The Neighborhood Social Environment and Objective Measures of Sleep in the Multi-Ethnic Study of Atherosclerosis

Association between household sleep environment and sleep health characteristics in middle-aged adults: The CARDIA sleep study

OBJECTIVES

Household environmental factors and sleep hygiene may contribute to poor sleep health. We identified associations between household sleep environment (HHSE) and sleep health characteristics in White and Black adults.

METHODS

This study included cross-sectional data from the CARDIA sleep ancillary study at Year 35 (n=711). HHSE was assessed in two domains (sleep disruptors and sleep hygiene) using a questionnaire, and higher scores indicated more sleep disruptors or poorer sleep hygiene. Sleep outcomes included (1) self-reported sleep quality and daytime sleepiness and (2) actigraphy-measured sleep duration, sleep percentage, sleep timing (midpoint sleep time), and sleep regularity. We used robust regression to estimate differences in sleep outcomes corresponding to each 1-point increment in HHSE. Racial differences in associations of interest were examined by testing for interaction.

RESULTS

Participants' mean age was 61.5 (SD=3.6) years, 63% were women, and 36.7% were Black. After multivariable adjustment (β [95% CI]), more sleep disruptors (0.145 [0.04, 0.24]) and poor sleep hygiene (0.170 [0.10, 0.23]) were associated with self-reported poor sleep quality. Poor sleep hygiene was associated with actigraphy-measured shorter sleep duration (-1.397 [-2.73, -0.01]) and sleep irregularity (0.017 [0.01, 0.02]). In stratified analysis, more sleep disruptors were associated with poor sleep quality (0.320 [0.10, 0.53]) and greater daytime sleepiness (0.330 [0.11, 0.54]) only in Black participants.

CONCLUSIONS

Poor HHSE was related to self-reported poor sleep quality and to objective shorter sleep duration and sleep irregularity. Targeted interventions to mitigate sleep disruptors and promote good sleep hygiene may help to improve sleep health.

Socioecological factors linked to co-occurring early childhood sleep health disparities and developmental outcomes: protocol for the sleep in preschoolers cross-sectional study

INTRODUCTION

Sleep deficiencies, such as sleep disordered breathing (SDB) and insufficient sleep, are linked to adverse health outcomes. These sleep deficiencies are more common in racial and ethnic minoritised children and have significant negative impacts on neurobehavioural and social-emotional development. Non-Latine Black/African American children are 4-6 times more likely than non-Latine White children to experience both SDB and short sleep duration. Although SDB and insufficient sleep often co-occur in young children, there is a paucity of research considering the potential unique and additive impacts of SDB and insufficient sleep on child outcomes, as well as racial disparities in these outcomes, thus hindering comprehensive interventions. Our study objectives are to (1) examine racial disparities in the neurobehavioural and social-emotional impacts of early childhood SDB and/or insufficient sleep and (2) identify proximal and distal socioecological factors linked to these sleep disparities and outcomes.

METHODS AND ANALYSIS

A cross-sectional observational study comparing neurobehavioural (executive functioning, attention, vigilance) and social-emotional functioning (social skills, emotion regulation) in 400 dyads consisting of caregivers and their otherwise healthy Black and White 3-5 year-old children and divided into four groups: (A) preschoolers with SDB; (B) preschoolers with insufficient sleep; (C) preschoolers with both SDB and insufficient sleep and (D) matched controls. Child SDB, insufficient sleep, neurobehavioural skills and social-emotional functioning are measured using validated objective and subjective assessment tools, with a subset of caregivers completing qualitative interviews. Primary outcomes include individual differences in neurobehavioural and social-emotional functioning in these groups of Black and White preschoolers, and multilevel socioecological factors associated with variation in outcomes. Quantitative data will be analysed using descriptive analyses, linear regression and comparison of model coefficients. Qualitative data will be coded using thematic analysis and a joint display to stratify qualitative themes by child race and sleep deficiencies.

ETHICS AND DISSEMINATION

The study protocol has been approved by the institutional review board of the Children's Hospital of Philadelphia and the University of Oregon. Results will be disseminated through peer-reviewed publications and conferences.

Racial and ethnic disparities in the perceived neighborhood walking environment and self-reported sleep health: A nationally representative sample of the United States

OBJECTIVES

To identify associations between perceived neighborhood walkability and sleep across racial and ethnic groups of US adults.

METHODS

Data from the 2020 National Health Interview Survey (N=27,521) were used to assess self-reported measures of walkability (pedestrian access, accessible amenities, unsafe walking conditions) and sleep (short and long duration; frequency of waking up unrested, trouble falling and staying asleep, sleep medication use). Stratified by racial and ethnic group, we calculated the age-adjusted prevalence of neighborhood walkability features and sleep measures and estimated prevalence ratios assessing associations between neighborhood walkability and sleep while adjusting for sociodemographic and health covariates.

RESULTS

The prevalence of unsafe walking conditions due to crime was lowest among non-Hispanic White adults (6.9%), and access to places to relax was lowest among non-Hispanic Black adults (72.5%). The prevalence of short sleep duration was highest among non-Hispanic Black adults (37.9%). Neighborhood environment features had differential associations with sleep when stratified by race and ethnicity. For example, walking path access was related to lower sleep medication use among non-Hispanic Asian adults (adjusted prevalence ratio (aPR): 0.42, 95% CI: 0.19-0.91) but greater use among non-Hispanic White adults (aPR: 1.24, 95% CI: 1.05-1.46). More associations were observed among non-Hispanic White adults than other groups; and the strongest magnitude of association was observed among non-Hispanic Asian adults (traffic and sleep medication aPR: 0.31, 95% CI: 0.12-0.84).

CONCLUSIONS

Associations between the neighborhood environment and sleep vary and may be inconsistent by race and ethnicity. Future research may help identify determinants.

Explanatory variables of objectively measured physical activity, sedentary behaviour and sleep in adults with type 1 diabetes: A systematic review

AIMS

This systematic review aimed to summarize knowledge on explanatory variables of PA, SB and sleep in adults with T1D to support the development of healthy lifestyle interventions.

METHODS

A systematic search of four databases (PubMed, Web of Science, Scopus and Embase) was performed. Only objective measurements of PA, SB and sleep were included and all explanatory variables were classified according to the socio-ecological model (i.e. intrapersonal, interpersonal, environmental and policy level). Risk of bias (ROB) (Joanna Briggs Institute appraisal checklists) and level of evidence (Evidence-Based Guideline Development) were assessed.

RESULTS

Twenty-one studies were included (66.7% low ROB). Most explanatory variables were situated at the intrapersonal level. A favourable body composition was associated with more time spent in total PA and moderate-to-vigorous PA (MVPA). Men with T1D spent more time in MVPA than women and a younger age was associated with increased MVPA. Barriers to PA were indeterminately associated with MVPA and HbA1c showed an indeterminate association with sleep. Explanatory variables of SB and light PA were not studied in at least two independent studies.

CONCLUSION

This review underscores the focus on the individual level to identify explanatory variables of movement behaviours in adults with T1D, despite the necessity for a socio-ecological approach to develop effective interventions. More evidence on psychological, interpersonal and environmental variables is needed as these are modifiable.

Socioeconomic status and sleep duration among a representative, cross-sectional sample of US adults

BACKGROUND

Sleep is a crucial determinant of physical and mental health outcomes, and insufficient sleep is highly prevalent among United States adults. Although some risk factors of poor sleep have been extensively studied, including substance use, age, health behaviors, and others, the associations between socioeconomic status (SES) and sleep remain inconclusive. There is limited evidence on SES and sleep duration among the US adult population. This study analyzed the relationships between three SES indicators (poverty, education, and food security), and sleep duration.

METHODS

We used responses from the 2017-March 2020 National Health and Nutrition Examination Survey (NHANES). Respondents younger than 25 years old were excluded. Sleep duration was classified using self-reported sleep time and stratified by work vs. non-workdays. SES was operationalized using three indicators: poverty-income ratio, educational attainment, and food security status. We imputed missing data for socioeconomic status and outcome variables using multiple imputation. Weighted Poisson regression models with robust standard errors were used to calculate the crude and adjusted prevalence ratios for insufficient sleep duration (< 7 h of self-reported sleep) on workdays and non-workdays separately by each of the three SES indicators.

RESULTS

We included a total of 8,457 individuals. In the adjusted model, participants with lower income, educational status, and food security had significantly higher prevalence of insufficient sleep duration on both workdays and non-workdays. For example, low-income individuals (poverty-income ratio < 1) had 1.22 (95% CI 1.04-1.44) and 2.08 (95% CI 1.61-2.67) higher prevalence of insufficient sleep as compared to high income individuals on workday and non-workdays, respectively. In general, we found larger differences by level of SES indicator for the non-workday than for the workday outcome. There were no major differences in gender-stratified analysis. We also found that lower SES was associated with higher prevalence of excessive sleep (≥ 9 h).

CONCLUSION

Socioeconomic status indicators are significantly associated with sleep duration in the US adult population. Lower SES correlates with increased prevalence of insufficient sleep duration, which has implications for the overall wellbeing of US adults with lower SES. Targeted interventions and further research are needed to reduce this disparity.

Sleep health inequities in vulnerable populations: Beyond sleep deserts

Despite the importance of sleep to overall health and well-being, there is a high prevalence of undiagnosed sleep disorders and adverse sleep health, particularly among vulnerable populations. Such vulnerable populations include people experiencing homelessness (PEH), refugees, and incarcerated individuals. In this narrative review, we provide an overview of the literature on sleep health and disorders among key and vulnerable populations (e.g., PEH, refugees, and incarcerated individuals). The limited research among these populations indicated a high prevalence of sleep disorders, mainly insomnia, short sleep duration, and fatigue. Substance abuse and PTSD were commonly found among PEH and refugee populations, respectively, which were was related to poor sleep. Similar across the included vulnerable populations, the individuals reside in environments/facilities with inopportune light exposure, noise disruption, inadequate bedding, and forced sleep schedules. Studies also found a high prevalence of psychosocial stress and reports of threats to safety, which were associated with poor sleep health outcomes. Additionally, several studies reported environmental barriers to adherence to sleep disorder treatment. This paper highlighted the conditions in which these vulnerable populations reside, which may inform interventions within these various facilities (homeless shelters, refugee camps, prisons/jails). The improvement of these facilities with a sleep equity focus may in turn improve quality of life and daily functioning.

Neighborhood social cohesion and sleep health among sexual minoritized US adults and intersections with sex/gender, race/ethnicity, and age

OBJECTIVES

Neighborhood social cohesion or living in communities characterized by trust and social ties may mitigate sleep disparities among sexual minoritized vs. heterosexual persons; but its relation to sleep health is understudied among sexual minoritized groups. To investigate associations between perceived neighborhood social cohesion and sleep health among adult US men and women who identified as "lesbian or gay, bisexual, or something else," we used cross-sectional National Health Interview Survey data (2013-2018).

METHODS

Participants reported neighborhood social cohesion (categorized as low or medium vs. high) and sleep characteristics. Adjusting for sociodemographic, health, and residential characteristics, we used Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% confidence intervals for poor sleep.

RESULTS

Among 4666 sexual minoritized adults, 44% reported low, 32% medium, and 24% high neighborhood social cohesion. Women, minoritized racial/ethnic groups, and young adults disproportionately reported low neighborhood social cohesion. Overall, low vs. high neighborhood social cohesion was associated with a higher prevalence of short sleep (PR=1.27 [95% confidence interval:1.11-1.45]) and all sleep disturbances (e.g., PRinsomnia symptoms=1.36 [1.19-1.55]). PRs were often higher as intersectionality or membership to multiple minoritized groups increased.

CONCLUSIONS

Lower perceived neighborhood social cohesion was associated with poorer sleep. Fostering community cohesiveness may mitigate sleep disparities among sexual minoritized adults.

Structural and social determinants of health: The multi-ethnic study of atherosclerosis

BACKGROUND

Researchers have increasingly recognized the importance of structural and social determinants of health (SSDOH) as key drivers of a multitude of diseases and health outcomes. The Multi-Ethnic Study of Atherosclerosis (MESA) is an ongoing, longitudinal cohort study of subclinical cardiovascular disease (CVD) that has followed geographically and racially/ethnically diverse participants starting in 2000. Since its inception, MESA has incorporated numerous SSDOH assessments and instruments to study in relation to CVD and aging outcomes. In this paper, we describe the SSDOH data available in MESA, systematically review published papers using MESA that were focused on SSDOH and provide a roadmap for future SSDOH-related studies.

METHODS AND FINDINGS

The study team reviewed all published papers using MESA data (n = 2,125) through January 23, 2023. Two individuals systematically reviewed titles, abstracts, and full text to determine the final number of papers (n = 431) that focused on at least one SSDOH variable as an exposure, outcome, or stratifying/effect modifier variable of main interest (discrepancies resolved by a third individual). Fifty-seven percent of the papers focused on racialized/ethnic groups or other macrosocial/structural factors (e.g., segregation), 16% focused on individual-level inequalities (e.g. income), 14% focused on the built environment (e.g., walking destinations), 10% focused on social context (e.g., neighborhood socioeconomic status), 34% focused on stressors (e.g., discrimination, air pollution), and 4% focused on social support/integration (e.g., social participation). Forty-seven (11%) of the papers combined MESA with other cohorts for cross-cohort comparisons and replication/validation (e.g., validating algorithms).

CONCLUSIONS

Overall, MESA has made significant contributions to the field and the published literature, with 20% of its published papers focused on SSDOH. Future SSDOH studies using MESA would benefit by using recently added instruments/data (e.g., early life educational quality), linking SSDOH to biomarkers to determine underlying causal mechanisms linking SSDOH to CVD and aging outcomes, and by focusing on intersectionality, understudied SSDOH (i.e., social support, social context), and understudied outcomes in relation to SSDOH (i.e., sleep, respiratory health, cognition/dementia).

Household and housing determinants of sleep duration during the COVID-19 pandemic: Results from the COHESION Study

BACKGROUND

Public health measures in response to the COVID-19 pandemic forced individuals to spend more time at home. We sought to investigate the relationship between housing characteristics and sleep duration in the context of COVID-19.

METHODS

Our exploratory study was part of the COvid-19: Health and Social Inequities across Neighborhoods (COHESION) Study Phase-1, a pan-Canadian population-based cohort involving nearly 1300 participants, launched in May 2020. Sociodemographic, household and housing characteristics (dwelling type, dissatisfaction, access to outdoor space, family composition, etc.), and self-reported sleep were prospectively collected through COHESION Study follow-ups. We explored the associations between housing and household characteristics and sleep duration using linear regressions, as well as testing for effect modification by income satisfaction and gender.

RESULTS

Our study sample involved 624 COHESION Study participants aged 50 ± 16years (mean±SD), mainly women (78%), White (86%), and university graduates (64%). The average sleep duration was 7.8 (1.4) hours. Sleep duration was shorter according to the number of children in the household, income dissatisfaction, and type of dwelling in multivariable models. Sleep was short in those without access to a private outdoor space, or only having a balcony/terrace. In stratified analyses, sleep duration was associated with housing conditions dissatisfaction only in those dissatisfied with their income.

CONCLUSION

Our exploratory study highlights the relationship between housing quality and access to outdoor space, family composition and sleep duration in the context of COVID-19. Our findings also highlight the importance of housing characteristics as sources of observed differences in sleep duration.

Interactions among neighborhood conditions, sleep quality, and episodic memory across the adult lifespan

OBJECTIVES

On average, adults racialized as non-Hispanic Black and Hispanic sleep more poorly than adults racialized as non-Hispanic White (hereafter, Black, Hispanic, White), but associations between factors that may moderate sleep-memory associations in these groups, such as neighborhood conditions, are unclear. Poorer neighborhood conditions (e.g. lower neighborhood cohesion) may be negatively associated with sleep quality and multiplicatively influence sleep-memory associations. We hypothesized lower ratings of neighborhood conditions would be associated with poorer sleep quality and moderate the association between sleep quality and episodic memory, especially in Black and Hispanic adults, who are disproportionately situated in poor neighborhood conditions.

DESIGN

Seven-hundred-thirty-six adults across the adult lifespan (27-89 years) were recruited from the northern Manhattan community as a part of the Offspring Study of Racial and Ethnic Disparities in Alzheimer's disease. Sleep quality was assessed using a modified version of the Pittsburgh Sleep Quality Index, and episodic memory was evaluated with the Buschke Selective Reminding Test. With multiple regression models, we measured associations between perceived neighborhood conditions and sleep quality and the interaction between sleep quality and neighborhood conditions on episodic memory stratified by racial/ethnic and gender identity groups.

RESULTS

Overall, poorer neighborhood conditions were associated with poorer sleep quality. In Black and Hispanic women, the sleep-memory association was moderated by neighborhood conditions. With more favorable neighborhood conditions, Black women showed an association between higher sleep quality and higher memory performance, and Hispanic women showed a protective effect of neighborhood (higher memory even when sleep quality was poor).

CONCLUSION

Poorer neighborhood experiences may contribute to poorer sleep quality across groups. In Black and Hispanic women, the association between sleep quality and episodic memory performance was dependent upon neighborhood conditions. These findings may inform tailored, structural level sleep interventions, aimed to improve neighborhood experiences and thereby sleep quality and episodic memory.

Depleted Housing Elicits Cardiopulmonary Dysfunction After a Single Flaming Eucalyptus Wildfire Smoke Exposure in a Sex-Specific Manner in ApoE Knockout Mice

Although it is well established that wildfire smoke exposure can increase cardiovascular morbidity and mortality, the combined effects of non-chemical stressors and wildfire smoke remains understudied. Housing is a non-chemical stressor that is a major determinant of cardiovascular health, however, disparities in neighborhood and social status have exacerbated the cardiovascular health gaps within the United States. Further, pre-existing cardiovascular morbidities, such as atherosclerosis, can worsen the response to wildfire smoke exposures. This represents a potentially hazardous interaction between inadequate housing and stress, cardiovascular morbidities, and worsened responses to wildfire smoke exposures. The purpose of this study was to examine the effects of enriched (EH) versus depleted (DH) housing on pulmonary and cardiovascular responses to a single flaming eucalyptus wildfire smoke (WS) exposure in male and female apolipoprotein E (ApoE) knockout mice, which develop an atherosclerosis-like phenotype. The results of this study show that cardiopulmonary responses to WS exposure occur in a sex-specific manner. EH blunts adverse WS-induced ventilatory responses, specifically an increase in tidal volume (TV), expiratory time (Te), and relaxation time (RT) after a WS exposure, but only in females. EH also blunted an increase in isovolumic relaxation time (IVRT) and the myocardial performance index (MPI) 1-week after exposures, also only in females. Our results suggest that housing alters the cardiovascular response to a single WS exposure, and that DH might cause increased susceptibility to environmental exposures that manifest in altered ventilation patterns and diastolic dysfunction in a sex-specific manner.

Self-reported neighborhood stressors and sleep quality among Puerto Rican young adults

OBJECTIVE

To examine the association between changes in self-reported neighborhood stressors and sleep quality and determine whether this varied by sociocultural context among Puerto Rican young adults.

METHODS

Data come from the Boricua Youth Study Health Assessment, a sample of Puerto Rican young adults from San Juan, Puerto Rico, and South Bronx, New York (n = 818; mean age=22.9years). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Neighborhood social stressors (disorder, social cohesion, and safety) were parent-reported in childhood and self-reported in young adulthood and categorized into: low in childhood/young adulthood (reference group), high in childhood/low in young adulthood, low in childhood/high in young adulthood, and high in childhood/young adulthood. Sociocultural context was based on participant residence during childhood (San Juan vs. South Bronx).

RESULTS

Adjusting for sociodemographic factors, living with high neighborhood stressors in both childhood and young adulthood (prevalence ratios=1.30, 95% CI: 1.01, 1.66) was associated with overall poor sleep (PSQI score >5). Among PSQI components, living with high neighborhood stressors in young adulthood only or in both time periods was associated with worse subjective sleep quality and daytime dysfunction. Additionally, there were various associations between the neighborhood stressor measures and PSQI components. Results did not differ by sociocultural context.

CONCLUSION

Findings suggest that living with high levels of neighborhood stressors during childhood and young adulthood may have a cumulative adverse impact on sleep quality in young adulthood.

Perceived childhood neighborhood safety and sleep health during childhood and adulthood among a cohort of African American women

OBJECTIVE

To investigate associations between perceived childhood neighborhood safety and sleep over the life course.

METHODS

Among a cohort of 1693 Black/African American women aged 23-35 years at enrollment (2010-2012), participants recalled neighborhood safety (safe vs. unsafe) when they were 5, 10, and 15 years old. Participants' mothers/caregivers and participants reported sleep-related health behaviors at age 5. We used ordinal logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for sleep-related health behaviors (i.e., rarely/never or sometimes vs. mostly/always going to bed by 8:00 p.m., bed in a quiet room, bed in a dimly lit or unlit room), separately. Adulthood sleep duration and insomnia symptoms were reported at enrollment and over three follow-up periods. We applied generalized estimating equations to log binomial regression models to estimate relative risks (RR) for adulthood sleep characteristics.

RESULTS AND CONCLUSIONS

Four percent of participants reported an unsafe neighborhood at age 5 years, only, and 12% reported an unsafe neighborhood at all ages. Participants in perceived unsafe vs. safe neighborhoods at age 5 had higher odds of poor sleep-related health behaviors (e.g., rarely/never or sometimes going to bed in a quiet room: OR = 1.73 [1.27-2.35]). Participants in perceived unsafe vs. safe neighborhoods throughout childhood had higher risk of short sleep (RR = 1.10 [1.02-1.18]) and insomnia symptoms (RR = 1.07 [1.00-1.15]) during adulthood after adjustment for life course socioeconomic characteristics and adulthood health behaviors and characteristics. Perceived unsafe childhood neighborhood was associated with poorer sleep over the life course and may serve as an early intervention target.

Association between self-perception of the neighborhood environment and sleep problems in older Brazilian adults: findings from ELSI-Brazil

This study aimed to investigate associations between neighborhood perception and sleep problems in older Brazilian adults. A cross-sectional study was conducted with 5,719 community-dwelling older adults (≥ 60 years) from the Brazilian Longitudinal Study of Aging (ELSI-Brazil, 2019-2021). The outcomes were self-reported sleep problems: poor sleep quality, daytime sleepiness, primary insomnia complaints, difficulty staying asleep, and waking up at dawn. The exposure variables were questions about the perception of participants about the physical and social environment of the neighborhood. Logistic regression was used in data analysis. Garbage, rubbish, or tall grass on the streets and the desire to move were associated with higher odds of poor sleep quality. Concern about falling due to damaged sidewalks, concern about having difficulties taking transportation, and concern about having difficulties crossing the street were associated with higher odds of all sleep problems. Sound/noise of buses and cars was associated with higher odds of some sleep problems. Perceiving the neighborhood as a good place to live was associated with lower odds of daytime sleepiness and primary insomnia complaints. Trusting most people in the neighborhood and perceiving that kids and younger people treat adults with respect were associated with lower odds of daytime sleepiness, primary insomnia complaints, and waking up at dawn. Being a good place for kids to play and raise teenagers was associated with lower odds of daytime sleepiness. These results can assist public administrators in creating urban planning policies aimed at improving neighborhood environments as a means of health promotion.

Depleted housing elicits cardiopulmonary dysfunction after a single flaming eucalyptus wildfire smoke exposure in a sex-specific manner in ApoE knockout mice

Although it is well established that wildfire smoke exposure can increase cardiovascular morbidity and mortality, the combined effects of non-chemical stressors and wildfire smoke remains understudied. Housing is a non-chemical stressor that is a major determinant of cardiovascular health, however, disparities in neighborhood and social status have exacerbated the cardiovascular health gaps within the United States. Further, pre-existing cardiovascular morbidities, such as atherosclerosis, can worsen the response to wildfire smoke exposures. This represents a potentially hazardous interaction between inadequate housing and stress, cardiovascular morbidities, and worsened responses to wildfire smoke exposures. The purpose of this study was to examine the effects of enriched (EH) versus depleted (DH) housing on pulmonary and cardiovascular responses to a single flaming eucalyptus wildfire smoke (WS) exposure in male and female apolipoprotein E (ApoE) knockout mice, which develop an atherosclerosis-like phenotype. The results of this study show that cardiopulmonary responses to WS exposure occur in a sex-specific manner. EH blunts adverse WS-induced ventilatory responses, specifically an increase in tidal volume (TV), expiratory time (Te), and relaxation time (RT) after a WS exposure, but only in females. EH also blunted a WS-induced increase in isovolumic relaxation time (IVRT) and the myocardial performance index (MPI) 1-wk after exposures, also only in females. Our results suggest that housing alters the cardiovascular response to a single WS exposure, and that DH might cause increased susceptibility to environmental exposures that manifest in altered ventilation patterns and diastolic dysfunction in a sex-specific manner.

Officer-Involved Killings of Unarmed Black People and Racial Disparities in Sleep Health

Importance

Racial disparities in sleep health may mediate the broader health outcomes of structural racism.

Objective

To assess changes in sleep duration in the Black population after officer-involved killings of unarmed Black people, a cardinal manifestation of structural racism.

Design, Setting, and Participants

Two distinct difference-in-differences analyses examined the changes in sleep duration for the US non-Hispanic Black (hereafter, Black) population before vs after exposure to officer-involved killings of unarmed Black people, using data from adult respondents in the US Behavioral Risk Factor Surveillance Survey (BRFSS; 2013, 2014, 2016, and 2018) and the American Time Use Survey (ATUS; 2013-2019) with data on officer-involved killings from the Mapping Police Violence database. Data analyses were conducted between September 24, 2021, and September 12, 2023.

Exposures

Occurrence of any police killing of an unarmed Black person in the state, county, or commuting zone of the survey respondent's residence in each of the four 90-day periods prior to interview, or occurence of a highly public, nationally prominent police killing of an unarmed Black person anywhere in the US during the 90 days prior to interview.

Main Outcomes and Measures

Self-reported total sleep duration (hours), short sleep (<7 hours), and very short sleep (<6 hours).

Results

Data from 181 865 Black and 1 799 757 White respondents in the BRFSS and 9858 Black and 46 532 White respondents in the ATUS were analyzed. In the larger BRFSS, the majority of Black respondents were between the ages of 35 and 64 (99 014 [weighted 51.4%]), women (115 731 [weighted 54.1%]), and college educated (100 434 [weighted 52.3%]). Black respondents in the BRFSS reported short sleep duration at a rate of 45.9%, while White respondents reported it at a rate of 32.6%; for very short sleep, the corresponding values were 18.4% vs 10.4%, respectively. Statistically significant increases in the probability of short sleep and very short sleep were found among Black respondents when officers killed an unarmed Black person in their state of residence during the first two 90-day periods prior to interview. Magnitudes were larger in models using exposure to a nationally prominent police killing occurring anywhere in the US. Estimates were equivalent to 7% to 16% of the sample disparity between Black and White individuals in short sleep and 13% to 30% of the disparity in very short sleep.

Conclusions and Relevance

Sleep health among Black adults worsened after exposure to officer-involved killings of unarmed Black individuals. These empirical findings underscore the role of structural racism in shaping racial disparities in sleep health outcomes.

Addressing sleep deserts: A proposed call for action

Sleep deserts are a major cause of health inequity. They occur primarily in disadvantaged neighborhoods because of structural racism, social and environmental factors, and dearth of medical services. We describe several strategies that can serve as a feasible action plan to target structural racism, environmental pollution, and impact of climate change. We also suggest ways healthcare providers in these underserved areas can incorporate sleep medicine into their practice. Lastly, we highlight strategies to increase community awareness of sleep health in a culturally sensitive manner. There are several ways, from a policy level to healthcare that we can begin to eliminate sleep deserts, which is urgently needed.

Perceived Neighborhood Characteristics and Sleep in Australian Adults

BACKGROUND

Poor sleep can contribute to poorer health and socioemotional outcomes. Sleep health can be influenced by a range of individual and other socioecological factors. Perceptions of neighborhood physical and social characteristics reflect broader social-level factors that may influence sleep, which have not been well studied in the Australian context. This study examined the association between perceived neighborhood characteristics and sleep in a large sample of Australians.

METHODS

Data were from 9,792 people aged 16 years or older, from Waves 16 and 17 of the nationally representative Household, Income and Labour Dynamics in Australia Survey. Associations between perceived neighborhood characteristics (neighborly interaction and support, environmental noise, physical condition, and insecurity) and self-reported sleep duration, sleep disturbance, and napping were examined using multiple logistic regression models.

RESULTS

"Neighborhood interaction and support" and "neighborhood physical condition" were not significantly associated with any sleep outcomes after adjusting for relevant covariates. However, "environmental noise" and "neighborhood insecurity" remained significantly associated with sleep duration and sleep disturbance. None of the neighborhood characteristics were associated with napping. Furthermore, associations did not significantly vary by gender.

CONCLUSIONS

This study highlights the potential benefit of public health policies to address noise and safety in neighborhoods to improve sleep.

Neighborhood determinants of sleep and the moderating role of cultural factors among native adolescents

OBJECTIVE

This study examined the association between neighborhood social environment and sleep among urban American Indian and Alaska Native (AI/AN) adolescents as well as the moderating role of cultural factors in this association.

METHOD

The analytic sample included 133 urban AI/AN adolescents (age 12-16, 57.1% female, Mage = 14.03, SDage = 1.35). Perceived neighborhood social environment included safety and cohesion. Cultural factors included AI/AN cultural identification and historical loss. Sleep duration, efficiency, and wake after sleep onset (WASO) were measured via actigraphy. Sleep disturbance was measured via a questionnaire.

RESULTS

Greater neighborhood safety was significantly associated with lower sleep disturbance (b = -2.17, SE = 0.8, p = .008), higher sleep efficiency (b = 1.75, SE = 0.64, p = .006), and lower WASO (b = -8.60, SE = 3.34, p = .01). Neighborhood cohesion was not associated with any sleep outcomes. Cultural factors moderated the association between neighborhood social environment and sleep outcomes (p < .05). Specifically, both neighborhood safety and cohesion were associated with lower sleep disturbance, only among individuals reporting higher levels of AI/AN cultural identification. Further, neighborhood safety was associated with greater sleep efficiency and lower WASO (i.e., better sleep) only among adolescents with higher contemplation of historical loss.

CONCLUSIONS

Findings highlight the importance of considering cultural factors in addressing sleep and health disparities. AI/AN cultural identification and a sense of historical loss may be important targets for identifying adolescents who might benefit the most from policies and interventions focused on improving the social environment in order to improve sleep and other health outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Neighborhood predictors of short sleep duration and bedtime irregularity among children in the United States: results from the 2019-2020 National Survey of Children's Health

BACKGROUND

Environmental factors may contribute to short sleep duration and irregular bedtime in children. Neighborhood factors and children's sleep duration and bedtime regularity remain a less investigated area. The aim of this study was to investigate the national and state-level proportions of children with short sleep duration and irregular bedtime and their neighborhood predictors.

METHODS

A total of 67,598 children whose parents completed the National Survey of Children's Health in 2019-2020 were included in the analysis. Survey-weighted Poisson regression was used to explore the neighborhood predictors of children's short sleep duration and irregular bedtime.

RESULTS

The prevalence of short sleep duration and irregular bedtime among children in the United States (US) was 34.6% [95% confidence interval (CI) = 33.8%-35.4%] and 16.4% (95% CI = 15.6%-17.2%) in 2019-2020, respectively. Safe neighborhoods, supportive neighborhoods, and neighborhoods with amenities were found to be protective factors against children's short sleep duration, with risk ratios ranging between 0.92 and 0.94, P < 0.05. Neighborhoods with detracting elements were associated with an increased risk of short sleep duration [risk ratio (RR) = 1.06, 95% CI = 1.00-1.12] and irregular bedtime (RR = 1.15, 95% CI = 1.03-1.28). Child race/ethnicity moderated the relationship between neighborhood with amenities and short sleep duration.

CONCLUSIONS

Insufficient sleep duration and irregular bedtime were highly prevalent among US children. A favorable neighborhood environment can decrease children's risk of short sleep duration and irregular bedtime. Improving the neighborhood environment has implications for children's sleep health, especially for children from minority racial/ethnic groups.

Racial and ethnic disparities in self-reported sleep duration: Roles of subjective socioeconomic status and sleep norms

OBJECTIVES

There are racial and ethnic disparities in sleep duration, with members of historically marginalized groups typically reporting shorter sleep than White Americans. This study examines subjective social status (SSS) as a moderator, and variation in ideal sleep norms as a mediator, of differences in sleep duration between racial/ethnic groups.

METHODS

Asian, Black, Hispanic, and non-Hispanic White respondents in an online survey reported their typical weeknight and weekend-night sleep duration, along with estimates of ideal sleep duration norms. Objective and subjective indicators of socioeconomic status were also assessed. A conditional process analysis was used to examine whether racial or ethnic differences in sleep duration were a) moderated by SSS and b) mediated by ideal sleep duration norms.

RESULTS

Racial/ethnic disparities in sleep duration varied by group. Hispanic participants reported shorter weeknight sleep than White participants. In Asian and Black participants, shorter weeknight sleep relative to White participants was only observed at medium (Black) or high (Black and Asian) levels of SSS. Shorter norms for ideal sleep duration partially mediated differences in sleep duration between Black and White adults, but not the other racial/ethnic groups. There was no evidence of moderated mediation. Neither income nor education moderated racial/ethnic disparities in sleep duration.

CONCLUSIONS

Racial and ethnic disparities in sleep duration may partially depend on SSS. Continued research into moderators and mediators of racial/ethnic differences in sleep duration is warranted.

Day-to-day deviations in sleep parameters and biological aging: Findings from the NHANES 2011-2014

OBJECTIVES

The majority of the previous research has focused on the impact of average sleep parameters on longevity. In this study, we aimed to investigate the associations of day-to-day deviations in sleep parameters with biological ages among 6052 adults participating in the 2011-2014 waves of the US National Health and Nutrition Examination Survey.

METHODS

Sleep parameters, including sleep duration, efficiency, midpoint, and day-to-day deviations in sleep parameters, including standard deviation of sleep duration (sleep variability), standard deviation of sleep midpoint (sleep irregularity), catch-up sleep, and social jetlag, were obtained from 4 to 7 days of 24-h accelerometer recording. We used physiological data to compute measurements of biological aging according to 3 published algorithms: PhenoAge, Klemera-Doubal method Biological Age, and homeostatic dysregulation.

RESULTS

After adjustment of multiple covariates, we observed that all parameters of day-to-day deviations in sleep were significantly associated with biological aging with larger sleep variability, larger sleep irregularity, more catch-up sleep, and more social jetlag linked with more advanced biological aging. The significant associations of sleep irregularity, catch-up sleep, and social jetlag with biological aging indices remained even after adjustment for sleep duration, efficiency, and midpoint.

CONCLUSION

In this study, we found that day-to-day deviations in sleep parameters are independently associated with biological aging in US general population. Since day-to-day deviation in sleep is a modifiable behavioral factor, our finding suggests that intervention aiming at increasing regularity in sleep patterns may be a novel approach for extending a healthy life span.

The perceived neighborhood walking environment and self-reported sleep health in a nationally representative sample of the United States

Neighborhood environment can influence sleep health; yet, there is a lack of data on specific environment features in nationally representative samples. We used the 2020 National Health Interview Survey to determine associations between perceived built and social environment factors related to pedestrian access (walking paths, sidewalks), amenities (shops, transit stops, entertainment/services, places to relax), and unsafe walking conditions (traffic, crime) and self-reported sleep duration and disturbances. Places to relax and pedestrian access were associated with better sleep health while unsafe walking conditions were associated with worse sleep health. Access to amenities (shops, transit stops, entertainment venues) had null associations with sleep health.

What complex factors influence sleep quality in college students? PLS-SEM vs. fsQCA

Introduction

Sleep quality has a significant impact on the health-related quality of life, particularly among college students. This study proposes a framework for identifying factors that influence college students' sleep quality, including stress, self-control, bedtime habits, and neighborhood environment.

Methods

The study employed a cross-sectional analytical approach on a convenience sample of 255 medical students from a private university in China during the 2021/2022 academic year, of which 80.39% (205) were women. Two complementary methodologies, partial least squares-structural equation modeling (PLS-SEM), and fuzzy sets qualitative comparative analysis (fsQCA), were utilized in the study.

Results

The results of the PLS-SEM analysis suggest that Stress and Self-control act as mediating variables in the model, with Bedtime habits and Neighborhood environment influencing sleep quality through these variables. Additionally, the fsQCA analysis reveals that Bedtime habits and Neighborhood environment can combine with Stress and Self-control, respectively, to influence sleep quality.

Discussion

These findings provide insight into how multiple factors, such as Stress, Self-control, Bedtime habits, and Neighborhood environment, can impact college students' sleep quality, and can be used to develop intervention programs aimed at improving it. Moreover, the use of both methodologies enables the expansion of new methodological approaches that can be applied to different contexts.

The neighborhood environment and sleep health in adolescents

OBJECTIVE

Neighborhood-level factors, including education, health and environment, and socioeconomic exposures, are important contextual determinants of child health. We explored whether these factors, measured via the Childhood Opportunity Index 2.0, were associated with sleep health in adolescents.

METHODS

Actigraphy was used to assess sleep duration, timing, and efficiency among 110 adolescents in eighth (13.9 (0.4)) and ninth (14.9 (0.4)) grade. Home addresses were geocoded and linked to Childhood Opportunity Index 2.0 scores (including 3 subtype scores and the 29 individual factor Z-scores). Mixed-effects linear regression was used to determine associations between the Childhood Opportunity Index 2.0 scores and the sleep outcomes, adjusting for sex, race, parent education, household income, school grade and weeknight status. Interactions were also tested by school grade, weeknight status, sex, and race.

RESULTS

No associations were observed between overall or subtype scores with sleep outcomes in adolescents. However, we detected associations between select individual Childhood Opportunity Index 2.0 Z-scores, spanning health & environment and education domains, and sleep outcomes. For example, greater fine particulate matter was associated with later timing of sleep onset and offset; ozone concentration was associated with earlier sleep onset and offset; greater exposure to extreme temperature was associated with later sleep onset and offset and increased odds of optimal sleep efficiency.

CONCLUSIONS

Specific neighborhood factors indexed by the Childhood Opportunity Index 2.0 were associated with sleep health among adolescents. In particular, neighborhood air quality measures were associated with sleep timing and efficiency, warranting further investigation.

Neighborhood Built Environment and Sleep Health: A Longitudinal Study in Low-Income and Predominantly African-American Neighborhoods

In the present study, we examined the associations between physical characteristics of neighborhoods and sleep health outcomes and assessed the mediating role of physical activity in these associations. A longitudinal study (the Pittsburgh Hill/Homewood Research on Eating, Shopping, and Health (PHRESH) Zzz Study; n = 1,051) was conducted in 2 low-income, predominately African-American neighborhoods in Pittsburgh, Pennsylvania, with repeated measures of neighborhood characteristics and sleep health outcomes from 2013 to 2018. Built environment measures of walkability, urban design, and neighborhood disorder were captured from systematic field observations. Sleep health outcomes included insufficient sleep, sleep duration, wakefulness after sleep onset, and sleep efficiency measured from 7-day actigraphy data. G-computations based on structural nested mean models were used to examine the total effects of each built environment feature, and causal mediation analyses were used to evaluate direct and indirect effects operating through physical activity. Urban design features were associated with decreased wakefulness after sleep onset (risk difference (RD) = -1.26, 95% confidence interval (CI): -4.31, -0.33). Neighborhood disorder (RD = -0.46, 95% CI: -0.86, -0.07) and crime rate (RD = -0.54, 95% CI: -0.93, -0.08) were negatively associated with sleep efficiency. Neighborhood walkability was not associated with sleep outcomes. We did not find a strong and consistent mediating role of physical activity. Interventions to improve sleep should target modifiable factors, including urban design and neighborhood disorder.

Sleep Health Education to Promote Public Health: Attitudes and Desired Learning Goals among Social Work Students

Social workers are often front line behavioral health providers for underserved populations, many of whom experience sleep disturbances. Inadequate sleep presents a public health challenge and is associated with many adverse physical health and mental health consequences. Social workers are uniquely positioned to promote sleep health among individuals experiencing health inequities. However, sleep is rarely included as part of the curricula in social work programs in the U.S. We conducted qualitative formative research to investigate social work students' perceptions of sleep education and desired sleep learning objectives. Twenty-five social work students were recruited via a listserv e-mail to participate in one of three focus groups. Participants believed sleep education could be beneficial in promoting client health and well-being. Desired learning goals included: (1) the importance of sleep; (2) identify symptoms of sleep deprivation and sleep disorders; (3) environmental and lifestyle factors that impact sleep; (4) behaviors to promote optimal sleep; and (5) sleep health as it relates to special populations (e.g., homelessness, substance using). Social work students expressed a desire to aquire knowledge on sleep health promotion as part of the social work curricula. Sleep education could be of considerable relevance to social work students, practitioners, and the clients they serve.

Objective and Subjective Neighborhood Crime Associated with Poor Sleep among Young Sexual Minority Men: a GPS Study

Sleep disparities in sexual minority male (SMM) populations have received relatively little attention but they may be critical to explaining other health disparities seen among SMM, via neural or hormonal pathways. Recent research suggests that crime may be a psychosocial stressor that contributes to sleep disparities but that finding has been based on subjective measures of crime. We conducted the P18 Neighborhood Study of 250 SMM in New York City, including 211 with adequate GPS tracking data. We used the GPS tracking data to define daily path area activity spaces and tested the associations of violent crime in those activity spaces and in the subject's residential neighborhood, perceived neighborhood safety, and witnessing crime with a subjective measure of sleep. Using quasi-Poisson regression, adjusted for individual and neighborhood socio-demographics, we found that SMM who witnessed more types of crime experienced significantly more nights of poor sleep over the course of a month (RR: 1.16, 95%CI: 1.05-1.27, p-value: < 0.01). We did not find any associations between violent crime rates in either the activity area or residential area and sleep. Our findings support the conclusion that personal exposure to crime is associated with sleep problems and provide further evidence for the pathway between stress and sleep. The lack of association between neighborhood crime levels and sleep suggests that there must be personal experience with crime and ambient presence is insufficient to produce an effect.

Multidimensional Environmental Factors and Sleep Health for Aging Adults: A Focused Narrative Review

The timing, amount, and quality of sleep are critical for an individual's health and quality of life. This paper provides a focused narrative review of the existing literature around multidimensional environments and sleep health for aging adults. Five electronic databases, Scopus, Web of Science, PubMed/Medline; EBSCOhost, PsycINFO (ProQuest), and Google Scholar yielded 54,502 total records. After removing duplicates, non-peer reviewed academic articles, and nonrelevant articles, 70 were included for review. We were able to categorize environmental factors into housing security, home environment, and neighborhood environment, and, within each environmental category, specific elements/aspects are discussed. This paper provides a comprehensive map connecting identified levels of influence (individual, home/house, and neighborhood-level) in which subfactors are listed under each level of influence/category with the related literature list. Our review highlights that multidimensional environmental factors can affect aging adults' sleep health and eventually their physical, mental, and cognitive health and that sleep disparities exist in racial minorities in socioeconomically disadvantaged communities in which cumulative environmental stressors coexist. Based on this focused narrative review on the multidimensional sleep environments for aging adults, knowledge gaps are identified, and future research directions are suggested.

Longitudinal neighbourhood determinants with cognitive health and dementia disparities: protocol of the Multi-Ethnic Study of Atherosclerosis Neighborhoods and Aging prospective cohort study

INTRODUCTION

The burden of Alzheimer's disease (AD) and AD-related dementias (ADRD) is increasing nationally and globally, with disproportionate impacts on lower-income, lower education and systematically marginalised older adults. Presence of inequalities in neighbourhood factors (eg, social context, physical and built environments) may affect risk of cognitive decline and be key for intervening on AD/ADRD disparities at the population level. However, existing studies are limited by a dearth of longitudinal, detailed neighbourhood measures linked to rich, prospective cohort data. Our main objective is to identify patterns of neighbourhood change related to prevalence of-and disparities in-cognitive decline and dementia.

METHODS AND ANALYSES

We describe the process of collecting, processing and linking extensive neighbourhood data to the Multi-Ethnic Study of Atherosclerosis (MESA), creating a 25+ years dataset. Within the MESA parent study, the MESA Neighborhoods and Aging cohort study will characterise dynamic, longitudinal neighbourhood social and built environment variables relevant to cognition for residential addresses of MESA participants. This includes administering new surveys, expanding residential address histories, calculating new measures derived from spatial data and implementing novel deep learning algorithms on street-level imagery. Applying novel statistical techniques, we will examine associations of neighbourhood environmental characteristics with cognition and clinically relevant AD/ADRD outcomes. We will investigate determinants of disparities in outcomes by socioeconomic position and race/ethnicity and assess the contribution of neighbourhood environments to these disparities. This project will provide new evidence about pathways between neighbourhood environments and cognitive outcomes, with implications for policies to support healthy ageing.

ETHICS AND DISSEMINATION

This project was approved by the University of Washington and Drexel University Institutional Review Boards (protocols #00009029 and #00014523, and #180900605). Data will be distributed through the MESA Coordinating Center. Findings will be disseminated in peer-reviewed scientific journals, briefs, presentations and on the participant website.

Street-view greenspace exposure and objective sleep characteristics among children

Greenspace may benefit sleep by enhancing physical activity, reducing stress or air pollution exposure. Studies on greenspace and children's sleep are limited, and most use satellite-derived measures that do not capture ground-level exposures that may be important for sleep. We examined associations of street view imagery (SVI)-based greenspace with sleep in Project Viva, a Massachusetts pre-birth cohort. We used deep learning algorithms to derive novel metrics of greenspace (e.g., %trees, %grass) from SVI within 250m of participant residential addresses during 2007-2010 (mid-childhood, mean age 7.9 years) and 2012-2016 (early adolescence, 13.2y) (N = 533). In early adolescence, participants completed >5 days of wrist actigraphy. Sleep duration, efficiency, and time awake after sleep onset (WASO) were derived from actigraph data. We used linear regression to examine cross-sectional and prospective associations of mid-childhood and early adolescence greenspace exposure with early adolescence sleep, adjusting for confounders. We compared associations with satellite-based greenspace (Normalized Difference Vegetation Index, NDVI). In unadjusted models, mid-childhood SVI-based total greenspace and %trees (per interquartile range) were associated with longer sleep duration at early adolescence (9.4 min/day; 95%CI:3.2,15.7; 8.1; 95%CI:1.7,14.6 respectively). However, in fully adjusted models, only the association between %grass at mid-childhood and WASO was observed (4.1; 95%CI:0.2,7.9). No associations were observed between greenspace and sleep efficiency, nor in cross-sectional early adolescence models. The association between greenspace and sleep differed by racial and socioeconomic subgroups. For example, among Black participants, higher NDVI was associated with better sleep, in neighborhoods with low socio-economic status (SES), higher %grass was associated with worse sleep, and in neighborhoods with high SES, higher total greenspace and %grass were associated with better sleep time. SVI metrics may have the potential to identify specific features of greenspace that affect sleep.

Neighborhoods and sleep health among adults: A systematic review

OBJECTIVE

Sleep is an important determinant of various health outcomes, and insufficient sleep and sleep disorders are a public health crisis in the United States. The objective of this review is to provide an update on scientific contributions to our understanding of the social/built environmental determinants of sleep health. In particular, this review focuses on the diverse measurements of neighborhood characteristics and sleep outcomes, as well as analytic approaches for quantifying the effect of neighborhood on sleep health.

METHODS

Two major electronic databases were searched and reviewed for relevant articles that examined the associations of social/built environments with sleep health. Inclusion criteria included peer-reviewed empirical studies on neighborhood-level characteristics and sleep health among adult populations.

RESULTS

Systematic searches in MEDLINE/PubMed and SCOPUS identified 52 eligible articles (out of 11,084). Various social/built environmental characteristics of neighborhoods were identified as potential determinants of sleep health, and the majority of studies examined neighborhood social capital, safety, and environmental stressors. However, 88% of included articles employed cross-sectional study designs, limiting causal identification. We found substantial differences in neighborhood measures, variations in sleep health measurements with the majority employing self-reported methods, and inconsistent model specifications. While the majority of articles (48%) utilized perceived neighborhood conditions as the main exposure, more recent studies (23%) employed geographic information systems to measure neighborhood characteristics.

CONCLUSIONS

To establish the causal relationships between social/physical neighborhood characteristics and sleep health, more studies should be conducted with longitudinal, quasi-experimental, and randomized trial designs coupled with objectively measured neighborhood and sleep health parameters.

Mediating role of psychological distress in the associations between neighborhood social environments and sleep health

STUDY OBJECTIVES

The characteristics of neighborhood social environments, such as safety and social cohesion, have been examined as determinants of poor sleep. The current study investigates associations between neighborhood social characteristics and sleep health, as well as the mediating role of psychological distress on these possible associations.

METHODS

Three waves of PHRESH Zzz (n = 2699), a longitudinal study conducted in two low-income, predominately Black neighborhoods, were utilized for this analysis. The characteristics of neighborhood social environments were measured using crime rates, a neighborhood social disorder index, and self-reported social cohesion. Sleep health was measured via 7 days of wrist-worn actigraphy as insufficient sleep, sleep duration, wake after sleep onset (WASO), and sleep efficiency. G-estimations based on structural nested mean models and mediation analyses were performed to estimate the effects of neighborhood social environments on sleep as well as direct/indirect effects through psychological distress.

RESULTS

Crime rate around residential addresses was associated with increased risk of insufficient sleep (risk ratio: 1.05 [1.02, 1.12]), increased WASO (β: 3.73 [0.26, 6.04]), and decreased sleep efficiency (β: -0.54 [-0.91, -0.09]). Perceived social cohesion was associated with decreased risk of insufficient sleep (OR: 0.93 [0.88, 0.97]). Psychological distress mediated part of the associations of crime and social cohesion with insufficient sleep.

CONCLUSIONS

Neighborhood social environments may contribute to poor sleep health in low-income, predominantly Black neighborhoods, and psychological distress can be a salient pathway linking these neighborhood characteristics and sleep health.

Racial and ethnic disparities in cardiometabolic disease and COVID-19 outcomes in White, Black/African American, and Latinx populations: Social determinants of health

Racial and ethnic-related health disparities in the United States have been intensified by the greater burden of Coronavirus Disease 2019 (COVID-19) in racial and ethnic minority populations. Compared to non-Hispanic White individuals, non-Hispanic Black and Hispanic/Latinx individuals infected by COVID-19 are at greater risk for hospitalization, intensive care unit admission, and death. There are several factors that may contribute to disparities in COVID-19-related severity and outcomes in these minority populations, including the greater burden of cardiovascular and metabolic diseases as discussed in our companion review article. Social determinants of health are a critical, yet often overlooked, contributor to racial and ethnic-related health disparities in non-Hispanic Black and Hispanic/Latinx individuals relative to non-Hispanic White individuals. Thus, the purpose of this review is to focus on the essential role of social factors in contributing to health disparities in chronic diseases and COVID-19 outcomes in minority populations. Herein, we begin by focusing on structural racism as a social determinant of health at the societal level that contributes to health disparities through downstream social level (e.g., occupation and residential conditions) and individual level health behaviors (e.g., nutrition, physical activity, and sleep). Lastly, we conclude with a discussion of practical applications and recommendations for future research and public health efforts that seek to reduce health disparities and overall disease burden.

Neighborhood Disadvantage Is Associated with Lower Quality Sleep and More Variability in Sleep Duration among Urban Adolescents

Differential social and contextual environments may contribute to adolescent sleep disparities, yet most prior studies are limited to self-reported sleep data and have not been conducted at a national level, limiting the variation in neighborhood contexts. This study examined the association between neighborhood disadvantage and objective measures of adolescent sleep. A racially and geographically diverse sample of American adolescents (N = 682) wore wrist-worn accelerometers, "actigraphs," for ≥ 5 nights. Neighborhood disadvantage was calculated using a standardized index of neighborhood characteristics (proportion of female-headed households, public assistance recipients, households in poverty, adults without high school degrees, and unemployed). Adolescents in more disadvantaged neighborhoods spent more time awake after falling asleep (4.0 min/night, p < .05), a greater percentage of nighttime sleep intervals awake (1%, p < .01), and had less consistent sleep duration (11.6% higher standard deviation, p < .05). Sleep duration and timing did not differ across neighborhood groups. These findings demonstrate that adolescents who live in more disadvantaged neighborhoods have lower quality, less consistent sleep.

Sleep in times of crises: A scoping review in the early days of the COVID-19 crisis

During the early days of the pandemic and in the context of a seemingly unknown global threat, several potential major sleep disruptors were identified by sleep researchers and practitioners across the globe. The COVID-19 pandemic combined several features that, individually, had been shown to negatively affect sleep health in the general population. Those features included state of crisis, restrictions on in-person social interactions, as well as financial adversity. To address the lack of a comprehensive summary of sleep research across these three distinctive domains, we undertook three parallel systematic reviews based on the following themes: 1) Sleep in times of crises; 2) Sleep and social isolation; and 3) Sleep and economic uncertainty. Using a scoping review framework, we systematically identified and summarized findings from these three separated bodies of works. Potential moderating factors such as age, sex, ethnicity, socioeconomic status, psychological predisposition, occupation and other personal circumstances are also discussed. To conclude, we propose novel lines of research necessary to alleviate the short- and long-term impacts of the COVID-19 crises and highlight the need to prepare the deployment of sleep solutions in future crises.

False beliefs about sleep and their associations with sleep-related behavior

OBJECTIVES

Understanding the association between sleep-related beliefs and behaviors may be useful in improving sleep health in the general population. This study examines false beliefs about sleep and their associations with self-reported sleep and related behaviors.

METHODS

Respondents in an online survey indicated the degree to which they agreed with 20 statements previously identified as sleep myths by experts in the field. A total sleep myths score was calculated for each participant, with higher scores reflecting greater false beliefs. Sociodemographic factors, behaviors, and knowledge related to sleep were also assessed.

RESULTS

Total sample size was 1120 adults residing in the United States (51.5% female; M age = 47.22). Overall, belief in sleep myths was relatively common, with 10 of 20 false statements endorsed by at least 50% of the sample. Sleep myth scores varied by sociodemographic factors, including age, gender, socioeconomic indicators, and region of residence. Higher sleep myth scores were associated with greater inconsistency in bedtimes (odds ratio: 1.07 [1.04-1.09]), more frequent napping (odds ratio: 1.11 [1.09-1.14]), more in-bed activities (β = 0.35, p < .001), engaging in behaviors incompatible with sleep hygiene recommendations (β = 0.24, p < .001), and perceiving fewer consequences of insufficient sleep (β = -0.13, p < .001). Those endorsing more myths reported shorter sleep on non-worknights (β = -0.09, p = .01) but not on worknights.

CONCLUSIONS

Belief in sleep myths is related to sleep health behavior and may be a modifiable target for intervention.

Racial Differences in Functional and Sleep Outcomes with Positive Airway Pressure Treatment

It is unclear if the response to positive airway pressure (PAP) treatment is different between African American (AA) and European Americans (EA). We examined whether race modifies the effects of PAP on sleep and daytime function. We assessed Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire, Psychomotor Vigilance Task and actigraphy in 185 participants with moderate-to-severe obstructive sleep apnea before and 3–4 months after PAP treatment. The participants were middle-aged (mean, 55.1 years), 83.8% men and 60.5% AA. Linear regression models were used to examine the effect of race on outcomes. The AA had smaller reductions in ESS (mean change (95% confidence interval, CI) AA, −2.30 [−3.35, −1.25] vs. EA, −4.16 [−5.48, −2.84] and frequency of awakenings (AA, −0.73 [−4.92, 3.47] vs. EA, −9.35 [−15.20, −3.51]). A race × PAP usage interaction term was added to the model to examine if the change in outcomes per 1 h increase in PAP usage differed by race. AA exhibited greater improvement in wake after sleep onset (β (95% CI) AA, −8.89 [−16.40, −1.37] vs. EA, 2.49 [−4.15, 9.12]) and frequency of awakening (β (95% CI) AA, −2.59 [−4.44, −0.75] vs. EA, 1.71 [−1.08, 4.50]). The results indicate the importance of race in evaluating outcomes following PAP treatment.

Perceived home sleep environment: associations of household-level factors and in-bed behaviors with actigraphy-based sleep duration and continuity in the Jackson Heart Sleep Study

STUDY OBJECTIVES

In an older African-American sample (n = 231) we tested associations of the household environment and in-bed behaviors with sleep duration, efficiency, and wakefulness after sleep onset (WASO).

METHODS

Older adult participants completed a household-level sleep environment questionnaire, a sleep questionnaire, and underwent 7-day wrist actigraphy for objective measures of sleep. Perceived household environment (self-reported) was evaluated using questions regarding safety, physical comfort, temperature, noise, and light disturbances. In-bed behaviors included watching television, listening to radio/music, use of computer/tablet/phone, playing video games, reading books, and eating. To estimate the combined effect of the components in each domain (perceived household environment and in-bed behaviors), we calculated and standardized a weighted score per sleep outcome (e.g. duration, efficiency, WASO), with a higher score indicating worse conditions. The weights were derived from the coefficients of each component estimated from linear regression models predicting each sleep outcome while adjusting for covariates.

RESULTS

A standard deviation increase in an adverse household environment score was associated with lower self-reported sleep duration (β = -13.9 min, 95% confidence interval: -26.1, -1.7) and actigraphy-based sleep efficiency (β = -0.7%, -1.4, 0.0). A standard deviation increase in the in-bed behaviors score was associated with lower actigraphy-based sleep duration (β = -9.7 min, -18.0, -1.3), sleep efficiency (β = -1.2%, -1.9, -0.6), and higher WASO (5.3 min, 2.1, 8.6).

CONCLUSION

Intervening on the sleep environment, including healthy sleep practices, may improve sleep duration and continuity among African-Americans.

The association between neighborhood social cohesion and sleep duration in Latinos

OBJECTIVES

To examine the association between neighborhood social cohesion and sleep duration among Latinos, and whether this association varies by Latino subgroup.

DESIGN

We used cross-sectional data from the 2013-2015 National Health Interview Survey (NHIS) on 13,537 Latino adults aged ≥18 years originating from 5 countries/regions (i.e. Latinos of Mexican/Mexican-American, Puerto Rican, Dominican, Central or South American, and Cuban/Cuban-American origin). Multivariate logistic regression models were used to estimate the associations between neighborhood social cohesion and sleep duration, and whether associations varied by Latino subgroup.

RESULTS

Among Mexicans/Mexican-Americans, medium and high levels of neighborhood social cohesion were associated with normal sleep duration, relative to short sleep duration (Odds Ratio [OR]: 1.31; 95% Confidence Interval [CI]: 1.08-1.57, and OR: 1.46; 95% CI: 1.26-1.69, respectively). Among Puerto Ricans, Cubans/Cuban Americans, and Central or South Americans, high neighborhood social cohesion was significantly associated with normal sleep duration (OR: 1.53; 95% Confidence Interval [CI]: 1.10-2.11, OR: 1.94; 95% CI: 1.10-3.42, and OR: 1.78; 95% CI: 1.35-2.34, respectively).

CONCLUSIONS

The variation in the contribution of neighborhood social cohesion to sleep duration by Latino subgroup should be considered in health promotion programs aimed at improving sleep among Latinos.

Racial-ethnic Differences in Actigraphy, Questionnaire, and Polysomnography Indicators of Healthy Sleep: The Multi-Ethnic Study of Atherosclerosis

A paradigm shift in sleep science argues for a systematic, multidimensional approach to investigate sleep's association with disease and mortality and to address sleep disparities. We utilized the comprehensive sleep assessment of the Multi-Ethnic Study of Atherosclerosis (2010- 2013), a cohort of U.S. White, Black, Chinese, and Hispanic adults and older adults (n=1,736; mean age=68.3), to draw 13 sleep dimensions and create composite Sleep Health Scores to quantify multidimensional sleep health disparities. After age and sex adjustment in linear regression, compared to White participants, Black participants showed the greatest global sleep disparity, then Hispanic and Chinese participants. We estimated relative 'risk' of obtaining favorable sleep compared to White adults at the component level by race/ethnicity (lower is worse). The largest disparities were in objectively-measured sleep timing regularity (RRBlack [95% CI]: 0.37 [0.29,0.47], RRHispanic: 0.64 [0.52,0.78], RRChinese: 0.70 [0.54,0.90]) and duration regularity (RRBlack: 0.55 [0.47,0.65], RRHispanic: 0.76 [0.66,0.88], RRChinese: 0.74 [0.61,0.90]), after sex and age adjustment. Disparities in duration and continuity were also apparent, and Black adults were additionally disadvantaged in %N3 (slow wave sleep), sleepiness, and sleep timing (24-hour placement). Sleep timing regularity, duration regularity, duration, and continuity may comprise a multidimensional cluster of targets to reduce racial-ethnic sleep disparities.

Associations of the residential built environment with adolescent sleep outcomes

STUDY OBJECTIVES

Over 75% of US high school students obtain insufficient sleep, placing them at risk for adverse health outcomes. Identification of modifiable determinants of adolescent sleep is needed to inform prevention strategies, yet little is known about the influence of the built environment on adolescent sleep.

METHODS

In this prospective study, actigraphy was used to assess sleep outcomes among 110 adolescents for 14 days each in eighth and ninth grades: duration (hours/night), onset and offset, and sleeping ≥8 hours. Home addresses were linked to built environment exposures: sound levels, tree canopy cover, street density, intersection density, population density, and housing density. Mixed-effects regression estimated associations of built environment measures with sleep outcomes, adjusting for sex, race, parent education, household income, household size, grade, weeknight status, and neighborhood poverty.

RESULTS

A 1-standard deviation (SD) increase in neighborhood sound was associated with 16 minutes later sleep onset (β = 0.28; 95% confidence interval (CI): 0.06, 0.49) and 25% lower odds of sleeping for ≥8 hours (odds ratio (OR) = 0.75, 95% CI: 0.59, 0.96). A 1-SD increase in neighborhood tree canopy was associated with 18 minutes earlier sleep onset (β = -0.31, 95% CI: -0.49, -0.13) and 10 minutes earlier sleep offset (β= -0.17, 95% CI: -0.28, -0.05). No associations were observed for density-based exposures.

CONCLUSIONS

Higher neighborhood sound level was associated with lower odds of sufficient sleep, while higher tree canopy cover was associated with more favorable sleep timing. Neighborhood sound levels and tree canopy cover are potential targets for policies and interventions to support healthier sleep among adolescents.

Does investing in low-income urban neighborhoods improve sleep?

STUDY OBJECTIVES

Neighborhood disadvantage is associated with poor sleep, which may contribute to and exacerbate racial and socioeconomic health disparities. Most prior work has been cross-sectional and thus it has not been possible to estimate causal effects.

METHODS

We leveraged a natural experiment opportunity in two low-income, predominantly African American Pittsburgh, PA neighborhoods, following a randomly selected cohort of households (n = 676) between 2013 and 2016. One of the neighborhoods received substantial public and private investments (housing, commercial) over the study period, while the other socio-demographically similar neighborhood received far fewer investments. Primary analyses used a difference-in-difference analysis based on neighborhood, to examine changes in actigraphy-assessed sleep duration, efficiency, and wakefulness after sleep onset (WASO), and self-reported sleep quality. Secondary analyses examined whether residents' proximity to investments, regardless of neighborhood, was associated with changes in sleep outcomes.

RESULTS

Resident sleep worsened over time in both neighborhoods with no significant differences among residents between the two neighborhoods. Secondary analyses, including covariate adjustment and propensity score weighting to improve comparability, indicated that regardless of neighborhood, those who lived in closer proximity to investments (<0.1 mile) were significantly less likely to experience decreases in sleep duration, efficiency, and quality, or increases in WASO, compared to those who lived farther away.

CONCLUSIONS

While we did not observe sleep differences among residents between neighborhoods, living closer to a neighborhood investment was associated with better sleep outcomes. Findings have relevance for public health and policy efforts focused on investing in historically disinvested neighborhoods.

Associations of insomnia with noise annoyance and neighborhood environments: A nationwide cross-sectional study in Japan

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Data on the association between insomnia and neighborhood noise are lacking.

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Insomnia is associated with noise annoyance from the neighborhood.

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Neighborhood noise should be considered in health and urban policy planning.

Despite the increasing knowledge on the association between neighborhood and health, few studies have investigated sleep disorders in Japan, particularly the impact of neighborhood noise on sleep. Thus, this study aimed to investigate the associations between insomnia symptoms and annoyance because of traffic and neighborhood noise in Japan, which has different neighborhood conditions compared with those of the western societies. Neighborhood built and socioeconomic environments roles were also examined. We used nationwide cross-sectional data collected through a 2015 online survey of Japanese adults aged 20–64 years (n = 4,243). Adjusted prevalence ratios for insomnia according to the exposures were estimated using the multilevel Poisson regression models. The results showed that having insomnia was significantly associated with experiencing neighborhood and traffic-noise annoyance. Neighborhood noise had a stronger and independent association with insomnia. However, the neighborhood environmental variables, including population density, deprivation index, and access to commercial areas, were not associated with insomnia. In conclusion, noise annoyance, particularly that sourced from neighbors, is an important factor in relation to sleep health. Health and urban-planning policymakers should consider neighborhood noise, in addition to traffic noise, as health-related issues in residential neighborhoods.

Greenspace redevelopment, pressure of displacement, and sleep quality among Black adults in Southwest Atlanta

BACKGROUND

Little is known on how greenspace redevelopment-creating or improving existing parks and trails-targeted for low-income and/or majority Black neighborhoods could amplify existing social environmental stressors, increase residents' susceptibility to displacement, and impact their sleep quality.

OBJECTIVE

To examine the relationship between social environmental stressors associated with displacement and sleep quality among Black adults.

METHODS

Linear regression models were employed on survey data to investigate the association between social environmental stressors, independently and combined, on sleep quality among Black adults residing in block groups targeted for greenspace redevelopment (i.e., exposed) and matched with block groups that were not (i.e., unexposed).

RESULTS

The independent associations between everyday discrimination, heightened vigilance, housing unaffordability, and subjective sleep quality were not modified by greenspace redevelopment, controlling for other factors. The association between financial strain and subjective sleep quality was different for exposed and unexposed participants with exposed participants having a poorer sleep quality. The combined model revealed that the association between financial strain and sleep quality persisted. However, for different financial strain categories exposed participants slept poorer and/or better than unexposed participants.

SIGNIFICANCE

Our findings suggest a nuanced relationship between social environmental stressors, pressure of displacement related to greenspace redevelopment, and sleep quality among Black adults.

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.

Examining Sleep Disturbance Among Sheltered and Unsheltered Transition Age Youth Experiencing Homelessness

BACKGROUND

The estimated 3.5-million transition age youth (TAY) who experience homelessness in the United States annually are routinely exposed to inadequate sleep environments and other psychosocial risk factors for deficient sleep. Although staying in a shelter versus being unsheltered may facilitate sleep, research suggests that perceived safety wherever one sleeps may be just as important. In this study, which is the first known study to investigate sleep disturbances among TAY experiencing homelessness, we examine associations of sleep disturbances with sheltered status and perceived safety of usual sleep environment.

METHODS

We surveyed TAY (aged 18-25) experiencing homelessness in Los Angeles, CA about their sleep, psychosocial health, and living situations. Participants (n=103; 60% sheltered) self-reported sleep disturbances using the Patient-Reported Outcomes Measurement Information System Sleep Disturbance short form, while individual items assessed sheltered status and perceived safety where they usually slept. Regression analyses examined associations of sheltered status and perceived sleep environment safety with sleep disturbance, adjusting for age, sex, race, self-rated health, depression symptoms, serious mental illness, high-risk drinking, and severe food insecurity.

RESULTS

Twenty-six percent of participants reported moderate-severe sleep disturbances. Sleep disturbance was not associated with sheltered status, but was positively associated with feeling unsafe in one's sleep environment, depression symptoms, severe food insecurity, and decreased age.

CONCLUSIONS

Our findings suggest that sleep disturbances among TAY experiencing homelessness are associated more closely with how safe one feels rather than one's sheltered status. This highlights the importance of providing safe places to live for sheltered and unsheltered TAY.

Racial disparities in sleep health between Black and White young adults: The role of neighborhood safety in childhood

OBJECTIVES

Black adults in the United States have shorter sleep durations and poorer sleep efficiency relative to White adults, yet reasons for these disparities are not well explicated. The objective of this study was to examine neighborhood safety in childhood as a mediator of subsequent racial disparities in sleep.

METHODS

Data were from Black and White young adults attending a large, predominantly White university in the Southeastern United States (N = 263; 52% Black, 53% female; Mean age = 19.21 years, SD = 1.01). Sleep parameters were assessed from eight nights of wrist actigraphy (time in bed, sleep duration, and efficiency) and an established self-report measure of daytime sleepiness. Residential histories from birth through age 18 were documented, and retrospective self-reports of neighborhood safety in childhood were assessed.

RESULTS

Black participants had less time in bed (p < 0.001), shorter sleep duration (p < 0.001), poorer sleep efficiency (p < 0.001), and more daytime sleepiness (p = 0.009) than White participants. Neighborhood safety mediated race differences in time in bed (p = 0.028), sleep duration (p = 0.033), and daytime sleepiness (p = 0.048), but not sleep efficiency. Findings were substantively unchanged after adjustment for family socioeconomic status, BMI, and substance use.

CONCLUSIONS

Findings support the hypothesis that neighborhood safety in childhood may partially account for race differences in subsequent sleep duration and daytime sleepiness. Addressing racial inequities in childhood neighborhood safety may be an important step toward reducing racial disparities in sleep health.

Association between perceived environmental pollution and poor sleep quality: results from nationwide general population sample of 162,797 people

OBJECTIVE/BACKGROUND

Perceived environmental pollution may play a significant role in understanding environmentally induced health-related symptoms. This study aimed to determine whether perceived environmental pollution is associated with poor sleep quality.

METHODS

We conducted a cross-sectional study using data from a nationwide sample of 162,797 individuals aged ≥19 years from the 2018 Korea Community Health Survey. The Pittsburgh Sleep Quality Index was used for assessing sleep quality. Five types of perceived environmental pollutants involving air, water, soil, noise, and green space were assessed. We investigate the association between perceived environmental pollution and poor sleep quality. We also investigated whether an increasing number of perceived environmental pollutants magnified the odds of poor sleep quality.

RESULTS

The prevalence of poor sleep quality was 42.7% (n = 69,554), and 15.6%, 10.1%, 11.9%, 23.0%, and 11.5% reported perceived environmental pollution concerning air, water, soil, noise, and green space, respectively. A perception of air, soil, or noise pollution was significantly associated with poor sleep quality. In addition, those perceiving a greater number of environmental pollutants had significantly higher odds of poor sleep quality. Notably, this association was magnified in individuals living in rural areas.

CONCLUSIONS

Perceived environmental pollution was significantly associated with poor sleep quality. Our results suggest that a more comprehensive exposure to environmental pollution may not only have a worse effect on health outcomes including sleep quality.

Vicarious Experience in Multi-Ethnic Study of Atherosclerosis (MESA) Is Associated with Greater Odds of Attaining the Recommended Leisure-Time Physical Activity Levels

BACKGROUND

Social cognitive theory posits that observing similar others succeed (i.e., vicarious experience) can improve self-efficacy. However, there are very limited data on the utility of vicarious experience in promoting physical activity (PA). This analysis examined the association between vicarious experience and leisure-time PA (LTPA) in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

Cross-sectional analysis of MESA participants who completed exam 5. LTPA and neighborhood factors were self-reported. Neighborhood factors were converted into aesthetic, walking, and safety scores. Group comparative analyses evaluated differences in variables of interest. The relationship between vicarious experience and recommended LTPA (≥ 7.5 MET-h/week) was assessed via logistic regression. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are reported.

RESULTS

Participants (N = 4579) were older (69.7 ± 9.4 years), 53% female, 41% Caucasian, 26% Black, 21% Hispanic, and 12% Chinese. Those who reported vicarious experience had 45% (95% CI 1.16-1.81) greater odds of attaining recommended LTPA. Unfavorable walking score was associated with lower odds of attaining recommended LTPA (OR = 0.89, 95% CI 0.79-1.00). The aesthetic and safety scales were not associated with LTPA (OR = 1.00 [95% CI 0.89-1.13] and OR = 0.91 [95% CI 0.82-1.10], respectively).

CONCLUSIONS

Programs exposing community-dwelling adults to peers engaging in PA could provide an effective public health approach to increase community-level PA participation.