Background: Obesity is a substantial problem in all areas of the U.S., but it is especially prevalent in the South. Of the seven states with 35% obesity or higher in the adult population, five are in the South (Robert Wood Johnson Foundation, 2018a). Even more alarming, nine of the ten states with the highest rates of childhood obesity in the nation are in the South (Robert Wood Johnson Foundation, 2018b).
Children who have obesity have a lower health-related quality of life and make increased visits to healthcare providers (Paulis et al., 2017). Having obesity during childhood increases the likelihood that an individual will have obesity as an adult (Malhotra, Ostbye, Riley, & Finkelstein, 2013), escalating the chances of diabetes, hypertension, stroke, and cardiovascular disease at an earlier age because the trajectory began during childhood (Centers for Disease Control and Prevention, 2013; Malhotra et al., 2013). A recent meta-analysis of pediatric cardiovascular risk associated with obesity determined that BMI had a positive association with childhood triglyceride levels and blood pressure (both systolic and diastolic) and had a negative association with adulthood high-density lipoprotein levels (Umer et al., 2017).
Sufficient sleep, for the sake of this study, is adequate, age-appropriate sleep duration (Ash & Taveras, 2017). Barriers to sufficient sleep from the literature include co-sleeping (Chen, Liu, & Liu, 2018), having televisions on, using electronics, and eating/drinking late at night or upon waking (Ash & Taveras, 2017).
Purpose: The specific aim of this study was to evaluate the sleep durations and sleep behaviors of Black children living in a low-socioeconomic area in the Southern U.S. Data gathered will inform future interventions to build on strengths and address problems regarding the sleep duration of the children, an obesity risk factor that is generally modifiable (Ash & Taveras, 2017). Considering sleep’s multi-factorial contribution to the risk for obesity, it is imperative to learn about sleep duration and sleep behaviors of Black children living in low-socioeconomic areas in the Southern U.S. to inform a culturally-appropriate intervention improving the children’s sleep to decrease the risk of obesity.
Methods: This exploratory, cross-sectional, mixed-methods study was designed to gather data via questionnaires (quantitative) and focus groups (qualitative). After institutional Investigational Review Board approval, parents/caregivers of Black children attending a child-care center in a low-socioeconomic area of the Southern U.S. were recruited to participate in the study and share information about their children’s sleep. A demographic questionnaire was created by the research team that included questions about the parents’/caregivers’ socioeconomic concerns and the children’s activity, sleep, and nutritional habits. It was created to complement the Children’s Sleep Habits Questionnaire (CSHQ; Owens, Spirito, & McGuinn, 2000), a nationally-recognized valid instrument with sensitivity of 0.80, specificity of 0.72, internal consistency of 0.41, and test/retest reliability ranging 0.62-0.79. There are 45 questions on the CSHQ, and it culminates in a total score and eight subscale scores that highlight factors/causes of sleep disorders in children (bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnias, sleep disordered breathing, and daytime sleepiness; Owens et al., 2000). Participants were asked to complete the questionnaires and return them to the child-care center prior to the focus group sessions to avoid bias.
A semi-structured interview guide for the focus groups was developed to explore perspectives of the parents/caregivers and provide context and depth to the quantitative data. The guide was augmented utilizing responses from the questionnaires that warranted further investigation. Each participant was asked to attend one focus group session lasting approximately an hour. Four sessions were scheduled for the convenience of the participants, and incentives were provided to each.
Results:
Sample characteristics. Of the 34 participants enrolled in the study, 33 (97%) were female, and 29 (85.3%) were mothers of the children attending the center. The other five participants were other family members who were caregivers of the children. The mean age was 32.3 (SD=11.1) years. Eighteen (52.9%) of the children of the participants were male, and the children's mean age was 4.4 (SD=3.7) years.
Quantitative results. The demographic question on annual household income was answered by 22 participants reporting a range of $5,000 to $75,000 with a mean of $21,468 (SD=$16,711) and median of $17,000. Most participants (n=20; 58.8%) acknowledged at least some degree of financial difficulties, 20 (58.8%) were enrolled in Supplemental Nutritional Assistance Program, and 23 (67.7%) were enrolled in Temporary Assistance for Needy Families.
Most participants indicated that sleep was “very important” to their children’s health (n=33, 97.1%), bedtime routines were “very important” (n=30, 88.2%), and their children slept the recommended amount (n=23, 67.7%) and “rarely” got too little sleep (n=24, 70.6%). Participants also reported the typical number of hours their children slept daily, including naps. Means varied by age group: Newborn (birth to 3 months) n=1, total=13 hours; Infant (4-11 months) n=2, M=11.75 hours, SD=1.77; Toddler (1-2 years) n=12, M=10.75 hours, SD=1.81; Preschool-age (3-5 years) n=11, M=9.68 hours, SD=1.2; School-age (6-13 years) n=7, M=10.04 hours, SD=2.08; and Teenage (14-17 years) n=1, total=7.75 hours.
Participants reported the following typical occurrences during the evenings/nights with their children: a television was on during the hour before bedtime (n=29, 85.3%); there is always a television in the child’s room (n=29, 85.3%); the child used electronics before bed (n=18, 52.9%); the child ate/drank after bedtime (n=16, 48.5%); the television was on where and while the child was sleeping (n=15, 44.1%); the child usually slept with someone else (n=15, 44.1%) even though most had their own beds (n=30, 88.2%); and the child drank caffeinated beverages with supper (n=12, 36.4%).
Results of the CSHQ indicated that 30 (88.2%) of the children scored above the cut-point of 41, indicating that there are clinically-supported sleep problems. The most frequently reported CSHQ subscale items were daytime sleepiness (M=13.7, SD=2.9) and parasomnias (e.g., sleep-walking and nightmares; M=8.53, SD=1.71). The only correlation identified between a demographic and CSHQ score/subscale score was between age of child and daytime sleepiness (r=.35, p=.04).
Qualitative results. Two members of the research team coded transcriptions from the focus groups, identifying common themes. Discrepancy was resolved through discussion and input of a third team member. Themes that were identified were:
- Barriers to adequate sleep
- Electronic use at bedtime
- Watching television
- Co-sleeping
- Waking up hungry/thirsty
- Medications/chronic diagnoses
- Facilitators of adequate sleep
- Having/keeping a routine
- Bath before bed
- Watching television
- Reading to child/child reading book
- Challenges to maintaining a bedtime routine
- Juggling schedules of multiple members of the household
- Caregiver work schedules conflicting with bedtime/sleep time
- Other children (varied bedtimes, noise, etc.)
Discussion:
The participants of the study reported typical amounts their children routinely slept. Of the six age groups represented, only the mean amount of sleep for the school-age group was in the range recommended by the National Sleep Foundation (n=7; M=10.04 hours; recommended=9-11 hours; Ash & Taveras, 2017). Means for children in the infant, toddler, and teenage groups were 0.25 hour less than the minimums, in the preschool-age group was 0.32 hour less than the minimum, and in the newborn group was 1 hour less than the minimum. Sleep duration was a problematic sleep factor for the children in this sample, supported by the results of the CSHQ (Owens et al., 2000).
The parent/caregivers who participated in this study identified that adequate sleep is very important to the health of their children; however, most of these children do not get the recommended duration of sleep regularly and have practices such as eating/drinking late at night, electronic usage at bedtime, having a television on, and co-sleeping that are disruptive to sleep (Ash & Taveras, 2017; Chen et al., 2018). These findings support the need for more education for the parents/caregivers on recommended sleep durations by age group and on sleep hygiene practices that facilitate sleep.
The results of this study are representative of Black children who live in low-income areas in the Southern U.S. It is feasible that these results may vary in other demographic groups. The goal of this study, however, was to explore this population of interest to inform development of a community-based intervention addressing sleep problems specific to the sample population.
Conclusion:
This study provided exploratory data on of the sleep patterns of Black children living in low-income areas in the Southern U.S. The fundamental barriers of adequate sleep, or sleep duration, in this sample were disruptive bedtime practices and knowledge of recommended sleep times for children. The next step in this research will be to develop an intervention that is culturally appropriate and relevant to this community. The intervention will address barriers to adequate sleep for children in efforts to decrease a contributor to obesity and improve the health and well-being of Black children living in a low-socioeconomic area in the Southern U.S.