Sleepless in COVID-19: racial disparities during the pandemic as a consequence of structural inequity

Philip Cheng, Melynda D Casement, Ruby Cuellar, Dayna A Johnson, David Kalmbach, Andrea Cuamatzi Castelan, Christopher L Drake, Philip Cheng, Melynda D Casement, Ruby Cuellar, Dayna A Johnson, David Kalmbach, Andrea Cuamatzi Castelan, Christopher L Drake

Abstract

Study objectives: Insomnia has been on the rise during the 2019 coronavirus disease (COVID-19) pandemic, which may disproportionately affect racial minorities. This study characterized racial disparities in insomnia during the pandemic and evaluated mechanisms for such disparities.

Methods: Participants included 196 adults (48 Black) from a 2016-2017 clinical trial of insomnia treatment who were reevaluated in April 2020. Race was evaluated as a predictor of change in insomnia, impact of COVID-19, and COVID-19 stress. Mediation models using the PRODCLIN method evaluated the extent to which: (1) COVID-19 impact accounted for Black-White disparities in change in insomnia, and (2) COVID-19 stress accounted for associations between discrimination and change in insomnia.

Results: Increases in insomnia symptoms during COVID-19 were greater in Black compared to White participants, with 4.3 times the odds of severe insomnia (Insomnia Severity Index ≥ 22). Symptom severity was associated with pre-pandemic experiences of discrimination. Black participants were also disproportionately impacted by COVID-19, with twice the odds of irreparable loss of income/employment and four times the rate of COVID-19 diagnoses in their sociofamilial network compared to White participants. The disproportionate impact of COVID-19 accounted for 69.2% of the relationship between race and change in insomnia severity, and COVID-19 related stress accounted for 66.5% of the relationship between prior history of racial discrimination and change in insomnia severity.

Conclusions: Black-White disparities in insomnia severity during COVID-19 may be driven by structural inequities resulting in the disproportionate impact of COVID-19 on Black Americans. Results lend support for the minority stress model in the context of sleep health.

Clinical trial registration: Sleep to Prevent Evolving Affecting Disorders (SPREAD). NCT number: NCT02988375. https://ichgcp.net/clinical-trials-registry/NCT02988375.

Keywords: COVID-19; discrimination; health disparities; insomnia; minority stress.

© Sleep Research Society 2021. Published by Oxford University Press on behalf of the Sleep Research Society.

Figures

Figure 1.
Figure 1.
Schematic of the mediation analyses. All analyses adjusted for treatment condition, sex, and household income as covariates. Pre-COVID-19 insomnia severity was subtracted from COVID-19 era insomnia severity to better approximate insomnia associated with the COVID-19 pandemic. Parameter estimates are included for the pathways. *p < .05.

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