Short sleep duration and interest in sleep improvement in a multi-ethnic cohort of diverse women participating in a community-based wellness intervention: an unmet need for improvement | BMC Women’s Health

Participants and procedure

This is a secondary analysis of baseline data from the Coalition for a Healthier Community for Utah Women and Girls (UWAG) study, a CBPR-facilitated randomized behavioral trial assessing the effectiveness of a 12-month wellness coaching intervention on women’s physical activity levels and dietary habits [23] among five communities of color in Salt Lake City: Black/African Americans, Central African Immigrants/Refugees, Hispanics/Latinos, Native Americans/Alaska Natives (AI/AN) and Native Hawaiians/Pacific Islanders (NHPI). Most of the Central African Immigrants/Refugees arrived in the U.S. with official refugee status but consider themselves to be immigrants and prefer this terminology, thus we utilize the terms Immigrants/Refugees to refer to this group. Detailed information about UWAG study methods and the cost-effectiveness of the intervention have been published previously [23,24,25]. The UWAG study was planned and carried out in partnership with Community Faces of Utah (CFU), a coalition of leaders of the five diverse communities listed above; Utah Department of Health staff; and researchers from the University of Utah who collaborate in conducting multi-cultural, community-engaged research. With a shared commitment to CBPR, the Coalition conducted a needs assessment to identify priority issues, collaboratively identified an intervention, designed a clinical trial, trained CHWs from each community known as wellness coaches, conducted the trial, and contributed to data analysis and interpretation. Dissemination of study findings also follows a CBPR approach, with participation from community members throughout the process.

The women who participated in the UWAG study were recruited from the five CFU communities by CHWs. The study was described to potential participants as a trial of a wellness coaching intervention designed to address behaviors associated with obesity and chronic disease. Inclusion criteria for the study were: self-identification as a woman; self-identification as a member of one of the 5 target communities; age 18 or older; not currently participating in a wellness coaching program; fluent in English, Spanish, or Kirundi; willing to be randomized; willing to be followed for 12 months; and willing to complete interviews and have health data collected at baseline, 4, 8, and 12 months. We excluded individuals who were less than 18 years of age; currently participating in a wellness coaching program; were not fluent in English, Spanish, or Kirundi; were unwilling to be randomized; were unwilling to be followed for 12-months; or who were unwilling to participate in interviews and health data collection.

During the intervention, participants worked with a CHW from their own community to assess their health behaviors and set goals for health behavior changes over 12 months within a culturally tailored motivational interviewing framework. Wellness coaching occurred at baseline, 4-months, 8-months, and 12-months. This study utilizes secondary data analysis of baseline data. Focus areas of wellness coaching included healthy eating, physical activity, sleep duration, smoking cessation, hypertension, obesity, and mental health. Participants were encouraged to set a goal related to healthy eating/physical activity and were then invited to set a goal for another area of their choice. The study was designed to compare a low-intensity wellness coaching program (4 coaching sessions over 1 year) with a high-intensity program (monthly coaching over 1 year plus monthly group activities). Data on self-reported average hours of sleep were collected during each woman’s initial baseline interview with her coach, and her interest in improving her sleep was documented during the coaching sessions.

All data used in the current analysis were collected at baseline and recorded in a REDCap database during the interview. Black/African American, NHPI, and AI/AN women were interviewed in English. Hispanic/Latina women had the option of either English or Spanish interviews, and African Immigrant/Refugee women were interviewed in English or Kirundi. Following the baseline interview, blood pressure and anthropometric measurements were taken, including height, weight (using an appropriately zeroed analogue scale), waist circumference, and hip circumference. After these measurements were taken, each participant received wellness coaching. Coaching sessions were in person and lasted 25 min on average. Each coaching session included a review of the woman’s self-reported health data and whether she was meeting health recommendations for fruit/vegetable servings per day, weekly minutes of physical activity, BMI, and hours of sleep per night. Recommendations for each of these areas were shared. Women reporting < 7 h of sleep were educated about the relationship between short sleep and heart disease, diabetes, depression, and obesity. The coaching session also included a review of each woman’s depressions screening score and self-reported stress management score, measured using the wellness wheel described below. Participants were then prompted to set no more than 3 goals based on the information they had just received about their health, with a primary goal targeting healthy eating or physical activity (study’s primary outcomes) and additional goals, if desired, on any topic of interest.

All study procedures were approved by the University of Utah Institutional Review Board (IRB_00055195) and the Phoenix Area Indian Health Service Institutional Review Board. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This trial was also registered with clinical trials.gov (#NCT02470156). Written informed consent was obtained from all participants.

Measures

Sleep

During the baseline interview, participants were asked, “On average, about how many hours do you sleep each night? (If respondent works a night shift, ask how many hours she sleeps during the day).” The data were recorded as discrete numbers and transformed into a dichotomous variable of (a) < 7 h and (b) 7 h or more.

Interest in sleep improvement

For the purpose of this study, interest in sleep improvement was defined as a participant setting a specific sleep-focused goal or identifying sleep as a focus area of improvement during the coaching session. The data come from text notes written by the wellness coaches, including notes describing specific goals and notes describing focus areas of interest.

Covariates, stress, and health behavior variables

Education and employment status were self-reported. Poverty status was calculated by comparing self-reported monthly income to the Federal Poverty Line (FPL) by year of survey and family size. Depression was measured using the Patient Health Questionnaire-2 (PHQ-2) [26], with scores greater than 3 out of 6 indicating a positive depression screen. Stress management scores and sleep wellness scores were measured using a wellness wheel with 4 dimensions of health (physical activity behaviors, eating behaviors, sleeping behaviors, and stress management behaviors) where participants were asked to identify their current health behaviors using a 0–10 scale. Higher scores indicate higher levels of stress management and higher levels of sleep wellness. Body mass index (BMI) was objectively measured by health coaches and calculated based on body weight (kg) / height (cm)² with overweight ≥ 26 for NHPI and ≥ 25 for others [27, 28]. Fruit and vegetable intake questions were based on the Behavioral Risk Factor Surveillance System questions [29] (i.e., number of times 100% fruit juice, fruit, beans (legumes), dark green vegetables, orange vegetables, and other vegetables were consumed over the past month) and were stratified into 5 or more vs. less than 5 [30]. Physical activity was assessed with the following question, “In an average week, how much time do you spend being physically active or doing exercise?” [31]. The data were stratified into those engaging in the recommended 150 min per week or more vs. those engaging in less than 150 min per week [32].

Data analysis

We first conducted analyses comparing the demographic and clinical factors with the self-report of < 7 h of sleep and interest in improving sleep using Chi-square test or Fisher’s Exact test (when expected cell counts were < 5). Next, we used logistic regression models to examine predictors of sleep duration and interest in sleep interventions, to understand the role of mental health and physical comorbidities, which have a bidirectional association with sleep duration. For sleep duration, we conducted 2 separate models: 1) demographic variables and BMI and 2) added comorbidities, stress management score, and health behavior variables to the variables included in model 1. A series of logistic regression models were also used to evaluate predictors of interest in improving sleep during wellness coaching and covariates of interest. Model 1 included demographic variables and BMI and model 2 added sleep duration and self-assessed sleep wellness. When comparing communities, Hispanic/Latina participants were used as the comparison group as this was the largest group included in the study. Individuals with missing data on one or more variables were excluded from the respective multivariable model; data were missing for 0-7% of respondents, depending on the specific variable.

Community-academic research team data review and interpretation process

As part of our CBPR process, the academic researchers analyzed the data and shared the findings with the community members on the research team. The entire team discussed how to interpret the data and foci for the discussion, with an emphasis on insights shared by community members [33] on the team. Additionally, study CHWs were asked to share their experiences working with women during the study, and their insights are included in the study results.