varied depending on the availability of the SDOH data (N = 851 to 1784). Bivariate and multiple regression analyses were conducted to examine the association between SDOH and previously identified postpartum symptom typologies. Area under the receiver operating characteristics curve (AUROC) was calculated to examine if adding SDOH variables contributes to predicting postpartum symptom typologies. The adjusted odds (aOR) of being in high symptom severity or occurrence typologies were greater for participants who had less than high school education (aOR = 2.29), experienced healthcare discrimination (aOR = 2.21), used governmental aid (aOR = 2.11), or were food insecure (aOR = 2.04). AUROC improved after adding SDOH. Considering experiences of different social-economic hardships influence postpartum symptom typologies, future practice and research should address SDOH to improve postpartum symptom experiences.

Correlates of multidimensional sleep in premenopausal women: The BioCycle study

Purpose

To identify sleep dimensions (characteristics) that co-occur in premenopausal women. The second aim was to examine associations between multiple dimensions of sleep and a set of demographic, lifestyle, and health correlates. The overarching goal was to uncover patterns of poor-sleep correlates that might inform interventions to improve sleep health of women in this age group.

Methods

The BioCycle Study included 259 healthy women aged 18-44y recruited between 2005 and 2007 from Western New York. Participants reported sleep data through daily diaries and questionnaires that were used to create five sleep health dimensions (duration, variability, timing, latency, and continuity). We used multivariate analysis - canonical correlation methods - to identify links among dimensions of sleep health and patterns of demographic, psychological, and occupational correlates.

Results

Two distinct combinations of sleep dimensions were identified. The first - primarily determined by low variability in nightly sleep duration, low variability in bedtime (timing), greater nocturnal awakening, and less sleep onset latency - was distinguished from the second - primarily determined by sleep duration.The first combination of sleep dimensions was associated with older age and higher parity, fewer depressive symptoms, and higher stress level. The second combination of sleep dimensions was associated with perception of longer sleep duration as optimal, lower parity, not engaging in shift work, older age, lower stress level, higher prevalence of depressive symptoms, and White race.

Conclusion

Among premenopausal women, we demonstrated distinct patterns of sleep dimensions that co-occur and vary by demographic, health, and lifestyle correlates. These findings shed light on the correlates of sleep health vulnerabilities among young women.

Maternal Sleep Quality and Executive Function are Associated with Perceptions of Infant Sleep

OBJECTIVES

This study examined the associations among maternal sleep quality, executive function, and perceptions of infant sleep in a sample of families recruited from human service and public health systems.

METHODS

Seventy-three mothers of infants 5-14 months old were included in the study. Mothers racially and ethnically identified as American Indian/Alaskan Native (4.1%), Asian (4.1%), Black/African American (12.3%), Latina (23.3%), more than one race (12.3%), Pacific Islander (1.4%), and White (42.5%). Mothers completed questionnaires assessing their own sleep (Pittsburgh Sleep Quality Index) and executive function (Behavior Rating Inventory of Executive Function) as well as their perceptions about their infant's sleep (Brief Infant Sleep Questionnaire).

RESULTS

Results of the path analysis indicated significant direct effects among maternal sleep quality, executive function, and perceptions of infant sleep. Significant indirect effects were found such that poor maternal sleep quality was linked to poorer perceptions of infant sleep through maternal executive dysfunction, adjusting for infant sleep patterns, infant age, and maternal race and ethnicity.

CONCLUSIONS

The current study highlights the potential role of maternal behavioral and cognitive factors in shaping mothers' perceptions about infant sleep. These findings support the need for health professionals and researchers to consider maternal sleep quality and executive function when addressing mothers' concerns about infant sleep.

Maternal Sleep Health, Social Support, and Distress: A Mixed-Methods Analysis of Mothers of Infants and Young Children in Rural US

OBJECTIVES

The purpose of this study was to explore sleep health in rural maternal populations through a social-ecological framework and identify risk and protective factors for this population.

METHODS

39 individuals who are mothers of infants or children under the age of 5 years completed an online survey, 35 of which completed a subsequent semi-structured interview. Recruitment was limited to one rural community and was in partnership with community healthcare providers. Results were integrated using a convergent, parallel mixed-methods design.

RESULTS

Poor sleep health and high prevalence of insomnia symptoms in rural mothers were evident and associated with social support and maternal distress. Qualitative content from interviews indicated that well-established precipitating and perpetuating factors for insomnia may contribute to poor maternal sleep health. Results also revealed a gap in knowledge and language surrounding sleep health among rural mothers.

CONCLUSIONS

Sleep health is challenged during the transition to motherhood and rural mothers have less access to specialized perinatal and behavioral health care than their urban counterparts. In this sample, poor sleep was attributable to distress in addition to nocturnal infant and child sleep patterns which has implications for psychoeducation and promotion of sleep health in mothers. Sleep is a modifiable health indicator that is associated with several other maternal health outcomes and should be considered an element of a comprehensive maternal health for prevention and intervention across individual, interpersonal, and societal domains of the social-ecological model of sleep health.

Maternal Perceptions of Evidence-Based Early Childhood Sleep Health Promotion Recommendations: An Explanatory Sequential Study

OBJECTIVES

The purpose of this explanatory sequential design study was to better understand caregivers' perceptions about and interest in evidence-based early childhood sleep health promotion recommendations.

METHOD

A purposeful sample of mothers of 20 1-5-year-old children (10 children exhibiting optimal sleep and 10 children exhibiting insufficient/fragmented sleep) attending a preschool serving a low socio-economic (SES) status metropolitan community were invited to participate in qualitative interviews. Data were coded according to a grounded theory approach and themes were identified within the optimal and suboptimal sleeper groups.

RESULTS

Mothers reported different approaches to managing electronics by optimal/suboptimal sleeper group, with mothers of optimal sleepers limiting access to electronics more than mothers in the suboptimal sleep group. Other themes of sleep health practices did not differ meaningfully between groups.

CONCLUSIONS

Maternal perspectives about early childhood sleep health were similar across optimal and suboptimal sleepers on most elements of child sleep health. Managing child sleep was contextually influenced and these results highlight the complexities of how families living in lower SES environments perceive common sleep recommendations. Thus, sleep health education efforts should be tailored to the needs and values of specific families and communities.

Getting Good Sleep with Family Support: The Role of Fear of Crime and Loneliness

Sleep problems in middle-aged and older people can threaten their physical and mental health. Family support is regarded as a key factor that affects sleep quality, but the influence mechanism remains underexplored. This study analyzes the mediating effects of fear of crime (FOC) and loneliness in the relationship between family support and sleep quality, and explores whether gender plays a moderating role between family support and FOC. A questionnaire survey was conducted among 1043 Chinese middle-aged and older people aged 45-93 years. Using 10,000 bootstrapped samples, the study shows that middle-aged and older people who receive more family support have better sleep quality, and FOC and loneliness play mediating role in this association. Gender moderates the relationship between family support and FOC. Compared with men, family support for females has a greater impact on their FOC condition, and the mediating effect of family support on sleep quality through FOC is also greater among women. Family support can affect sleep quality through the chain mediating effect of FOC and loneliness for women. This study provides an in-depth understanding of the relationship between family support and sleep quality.

Variation in Caregiver-Reported Child Sleep Patterns and Problems by Family Socioeconomic Indicators

OBJECTIVE

Previous studies of sleep patterns, as well as rates and correlates of perceived problems in early childhood, indicate variation by neighborhood-level socioeconomic indicators. The purpose of this study was to examine variation in (1) sleep patterns, behaviors, and problems by family-based socioeconomic indicators (income-to-needs ratio and caregiver education level) and (2) sociodemographic and sleep correlates of a caregiver-endorsed child sleep problem across and within socioeconomic indicator groups in a diverse sample.

METHODS

Two hundred eighty-three caregiver-child dyads (ages 1-5 years) completed the Brief Child Sleep Questionnaire. Family-level socioeconomic indicators included income-to-needs ratio and caregiver educational level.

RESULTS

Sleep patterns varied based on income-to-needs ratio, with children living in poverty experiencing the longest sleep onset latencies and night awakening durations and shortest nighttime sleep durations. Rates of an endorsed child sleep problem were similar across income-to-needs groups. Although sleep patterns did not vary by caregiver education level, caregivers with an education beyond high school were more likely to endorse a child sleep problem; later bedtimes, more frequent night awakenings, and greater bedtime difficulties were the strongest correlates of a perceived sleep problem in this subgroup. No specific correlates of a child sleep problem emerged for those with a high school education or less.

CONCLUSION

Sleep patterns may be more robustly linked to family income-to-needs ratio, whereas perceptions of a child sleep problem may be more linked to caregiver education level. Clinicians should consider expanding sleep screening questions to include specific sleep outcomes to effectively assess child sleep and guide intervention.

Mental health and sleep quality of low-income mothers of one-year-olds during the COVID-19 pandemic

The COVID-19 pandemic and subsequent social restrictions created an unprecedented context for families raising young children. Although studies have documented detrimental effects of the pandemic on maternal well-being, less is known about how the pandemic specifically impacted low-income mothers. We examined depression, anxiety, and sleep quality among low-income mothers of one-year-olds during the early months of the pandemic using data from the Baby's First Years study. Focusing on the control group (n = 547), we compared mothers interviewed before March 14th, 2020 (n = 342) to mothers interviewed between March 14th and June 30th, 2020 (n = 205) to determine whether the pandemic was associated with differences in mental health and sleep quality. Mothers were recruited from four cities in the United States, and most of the sample identified as Hispanic (42.2%) or Black, non-Hispanic (38.6%). We found that mothers interviewed during the pandemic reported better mental health and sleep quality. While we cannot speak to longer-term impacts of the pandemic, it is possible low-income mothers experienced relief from daily stressors during the initial shelter-in-place orders, which may have led to improvements in well-being. These results have implications for understanding how complex life stressors influence mental health and sleep quality among low-income mothers raising young children.

Health Disparities in Pediatric Sleep

This article reviews disparities in pediatric sleep health and sleep disorders from early childhood through adolescence (birth to age 18 years). Sleep health is a multidimensional construct including sleep duration, consolidation, and other domains, whereas sleep disorders reflect both behaviorally (eg, insomnia) and medically based (eg, sleep disordered breathing) sleep diagnoses. Using a socioecological framework, we review multilevel (ie, child, family, school, health-care system, neighborhood, and sociocultural) factors linked to sleep health disparities. Mechanistic research and studies using an intersectional lens to understand overlapping marginalized identities are needed to inform multilevel interventions to promote sleep health equity in pediatrics.

Psychological Distress Prospectively Predicts Later Sleep Quality in a Sample of Black American Postpartum Mothers

Objective: Previous longitudinal studies have demonstrated prospective relationships between maternal sleep quality and subsequent psychological distress in the postpartum period. Despite evidence for prospective relationships between mood and subsequent sleep quality in adult populations, this direction has not been examined in postpartum women. We aimed to test prospective relationships between sleep quality and subsequent psychological distress, as well as the plausible reverse possibility, in a sample of Black American postpartum mothers (n = 146).Participants: Mothers were recruited prenatally from two hospitals in a Southeastern city of the United States. Eligible and interested mothers enrolled in a follow-up study on infant development. Data from the current study were obtained during the follow-up study.Method: Mothers reported on their psychological distress (i.e., anxiety, depression, stress) and sleep quality at 3- and 6-months postpartum. We performed hierarchical linear regressions to explore whether 1) maternal sleep quality at 3-months postpartum would predict maternal psychological distress at 6-months postpartum, after adjustment for mothers' earlier psychological distress, and 2) whether psychological distress at 3-months postpartum would predict maternal sleep quality at 6-months postpartum, after adjustment for mothers' earlier sleep quality.Results: Maternal sleep quality at 3-months postpartum was not a significant predictor of psychological distress at 6-months postpartum. However, maternal psychological distress at 3-months postpartum was a significant predictor of sleep quality at 6-months postpartum.Conclusions: Mothers' psychological distress earlier in the postpartum was a significant predictor of their later sleep quality. Replication is needed in large, prospective studies, with results stratified by race/ethnicity.

Postpartum sleep health in a multiethnic cohort of women during the COVID-19 pandemic in New York City

OBJECTIVE/DESIGN

Cross-sectional study to examine the determinants of sleep health among postpartum women during the COVID-19 pandemic in New York City (NYC).

SETTING/PARTICIPANTS

A subset of participants recruited as part of the COVID-19 Mother Baby Outcomes (COMBO) cohort at Columbia University (N = 62 non-Hispanic White, N = 17 African American, N = 107 Hispanic).

MEASUREMENTS

Data on maternal sleep, COVID-19 infection during pregnancy, sociodemographic, behavioral, and psychological factors were collected via questionnaire at 4 months postpartum. Self-reported subjective sleep quality, latency, duration, efficiency, disturbances, and daytime dysfunction were examined as categorical variables (Pittsburgh Sleep Quality Index [PSQI]). Associations between sleep variables and COVID-19 status, time of the pandemic, sociodemographic, behavioral, and psychological factors were estimated via independent multivariable regressions.

RESULTS

Mothers who delivered between May-December 2020, who delivered after the NYC COVID-19 peak, experienced worse sleep latency, disturbances and global sleep health compared to those who delivered March-April 2020, the peak of the pandemic. Maternal depression, stress and COVID-19-related post-traumatic stress were associated with all sleep domains except for sleep efficiency. Maternal perception of infant's sleep as a problem was associated with worse global PSQI score, subjective sleep quality, duration, and efficiency. Compared to non-Hispanic White, Hispanic mothers reported worse global PSQI scores, sleep latency, duration and efficiency, but less daytime dysfunction.

CONCLUSIONS

These findings provide crucial information about sociodemographic, behavioral, and psychological factors contributing to sleep health in the postpartum period.

Correlates of a caregiver-reported child sleep problem and variation by community disadvantage

BACKGROUND

Previous studies of sleep patterns and perceived problems in early childhood indicate variation by family socioeconomic status. The purpose of this study was to examine variation in correlates of a caregiver-perceived child sleep problem across and within levels of community disadvantage in a large US sample.

METHODS

Caregivers of 14,980 young children (ages 0-35.9 months) in the US completed the Brief Infant Sleep Questionnaire-Revised (BISQ-R) on the freely and publicly available Johnson's® Bedtime® Baby Sleep App. Zip code was used to identify a Distressed Communities Index (DCI) score, which represents community disadvantage based on neighborhood indicators.

RESULTS

Across all levels of community disadvantage, caregivers who reported greater impact of child sleep on their own sleep, bedtime difficulty, more frequent and longer night wakings, and increased total nighttime sleep were more likely to endorse a child sleep problem. These associations varied by level of community disadvantage. For caregivers living in more disadvantaged communities, impact of child sleep on their own sleep and night wakings were the strongest correlates of endorsing a child sleep problem, whereas for those in more advantaged communities the impact of child sleep on their own sleep and night wakings as well as additional aspects of sleep health, such as short sleep duration, were associated with endorsement of a child sleep problem.

CONCLUSIONS

Findings suggest that families living in more distressed communities are most likely to identify the impact of child sleep on their own sleep and night wakings in reporting a child sleep problem, whereas those from more prosperous communities consider these factors as well as other sleep parameters, including sleep duration. Clinicians should consider expanding screening questions for child sleep problems to include the perceived impact on caregiver sleep.

The Impact of a Randomized Controlled Trial of a Lifestyle Intervention on Sleep Among Latina Postpartum Women

BACKGROUND

Poor sleep is associated with adverse outcomes among postpartum women. Exercise may improve sleep, but this has not been well examined in the postpartum period.

PURPOSE

To examine the impact of a culturally modified, individually tailored lifestyle intervention on sleep outcomes among postpartum Latina women.

METHODS

Estudio PARTO was a randomized controlled trial aimed at reducing Type 2 diabetes among Latina women with abnormal glucose tolerance in pregnancy. Participants were randomized to a lifestyle (i.e., diet and exercise; n = 70) or a health and wellness control intervention (n = 78) in late pregnancy (baseline). The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality (PSQI score), onset latency (minutes per night), duration (hours per night), efficiency (percentage of the time in bed asleep), and daytime dysfunction at baseline, 6 weeks, 6 months, and 12 months postpartum.

RESULTS

Mean PSQI score (6.56 ± 3.87), sleep duration (6.84 ± 1.75 hr/night), and sleep efficiency (79.70% ± 18.10%) did not differ between the arms at baseline. Mixed-effects models indicated a greater decrease of 1.29 in PSQI score (i.e., improved sleep quality) in the lifestyle versus health and wellness arm (95% confidence interval [CI] = -2.50 to -0.08, p = .04) over follow-up. There was the suggestion of a smaller decrease in sleep duration (mean = 0.48 hr/night, 95% CI = -0.10 to 1.06, p = .10) in the lifestyle versus health and wellness arm. There were no statistically significant differences in other sleep outcomes between arms.

CONCLUSIONS

Findings suggest that lifestyle interventions improve sleep quality but not sleep duration, sleep onset latency, sleep efficiency, or daytime dysfunction in postpartum Latina women and, therefore, may hold promise for improving subsequent mental and physical health in this population.

CLINICAL TRIALS REGISTRATION

NCT01679210.

Social-ecological considerations for the sleep health of rural mothers

Using a social-ecological framework, we identify social determinants that interact to influence sleep health, identify gaps in the literature, and make recommendations for targeting sleep health in rural mothers. Rural mothers experience unique challenges and protective factors in maintaining adequate sleep health during the postpartum and early maternal years. Geographic isolation, barriers to comprehensive behavioral medicine services, and intra-rural ethno-racial disparities are discussed at the societal (e.g., public policy), social (e.g., community) and individual levels (e.g., stress) of the social-ecological model. Research on sleep health would benefit from attention to methodological considerations of factors affecting rural mothers such as including parity in population-level analyses or applying community-based participatory research principles. Future sleep health programs would benefit from using existing social support networks to disseminate sleep health information, integrating behavioral health services into clinical care frameworks, and tailoring culturally-appropriate Telehealth/mHealth programs to enhance the sleep health of rural mothers.

A mixed methods study of perinatal sleep and breastfeeding outcomes in women at risk for postpartum depression

INTRODUCTION

Pregnant and postpartum women experience significant sleep disruption, but the role of perinatal sleep disturbances in breastfeeding is understudied.

METHODS

In this observational cohort study, we used mixed methods to examine associations between perinatal sleep and breastfeeding. Forty-eight women (mean age 28.2 ± 4.9 years) who were euthymic at enrollment but had a history of major depression (n = 43) or bipolar disorder (n = 5) had sleep recorded with wrist actigraphy. We determined feeding status through daily diaries and used semi-structured interviews to identify themes regarding participants' experiences, breastfeeding decisions, and behaviors. To examine whether sleep disturbance during pregnancy predicted breastfeeding (BF) rates, we defined "lower sleep efficiency" (LSE) and "higher sleep efficiency" (HSE) groups based on the median split of actigraphic SE at 33 weeks' gestation (cutoff SE = 84.9%) and classified mothers as No-BF, Mixed-BF (BF + formula), and Exclusive-BF at 2 weeks postpartum.

RESULTS

Percentages of women who did any breastfeeding were: Week 2 = 72.3%, Week 6 = 62.5%, Week 16 = 50%. LSE mothers were less likely than HSE mothers to initiate breastfeeding (percent No-BF: LSE = 45.8%, HSE = 16.7%, P < .05). Average actigraphic sleep onset, sleep offset, time in bed, sleep duration, and SE did not differ based on breastfeeding status at any time point. Qualitative themes included insufficient preparation for the demands of breastfeeding, interrupted and nonrestorative sleep, and unrelenting daytime tiredness.

CONCLUSIONS

In our sample, preserved actigraphic SE during pregnancy was associated with initiation and continuation of breastfeeding. Future work should examine whether improving sleep in pregnancy improves mothers' feeding experiences.

Determinants of postpartum sleep duration and sleep efficiency in minority women

STUDY OBJECTIVES

To examine demographic, psychosocial, and behavioral determinants of postpartum sleep duration and sleep efficiency among a cohort of black and Latina women.

METHODS

Data were from 148 women (67% black, 32% Latina) at 5 months postpartum, recruited from an academic medical center in Philadelphia. Relevant demographic, psychosocial and behavioral predictors were assessed via questionnaire. Nocturnal sleep was objectively measured for 1 week using wrist actigraphy. Sleep duration was examined as a continuous variable and in categories (<7 versus ≥7 h per night); sleep efficiency was examined as a continuous variable. Independent multiple linear regression models were built to evaluate significant determinants of sleep.

RESULTS

Adjusted models revealed that breastfeeding, having a bedtime after midnight, and being employed were associated with shorter sleep duration (-25-33 min, all p < 0.05). Multiparity, being unmarried, being employed, breastfeeding, having a bedtime after midnight, bedsharing, and responding to infant awakenings by getting up immediately rather than waiting a few minutes to see if the infant fell back asleep, were all significant determinants of sleeping <7 h per night (OR varying: 2.29-4.59, all p < 0.05). Bedsharing was the only variable identified from the multiple regression model that associated with poorer sleep efficiency (-3.8%, p < 0.05).

CONCLUSIONS

Findings may inform interventions for improving postpartum sleep in socioeconomically disadvantaged, racial/ethnic minority postpartum women.

Recruitment planning for clinical trials with a vulnerable perinatal adolescent population using the Clinical Trials Transformative Initiative framework and principles of partner and community engagement

Recruitment planning is needed to establish a foundation for obesity prevention research with high risk, disadvantaged perinatal adolescent populations. In the context of developing clinical trial protocols, investigators partnered with Mississippi's Nutrition Program for Women, Infants and Children (WIC) and adopted the Clinical Trials Transformative Initiative (CTTI) framework for recruitment planning to identify and mitigate challenges to recruitment early in the clinical trial development process. The recruitment protocol consisted of 20 passive strategies grounded in principles of partner and community engagement and was flexible, accommodating, altruistic, community-focused, and minimally burdensome to partners and participants. The recruitment goal included 150 adolescent-coparticipant dyads and 145 dyads (96.7%) were successfully recruited. Investigators demonstrated the feasibility of recruiting a disadvantaged and vulnerable perinatal adolescent population that is underrepresented in health research, in one of the most persistently impoverished and poor health regions in the U.S. Four important aspects of recruitment planning using the CTTI framework are discussed including: (1) establishing partnerships with trusted community resources is a paramount investment; (2) dedicating time and resources to know and go to your community is invaluable; (3) fostering trust by offering convenient, continuous and clear communication; and (4) encouraging collaboration and participation through limiting partner and participant burden. Establishing organizational and community partnership requires a substantial amount of invaluable time and fosters recruitment success. Following the CTTI recommendations for recruitment planning led to a robust recruitment protocol that will be used in future intervention trials with an understudied perinatal adolescent population with high risk for poor maternal and fetal health outcomes.

Socioeconomic disadvantage and sleep in early childhood: Real-world data from a mobile health application

OBJECTIVES

To examine whether increased socioeconomic disadvantage, indexed using a measure of community distress, was associated with variation in caregiver-reported early childhood sleep patterns and problems in a large US sample using a mobile health application (app).

DESIGN

Cross-sectional.

SETTING

Data were collected using the free, publicly available Johnson's Bedtime© baby sleep app.

PARTICIPANTS

A total of 14,980 caregivers (85.1% mothers) of children ages 6-35.9 months (M = 13.88 months; 52.6% boys) participated in this study.

MEASURES

Caregivers reported on child sleep using the Brief Infant Sleep Questionnaire-Revised. Socioeconomic disadvantage was indexed by zip code using the Distressed Communities Index (DCI), which combines seven US census indicators of socioeconomic disadvantage. DCI scores range from prosperous (lowest quintile) to distressed (highest quintile).

RESULTS

Socioeconomic disadvantage was significantly associated with later bedtimes, longer sleep onset latency, and shorter nighttime and 24-hour (total) sleep duration, with children living in distressed communities showing the poorest sleep. However, caregivers living in distressed communities reported a significantly lower prevalence of overall child sleep problems (43% vs 58% in prosperous communities), and more confidence in managing child sleep (42% vs 34% in prosperous communities).

CONCLUSIONS

Children living in the most distressed communities have the poorest reported sleep patterns and bedtime behaviors; however, their caregivers are less likely to report problematic child sleep. These findings highlight the need for community-level sleep health promotion interventions, as well as further investigation of caregiver perceptions about child sleep and sleep health promotion among families living in socioeconomically disadvantaged contexts.

Perspectives on Sleep from Multiethnic Community Parents, Pediatric Providers, and Childcare Providers

OBJECTIVE

To describe the perceptions of (1) parents, childcare, and health care providers regarding sleep health among multiethnic infants and toddlers living with socioeconomic adversity, (2) factors that contribute to sleep health and its consequences, and (3) best ways to promote sleep health in these children.

METHODS

Nested within a larger community-engaged mixed methods study, we used a descriptive qualitative design to describe the experience of multiethnic young parents who were raising 6- to 36-month-old children, pediatric health care providers, and childcare providers living and working in an urban under-resourced community. Semistructured interviews with 25 parents and 16 providers were conducted, transcribed, coded, and analyzed using thematic analysis by a 6-member research team. Interviews continued until themes were saturated.

RESULTS

Parent responses and provider responses resulted in overlapping and divergent findings. Common themes among all respondents were the importance of sleep, interest and desire for more sleep health information, and common environmental/social impediments to healthy family sleep. Divergent themes included the importance of bedtime routines and timing, views on the family bed, importance of naps, and healthy sleep aids. Childcare centers were suggested as good sites for sleep health promotion programs.

CONCLUSION

Sleep is a topic of interest and importance for young families. There are unique family challenges to be considered in any sleep health promotion program tailored to the needs of the community. The voices of parents and community providers are valuable assets informing the development of novel family-friendly approaches for decreasing sleep disparities and improving the health of young children and families.

Sleep Health in Women of Childbearing Age

The concept of sleep health (adequate sleep duration and continuity, regular timing, satisfaction with sleep, and ability to maintain wakefulness during the day) is consistent with a definition of health as more than the absence of disease. Yet past research on women's sleep focused primarily on biological influences (e.g., hormonal fluctuations) or specific sleep disorders. We reviewed the literature on sleep health in women of childbearing age from the perspectives of health promotion and the social ecological model and identified needs for future research and intervention. At least 40% of women of childbearing age report inadequate sleep, and sleep is associated with short- and long-term health and performance outcomes. Numerous sociodemographic, psychosocial, role, familial, and community factors contribute to sleep, but few studies have addressed the contributions of these factors to sleep health in women of childbearing age, aside from those who are pregnant. Understanding these factors may assist in identifying women at particular risk for sleep difficulty; some may be modifiable, and other may signal the need for sleep interventions tailored to specific circumstances. Low-income women and those in ethnic and racial minority groups are at particular risk for disparities in sleep health. There is a need for research that addresses these factors and the development of interventions at the individual, family, and community levels to promote sleep health. Screening and intervention to promote health sleep and decrease sleep difficulty should be a standard of care in clinical, community, and workplace settings frequented by women.

Perspectives of pregnant and postpartum women and obstetric providers to promote healthy lifestyle in pregnancy and after delivery: a qualitative in-depth interview study

BACKGROUND

Pregnancy provides an opportunity to promote healthy lifestyle behaviors. This study's aim was to explore the perspectives of pregnant and postpartum women and obstetric providers around behavioral lifestyle changes in pregnancy and postpartum.

METHODS

We conducted a qualitative study with pregnant and postpartum patients recruited from 2 prenatal care clinics at an urban, academic hospital in the United States. In-depth interviews with 23 pregnant or postpartum women and 11 obstetric providers were completed between October 2015-April 2016. Interviews were audio-recorded and transcribed verbatim. We coded transcripts for thematic content and applied the PRECEDE-PROCEED framework for results to directly inform program development.

RESULTS

Six themes highlighted the predisposing, enabling and reinforcing factors that enable and sustain health behavior changes in pregnancy and postpartum: 1) "Motivation to have a healthy baby" during pregnancy and to "have my body back" after delivery, 2) Pre-pregnancy knowledge and experiences about pregnancy and the postpartum period, 3) Prioritizing wellness during pregnancy and postpartum, 4) The power of social support, 5) Accountability, 6) Integration with technology to reinforce behavior change.

CONCLUSIONS

In this qualitative study, pregnant and postpartum women and obstetric providers described themes that are aimed at encouraging lifestyle changes to promote healthy weight gain in pregnancy and can directly inform the development of a behavioral weight management intervention for pregnant and postpartum women that is patient-centered and tailored to their needs.

Adapting sleep hygiene for community interventions: a qualitative investigation of sleep hygiene behaviors among racially/ethnically diverse, low-income adults

BACKGROUND

Despite the high prevalence of inadequate sleep in racially/ethnically diverse, low-income adults, there is scant research targeting sleep health interventions among underserved populations. Sleep hygiene (SH) recommendations may help promote sleep health for the general population; however, they likely require tailoring to optimize uptake and effectiveness in the "real world" given socio-contextual factors. As an initial step to developing contextually appropriate and effective community-based SH interventions, we conducted qualitative research to understand SH behaviors, beliefs, and barriers in a low-income, ethnically diverse sample of adults.

METHODS

We recruited 24 racially/ethnically diverse adults from an affordable housing community who self-reported sleeping ≤6 hours on average. Participants were invited to either an individual interview (n = 5) or a focus group (n = 3). A deductive, thematic-analysis approach was employed. Data collection and interpretation were informed by the Socio-Contextual Model of Behavior Change.

RESULTS

There was evidence of high acceptability of SH and interest in improving sleep health. Barriers to implementing SH were multifaceted, including individual (knowledge, motivation, habits, medical issues, stress, trauma), interpersonal (caregiving), organizational (job strain), and environmental (noise) factors.

CONCLUSIONS

Future strategies for adapting behavioral SH interventions should target knowledge, skill development, and behavioral change domains, such as motivation, social support, and self-efficacy. In addition, adapting SH beyond the clinical context for a high-need community population requires attention to multilevel sociocontextual factors that contribute to sleep health, particularly chronic stress, prior trauma, and adverse sleeping environments. Development of novel trauma-informed SH interventions may promote effective and safe implementation.

Targeting pregnancy-related weight gain to reduce disparities in obesity: Baseline results from the Healthy Babies trial

BACKGROUND

Obesity affects African American women more than any other group in the US. Pregnancy represents a critical life stage of heightened vulnerability for new or persistent obesity, yet few interventions have been effective in reducing excessive gestational weight gain among African American women. We describe the design and baseline findings of Healthy Babies, a two-arm randomized controlled trial testing a mobile health intervention to minimize excessive gestational weight gain versus usual care in this high risk group.

METHODS

African American women in early pregnancy were recruited from two large obstetric practices as well as Philadelphia Women, Infants, and Children's clinics. Participants randomized to the intervention received behavior change goals, daily text messages with feedback, web-based weight gain graphs, health coaching, and a Facebook support group. Data collection included baseline (<22 weeks' gestation), 36-38 weeks' gestation, and 6-month postpartum anthropometric measures and assessments of demographics, contextual factors and behavioral targets. The primary outcome was prevalence of excessive gestational weight gain.

RESULTS

Among participants at baseline (n = 262), the majority met criteria for obesity (63%), were multiparous (62%), single (77%), and were on average 25.6 ± 5.4 years old with a gestational age of 13.9 ± 4.1 weeks. While 82% completed high school, 61% met criteria for inadequate health literacy. Nearly 20% were food insecure. Eighty-eight percent reported a gestational weight gain goal discordant with Institute of Medicine guidelines. There were no significant differences in baseline characteristics between study arms.

CONCLUSIONS

Participants represent a high-risk group for excessive gestational weight gain with demonstrated need for intervention.

Perceived Toddler Sleep Problems, Co-sleeping, and Maternal Sleep and Mental Health

OBJECTIVE

Childhood sleep problems are associated with insufficient parental sleep and adverse maternal mental health symptoms, which may be exacerbated when mothers/toddlers co-sleep (i.e., bed/room sharing). This study examines maternal sleep duration as a mechanism linking perceived toddler sleep problems with maternal mental health and examines whether these associations vary by co-sleeping, in addition to exploring alternative models.

METHODS

Low-income mothers of toddlers (n = 280) (age 12-32 months) recruited from Women, Infants, and Children and pediatric clinics provided demographic information and completed questionnaires on their toddler's sleep and their own sleep duration and mental health symptoms (depressive symptoms, anxiety, and stress). Indirect and conditional indirect models were conducted to examine the relation between perceived toddler sleep problems and maternal mental health.

RESULTS

Perceived toddler sleep problems were associated with an average decrease of 51 minutes in maternal sleep when co-sleeping (mean = 6.1 h). Maternal sleep duration mediated the relation between perceived toddler sleep problems and maternal symptoms of depression, anxiety, and stress for co-sleeping mothers. Maternal sleep duration did not mediate relations between maternal mental health symptoms and perceived toddler sleep problems.

CONCLUSION

This study provides a conceptual model by which parent and child sleep is related to parental mental health. Practitioners might consider alternatives to co-sleeping when discussing sleep arrangements with parents. Future studies should replicate results longitudinally and examine whether reducing co-sleeping improves maternal sleep duration and reduces perceptions of toddler sleep problems.

Sleep in the Postpartum: Characteristics of First-Time, Healthy Mothers

Goals for the present study were to (a) describe the sleep of healthy new mothers over a 6-month postpartum period, (b) examine how sleep quality relates to daytime levels of fatigue and sleepiness, and (c) evaluate the relationship between mothers' and infants' sleep parameters. The sample consisted of 37 healthy, partnered, first-time mothers who had experienced full-term vaginal birth and had a healthy infant. We investigated infants' sleep parameters and mothers' sleep, mood, and daytime functioning 2 and 6 months postpartum. We found that at 2 months postpartum, mothers reported sleeping 6 hours at night and just under one hour during the day. Despite relatively frequent nocturnal awakenings, mothers experienced minimal insomnia, nonrefreshing sleep, anxiety, depression, daytime sleepiness, or fatigue at either 2 or 6 months. The most robust relationship between mothers' and infants' sleep was in the number of nocturnal sleep-wake episodes. Of note is that none of the infant sleep parameters was related to mothers' anxiety, depression, fatigue, sleepiness, or nonrefreshing sleep at either time period. Our results indicate that (1) selected low risk new mothers are resilient in terms of sleep quality, daytime functioning, and mood and (2) these are independent of their infants' sleep parameters.