Dayna A. Johnson, PhD, MPH, MS
The high prevalence of sleep disorders is a public health burden. There is a large proportion of society with an undiagnosed sleep disorder and therefore untreated. Sleep disorders can have an impact on the quality of life and are associated with adverse health outcomes including mortality. Because of the dire consequences, it is imperative to understand the barriers to diagnosis and care.
Certain populations such as individuals of lower socioeconomic status, those who reside in disadvantaged areas (e.g., rural communities) and racialized minority groups are met with significant challenges that serve as barriers to diagnosis and care for sleep disorders. The barriers range from individual-level factors to structural factors, which are interconnected. In other words, individuals are nested in broader contexts that shape individual behaviors and adherence to treatments. Understanding and addressing the barriers requires a holistic approach to consider individual behaviors, living environments, and policies.
One major significant barrier to sleep apnea care is diagnosis. Unlike other health behaviors or conditions such as diet, physical activity or blood pressure, there are limited campaigns around identifying symptoms of sleep disorders. This is important for educating the public on identifying potential risks for sleep disorders. The Office of Disease Prevention and Health Promotion’s Healthy People 2030 set a goal to increase the proportion of adults with sleep apnea symptoms who get evaluated by a health care provider. However, the progress toward this goal is little or has no detectable change. It will be important to consider the barriers to diagnosis to meet this goal.
Lack of access to a sleep clinician can hinder receiving a diagnosis and treatment. Being uninsured or underinsured can be a significant limitation to accessing a specialist and receiving treatment. For those who may be underinsured, they may encounter barriers such as delays in patient care due to challenging insurer policies. There are also limited sleep specialists in some areas, creating several months of wait periods to see a physician. While there is a shortage of providers delivering certain sleep therapies such as cognitive behavioral therapy for insomnia, it is critical to consider other health professionals who can be effectively trained to deliver this therapy. This strategy may increase availability to a sleep specialist.
Transportation and type of employment can also be barriers to care. Depending on the location of the sleep clinic, it can be expensive or involve a long commute time to the health care facility. Most medical offices have traditional work hours, which can be a barrier for someone who is a low-wage employee with limited time off or no paid time off. Further, undergoing a sleep study overnight in a laboratory may not be possible for some individuals. Thus, this process of diagnosis disregards single parents who may not have childcare overnight or individuals who work multiple jobs. Ideally, use of in-home sleep screening could be beneficial, but it may only advantage certain groups.
While telemedicine is an avenue to increase access to care, this only benefits a fraction of society. Further, as technology advances, individuals of lower socioeconomic status tend not to benefit from these advances due to the persistent digital divide that exists in society. There are populations that do not have access to smartphones and/or the internet to engage in a telemedicine appointment. While the integration of sleep data from wearables into medical practice is promising, there are entire populations that will not benefit from this advancement. The challenge to medical providers will be to remove the geographic/transportation and technology barriers and “meet the people where they are” by providing sleep specialists in the community.
In increasing access to care, it is important that primary care/family doctors are knowledgeable about sleep disorders to either make a proper referral or provide a treatment. There is a limited amount of time to interact with a health care provider at an appointment. As a result of the limited time and/or clinician knowledge around sleep, sleep health or sleep disorders are frequently not discussed. In combining the lack of discussion initiated by the provider with lack of individual knowledge around symptoms, a sleep disorder may go unnoticed. Therefore, many of these barriers are interrelated and can prevent proper care.
Systemic inequities are also barriers to care. Clinicians can hold different biases, which can determine whether they provide a certain treatment or make a referral based on whether they believe someone will adhere to the recommendation. These biases are often rooted in stigma and discrimination, which can exacerbate sleep disparities. Supported by egregious historical events, there is a mistrust that is held by certain communities with the health care system. This mistrust may prevent people, particularly those who are most-at-risk, from getting care. It is vital to ameliorate medical mistrust.
Lastly, removing barriers to care involves understanding and addressing social determinants of sleep health/disorders. We must create policies that provide proper insurance regardless of employment status, educate the public on sleep disorders, enhance resources, and make culturally competent sleep specialists available in the communities who need them most. I challenge my colleagues to consider the circumstances their disadvantaged patients may encounter and develop culturally relevant treatment strategies that enhance access to care.
Dayna A. Johnson, PhD, MPH, MS, is an assistant professor in the Department of Epidemiology at Rollins School of Public Health at Emory University in Atlanta.
This article appeared in volume eight, issue four of Montage magazine.
