Behavioral Medicine
ISSN: 0896-4289 (Print) 1940-4026 (Online) Journal homepage: http://www.tandfonline.com/loi/vbmd20
Immigration and Sleep Problems in a Southern European Country: Do Immigrants Get the Best Sleep? Nazmy Villarroel PhD & Lucía Artazcoz PhD To cite this article: Nazmy Villarroel PhD & Lucía Artazcoz PhD (2016): Immigration and Sleep Problems in a Southern European Country: Do Immigrants Get the Best Sleep?, Behavioral Medicine, DOI: 10.1080/08964289.2015.1122568 To link to this article: http://dx.doi.org/10.1080/08964289.2015.1122568
Accepted author version posted online: 25 Jan 2016.
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ACCEPTED MANUSCRIPT Running title: Immigration and sleep problems
Immigration and Sleep Problems in a Southern European Country: Do Immigrants Get
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the Best Sleep?
Authors Nazmy Villarroel, PhD 1 2 Lucía Artazcoz, PhD 1* 2 3 4 *Correspondence: [email protected] 1 Agència de Salut Pública, Barcelona, Spain 2 CIBER en Epidemiología y Salud Pública (CIBERESP), Spain 3 Universitat Pompeu Fabra, Barcelona, Spain 4 Institute of Biomedical Research (IIB-Sant Pau), Barcelona, Spain
ABSTRACT This study aims to analyze differences in the prevalence of insomnia symptoms and nonrestorative sleep (NRS) between people born in Spain and immigrants from the seven countries 1
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ACCEPTED MANUSCRIPT with most immigrants in Spain. The data come from the 2006 Spanish National Health Survey (SNHS). The sample was composed of all individuals aged 16-64 years from Spain and the seven countries with most immigrants in Spain [n=22,224]. In both sexes, people from Bolivia had a higher prevalence of insomnia symptoms and NRS. Conversely, people from Ecuador, Morocco
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and Romania had less insomnia symptoms and NRS than Spanish-born participants. No differences were found between Spanish-born participants and Colombians, Peruvians and Argentinian women. Poor living conditions in the country of origin and in the host country, discrimination and culturally-related lifestyles could be related to the poorer sleep health among Bolivian men. Acculturation may explain the similar sleep health patterns between Spanish-born participants and long-term immigrants. Keywords: Immigrants, Spain, sleep disorders, socio-economic factors, gender
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ACCEPTED MANUSCRIPT INTRODUCTION Sleep, until recently, has been a neglected topic in public health. 1,2 However, poor sleeping patterns are increasingly recognized as an important risk factor for health, with several studies showing an association between sleep disorders and mortality3,4 as well as physical and mental
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health outcomes.5–7 Inadequate sleep impairs attention, alertness, and reaction time, and can cause increased risk of accidents, poor cognitive function and deteriorated overall social functioning. Short sleep is also associated with hypertension, myocardial infarction and stroke, as well as with increased anxiety and hypomania. 8 Few studies, most of them carried out in the US, have explored immigration status relating to sleep, and there appears to be a generally protective effect of being an immigrant. 9–11 However, it should be noted that these results cannot be extrapolated to Europe since, contrary to the US, in Europe most migrants have poorer health status as compared to the majority population, even after controlling for age, gender, and socioeconomic factors.12 Moreover, it has been suggested that acculturation can be related to poor sleep quality among immigrants who have been living for a longer period of time in the host country. 9,13,14 Yet, there are few studies about factors related to poorer living and working conditions among immigrants that could also worsen their sleep quality.15 Contextual and individual socioeconomic factors may play an important role in modulating sleeping patterns.16 For example, it has been reported that lower income and educational attainment is associated with more sleep complaints; that employment is associated with less sleep complaints and unemployment with more; and that married individuals report less sleep
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ACCEPTED MANUSCRIPT complaints.17 Cultural differences in attitudes related to sleep have proposed to contribute to explain differences in sleep health between immigrant and native populations. 10 Moreover, several studies suggest ethnic differences in sleep. 18,19 Additionally, there are gender differences in sleep quality with women reporting higher levels of sleep complaints than men. 20 Biological
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or physiological sex differences are often identified as explanations for women‘s higher levels of disturbed sleep21,22 and psychological explanations are also prevalent. 23 However, studies of gender differences in sleep less frequently consider sociological explanations like family characteristics, working conditions or socio-economic status.24,25 Sleep characteristics in the general population have been studied, for the most part, by assessing sleep duration as the outcome but it has been reported that subjects tend to over-estimate selfreported sleep duration when compared against objective measures. 26 Additionally, previous studies about immigration and health status face the limitation of the aggregation of immigrants in a single category. However, it is important to bear in mind that migrants constitute heterogeneous groups with several factors that may influence their health status such as factors in the country of origin, including cultural background (e.g. early life risk factors, diet); factors related to the act of migration (forced or voluntary); factors during the migration process; socioeconomic factors in the host country (e.g. poor socioeconomic conditions or loss of social status).27 After decades of being a country with net emigration, in recent years immigration to Spain has grown rapidly. On the brink of the twenty-first century, a set of interlinked factors resulted in a massive increase in migration to Spain of citizens mainly from Ecuador, Colombia and Bolivia.
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ACCEPTED MANUSCRIPT These new migratory flows coexisted with the sustained action of already existing migratory networks, such as the Argentinean or Peruvian ones. The importance that Spain has acquired as a migratory destination for Ecuadorians and Colombians must be seen within the context of toughened US immigration policies, particularly following the terrorist attacks of 11 September
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2001. On the other hand, the rhythm of these migratory flows correlates with the dates in which Spain imposed compulsory visas on each country. 28 Moreover, the Spanish economy responded to a remarkable inflow from Eastern European countries (mainly from Romania) in recent years.29 As far as we know, in Europe there are no studies based on representative samples about sleep complaints that compare natives and immigrants. Our study, based on a large representative sample of people living in Spain, hypothesized that: 1) patterns of sleep health differ according to country of birth, even among countries within the same geographic region or with a similar level of development; 2) these patterns also differ between men and women; and 3) these differences according to country of birth are largely explained by socioeconomic status, employment status, family characteristics and social support. The objectives of this study were to: 1) analyze differences in the prevalence of insomnia symptoms and non-restorative sleep (NRS) between people born in Spain and immigrants from the seven countries with most immigrants in Spain; 2) examine whether these differences are explained by socioeconomic status, employment status, family characteristics or social support; and 3) determine whether these patterns of association differ by gender. METHODS
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ACCEPTED MANUSCRIPT Study population and data collection This is a cross-sectional study based on data from the 2006 Spanish National Health Survey (SNHS), a cross-sectional survey of a representative sample of the non-institutionalized population of Spain. A sample was selected using a multiple stage random sampling strategy.
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The first-stage units were census tracts. The second-stage units were family households. The sample size was 29,476. Data were collected through face-to-face interviews at home between June 2006 and June 2007. The response rate was 96.1% (64.6% were from the initial random selection, and 31.7% were replacements for those from the initial selection). 30 For the purposes of this study, we selected individuals aged 16-64 years from Spain and from the seven most represented countries: Argentina, Bolivia, Colombia, Ecuador, Peru (South America), Romania (Eastern Europe) and Morocco (North Africa) [n=22,224]. Variables Country of birth was the main predictor variable, with Spanish-born participants taken as the reference group. Sleep health outcomes Insomnia Symptoms Insomnia symptoms were measured with three items: ―Do you have trouble falling asleep‖, ―Do you wake up during the night and have difficulty going back to sleep,‖ and ―Do you wake up too early in the morning and be unable to get back to sleep‖, in the previous four weeks from 1 (‗never‘) to 5 (‗every day‘). These questions are included in the Athens Insomnia Scale of five
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ACCEPTED MANUSCRIPT items (AIS-5)31 - that is one of the more common scales used for measuring insomnia -, they have face validity and the Cronbach‘s alpha coefficient was 0.75. We created the variable insomnia symptoms by calculating the mean of the three questions and dichotomizing this variable such that individuals with values above the 75% percentile were considered as having
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insomnia symptoms, and the remainder as not having insomnia symptoms. Non-restorative sleep (NRS) NRS is defined as a subjective feeling of being unrefreshed upon awakening, which may be the result of poor quality or unrestful sleep.32 It was measured through the question ―Do your sleeping hours allow enough rest?‖ as a dichotomous variable (yes/no). Covariates Socio-economic position was approximated by educational attainment, in three categories: high (university studies, the reference category), medium (secondary school) and low (basic or no education). Participants‘ employment status was recorded as employed, unemployed, full-time home-maker, or other. Family characteristics were captured by marital status (single; married, the reference category; cohabiting; or separated/divorced/widowed) and number of children (0, 1, ≥2). Social support was approximated by the mean score of eight statements adapted from the Duke-UNC Functional Social Support Questionnaire, 33 each on a scale from 1 (―much less than I would like‖) to 5 (―as much as I would like‖). The questionnaire covers two dimensions of social support: i) access to a confidant or someone with whom to share problems and receive guidance; and ii) affective social support, which refers to emotional support allowing expressions of love, affection, and sympathy, addressed by three questions and scored from 3 to 15 (minimum and 7
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ACCEPTED MANUSCRIPT maximum affective social support, respectively). Cronbach‘s alpha coefficients were 0.86 and 0.78 for the confidant and affective dimensions of social support, respectively. Data analysis First, we tested for differences in each dependent and independent variable between sexes Downloaded by [University of Massachusetts, Amherst] at 05:11 16 March 2016
stratified by country of birth, using the chi-square test for categorical variables, the t-test for age, and the Kolmogorov-Smirnov test for the two dimensions of social support. Second, we fit sexstratified multivariate logistic regression models following a four-step hierarchical modeling strategy: model 1 was adjusted for age; model 2 was additionally adjusted for socio-economic position; model 3 was additionally adjusted for employment status; model 4 was additionally adjusted for family characteristics, and confidant and affective social support. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated, and each analysis included weights derived from the sampling design. The percentage of missing values for the dependent variables was 1.1% for insomnia symptoms and 0.7% for NRS. The percentage of missing values for the independent variables was 0.5% for educational level, 3.4% for confidant social support an 3.5% for affective social support. For the rest of the independent variables the missing percentage was 0.0%. Finally, for the logistic regression models, the number of missing cases was 4.9% for men and 3.8% for women for insomnia symptoms models, and 4.8% to 4.0% respectively for NRS models. Due to the low number of missing cases, subjects with missing data were excluded from the analysis. RESULTS
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ACCEPTED MANUSCRIPT General description of the population The results of a general descriptive analysis are shown in Table 1. We observed notable differences in the gender ratio between countries, with a higher percentage of women among immigrants from Ecuador, Bolivia and Colombia, a higher number of men among individuals
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from Spain and Morocco, and even gender proportions among immigrants from Argentina, Peru and Romania. Women were generally more likely to report sleep disorders and NRS than men, except those from Bolivia. We observed no gender differences in educational attainment among immigrants from Bolivia, Colombia, Morocco or Peru. Compared to men, women from Spain and Argentina had a lower level of education, whereas those from Ecuador and especially Romania had a higher level of education. The rate of employment was higher among men from all countries, especially those from Morocco, among whom 84.4% and 24.7% of men and women were employed, respectively. Women from Spain, Argentina and Romania enjoyed higher levels of confidant social support than men, whereas no gender differences were observed among immigrants from other countries. Men from Ecuador and Peru and women from Romania reported having higher levels of affective social support than members of the opposite sex; no gender differences were found among individuals from the other countries. [Insert table 1] Between-country differences in insomnia symptoms
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ACCEPTED MANUSCRIPT We observed no significant differences in patterns of insomnia symptoms between men and women (Table 2). Bolivian men and women reported more insomnia symptoms than Spanishborn participants (fully adjusted model, aOR= 4.48, 95% CI=2.33-8.63 for men; aOR= 1.93, 95% CI=1.24-3.00 for women), whereas Romanians, Moroccans and Ecuadorians were less
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likely to report insomnia symptoms. Argentinean men, but not women, were also less likely to report insomnia symptoms, whereas no significant differences were observed among individuals from Colombia or Peru, compared to Spanish-born participants. [Insert table 2] Between-country differences in NRS The results of the multivariate logistic regression analyses for NRS were very similar to those for insomnia symptoms (Table 3). The prevalence of NRS among Bolivians of both sexes was higher than among Spanish-born participants. Both men and women born in Ecuador, Morocco and Romania were less likely to report NRS and the prevalence was also lower among Argentinean men. No significant differences in NRS were observed among Argentinean women or among men and women from Colombia and Peru, compared to Spanish-born participants. [Insert table 3] DISCUSSION
To our knowledge, this is the first study based on a large and representative sample of a European country that compares sleep health in native individuals to that among immigrants
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ACCEPTED MANUSCRIPT from a range of countries. Moreover, it examines NRS, which despite being part of the defining features of insomnia, has been less studied than other symptoms of primary insomnia. 32 Main findings of this study The study has produced four main findings: 1) Bolivian immigrants had the highest prevalence Downloaded by [University of Massachusetts, Amherst] at 05:11 16 March 2016
of insomnia symptoms and NRS, primarily among men; 2) the prevalence of insomnia symptoms and NRS was lower among people from Ecuador, Morocco and Romania compared to Spanishborn participants; 3) there were no differences in sleep complaints between Spanish people and Colombians, Peruvians and Argentinian women; and 4) patterns of between-country differences of sleep problems only slightly differed by gender. Moreover, results hardly changed after adjusting for socioeconomic status, employment status, family characteristics and social support. There are several potential explanations for our findings such as culturally-related factors, living conditions in the country of origin and in the host country, length of residence in Spain and discrimination.27 Culturally-related factors The poorer sleep health among Bolivians could also be explained by the relationship between cultural influences and lifestyle patterns. 13 For instance, 82.6% of Bolivian men in our study had drunk alcohol in the previous two weeks compared to 72.9% among Spanish men. Moreover, 48.9% of men from Bolivia were current smokers, compared to 39.2% among Spanish men. However, no differences in prevalence of alcohol consumption and smoking were observed between women from Bolivia and Spain (results not shown).
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ACCEPTED MANUSCRIPT Compared to immigrants from Morocco, Ecuador and Romania, a high prevalence of insomnia symptoms and NRS was observed among Spanish-born participants. The prevalence of poor sleep health among Spanish-born participants does not differ substantially from the findings of a previous study, in which the prevalence of insomnia was 17.6% among men and 23.9% among
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women.34 Spanish-born participants have more dispersed and more nocturnal timetables than individuals from the rest of Europe, so people go to bed later. For example, a study carried out in the European Union showed that Spanish people have more nocturnal habits than the European average, such that 45% of Spanish-born participants go to bed between midnight and 1 am, and 20% go to bed after this time. Spanish-born participants also take a two-hour break during each workday, so that the working population arrives home late, and television programming adapts to these working hours and as a consequence Spanish people go to bed at dawn. Hence, it could be argued that these schedules could affect Spanish-born participant‘s quality of sleep. Migration from Ecuador and Romania is very recent and therefore these groups may maintain the healthy sleeping behaviors of their countries of origin. Conversely, the lack of differences in insomnia symptoms and NRS between Spanish-born participants and individuals from Peru and Colombia, as well as most Argentineans, could be explained by a process of acculturation characterized by the adoption of Spanish sleeping behaviors, since these groups have been living in Spain for a longer period of time. This is consistent with studies that report that acculturation has led to worse sleep habits among immigrants.9,13,14 Flows from Latin America into Spain are very recent. According to data for 2007 35, Ecuadorians and Bolivians arrived almost exclusively during the decade 1997-2006 (94% and 97%, respectively), 89% of Colombians arrived during the past decade and 7% did so 12
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ACCEPTED MANUSCRIPT between 1987 and 1996. However, in the case of Argentina and Peru "only" about 40% came in the last decade (47% and 50% respectively between 2002 and 2006), while 17% arrived before 1987. The good sleep health among Moroccans was an unexpected finding. Morocco is a North
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African country with the lowest HDI among the countries studied. 36 It is the country with the oldest migratory tradition in Spain, and Moroccan immigrants are exposed to serious discrimination due to the poor relations between these countries which has been nurtured for centuries. The general feeling of Moroccan-born people is that Spain treats them worse than other European countries.37 However, it should be noted that Moroccans were the only group from an Islamic country that was analyzed in this study. The Quran emphasizes the beneficial effects of sleep and the importance of maintaining diurnal patterns of light and darkness. 38 Also, Islam prohibits drinking alcohol such that the prevalence of alcohol consumption in the two weeks prior to interview was 19.4% and 3.6% among Moroccan men and women, compared to 72.9% and 47% among Spanish men and women, respectively. Similarly, the prevalence of current smoking among Moroccans is lower than among individuals from other countries: 38% and 7.8% among men and women, compared to 39.2% and 30.4% among Spanish men and women, respectively (results not shown). These results are consistent with a previous study based on the same sample that found an unexpected good mental health status among Moroccans living in Spain.39 Living conditions in the country of origin
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ACCEPTED MANUSCRIPT In the context of migration and population mobility the health characteristics of pre-departure migrant populations can be very diverse, reflecting disparities in the determinants of health at both individual and societal levels40 Our results among Bolivians are consistent with those from a previous study based on the same survey, which found that the prevalence of poor health status
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and poor mental health was much higher among Bolivians, primarily among men. 39 Living conditions in Bolivia are poorer than in other South American countries, such that, for example, it has the lowest Human Development Index (HDI) of all Latin American countries. 36 According to the 2001 census, 64% of the total population had insufficient income to cover their basic needs, and increasing urban poverty and a lack of opportunities in rural areas promoted migration of the indigenous and rural population. 41 Therefore, the current poorer health outcomes of Bolivian immigrants may partially reflect hazardous cumulative socioeconomic exposures experienced in childhood and youth in their own country. Unfortunately, this information was not available in our dataset. More research is needed about immigration and health status taken into account the cumulative experience of the life-course. Living conditions in the host country With respect to immigrants from other Latin American countries, Bolivians are the most recently arrived immigrant group in Spain and face more severe barriers imposed by the Spanish legal system, compared to Latin American immigrants who arrived previously. Several studies indicate that the living conditions of Latin American immigrants improve with years of residence in Spain, and that a high proportion of recent Latin American immigrants work in jobs below their level of qualification, but that this proportion decreases with years of residence. 41,42 In
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ACCEPTED MANUSCRIPT 2007, Bolivian males were in the lowest rank of income among immigrant men in Spain 35 and among Latin-American immigrants only Bolivia had a majority whose annual income was less than €10,000.41 Bolivians are also more likely to live in deprived areas with neighborhood disorder that could negatively affect their sleep. 43
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Discrimination Discrimination in both the origin and host countries is another contributing explanation. Ethnic composition varies markedly between the five Latin American countries examined. For example, the percentage of white people is 5% in Bolivia, 15% in Ecuador and Peru, 20% in Colombia, whereas it is 97% in Argentina.44 It has been reported that indigenous people are more likely to be disadvantaged and marginalized within their own countries. For example, they have poorer health indicators, including negative emotional states such as reduced self-esteem, self-efficacy and self-control, as well as pessimism, aggression, hyper-vigilance, and rumination.45 Moreover, once in the host country, non-white people are more likely to suffer from racism or discrimination and its health consequences. Several studies carried out in Spain have observed that Latin-American immigrants who are ethnically different are more likely to experience discrimination.46 Furthermore, perceived racism has been associated with increased risk of having sleep disturbance and depression. 47,48 For instance, in the sample analyzed in this study, 52% of Bolivian men and women, had experienced discrimination in their jobs in the previous year, compared to 12.1% and 0% among Argentinean men and women respectively (results not shown). These results have been found in this study, even though this variable has not been used as an explanatory variable due to the low response rate in this question by country of birth.
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ACCEPTED MANUSCRIPT Limitations Since this study is based on secondary data, we were unable to determine the processes by which some migration-related factors may have reduced or enhanced risk of poor sleep health. Unfortunately information about time living in Spain was not collected but the immigration
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phenomenon in Spain is very recent and information about length of residence by countries was available for the contextualization of the results. Although it could be argued that variation in reporting cultural differences could result in bias, it should be noted that five of the seven nonSpanish countries examined are in South America and have similar cultural backgrounds, and yet we have still observed differences in sleep health between them. Finally, the small sample size of Peruvians and Bolivian men is another limitation. However, it should be noted that the confidence intervals for these groups are narrow and therefore our findings are not the consequence of a lack of statistical power. CONCLUSIONS Although previous studies have considered Hispanic people as a single category, 49,50 we have observed that in Spain sleep patterns among Latino-Americans differ according to country of birth. Poorer sleep health among Spanish-born participants compared to most recently arrived immigrants and with Moroccans could be related to unhealthier traditional Spanish schedules and daily routines. The good sleep health of Moroccans, despite the low HDI of their country and their poor living and working conditions in Spain, could be partly explained by the Islamic religion. On the other hand, poorer living conditions in both the origin and destination countries, as well as discrimination and less healthy lifestyles could be associated with the poorer sleep
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ACCEPTED MANUSCRIPT health among Bolivians. Acculturation may explain the similar sleep health patterns between Spanish-born participants and immigrants from countries that have been living in Spain for a longer period of time. Future research is needed on the cultural factors that seem to be related to Spanish-born participant‘s poorer sleep health. Policies are needed in different areas in order to
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improve daily routines and schedules that can be harmful to the sleep health of Spanish-born participants. Conflict of interests None to declare Acknowledgements The project could not have been completed without cooperation of the unit for the National Health Survey in Spain and the General Division of Health Information and Innovation from the Ministry of Health, Social Services and Equality in Spain.
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Broadhead WE, Gehlbach SH, de Gruy F V, Kaplan BH. The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients. Med Care. 1988;26:709-723. doi:10.1097/00005650-198807000-00006.
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Ohayon M, Sagales T. Prevalence of insomnia and sleep characteristics in the general population of Spain. Sleep Med. 2010;11(10):1010-1018.
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Cacopardo M, Maguid A, Martínez R. New emigration of Latin American people to Spain: the case of Argentineans from a compared perspective. Papeles de Población. 2007;13:9-44.
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Baldwin CM, Ervin A-M, Mays MZ, et al. Sleep disturbances, quality of life, and ethnicity: the Sleep Heart Health Study. J Clin Sleep Med. 2010;6(2):176-183. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2854706&tool=pmcentrez&re ndertype=abstract.
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ACCEPTED MANUSCRIPT Table 1. General description of the sample, stratified by sex and country of birth. P-values represent comparison between men and women. Spanish National Health Survey, 2006.
Spain Men Women
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Mean age (SD)
Argentina Men Women
Bolivia Men Women
Colombia Men Women
(N=10,32 (N=9,901) (N=106) (N=105) (N=46) (N=120) (N=112) (N=171) 5) 40 (13.2) 33 (10.7) 37 (11.0) 30 (8.3) 31 (10.4) 34 (10.8) 37 (11.1)b 39 (13.1) % % % % % % % %
Sleep health outcomes 16.4
27.2c
3.9
28.9c
47.6
35.7
20.5
28.1b
18.9
28.6c
25.7
23.8
50.0
42.2
21.6
31.4c
Educational level Higher Medium Lower
19.9 49.0 31.1
20.0c 44.8 35.2
21.5 72.0 6.5
21.0 58.1 21.0
21.3 66.0 12.8
11.7 65.8 22.5
17.0 51.8 31.3
18.1a 61.4 20.5
Employment status Working Unemployed Housekeeper Other
73.6 7.4 0.1 18.8
50.6c 10.2 24.7 14.6
80.2 16.0 3.8
58.7c 16.3 15.4 9.6
73.9 8.7 17.4
82.6a 5.0 1.7 10.7
88.5 2.7 8.8
75.4 9.4 15.2 -
53.4 7.4 36.1 3.2
60.7 7.2 25.4 6.8
37.7 21.7 39.6 0.9
51.4 29.5 15.2 3.8
34.8 26.1 30.4 8.7
43.3 25.0 27.5 4.2
42.0 24.1 27.7 6.3
57.0 15.1 17.4 10.5
53.3 20.4
43.0 24.0
58.9 18.7
51.4 20.0
87.2 6.4
56.7c 16.7
64.9 18.0
29.8 35.7
Insomnia symptoms Non-restorative sleep
Family Characteristics Marital status Married Cohabiting Single Previously married Number of children 0 1
25
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ACCEPTED MANUSCRIPT ≥2
26.0
33.0
22.4
28.6
6.4
26.7
17.1
34.5
25.0
25.0
24.0
23.4
23.5
22.0
22.0
23.0
(22.025.0)c 15.0
(20.025.0) 15.0
(22.025.0)a 15.0
(20.624.0) 15.0
(18.825.0) 15.0
(17.025.0) 14.0
(19.025.0) 14.0
(14.015.0)b
(14.015.0)
(14.015.0)
(13.015.0)
(12.015.0)
(12.815.0)
(12.015.0)a
Social support Median xyz social support score (IQR)*
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Confidant Social Support
(21.025.0) Affective Social 15.0 Support (14.015.0) a
P
ISSN: 0896-4289 (Print) 1940-4026 (Online) Journal homepage: http://www.tandfonline.com/loi/vbmd20
Immigration and Sleep Problems in a Southern European Country: Do Immigrants Get the Best Sleep? Nazmy Villarroel PhD & Lucía Artazcoz PhD To cite this article: Nazmy Villarroel PhD & Lucía Artazcoz PhD (2016): Immigration and Sleep Problems in a Southern European Country: Do Immigrants Get the Best Sleep?, Behavioral Medicine, DOI: 10.1080/08964289.2015.1122568 To link to this article: http://dx.doi.org/10.1080/08964289.2015.1122568
Accepted author version posted online: 25 Jan 2016.
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ACCEPTED MANUSCRIPT Running title: Immigration and sleep problems
Immigration and Sleep Problems in a Southern European Country: Do Immigrants Get
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the Best Sleep?
Authors Nazmy Villarroel, PhD 1 2 Lucía Artazcoz, PhD 1* 2 3 4 *Correspondence: [email protected] 1 Agència de Salut Pública, Barcelona, Spain 2 CIBER en Epidemiología y Salud Pública (CIBERESP), Spain 3 Universitat Pompeu Fabra, Barcelona, Spain 4 Institute of Biomedical Research (IIB-Sant Pau), Barcelona, Spain
ABSTRACT This study aims to analyze differences in the prevalence of insomnia symptoms and nonrestorative sleep (NRS) between people born in Spain and immigrants from the seven countries 1
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ACCEPTED MANUSCRIPT with most immigrants in Spain. The data come from the 2006 Spanish National Health Survey (SNHS). The sample was composed of all individuals aged 16-64 years from Spain and the seven countries with most immigrants in Spain [n=22,224]. In both sexes, people from Bolivia had a higher prevalence of insomnia symptoms and NRS. Conversely, people from Ecuador, Morocco
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and Romania had less insomnia symptoms and NRS than Spanish-born participants. No differences were found between Spanish-born participants and Colombians, Peruvians and Argentinian women. Poor living conditions in the country of origin and in the host country, discrimination and culturally-related lifestyles could be related to the poorer sleep health among Bolivian men. Acculturation may explain the similar sleep health patterns between Spanish-born participants and long-term immigrants. Keywords: Immigrants, Spain, sleep disorders, socio-economic factors, gender
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ACCEPTED MANUSCRIPT INTRODUCTION Sleep, until recently, has been a neglected topic in public health. 1,2 However, poor sleeping patterns are increasingly recognized as an important risk factor for health, with several studies showing an association between sleep disorders and mortality3,4 as well as physical and mental
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health outcomes.5–7 Inadequate sleep impairs attention, alertness, and reaction time, and can cause increased risk of accidents, poor cognitive function and deteriorated overall social functioning. Short sleep is also associated with hypertension, myocardial infarction and stroke, as well as with increased anxiety and hypomania. 8 Few studies, most of them carried out in the US, have explored immigration status relating to sleep, and there appears to be a generally protective effect of being an immigrant. 9–11 However, it should be noted that these results cannot be extrapolated to Europe since, contrary to the US, in Europe most migrants have poorer health status as compared to the majority population, even after controlling for age, gender, and socioeconomic factors.12 Moreover, it has been suggested that acculturation can be related to poor sleep quality among immigrants who have been living for a longer period of time in the host country. 9,13,14 Yet, there are few studies about factors related to poorer living and working conditions among immigrants that could also worsen their sleep quality.15 Contextual and individual socioeconomic factors may play an important role in modulating sleeping patterns.16 For example, it has been reported that lower income and educational attainment is associated with more sleep complaints; that employment is associated with less sleep complaints and unemployment with more; and that married individuals report less sleep
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ACCEPTED MANUSCRIPT complaints.17 Cultural differences in attitudes related to sleep have proposed to contribute to explain differences in sleep health between immigrant and native populations. 10 Moreover, several studies suggest ethnic differences in sleep. 18,19 Additionally, there are gender differences in sleep quality with women reporting higher levels of sleep complaints than men. 20 Biological
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or physiological sex differences are often identified as explanations for women‘s higher levels of disturbed sleep21,22 and psychological explanations are also prevalent. 23 However, studies of gender differences in sleep less frequently consider sociological explanations like family characteristics, working conditions or socio-economic status.24,25 Sleep characteristics in the general population have been studied, for the most part, by assessing sleep duration as the outcome but it has been reported that subjects tend to over-estimate selfreported sleep duration when compared against objective measures. 26 Additionally, previous studies about immigration and health status face the limitation of the aggregation of immigrants in a single category. However, it is important to bear in mind that migrants constitute heterogeneous groups with several factors that may influence their health status such as factors in the country of origin, including cultural background (e.g. early life risk factors, diet); factors related to the act of migration (forced or voluntary); factors during the migration process; socioeconomic factors in the host country (e.g. poor socioeconomic conditions or loss of social status).27 After decades of being a country with net emigration, in recent years immigration to Spain has grown rapidly. On the brink of the twenty-first century, a set of interlinked factors resulted in a massive increase in migration to Spain of citizens mainly from Ecuador, Colombia and Bolivia.
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ACCEPTED MANUSCRIPT These new migratory flows coexisted with the sustained action of already existing migratory networks, such as the Argentinean or Peruvian ones. The importance that Spain has acquired as a migratory destination for Ecuadorians and Colombians must be seen within the context of toughened US immigration policies, particularly following the terrorist attacks of 11 September
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2001. On the other hand, the rhythm of these migratory flows correlates with the dates in which Spain imposed compulsory visas on each country. 28 Moreover, the Spanish economy responded to a remarkable inflow from Eastern European countries (mainly from Romania) in recent years.29 As far as we know, in Europe there are no studies based on representative samples about sleep complaints that compare natives and immigrants. Our study, based on a large representative sample of people living in Spain, hypothesized that: 1) patterns of sleep health differ according to country of birth, even among countries within the same geographic region or with a similar level of development; 2) these patterns also differ between men and women; and 3) these differences according to country of birth are largely explained by socioeconomic status, employment status, family characteristics and social support. The objectives of this study were to: 1) analyze differences in the prevalence of insomnia symptoms and non-restorative sleep (NRS) between people born in Spain and immigrants from the seven countries with most immigrants in Spain; 2) examine whether these differences are explained by socioeconomic status, employment status, family characteristics or social support; and 3) determine whether these patterns of association differ by gender. METHODS
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ACCEPTED MANUSCRIPT Study population and data collection This is a cross-sectional study based on data from the 2006 Spanish National Health Survey (SNHS), a cross-sectional survey of a representative sample of the non-institutionalized population of Spain. A sample was selected using a multiple stage random sampling strategy.
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The first-stage units were census tracts. The second-stage units were family households. The sample size was 29,476. Data were collected through face-to-face interviews at home between June 2006 and June 2007. The response rate was 96.1% (64.6% were from the initial random selection, and 31.7% were replacements for those from the initial selection). 30 For the purposes of this study, we selected individuals aged 16-64 years from Spain and from the seven most represented countries: Argentina, Bolivia, Colombia, Ecuador, Peru (South America), Romania (Eastern Europe) and Morocco (North Africa) [n=22,224]. Variables Country of birth was the main predictor variable, with Spanish-born participants taken as the reference group. Sleep health outcomes Insomnia Symptoms Insomnia symptoms were measured with three items: ―Do you have trouble falling asleep‖, ―Do you wake up during the night and have difficulty going back to sleep,‖ and ―Do you wake up too early in the morning and be unable to get back to sleep‖, in the previous four weeks from 1 (‗never‘) to 5 (‗every day‘). These questions are included in the Athens Insomnia Scale of five
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ACCEPTED MANUSCRIPT items (AIS-5)31 - that is one of the more common scales used for measuring insomnia -, they have face validity and the Cronbach‘s alpha coefficient was 0.75. We created the variable insomnia symptoms by calculating the mean of the three questions and dichotomizing this variable such that individuals with values above the 75% percentile were considered as having
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insomnia symptoms, and the remainder as not having insomnia symptoms. Non-restorative sleep (NRS) NRS is defined as a subjective feeling of being unrefreshed upon awakening, which may be the result of poor quality or unrestful sleep.32 It was measured through the question ―Do your sleeping hours allow enough rest?‖ as a dichotomous variable (yes/no). Covariates Socio-economic position was approximated by educational attainment, in three categories: high (university studies, the reference category), medium (secondary school) and low (basic or no education). Participants‘ employment status was recorded as employed, unemployed, full-time home-maker, or other. Family characteristics were captured by marital status (single; married, the reference category; cohabiting; or separated/divorced/widowed) and number of children (0, 1, ≥2). Social support was approximated by the mean score of eight statements adapted from the Duke-UNC Functional Social Support Questionnaire, 33 each on a scale from 1 (―much less than I would like‖) to 5 (―as much as I would like‖). The questionnaire covers two dimensions of social support: i) access to a confidant or someone with whom to share problems and receive guidance; and ii) affective social support, which refers to emotional support allowing expressions of love, affection, and sympathy, addressed by three questions and scored from 3 to 15 (minimum and 7
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ACCEPTED MANUSCRIPT maximum affective social support, respectively). Cronbach‘s alpha coefficients were 0.86 and 0.78 for the confidant and affective dimensions of social support, respectively. Data analysis First, we tested for differences in each dependent and independent variable between sexes Downloaded by [University of Massachusetts, Amherst] at 05:11 16 March 2016
stratified by country of birth, using the chi-square test for categorical variables, the t-test for age, and the Kolmogorov-Smirnov test for the two dimensions of social support. Second, we fit sexstratified multivariate logistic regression models following a four-step hierarchical modeling strategy: model 1 was adjusted for age; model 2 was additionally adjusted for socio-economic position; model 3 was additionally adjusted for employment status; model 4 was additionally adjusted for family characteristics, and confidant and affective social support. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated, and each analysis included weights derived from the sampling design. The percentage of missing values for the dependent variables was 1.1% for insomnia symptoms and 0.7% for NRS. The percentage of missing values for the independent variables was 0.5% for educational level, 3.4% for confidant social support an 3.5% for affective social support. For the rest of the independent variables the missing percentage was 0.0%. Finally, for the logistic regression models, the number of missing cases was 4.9% for men and 3.8% for women for insomnia symptoms models, and 4.8% to 4.0% respectively for NRS models. Due to the low number of missing cases, subjects with missing data were excluded from the analysis. RESULTS
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ACCEPTED MANUSCRIPT General description of the population The results of a general descriptive analysis are shown in Table 1. We observed notable differences in the gender ratio between countries, with a higher percentage of women among immigrants from Ecuador, Bolivia and Colombia, a higher number of men among individuals
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from Spain and Morocco, and even gender proportions among immigrants from Argentina, Peru and Romania. Women were generally more likely to report sleep disorders and NRS than men, except those from Bolivia. We observed no gender differences in educational attainment among immigrants from Bolivia, Colombia, Morocco or Peru. Compared to men, women from Spain and Argentina had a lower level of education, whereas those from Ecuador and especially Romania had a higher level of education. The rate of employment was higher among men from all countries, especially those from Morocco, among whom 84.4% and 24.7% of men and women were employed, respectively. Women from Spain, Argentina and Romania enjoyed higher levels of confidant social support than men, whereas no gender differences were observed among immigrants from other countries. Men from Ecuador and Peru and women from Romania reported having higher levels of affective social support than members of the opposite sex; no gender differences were found among individuals from the other countries. [Insert table 1] Between-country differences in insomnia symptoms
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ACCEPTED MANUSCRIPT We observed no significant differences in patterns of insomnia symptoms between men and women (Table 2). Bolivian men and women reported more insomnia symptoms than Spanishborn participants (fully adjusted model, aOR= 4.48, 95% CI=2.33-8.63 for men; aOR= 1.93, 95% CI=1.24-3.00 for women), whereas Romanians, Moroccans and Ecuadorians were less
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likely to report insomnia symptoms. Argentinean men, but not women, were also less likely to report insomnia symptoms, whereas no significant differences were observed among individuals from Colombia or Peru, compared to Spanish-born participants. [Insert table 2] Between-country differences in NRS The results of the multivariate logistic regression analyses for NRS were very similar to those for insomnia symptoms (Table 3). The prevalence of NRS among Bolivians of both sexes was higher than among Spanish-born participants. Both men and women born in Ecuador, Morocco and Romania were less likely to report NRS and the prevalence was also lower among Argentinean men. No significant differences in NRS were observed among Argentinean women or among men and women from Colombia and Peru, compared to Spanish-born participants. [Insert table 3] DISCUSSION
To our knowledge, this is the first study based on a large and representative sample of a European country that compares sleep health in native individuals to that among immigrants
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ACCEPTED MANUSCRIPT from a range of countries. Moreover, it examines NRS, which despite being part of the defining features of insomnia, has been less studied than other symptoms of primary insomnia. 32 Main findings of this study The study has produced four main findings: 1) Bolivian immigrants had the highest prevalence Downloaded by [University of Massachusetts, Amherst] at 05:11 16 March 2016
of insomnia symptoms and NRS, primarily among men; 2) the prevalence of insomnia symptoms and NRS was lower among people from Ecuador, Morocco and Romania compared to Spanishborn participants; 3) there were no differences in sleep complaints between Spanish people and Colombians, Peruvians and Argentinian women; and 4) patterns of between-country differences of sleep problems only slightly differed by gender. Moreover, results hardly changed after adjusting for socioeconomic status, employment status, family characteristics and social support. There are several potential explanations for our findings such as culturally-related factors, living conditions in the country of origin and in the host country, length of residence in Spain and discrimination.27 Culturally-related factors The poorer sleep health among Bolivians could also be explained by the relationship between cultural influences and lifestyle patterns. 13 For instance, 82.6% of Bolivian men in our study had drunk alcohol in the previous two weeks compared to 72.9% among Spanish men. Moreover, 48.9% of men from Bolivia were current smokers, compared to 39.2% among Spanish men. However, no differences in prevalence of alcohol consumption and smoking were observed between women from Bolivia and Spain (results not shown).
11
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ACCEPTED MANUSCRIPT Compared to immigrants from Morocco, Ecuador and Romania, a high prevalence of insomnia symptoms and NRS was observed among Spanish-born participants. The prevalence of poor sleep health among Spanish-born participants does not differ substantially from the findings of a previous study, in which the prevalence of insomnia was 17.6% among men and 23.9% among
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women.34 Spanish-born participants have more dispersed and more nocturnal timetables than individuals from the rest of Europe, so people go to bed later. For example, a study carried out in the European Union showed that Spanish people have more nocturnal habits than the European average, such that 45% of Spanish-born participants go to bed between midnight and 1 am, and 20% go to bed after this time. Spanish-born participants also take a two-hour break during each workday, so that the working population arrives home late, and television programming adapts to these working hours and as a consequence Spanish people go to bed at dawn. Hence, it could be argued that these schedules could affect Spanish-born participant‘s quality of sleep. Migration from Ecuador and Romania is very recent and therefore these groups may maintain the healthy sleeping behaviors of their countries of origin. Conversely, the lack of differences in insomnia symptoms and NRS between Spanish-born participants and individuals from Peru and Colombia, as well as most Argentineans, could be explained by a process of acculturation characterized by the adoption of Spanish sleeping behaviors, since these groups have been living in Spain for a longer period of time. This is consistent with studies that report that acculturation has led to worse sleep habits among immigrants.9,13,14 Flows from Latin America into Spain are very recent. According to data for 2007 35, Ecuadorians and Bolivians arrived almost exclusively during the decade 1997-2006 (94% and 97%, respectively), 89% of Colombians arrived during the past decade and 7% did so 12
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ACCEPTED MANUSCRIPT between 1987 and 1996. However, in the case of Argentina and Peru "only" about 40% came in the last decade (47% and 50% respectively between 2002 and 2006), while 17% arrived before 1987. The good sleep health among Moroccans was an unexpected finding. Morocco is a North
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African country with the lowest HDI among the countries studied. 36 It is the country with the oldest migratory tradition in Spain, and Moroccan immigrants are exposed to serious discrimination due to the poor relations between these countries which has been nurtured for centuries. The general feeling of Moroccan-born people is that Spain treats them worse than other European countries.37 However, it should be noted that Moroccans were the only group from an Islamic country that was analyzed in this study. The Quran emphasizes the beneficial effects of sleep and the importance of maintaining diurnal patterns of light and darkness. 38 Also, Islam prohibits drinking alcohol such that the prevalence of alcohol consumption in the two weeks prior to interview was 19.4% and 3.6% among Moroccan men and women, compared to 72.9% and 47% among Spanish men and women, respectively. Similarly, the prevalence of current smoking among Moroccans is lower than among individuals from other countries: 38% and 7.8% among men and women, compared to 39.2% and 30.4% among Spanish men and women, respectively (results not shown). These results are consistent with a previous study based on the same sample that found an unexpected good mental health status among Moroccans living in Spain.39 Living conditions in the country of origin
13
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ACCEPTED MANUSCRIPT In the context of migration and population mobility the health characteristics of pre-departure migrant populations can be very diverse, reflecting disparities in the determinants of health at both individual and societal levels40 Our results among Bolivians are consistent with those from a previous study based on the same survey, which found that the prevalence of poor health status
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and poor mental health was much higher among Bolivians, primarily among men. 39 Living conditions in Bolivia are poorer than in other South American countries, such that, for example, it has the lowest Human Development Index (HDI) of all Latin American countries. 36 According to the 2001 census, 64% of the total population had insufficient income to cover their basic needs, and increasing urban poverty and a lack of opportunities in rural areas promoted migration of the indigenous and rural population. 41 Therefore, the current poorer health outcomes of Bolivian immigrants may partially reflect hazardous cumulative socioeconomic exposures experienced in childhood and youth in their own country. Unfortunately, this information was not available in our dataset. More research is needed about immigration and health status taken into account the cumulative experience of the life-course. Living conditions in the host country With respect to immigrants from other Latin American countries, Bolivians are the most recently arrived immigrant group in Spain and face more severe barriers imposed by the Spanish legal system, compared to Latin American immigrants who arrived previously. Several studies indicate that the living conditions of Latin American immigrants improve with years of residence in Spain, and that a high proportion of recent Latin American immigrants work in jobs below their level of qualification, but that this proportion decreases with years of residence. 41,42 In
14
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ACCEPTED MANUSCRIPT 2007, Bolivian males were in the lowest rank of income among immigrant men in Spain 35 and among Latin-American immigrants only Bolivia had a majority whose annual income was less than €10,000.41 Bolivians are also more likely to live in deprived areas with neighborhood disorder that could negatively affect their sleep. 43
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Discrimination Discrimination in both the origin and host countries is another contributing explanation. Ethnic composition varies markedly between the five Latin American countries examined. For example, the percentage of white people is 5% in Bolivia, 15% in Ecuador and Peru, 20% in Colombia, whereas it is 97% in Argentina.44 It has been reported that indigenous people are more likely to be disadvantaged and marginalized within their own countries. For example, they have poorer health indicators, including negative emotional states such as reduced self-esteem, self-efficacy and self-control, as well as pessimism, aggression, hyper-vigilance, and rumination.45 Moreover, once in the host country, non-white people are more likely to suffer from racism or discrimination and its health consequences. Several studies carried out in Spain have observed that Latin-American immigrants who are ethnically different are more likely to experience discrimination.46 Furthermore, perceived racism has been associated with increased risk of having sleep disturbance and depression. 47,48 For instance, in the sample analyzed in this study, 52% of Bolivian men and women, had experienced discrimination in their jobs in the previous year, compared to 12.1% and 0% among Argentinean men and women respectively (results not shown). These results have been found in this study, even though this variable has not been used as an explanatory variable due to the low response rate in this question by country of birth.
15
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ACCEPTED MANUSCRIPT Limitations Since this study is based on secondary data, we were unable to determine the processes by which some migration-related factors may have reduced or enhanced risk of poor sleep health. Unfortunately information about time living in Spain was not collected but the immigration
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phenomenon in Spain is very recent and information about length of residence by countries was available for the contextualization of the results. Although it could be argued that variation in reporting cultural differences could result in bias, it should be noted that five of the seven nonSpanish countries examined are in South America and have similar cultural backgrounds, and yet we have still observed differences in sleep health between them. Finally, the small sample size of Peruvians and Bolivian men is another limitation. However, it should be noted that the confidence intervals for these groups are narrow and therefore our findings are not the consequence of a lack of statistical power. CONCLUSIONS Although previous studies have considered Hispanic people as a single category, 49,50 we have observed that in Spain sleep patterns among Latino-Americans differ according to country of birth. Poorer sleep health among Spanish-born participants compared to most recently arrived immigrants and with Moroccans could be related to unhealthier traditional Spanish schedules and daily routines. The good sleep health of Moroccans, despite the low HDI of their country and their poor living and working conditions in Spain, could be partly explained by the Islamic religion. On the other hand, poorer living conditions in both the origin and destination countries, as well as discrimination and less healthy lifestyles could be associated with the poorer sleep
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ACCEPTED MANUSCRIPT health among Bolivians. Acculturation may explain the similar sleep health patterns between Spanish-born participants and immigrants from countries that have been living in Spain for a longer period of time. Future research is needed on the cultural factors that seem to be related to Spanish-born participant‘s poorer sleep health. Policies are needed in different areas in order to
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improve daily routines and schedules that can be harmful to the sleep health of Spanish-born participants. Conflict of interests None to declare Acknowledgements The project could not have been completed without cooperation of the unit for the National Health Survey in Spain and the General Division of Health Information and Innovation from the Ministry of Health, Social Services and Equality in Spain.
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ACCEPTED MANUSCRIPT Table 1. General description of the sample, stratified by sex and country of birth. P-values represent comparison between men and women. Spanish National Health Survey, 2006.
Spain Men Women
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Mean age (SD)
Argentina Men Women
Bolivia Men Women
Colombia Men Women
(N=10,32 (N=9,901) (N=106) (N=105) (N=46) (N=120) (N=112) (N=171) 5) 40 (13.2) 33 (10.7) 37 (11.0) 30 (8.3) 31 (10.4) 34 (10.8) 37 (11.1)b 39 (13.1) % % % % % % % %
Sleep health outcomes 16.4
27.2c
3.9
28.9c
47.6
35.7
20.5
28.1b
18.9
28.6c
25.7
23.8
50.0
42.2
21.6
31.4c
Educational level Higher Medium Lower
19.9 49.0 31.1
20.0c 44.8 35.2
21.5 72.0 6.5
21.0 58.1 21.0
21.3 66.0 12.8
11.7 65.8 22.5
17.0 51.8 31.3
18.1a 61.4 20.5
Employment status Working Unemployed Housekeeper Other
73.6 7.4 0.1 18.8
50.6c 10.2 24.7 14.6
80.2 16.0 3.8
58.7c 16.3 15.4 9.6
73.9 8.7 17.4
82.6a 5.0 1.7 10.7
88.5 2.7 8.8
75.4 9.4 15.2 -
53.4 7.4 36.1 3.2
60.7 7.2 25.4 6.8
37.7 21.7 39.6 0.9
51.4 29.5 15.2 3.8
34.8 26.1 30.4 8.7
43.3 25.0 27.5 4.2
42.0 24.1 27.7 6.3
57.0 15.1 17.4 10.5
53.3 20.4
43.0 24.0
58.9 18.7
51.4 20.0
87.2 6.4
56.7c 16.7
64.9 18.0
29.8 35.7
Insomnia symptoms Non-restorative sleep
Family Characteristics Marital status Married Cohabiting Single Previously married Number of children 0 1
25
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26.0
33.0
22.4
28.6
6.4
26.7
17.1
34.5
25.0
25.0
24.0
23.4
23.5
22.0
22.0
23.0
(22.025.0)c 15.0
(20.025.0) 15.0
(22.025.0)a 15.0
(20.624.0) 15.0
(18.825.0) 15.0
(17.025.0) 14.0
(19.025.0) 14.0
(14.015.0)b
(14.015.0)
(14.015.0)
(13.015.0)
(12.015.0)
(12.815.0)
(12.015.0)a
Social support Median xyz social support score (IQR)*
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Confidant Social Support
(21.025.0) Affective Social 15.0 Support (14.015.0) a
P
