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| Included articles (citation and class) | AI/AN sample description | Prevalence and correlates of insufficient sleep or insomnia | Sleep assessment measure | Author recommendations |
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| (1) Ehlers et al. [46], peer-reviewed article | n = 386 AI/AN adult participants from 8 contiguous rural reservations | (i) Short sleep duration present in 15% for those sleeping <6 hours and 30% for those sleeping <7 was associated with age (>30), higher AI ancestry, and having a high school diploma.
(ii) Lifetime diagnoses of substance use disorders, anxiety, and affective disorders were associated with higher PSQI cores.
(iii) Sleep latency was predicted by alcohol use disorders and affective disorders; night/early morning awakenings were associated with anxiety and affective disorders.
(iv) Anxiety and alcohol use disorders were associated with bad dreams. | (i) PSQI | (i) Longitudinal studies to determine the nature of the sleep-mental health disorder relationships.
(ii) Assessment of bad dreams among AI/ANs as a culturally appropriate method of assessing for psychiatric and substance use disorders. |
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| (2) Nuyujukian et al. [47], peer-reviewed article | n = 1,899 AI/AN adults with prediabetes from 36 health care programs in 18 states serving 80 tribes and 11 IHS areas | (i) Short sleep duration (present in more than 40% of the sample), but not long sleep duration, was associated with increased diabetes risk among AI/ANs with prediabetes. BMI and weight loss reduced these relationships so that they were no longer significant.
(ii) Correlates of short sleep duration included the following: higher BMI, higher comorbidities, lower levels of physical activity, unhealthy diet, and worse self-reported health. | (i) Single item: “how many hours a night do you sleep on average?” | (i) The addition of sleep education to diabetes and weight loss problems.
(ii) Further investigation into the reasons for the short sleep duration among AI/ANs. |
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| (3) Chapman et al. [48], peer-reviewed article | n = 11,507 AI/AN adult participants from a national sample: BRFSS 2009–2010 data | (i) Prevalence of insufficient sleep was higher among AI/ANs compared to Whites (34.2% vs 27.4%). Frequent mental distress + demographics and obesity and lifestyle indicators reduced this relationship to nonsignificance.
(ii) Insufficient sleep was associated with physical inactivity, frequent mental distress, smoking, and binge drinking. | (i) Single item: “during the past 30 days, for about how many days have you felt you did not get enough rest or sleep?” | (i) CBT-I and sleep education as interventions for addressing sleep to promote health and prevent disease among AI/ANs.
(ii) Studies of health interventions addressing frequent mental distress among AI/ANs. |
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| (4) Sabanayagam et al. [49], peer-reviewed article | n = 449 AI enrolled tribal members ages >55 from the US southeast region | (i) Short sleep duration prevalence was 15% and was associated with smoking, depression, chronic pain, and back pain; women reported difficulty falling asleep at higher rates than men.
(ii) CVD was highest among those with short sleep duration and lowest among those sleeping seven hours after adjusting for confounds.
(iii) Daytime sleepiness and difficulty falling asleep were also associated with CVD; with all three sleep variables taken into account, only daytime sleepiness was significantly associated with CVD. | Three items:
(i) Sleep duration: “on average, how long do you sleep per night?” and “how many total hours do you sleep in an average 24-hour period?”
(ii) Daytime sleepiness: “how often do you fall asleep during the day against your will?”
(iii) Difficulty falling asleep: “how often do you have difficulty falling asleep or staying asleep?” | (i) Further studies in order to confirm findings.
(ii) The addition of sleep interventions in CVD intervention programs among AI/ANs if current findings are confirmed by further studies. |
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| (5) Ehlers et al. [53], peer-reviewed article | n = 219 AI participants, ages 18–30 from 8 contiguous reservations in the US | (i) Prevalence of short sleep duration was not reported. AI participants had higher overall PSQI scores, longer sleep latencies and longer sleep durations, and more problems with breathing and bad dreams compared to Mexican Americans.
(ii) For the overall sample, binge drinking predicted longer sleep latencies, bad dreams, higher PSQI scores, and more problems with breathing after adjusting for demographics. | (i) PSQI | (i) Assessment of sleep quality, including difficulty falling asleep, sleep quality, and bad dreams in AI/AN young adults.
(ii) Longitudinal studies examining associations between binge drinking and PSQI scores. |
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| (6) Taylor et al. [50], peer-reviewed article | n = 74 AI/AN active duty service members | (i) Prevalence of insomnia was highest among AI/ANs (33.7% vs 15.1%–21.4% for other races/ethnicities) and were associated with older age, more military deployments, longer military careers, more marriages, and more children.
(ii) Those with insomnia had higher rates of childhood abuse, more severe mental health symptoms, more recent stressful events, lower unit cohesion, and lower trait resilience levels.
(iii) Predictors of insomnia (among all groups) after controlling for demographics included lower levels of social support, unit cohesion, childhood physical neglect, back pain, extremity pain, history of head injury, number of marriages, depression, PTSD severity, fatigue, anxiety, alcohol use, and stressful life events. | (i) ISI | None specific to AI/ANs; the following were made regarding military personnel:
(i) Experimental, prospective, and intervention research in order to clarify the relationship the direction of the sleep-mental and physical health associations.
(ii) Assessment and treatment of insomnia.
(iii) Large-scale longitudinal studies to clarify relationships among sleep disorders, comorbidities, and correlates.
(iv) Treatment studies that address the specific needs of military personnel. |
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| (7) Arnold et al. [55], peer-reviewed article | n = 80 AI adolescents enrolled in the Lumbee tribe, ages 11–18 | (i) Prevalence was not reported. Mean time in bed was 8.1 hours, with a range from 5–10 hours. Sleepiness was associated with depression but not suicidality while time in bed was not associated with depression but with decreased odds of suicidality; lower levels of connection to Lumbee culture and nonheterosexual orientation were associated with depression.
(ii) Less time in bed and depression predicted suicidality; depression was associated with sleepiness, suicidality, and self-esteem. | (i) ESS (modified)
(ii) Two items measuring average time in bed: “(1) what time do you usually go to bed if you have school the next morning?” “(2) what time do you usually wake up on school days?” | (i) Comprehensive assessment of sleep problems among AI youth with depression/suicide risk.
(ii) Treatment of sleep problems in order to improve AI/AN mental health.
(iii) Development of culturally sensitive interventions for depression and suicidality. |
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| (8) Shore et al. [51], peer-reviewed article | n = 305 adult participants from the Northern Plains (PRA) | (i) Difficulty sleeping was reported by 28% of those with PTSD vs 13.4% for those with no trauma and 21% for those with at least one trauma.
(ii) Those with combat-related PTSD indicated higher rates of difficulty sleeping (45.4% vs 25.4%) compared to the overall sample.
(iii) No health correlates in addition to PTSD were reported. | (i) Five items from the Mississippi Scale for Combat-Related PTSD for difficulty sleeping and nightmares: trouble sleeping, nightmares, awakening due to nightmares, daydreams, and fear of going to sleep at night. | (i) Clinician awareness regarding high rate of nightmares and sleep disturbance among AI veterans.
(ii) Clinician awareness of the importance of dreams for AIs as well as education regarding their patient’s specific tribes and their beliefs about dreams.
(iii) Assessment of every patient’s cultural background including cultural identification, beliefs, and practices.
(iv) Further research to improve the provision of culturally appropriate care by investigating the meaning, context, and frequency of nightmares among AI/ANs with trauma and PTSD.
(v) Consideration of referrals to traditional healers or cultural consultants for those with strong AI/AN identification. |
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| (9) Cook and Burd [56], peer-reviewed article | n = 115 AI/AN children, ages 7 to 20, from two reservation schools | (i) Prevalence of insomnia symptoms or insufficient sleep was not reported. Six factors emerged in factor analysis: (1) unusual or sensational behaviors (reluctance to accept the conventions of sleep),(2) insecure, fearful behaviors, (3) Daytime napping and fatigue, (4) waking up difficulties, (5) Physical discomfort and pain, and(6) difficulties falling asleep.
(ii) Health correlates were not reported. | (i) PSDQ (scale items were taken from the SHQ, developed by one of the authors). | (i) Further research and refinement of the scale in an effort to improve diagnosis and treatment of sleep disturbance.
(ii) The measure was found to be appropriate for use with AN/AI youth seen at the authors’ clinic, but the investigators highlighted a need for refinement of their measure to improve diagnosis and treatment. |
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| (10) Farrell [52], dissertation | n = 232 students, ages 12–21 from a national sample who self-identified as AI/AN | (i) 25% of participants were identified as having insomnia.
(ii) “Insomnia” predicted depression but not suicidal ideation or suicide attempts in this sample. | (i) Single item from the General Health Questionnaire: “trouble falling asleep or staying asleep” during the past 12 months. | (i) Further research examining sleep and suicidality in AI/AN groups by region and in groups or communities with high suicide rates.
(ii) Use of these research findings in prevention, assessment, and treatment of suicide among AI/AN adolescents. |
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| (11) Liu et al. [20], government document | n = ∼11,500 AI/AN adult participants from a national sample: BRFSS 2014 data | (i) AI/AN participants had lower prevalence of healthy sleep duration compared to Whites (59.6% vs 66.8%).
(ii) Health correlates were not reported. | (i) Single item: “on average, how many hours of sleep do you get in a 24-hour period?” | (i) Provision of healthy sleep through health education and behavior change.
(ii) Address insomnia symptoms with improved sleep habits or psychological or behavioral therapies.
(iii) Regarding sleep aids (either over the counter or prescription), the authors state that there are no recommendations by professional sleep organizations regarding efficacy or safety. |
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| (12) Hobbs [54], dissertation | n = 58 AI/AN nurses, ages 25 to 61 | (i) Prevalence of insufficient sleep was not reported. Sleep length (calculated by Actiware™ data using a subsample) was short for the overall sample (5 hours and 34 minutes for AI/AN and 6 hours and 10 minutes for White nurses); this difference was nonsignificant.
(ii) Sleep efficiency ratio was lower for AI/AN nurses in the subsample; they had more frequent wake after sleep onset, reported more difficulty falling asleep, and took fewer and shorter naps compared to White nurses. | (i) ESS
(ii) Actiwatch™
(iii) Activity and sleep diaries
(iv) Eight self-report items assessing sleep habits: satisfaction with sleep, sleep quality, restfulness after sleep, waking up earlier than intended, difficulty falling asleep, and use of sleeping pills, over-the-counter sleep aids, or alcohol as a sleep aid.
(v) Early/Late Preferences Scale | (i) Hospital administrators might want to consider the effects of short sleep duration on mistakes by nurses working nightshifts.
(ii) Further studies examining situational sleepiness with larger, more diverse samples.
(iii) Further studies examining the effects of tobacco on sleep among AI/AN nurses. |
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