Social, Cultural, and Environmental Influences on Sleep · • Prior to the late 1700s co-sleeping was the norm in all societies. • Today in many cultures the practice of co-sleeping

Social, Cultural, and Environmental

Influences on SleepBonita Chamberlin, Ph.D.

2018 Focus Fall Conference

for Respiratory Care, Sleep Medicine and Pulmonary Diagnostics

Irvine, CA

September 14-15, 2018

Institute for Continuing Education � https://ceu.org



Sleep Mythology Throughout History

• A great deal is

written about China,

and the metaphors of

awaking after a long

slumber are

common.

• Napoleon “said that

when the Chinese

giant awoke, the

world would

tremble.”


• Hypnos was the god of sleep in Greek mythology. (Roman mythology=Sommus) He is depicted in myth and literature as a gentle, benevolent force who brings the restorative gift of sleep to mortals and gods alike.

• Hypnos and twin brother , Thanatos, the god of peaceful death, were often portrayed together in myth and art. The pair cooperated on a number of occasions.

Personification of Sleep


The Family Tree of Hypnos

Father: Erebus, the deity of Darkness

Mother: Nyx, the deity of the Night.

Wife: Pasithea, the deity of hallucinations

Sons:Morpheus: The Winged God of Dreams, able to take any human form in dreams.

Phobetor: He was the one who created the scary dreams; the personification of nightmare, taking the form of huge and scary animals.

Phantasus: He was the one creating the fake and illusional dreams, and had no animus form.

Ikelos: He was the one creating the true dreams,making them more realistic.


In Art

• Artists have found sleep a fascinating subject,

among them: Sandro Botticelli, Henri Rousseau,

Vincent van Gogh, Francisco de Goya, Giorgione.

• Aside from being some of the most imaginative

and renowned makers in the history of art, these

old masters share a common interest: depicting

the mysterious state of sleep.


Ode to the God of Sleep


Vincent Van Gogh, “Noon: Rest from Work”, 1890


John William Waterhouse, “Sleep and His Half-brother Death,” 1874


Henri Rousseau, “The Sleeping Gypsy,” 1897


John Singer Sargent, “Repose (Nonchaloire),” 1911


Sandro Botticelli, “Mars and Venus,” ca. 1483


Giraffe Dreaming


In the Jewish Religion

• Why did God design sleep and rest? Perhaps God works best at night, when we’re sleeping.

• Do you recall when the Hebrew day begins? At dusk, when the sun is going down, not in the morning when it is coming up, as we think of a new day.


The Kabbalah of Sleep

When discussing sleep, there are always two sides of the coin: the body and the soul.

• For the body's perspective, the Talmud refers to sleep as 1/60th of death -- and for good reason. Our eyes are closed. Conscious powers become weakened, and we lose control of many of our faculties.

• Yet, for the soul, it is a time of rejuvenation.

• According to the Kabbalah, the soul's essential powers are in fact strengthened and more apparent while one is asleep.


In Fairy Tales

The Princess and the Pea



Rip Van Winkle



Objectives

1. Discuss the various cultural influences on sleep.

2. Identify and review the validity of a universal

pattern of sleep.

3. Explain how different societies define what is

problematical about sleep and how to solve the

issues and difficulties that arise in and around

sleep.

4. Discuss the diversity of coping mechanisms

developed for dealing with sleep related

problems/disorders.

Institute for Continuing Education � https://ceu.org Institute for Continuing Education � https://ceu.org

• During a 24-hour day, over a billion people revert to a

primitive but still not yet understood behavior: they sleep.

• Apart from the sheer biologic inevitability of sleep, the

cultural, social, and broadly defined environmental factors

that affect this state are fascinating.

• Planes fly, dogs bark, babies cry, families share bedrooms for

sleep or provide overnight care, and nocturnal road traffic

punctuates the silence.

• The seasons come and go, with their changes in light,

temperature, and air quality.

• For some, life in a war zone threatens security and safety at

night.

• Segments of society or entire cultures may discourage (or

encourage) naps.

• In many countries, substantial proportions of the workforce

perform shift work.


What is Culture?

A group’s values, norms,

practices, and ways of life


Criteria for Defining Culture

1. Having a common pattern of communication, sound system, or language unique to the group;

2. Similarities in dietary preferences and preparation methods;

3. Common patterns of dress;

4. Predictable relationship and socialization patterns between members of the culture;

5. A common set of shared values, beliefs and behavior.

6. What is accepted and not accepted.


Cultural Factors versus Biological Factors

• Sleep is a biological factor.

• Sleep is an interplay between culture and biology.

• Many sleep practices are unique to culture.

• Cultural factors are important determinants of sleep practices and behaviors and influence the type and frequency of sleep problems.


Sleep as a Basic Human Need

• As life gets busier, the combination of urban life and increasing noise pollution means people all over the world are reporting sleep problems.

• It costs billions in lost work productivity, and fatigue has been partly to blame in major calamities like the Exxon Valdez Oil spill and the Chernobyl nuclear disaster.

• And then there’s the personal cost to one’s mental and physical health.


Western Ritual of Sleep

• In the urban middle-class of the Euro-American

societies we find a particular pre-sleep bedtime

“ritual” that is ideally characterized by certain

features:

– It usually takes place within the nuclear family;

– It is centered on the private space of a bedroom;

– It includes a patterned set of activities centered on an

evening meal, bathing special clothing and toys, stories

and lullabies, tucking or coddling the child, and then

leaving the child alone in its room.


A Surprising Twist to the Familiar Ritual

of the Simplicity of Sleep

• It simply doesn’t apply to people currently living outside of the modern Western world.

• Findings rip the covers off any thought that people everywhere sleep pretty much alike.

• Until recently, anthropologists have rarely scrutinized the sleep patterns and practices of different cultures, much less those of different classes and ethnic groups in the United States.


Personal Experience

• Anthropologist

• Lived and worked internationally in over 50

countries for over 35 years

• Worked at the grass roots level and became aware

of the different sleeping mechanisms.

• This included people in everyday environment,

during war, and in refugee camps


Outline

• Scope and impact of sleep problems in children;

• Examination of sleep practices in different cultural

settings, including;– co-sleeping– bedtime rituals– the sleeping environment– napping– and parental expectations regarding “normal” sleep in

children.

• Impact on clinical and educational cross-cultural

collaboration;

• Need for future research to explore cultural

differences and similarities.


Co-sleeping“A baby must not sleep in an empty room alone, and an adult must keep watch next to it.”

Korean proverb

• Solitary infant sleeping is principally a western practice which

is quite young in terms of human history.

• Prior to the late 1700s co-sleeping was the norm in all

societies.

• Today in many cultures the practice of co-sleeping continues,

with babies seen as natural extensions of their mothers for the

first one or two years of life.

• Co-sleeping in such cultures is seen as best for both babies and

mothers; the western pattern of placing small infants alone in

rooms of their own is seen as aberrant.


Attitudes Toward Co-sleeping

• Co-sleeping from birth is recommended by La Leche

League International, the world’s leading breastfeeding

organization.

• The benefits of co-sleeping to the nursing couple

include increased access with less disturbance of sleep

for both mother and infant.

• In spite of frequent arousals, mothers report that they

get more sleep co-sleeping than they do sleeping apart

from their babies.


• An additional benefit of co-sleeping and unrestricted

night nursing is natural child spacing.

• Co-sleeping is also reported to lead to a reduction in

night fears and to the fulfillment of the maternal

protective instinct.

• Many co-sleeping advocates also believe that co-sleeping

ultimately leads to more confident and independent

children.

• In China, the prevalence of regular bedsharing was

18.2% and as high as 55.8% in 7-year-olds;

• Rates of co-sleeping in Japan within the same group are

59%.


• In America, the infant is seen more as a dependent

biological organism who needs to be made increasingly

independent of others.

• Indeed, “...the Japanese think the U.S. culture rather

merciless in pushing small children toward such

independence at night”.

• “An American mother -infant relationship consists of

two individuals...On the other hand, a Japanese mother

infant relationship consists only one individual, i.e.,

mother and infants are not divided.” Japanese infants

and children usually sleep adjacent to their mothers,

fathers or extended family members through the age of

15.

• In Korea, 73.5% of mothers approved of bedsharing

between 3 and 6 years old.

• In Italy there is a 3.5% prevalence of co-sleeping among

10- to 11-year-old children.

• In Swiss children the prevalence of bedsharing between

the ages of 1 month and 10 years was at 38%.

• In contrast, a recent U.S. survey indicated that only 9.2%

of infants usually shared a bed with parents, with African-

Americans, Hispanics, and Southeast Asians, having the

highest rates.

• In the U.S., co-sleeping is often associated with lower

socio-economic status, less parental education, and

increased family stress.


• Shared spaces feature constant background noise from

other sleepers, domestic animals, fires maintained for

warmth and protection from predators, and other

people’s nearby nighttime activities.

• Communal sleep equals safe sleep, because sleepers can

count on there being someone else up or easily

awakened at all hours of the night to warn others of a

threat or emergency.


In clinical pediatrics, co-sleeping is the

political third rail. “If you touch it, you die”.

• Be aware of your cultural background in thinking about what

constitutes “normal, healthy and desirable” infant sleep –

characteristic of Western society, and others’ cultural values,

concerns for morality, and sleeping arrangements.

• Data collected on the solitary sleeping, bottle-fed infant

continue to provide the basis for definitions of, and research

into, clinically “normal” infant sleep-wake patterns.

• These data continue to serve as the gold standard

against which, parents and professionals evaluate

infant sleep development.


Sudden Infant Death Syndrome

• Contact with a parent’s body helps regulate an infant’s

breathing and other physiological functions, perhaps

lowering the risk for sudden infant death syndrome.

• A Vietnamese mother was told about sudden infant

death syndrome, with which she was unfamiliar. She

surmised that “...the custom of being with the baby

must prevent this disease. If you are sleeping with

your baby, you always sleep lightly. You notice if his

breathing changes...Babies should not be left alone”.

• Further to the point, another of the Vietnamese

mothers added: “Babies are too important to be left

alone with nobody watching them”.


Monophasic versus Polyphasic Sleep

• Polyphasic sleep is a variant of a sleep pattern that is

in opposition to monophasic sleep.

• In monophasic sleep, an individual or an animal

sleeps in a single block during a single wake-sleep cycle

of 24 hours.

• Polyphasic sleep is also set apart from a biphasic

sleep in which there are two blocks of sleep in 24

hours, i.e. the night sleep and the typical Latin siesta.


Monophasic versus Polyphasic Sleep

• Babies also sleep polyphasically, and gradually lose

their nap slots until they become roughly biphasic

around the age of one.

• Adults are largely biphasic. Although a majority of

westerners do not nap on a regular basis their alertness

shows a slump in the middle of the day.


Uberman’s Sleep Schedule

The theory behind Uberman’s Sleep Schedule is that with some effort, we can train our brain to sleep along the ancient polyphasic cycle and gain lots of waking time on the way, mostly by shedding the lesser important stages of sleep.


Environment

• One major source of differences in sleep is the widespread availability of artificial light, which has led to significant changes in the sleep patterns in the industrialized west.

• It seems likely that today we sleep at least an hour less each night than was the custom even a century ago, and probably several hours less than before industrialization and electricity.

• According to some studies, artificial lighting has encouraged both a later sleep onset time but also the tendency to sleep in a single concentrated burst throughout the night (monophasic sleep), rather than the more segmented and broken-up sleep patterns (polyphasic or biphasic sleep) still found in many societies.


Japan

• People work such long hours they are at risk of karoshi, or death from overwork.

• “One of the interesting cultural features of Japan that makes it quite distinct from Northern Europe is the tolerance of sleep in what...would be considered inappropriate times and inappropriate places.

• People in Japan are quite happy to sleep almost anywhere.


It is socially acceptable in Japan

of a unique form of napping

called “inemuri” (literally, ‘to be

present and sleep’), in which the

sleeper is in a situation not

ordinarily meant for sleep such

as at work or at a social event.


Napping

• There is growing literature on the subject of daytime

napping and its relationship to nighttime sleep patterns

and biologically driven total sleep requirements.

• The term “siesta culture” is widely used to refer to

cultures that sanction napping by adults.

– “nap” cultures—in which individual or collective napping occurs and is considered normal but other aspects of social and institutional life continue (e.g., Japan)

– “siesta” cultures, redefined to refer specifically to those societies in which nap or rest time at the heat-filled midday is institutionalized to the extent that businesses and government offices close down and ordinary public social interaction ceases for the duration (e.g., Italy, Mexico, Spain.)


• Cultures that institutionalize napping stand in strong

contrast to the American and Northern European

monophasic sleep culture.

• In these, daytime sleep is discouraged and avoided (or

relegated to socially recognized “time-out” occasions such

as weekends and vacations) except for infants and young

children.

• Preschool or day care settings for American children

frequently have institutionalized and enforced nap times as

part of their daily routines.


• Although in countries around the Mediterranean and in

South America, Africa, and Asia a biphasic sleep pattern is

still predominant, daytime napping as a cultural standard is

slowly disappearing.

• In some countries such as Chile, Greece, and, more

recently, China, the disappearance of the once-

institutionalized siesta

has been accelerated by governmental decree.

• On the whole, with globalization and ‘24/7’ economies,

daytime napping as a cultural standard is slowly

disappearing.


Sleeping Environment

• Sleeping rooms and sleeping surfaces also differ across

cultures.

• Japanese children and parents often sleep in the same

room, but they often sleep on futons that are spread out

in the middle of the room with their edges almost

touching during the night.

• In this way a parent can easily reach out to calm or

comfort a child, and can readily roll over and join the

other parent.


• In India, infants typically sleep carried in close physical

proximity to their mothers in a pouch-like arrangement, or in a

traditional ‘cloth cradle’ sling suspended from bamboo poles.

• Older infants sleep in wooden cradles, cotton beds, or bamboo

mats, all of which are placed in a communal living space rather

than a separate ‘bed room’.

• Italian parents reported it customary and preferable to have

infants sleep in their rooms with them, irrespective of

availability of separate rooms for children and parents.

• Many cultures consider the American norm of putting children

to bed in separate rooms to be ‘unkind’.

• In comparison to non-Western societies, the ‘optimal’ sleeping

space in Western settings is also much more likely to be free

of or provide minimal sensory stimulation (noise, light,

odors, temperature extremes).


Thumbsucking and Transitional Objects

• The use of “sleep aids” by young children is part of the

process by which they learn to sleep alone.

• In the absence of a parent or attachment figure, a young

child might adopt a “special object” (blanket, favored

toy, or stuffed animal) to which they attribute special

qualities.

• These objects serve to comfort a young child during

awakenings or while falling asleep.

• In western cultures the use of transitional objects is

depicted as a natural stage through which all children

pass.

• Use of such objects, however, is not universal, but again

dependent upon the social context within which

a child’s nightly sleep experience begins and ends.


What are “Sleep Problems”?

• Most conceptualizations of “sleep problems” are

based on culturally and parentally-constructed

definitions and expectations, not biology.

• In reality, infant sleep development plays out

differently in diverse family settings wherein infant

feeding and nighttime nurturing behaviors, and

parental needs and goals, vary.

• The legitimacy of these variations continue to be

largely ignored in both professional as well as popular

discourse and a “one size fit all” approach to sleeping

arrangements continues to be advocated.


Problem—Vulnerable Populations

• Children at high risk for developmental and behavioral

problems are even more likely to experience ‘double

jeopardy’ as a result of sleep problems.– chaotic home environments

– chronic medical issues

– and neglect

• They are also less likely to be diagnosed with sleep

problems because of limited access to healthcare

services.

• They are less likely to receive adequate treatment and

more likely to suffer serious consequences from those

sleep problems.


Case Study—Afghanistan

• Sleeping persons are unable to control their environment and

are obliged to devise means of protection in this heightened

state of vulnerability.

• This is even more acute when night-time fears add to

insecurity, as it is the case in refugee camps at unstable border

zones

• Sleep integrity is overshadowed by the possibility of natural

disasters as well as such potential dangers as exposure to

domestic and gender-based violence, burglary and attacks on

refugee camps

• Refugee settlements are located on the territory of nation

states, so refugees are excluded from the legal protection

applied to citizens.





Mothers swaddle babies secured with a rope to prevent them from moving. For most of the day, the infant lies in a wooden cradle. Afghans believe babies are happier the more tightly they are bound.


• Ethnic and cultural differences can strongly

influence the sleep experience.

• A study examined whether differences in culture

and ethnicity, socioeconomic and health factors,

and coping styles influence sleep patterns among

women living in the U.S.

• A multiethnic sample of 1,440 women living in

Brooklyn included African Americans, English-

speaking Caribbeans, Haitians, Dominicans,

Eastern Europeans, and European Americans.

Insomnia


• Data show that 77% of women of Eastern European

ancestry had the highest rate of insomnia symptoms;

• 70% other white (European American) women expressed

similar symptoms, as did 71% African-American women

and 73% Dominicans .

• Only 34% of English-speaking Caribbean women and 33%

of Haitians reported having insomnia. Better coping

mechanisms may explain the low rate of insomnia among

English-speaking Caribbeans and Haitians.

• Differences in socioeconomic status and health seemed to

influence the various outcomes.

• Women from Eastern Europe reported more physical

ailments than other women in the study; however, white

women, in general, were more likely to seek medical

attention than African-American women.


Lack of Sleep

• Lack of sleep can impair concentration, increase anxiety,

and lead to depression.

• People who work too hard are already impairing their

bodies.

• It also can increase the risk for heart disease and diabetes.

• If you look at very large populations and you look at the

people who sleep the least, they, in epidemiological

terms, die the fastest.

• Understanding the social and cultural factors that

contribute to insomnia may shed new light on this

troublesome condition.


Prone versus Supine (SIDS)

• 20 years ago researchers found that prone sleeping

newborns slept longer and deeper than did supine

sleeping infants.

• That is, infants sleeping on their backs experienced

twice as many motor activities during sleep and more

awakenings than did prone sleeping newborns.

• Since the goal is to promote sleep, and not awakenings,

it is easy to understand why these earlier data provided

evidence for why infants should be placed in the prone

position.


• Yet, it has been suggested that some infants who die

of SIDS perhaps cannot arouse or awaken easily or

fast enough to terminate a cardio-respiratory crisis

during sleep, especially while in deep sleep where

arousal thresholds are higher.

• These findings raise the possibility that the supine

sleep might well be safer precisely because of the

increased arousal and motor activity which

accompanies it, even though the implications of this

possibility conflicts with cultural strategies to

promote early “deep” sleep in infants as early in life

as possible.


Sudden Death During Sleep of SE Asians

Sudden and unexpected death during sleep occurs among adult

Southeast Asian refugees in the United States.

• On average, the annual rate of sudden death among men,

ages 25-44 years, in the U.S. was:

– 92/100,000 among Laotian, Hmong and Cambodians

(equivalent to the sum of the rates of the leading five

causes of natural death among U.S. men of the same

group)

• Sudden death during sleep has also been reported in:

– Filipinos in the Philippines, United States, and Guam;

– Japanese in Japan;

– Natives of Guam

– Chinese immigrants in the Philippines


Asian Sudden Death Syndrome versus

Western Populations

• Among Western adults, sudden death is strongly

associated with atherosclerotic heart disease, not

associated with sleep, and is more likely to occur with

increasing age.

• The Southeast Asian victims of sudden death were

remarkable in their absence of cardiovascular disease.

Coronary atherosclerosis was absent or minimal in 45

of 49 cases reviewed.


Conclusion

• Western societies treat sleep more as an unavoidable

stretch of downtime than as a prelude to sex or a time for

inner reflection. Only intensive investigations across

cultures and classes will illuminate the lushness of sleep’s

landscape.

• We are going to have to reconceptualize what it means to

sleep normally.

• The traditional sleep research paradigm is inadequate for

the diversity of family sleep practices it must and should

accommodate.


Be Aware of Your Cultural Values

• Keep in mind cultural influences on the advice you give.

• Children who have difficulty falling asleep alone at bedtime,

who wake at night and ask for parental attention, or who

continue to nurse at night—is problematic only in relation

to our (Western) society’s expectations.

• Your advice on transitional objects, breast feeding, co-

sleeping may be biased toward traditional Euro-American

views of childrearing, especially those about bedtime and

nighttime behavior.

• In giving advice about sleep be aware of your own cultural

values, examine closely your patients’ cultural and family

contexts, and assess parental reactions to children’s sleep

behaviors.


Summary

• It is clear from this discussion that cultural issues not

only shape how children and families sleep and the

types of sleep problems they experience, but must also

be a key consideration in determining future research

directions in sleep and education of both healthcare

professionals and the public.

• Increased cross-cultural sleep research is critically

needed not only to improve the standard of care

across nations, but to enhance basic knowledge about

the causes and impact of sleep disorders.


• There is also a critical need for patient/parent educational

materials regarding normal sleep, healthy sleep patterns

and behaviors, and signs of sleep problems that are

appropriately tailored for differences in literacy level,

language, cultural values, and knowledge level of the target

audience.

• Finally, availability of clinical sleep diagnostic and

treatment services for children, especially subspecialty

expertise, varies, but in general in most countries is

inadequate, even in urban centers.

• Therefore, there is an urgent need to share clinical

resources regarding the diagnosis and treatment of sleep

problems in children such as educational materials, sleep

questionnaires, behavioral treatment strategies, etc.


• Culturally-competent healthcare involves awareness

of one’s own cultural sensitivities and biases, implies

an adequate knowledge base regarding culturally

based patient beliefs and practices.

• It also includes the acquisition of cultural skills such

as the use of culturally-appropriate language and the

consideration of culture in assessment and treatment

of patients, and requires exposure to and encounters

with cultural issues in clinical practice.

• Thus, culturally competent care is, ultimately,

individualized care that is mindful of and responsive

to the experience of health and illness from the

patient’s and family’s perspective, and should be the

goal to which, as sleep medicine professionals, we

should aspire.


Documents

Social, Cultural, and Environmental Influences on Sleep · • Prior to the late 1700s co-sleeping was the norm in all societies. • Today in many cultures the practice of co-sleeping