Behavioral Sleep Medicine

ISSN: 1540-2002 (Print) 1540-2010 (Online) Journal homepage: http://www.tandfonline.com/loi/hbsm20

Individual Correlates of Sleep Among Childbearing

Age Women in Canada

Lydi-Anne Vézina-Im, Alexandre Lebel, Pierre Gagnon, Theresa A. Nicklas &

Tom Baranowski

To cite this article: Lydi-Anne Vézina-Im, Alexandre Lebel, Pierre Gagnon, Theresa A. Nicklas
& Tom Baranowski (2018): Individual Correlates of Sleep Among Childbearing Age Women in
Canada, Behavioral Sleep Medicine, DOI: 10.1080/15402002.2018.1435547

To link to this article: https://doi.org/10.1080/15402002.2018.1435547

Published online: 13 Feb 2018.

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BEHAVIORAL SLEEP MEDICINE
https://doi.org/10.1080/15402002.2018.1435547

Individual Correlates of Sleep Among Childbearing Age Women in

Canada
Lydi-Anne Vézina-Im a, Alexandre Lebelb,c, Pierre Gagnonc, Theresa A. Nicklasa,
and Tom Baranowskia
a
Children’s Nutrition Research Center, Baylor College of Medicine, Houston, Texas, USA; bGraduate School of Urban
Planning and Land Management, Laval University, Quebec City, Quebec, Canada; cEvaluation Platform on Obesity
Prevention, Quebec Heart and Lung Research Institute, Quebec City, Quebec, Canada

ABSTRACT
Objective/Background: Women of childbearing age (WOCBA) may be at
high risk for short or poor sleep. Yet few studies have focused on this
population. The study objective was to identify individual correlates of
sleep duration and quality among WOCBA. Participants: The sample con-
sisted of 9,749 WOCBA aged 18–44 years from the Canadian Community
Health Survey 2011–2014. Methods: All variables were self-reported. Sleep
duration was dichotomized as insufficient (< 7 hr/night) or adequate
(≥ 7 hr/night). A composite score of sleep quality was dichotomized as
having sleeping problems none/little or some/most/all the time. Age, eth-
nicity, level of education, household income, mood disorders, parity, geo-
graphical location, fruit and vegetable (FV) intake, physical activity, smoking
and alcohol consumption were tested as correlates of sleep duration or
quality using hierarchical logistic regression. Results: Ethnicity, parity, geo-
graphical location and smoking were correlates of sleep duration; this
model discriminated 56.9% of WOCBA. Ethnic minorities, WOCBA with
many children, living in urban areas and smoking were associated with
lower odds of having adequate sleep duration. Ethnicity, level of education,
mood disorders, geographical location, FV intake, and alcohol consumption
were correlates of sleep quality; this model discriminated 59.0% of WOCBA.
Ethnic minorities, lower level of education, mood disorders, living in urban
areas, low FV intake, and alcohol consumption were associated with lower
odds of having quality sleep. Conclusions: Some WOCBA may be more at
risk for short or poor sleep based on their demographics and health
behaviors. This can be used to identify which WOCBA are most in need of
sleep interventions.

Background
Sleep is part of a healthy lifestyle (Claas & Arnett, 2016) that is important for physical (Itani,
Jike, Watanabe, & Kaneita, 2017) and mental health (Freeman et al., 2017), and a national public
health priority in the United States (U.S.; U.S. Department of Health and Human Services, 2016).
Short sleep has been associated with obesity, diabetes mellitus, coronary heart diseases, hyper-
tension, cardiovascular diseases, and mortality (Itani et al., 2017). Poor sleep quality has been
associated with increased A1c in adults diagnosed with type 2 diabetes (Lee, Ng, & Chin, 2017),
and obesity or high body fat among adults (Rahe, Czira, Teismann, & Berger, 2015). Insomnia is
a risk factor for mental health problems among adults (Freeman et al., 2017).

CONTACT Lydi-Anne Vézina-Im lydi-anne.vezina-im@bcm.edu Children’s Nutrition Research Center, Baylor College of
Medicine, 1100 Bates Street, Houston, TX 77030, USA.
© 2018 Taylor & Francis Group, LLC
2 L.-A. VÉZINA-IM ET AL.

Both sleep duration and quality are important for health (St-Onge et al., 2016). The U.S. National
Sleep Foundation recommends between 7 and 9 hr of sleep among adults ages 18 to 64 years
(Hirshkowitz et al., 2015). Canada developed sleep duration recommendations for children and
youth 5 to 17 years of age (Tremblay et al., 2016), but not for adults. No consensus exists on how to
measure sleep quality. The most common measure of sleep quality in clinical and nonclinical
samples (Mollayeva et al., 2015) is the Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds,
Monk, Berman, & Kupfer, 1989). The PSQI has seven components: overall quality, latency (i.e., time
to fall asleep at night), duration, efficiency (i.e., a ratio of time asleep over time spent in bed),
disturbances (i.e., frequency of awakenings at night), use of sleeping medication, and daytime
dysfunction (i.e., having trouble staying awake and getting things done during daytime; Buysse
et al., 1989).
Comprehensive, empirically based approaches to designing health promotion interventions, such
as Intervention Mapping (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011) and the Behavior
Change Wheel (Michie, Atkins, & West, 2014), recommend identifying the correlates of a given
behavior as the first step in designing effective interventions. Correlates are factors thought to
influence an outcome of interest (Gielen, McDonald, Gary, & Bone, 2008). Few studies have
identified the correlates of sleep (Grandner et al., 2015).
Ecological models of health behavior are based on five principles: (a) there may be multiple levels
of influence on health behaviors; (b) environmental contexts can be correlates of health behaviors;
(c) interactions may exist between the different levels of influence; (d) ecological models should be
behavior-specific; and (e) multilevel interventions should be most effective in changing behaviors
(Sallis & Owen, 2015). According to ecological models (Sallis & Owen, 2015) and previous reviews
on sleep among adults (Grandner, 2017; Jackson, Redline, & Emmons, 2015), the correlates of sleep
can be classified into three broad categories: (a) individual (e.g., demographic, psychological, and
behavioral variables); (b) social (e.g., family); and (c) environmental ones (e.g., physical environment
and policies).
In the 2009 Behavioral Risk Factor Surveillance System (BRFSS) data, individual correlates of
short sleep among U.S. adults included being female, White or Black/African-American, unem-
ployed, without health insurance, not married, younger age, lower income, lower level of education,
lower physical activity (PA), lower fruit and vegetable (FV) consumption, lower overall self-reported
health, larger household size, higher alcohol consumption, and smoking (Grandner et al., 2015). A
number of studies have reported demographic differences including female sex (Carrier et al., 2017;
Nugent & Black, 2016; Walsemann, Ailshire, Fisk, & Brown, 2017), older age (Carrier et al., 2017;
Fischer, Lombardi, Marucci-Wellman, & Roenneberg, 2017; Gadie, Shafto, Leng, & Kievit, 2017;
Schwarz et al., 2017), and ethnic (Grandner, Williams, Knutson, Roberts, & Jean-Louis, 2016;
Jackson et al., 2015; Laposky, Van Cauter, & Diez-Roux, 2016; Malone, Patterson, Lozano, &
Hanlon, 2017; Walsemann et al., 2017; Whinnery, Jackson, Rattanaumpawan, & Grandner, 2014),
and socioeconomic disparities (Grandner et al., 2016; Jackson et al., 2015; Laposky et al., 2016;
Whinnery et al., 2014) in sleep among adults. Behavioral influences have included higher FV intake
(Duke, Williamson, Snook, Finch, & Sullivan, 2017; Patterson, Malone, Lozano, Grandner, &
Hanlon, 2016; St-Onge, Mikic, & Pietrolungo, 2016) and higher PA (Cassidy, Chau, Catt, Bauman,
& Trenell, 2016; Kredlow, Capozzoli, Hearon, Calkins, & Otto, 2015; Soltani et al., 2012), which
would promote sleep, while any smoking (Jaehne et al., 2012; Riedel, Durrence, Lichstein, Taylor, &
Bush, 2004; Wetter & Young, 1994) and higher alcohol consumption (Feige et al., 2006; Geoghegan,
O’Donovan, & Lawlor, 2012; Thakkar, Sharma, & Sahota, 2015) would negatively affect sleep in
adults. Mood disorders such as depression and anxiety disrupt adult sleep (Cox & Olatunji, 2016;
Medina, Lechuga, Escandon, & Moctezuma, 2014; Murphy & Peterson, 2015).
Women were more at risk for short (Grandner et al., 2015) and poor sleep quality (Mehta, Shafi,
& Bhat, 2015; Nugent & Black, 2016), since their sleep can be influenced by menstrual cycle,
pregnancy, and menopause (Mehta et al., 2015). According to data from the U.S. National Health
and Nutrition Examination Survey, women of childbearing age (WOCBA) from 15 to 44 years of age
 BEHAVIORAL SLEEP MEDICINE 3

reported poor sleep quality more frequently compared to pregnant women of the same age range
(Amyx, Xiong, Xie, & Buekens, 2017). Thus, studies investigating the correlates of sleep should be
separated by sex and focus on WOCBA who may be at particular risk for short or poor sleep. To our
knowledge, no study has identified the correlates of sleep among WOCBA. This study identified the
individual correlates of sleep (i.e., demographic and behavioral variables) among WOCBA in Canada
using data from the Canadian Community Health Survey (CCHS).

Methods
Data source and population
Data were from the CCHS, 2011–2014. The CCHS is a repeated cross-sectional annual survey that
collects health information among a nationally representative sample of noninstitutionalized civilian
Canadians aged 12 years and older. The CCHS has three components: core content asked of all
respondents; optional content chosen by health regions; and rapid response modules asked of all
respondents living in the 10 provinces for one collection period. Questions on sleep were part of the
optional content and therefore not asked of participants from all Canadian provinces or territories.
The years 2011–2014 were chosen because they contained information on sleep duration and quality.
Questions on demographics and behaviors related to sleep were part of the core content and thus
asked of all respondents. More detailed information on the CCHS can be found on Statistics
Canada’s website (www.statcan.gc.ca).
The population under study consisted of WOCBA (18–44-year-old females), as defined by the
Centers for Disease Control and Prevention (2015). Pregnant women and those for whom it was not
possible to ascertain whether they were pregnant or not were excluded from the analyses.

Variables
Sleep
Sleep duration and quality were reported by participants. Sleep duration was measured using the
following item: “How long do you usually spend sleeping each night?” Possible responses were:
under 2 hr; 2 hr to less than 3 hr; 3 hr to less than 4 hr; 4 hr to less than 5 hr; 5 hr to less than 6 hr;
6 hr to less than 7 hr; 7 hr to less than 8 hr; 8 hr to less than 9 hr; 9 hr to less than 10 hr; 10 hr to less
than 11 hr; 11 hr to less than 12 hr; and 12 hr or more. Sleep quality was measured with the
following three items: “How often do you have trouble going or staying asleep?”; “How often do you
find your sleep refreshing?” and “How often do you find it difficult to stay awake when you want
to?” (Cronbach’s alpha: 0.48). Possible answers were: none of the time; a little of the time; some of
the time; most of the time; and all of the time. The first item measured sleep latency (i.e., time for
falling asleep at night or having trouble falling asleep) and sleep disturbances (i.e., awakenings at
night or having trouble staying asleep) and the third item measured daytime dysfunction (i.e.,
trouble staying awake and getting things done) according to the PSQI (Buysse et al., 1989). A
composite score of sleep quality was created by summing the answers to the three items. A higher
score (range 3 to 15) indicated poorer sleep quality.

Demographics
Age, ethnicity, level of education, household income, mood disorders, parity, and geographical
location were tested as individual correlates of sleep. Respondents were asked their age in years
and their exact date of birth to confirm their age. Ethnicity was assessed using the following item:
“You may belong to one or more racial or cultural groups on the following list. Are you . . . White,
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.), Chinese, Black, Filipino, Latin American,
Arab, Southeast Asian (e.g., Vietnamese, Cambodian, Malaysian, Laotian, etc.), West Asian (e.g.,
Iranian, Afghan, etc.), Korean, Japanese, Other [Specify]?” South Asian, Chinese, Filipino, Southeast
4 L.-A. VÉZINA-IM ET AL.

Asian, West Asian, Korean, and Japanese were combined into a category labeled “Asian.” Level of
education was measured using the following item: “What is the highest certificate, diploma or degree
that you have completed?” Possible answers were: less than high school diploma or its equivalent;
high school diploma or a high school equivalency certificate; Trade Certificate or Diploma; College,
CEGEP1 or other nonuniversity certificate or diploma (other than trades certificates or diplomas);
university certificate or diploma below the bachelor’s level; bachelor’s degree; and university certi-
ficate, diploma, or degree above the bachelor’s level. Statistics Canada provides a variable in which
these categories are collapsed into four levels of education: less than high school; high school
diploma; some postsecondary studies; and postsecondary certificate, diploma, or university degree.
Household income was measured using the following item: “What is your best estimate of the total
income received by all household members, from all sources, before taxes and deductions, in the past
12 months?” Missing data on household income are imputed by Statistics Canada using statistical
techniques. The presence of mood disorders was measured using the following item: “We are
interested in conditions diagnosed by a health professional and [that] are expected to last or have
already lasted 6 months or more. Do you have a mood disorder such as depression, bipolar disorder,
mania or dysthymia?” (yes or no). A parity variable was created using information on living
arrangement and on household size of the CCHS. Geographical location was measured using the
urban-rural classification of the CCHS and was classified as urban, fringe or rural.

Behavioral variables
FV intake, PA, smoking, and alcohol status were tested as individual correlates of sleep. FV intake
was measured using the following six items: “How often do you usually drink fruit juices such as
orange, grapefruit, or tomato?”; “Not counting juice, how often do you usually eat fruit?”; “How
often do you usually eat green salad?”; “How often do you usually eat potatoes, not including French
fries, fried potatoes, or potato chips?”; “How often do you usually eat carrots?”; and “Not counting
carrots, potatoes, or salad, how many servings of other vegetables do you usually eat?” Participants
could answer in terms of times per day, week, month, or year for the first five items and they could
answer in terms of servings per day, week, month, or year for the last item. All the answers were
converted into times per week or servings per week since the majority of respondents had used these
options. PA was measured using the following item: “Have you done any of the following (walking
for exercise, gardening or yard work, swimming, bicycling, popular or social dance, home exercises,
ice hockey, ice skating, in-line skating or rollerblading, jogging or running, golfing, exercise class or
aerobics, downhill skiing or snowboarding, bowling, baseball or softball, tennis, weight-training,
fishing, volleyball, basketball, soccer, any other, no physical activity) in the past 3 months?” (yes or
no). Smoking was measured using the following item: “At the present time, do you smoke cigarettes
daily, occasionally or not at all?” (daily/occasionally/not at all). Alcohol status was measured using
the following item: “During the past 12 months, have you had a drink of beer, wine, liquor, or any
other alcoholic beverage?” (yes or no).

Statistical analyses
Sleep duration was dichotomized as insufficient (< 7 hr per night) or adequate (≥ 7 hr per night)
according to the U.S. National Sleep Foundation recommendations (Hirshkowitz et al., 2015). The
overall sleep quality score was dichotomized as having trouble going to sleep or staying asleep, not
finding sleep refreshing (item reversed), and finding it difficult to stay awake when you want to,
none/little of the time, or some/most/all the time. Individual correlates of sleep duration and quality
were identified by means of hierarchical logistic regression analyses with survey weights. Survey
weights were used to account for the complex sampling plan of the CCHS and to obtain data that is
representative of the Canadian population. The assumption of the linearity of the logit was verified
1
CEGEP is a two-year pre-university college education that is only offered in the province of Quebec.
 BEHAVIORAL SLEEP MEDICINE 5

using the Box-Tidwell approach (Tabachnick & Fidell, 2013). For both sleep duration and quality,
the variables were entered in three steps: demographics only (age, ethnicity, level of education,
household income, mood disorders, parity, and geographical location); behavioral variables only (FV
intake, PA, smoking, and alcohol status); and demographic and behavioral variables to assess which
were the most important correlates of sleep. The area under the ROC curve as a measure of model
fitting was reported for each model (Hosmer & Lemeshow, 2000). An area under the ROC curve of
50% is considered no discrimination; between 70% and 80%, acceptable; between 80% and 90%,
excellent; and 90% or more, outstanding (Hosmer & Lemeshow, 2000). Alpha level was set at
p < 0.05 and all analyses were performed using SAS, version 9.3 (SAS Institute, Cary, NC, USA).

Results
Sample characteristics
The sample consisted of 9,749 WOCBA. The mean age was 31.07 ± 0.15 years and the majority
(80.8%) were non-Hispanic White. Less than a fifth (17.8%) of the sample were immigrants. The
majority (68.6%) had a postsecondary certificate or diploma or a university degree and the mean
household income was CA$ 78,650 ± 1,037.19. Mean parity was less than one child (0.87 ± 0.02) and
the majority (85.3%) lived in urban areas. Slightly more than half of the sample (55.7%) slept the
recommended 7–9 hr per night and the average score for sleep quality was 8.04 ± 0.03, indicating an
overall good sleep quality. Complete sample characteristics are presented in Table 1.

Individual correlates of sleep duration

Ethnicity, parity, and geographical location were the only demographic variables significantly
associated with sleep duration; this model discriminated 56.1% of WOCBA (see Step 1 in
Table 2). Compared to White WOCBA, Asian, Black, and Arab WOCBA had lower odds of having
adequate sleep duration. WOCBA with a greater number of children had lower odds of having
adequate sleep duration. Living in rural areas was associated with higher odds of having adequate
sleep duration. FV intake and smoking were the only behavioral variables significantly associated
with sleep duration; this model discriminated 52.9% of WOCBA (see Step 2 in Table 2). FV intake
was associated with higher odds of having adequate sleep duration, while smoking was associated
with lower odds of having adequate sleep duration. When demographic and behavioral variables
were both entered into the model, only ethnicity, parity, geographical location, and smoking
remained significant correlates of sleep duration; this model discriminated 56.9% of WOCBA (see
Step 3 in Table 2). All models poorly discriminated WOCBA based on their sleep duration with
areas under the ROC curve below the 70% threshold (Hosmer & Lemeshow, 2000).

Individual correlates of sleep quality

Level of education and mood disorders were the only nonbehavioral variables significantly associated
with sleep quality; this model discriminated 57.3% of WOCBA (see Step 1 in Table 3). Compared to
WOCBA with a postsecondary certificate, diploma, or a university degree, those with a high school
diploma or some postsecondary studies had lower odds of having quality sleep. WOCBA with mood
disorders had lower odds of having quality sleep. FV intake and smoking were the only behavioral
variables significantly associated with quality sleep; this model discriminated 56.0% of WOCBA (see
Step 2 in Table 3). FV intake was associated with higher odds of having quality sleep, while on the
opposite, smoking was associated with lower odds of having quality sleep. When demographic and
behavioral variables were both entered into the model, ethnicity, level of education, the presence of
mood disorders, geographical location, FV intake, and alcohol consumption were significant corre-
lates of quality sleep and this model discriminated 59.0% of WOCBA (see Step 3 in Table 3).
6 L.-A. VÉZINA-IM ET AL.

Table 1. Weighted sample characteristics (N = 9,749).

Variables Mean or % (standard error)
Age (years) 31.07 (0.15)
Ethnicity, %
● Non-Hispanic White 80.80 (0.89)
● Asian 9.54 (0.69)
● Black 3.35 (0.34)
● Latin American 2.51 (0.36)
● Arab 2.76 (0.43)
● Other 1.04 (0.24)
Immigrants, % 17.82 (0.80)
● Number of years since immigrateda 10.36 (0.49)
Level of education, %
● Less than high school diploma 7.22 (0.47)
● High school diploma 15.28 (0.68)
● Some postsecondary studies 8.95 (0.52)
● Postsecondary certificate, diploma, or university degree 68.55 (0.86)
Household income (CA$) 78,650 (1,037.19)
Mood disorders, % 8.39 (0.51)
Number of children 0.87 (0.02)
Geographical location, %
● Urban 85.29 (0.56)
● Fringe 1.36 (0.18)
● Rural 13.35 (0.53)
Sleep duration, %
● Insufficient (< 7 hr/night) 38.03 (0.92)
● Adequate (7–9 hr/night) 55.72 (0.93)
● Excessive (> 9 hr/night) 6.25 (0.42)
Sleep quality score (range: 3–15)b 8.04 (0.03)
● Latency and disturbances (range: 1–5)b 2.47 (0.02)
● Finding sleep refreshing (range: 1–5)b 3.45 (0.02)
● Daytime dysfunction (range: 1–5)b 2.11 (0.02)
Note. aOnly includes people who are immigrants. bHigher scores indicate poorer overall sleep quality, more frequent troubles
falling and staying asleep, more frequent sleep not refreshing (item reversed), and more frequent difficulties staying awake when
needed.

Compared to White WOCBA, Arab WOCBA had lower odds of having quality sleep. Compared to
WOCBA with a postsecondary certificate, diploma, or a university degree, those with some post-
secondary studies had lower odds of having quality sleep. Mood disorders and alcohol consumption
were associated with lower odds of having quality sleep while living in rural areas and FV intake
were associated with higher odds of having quality sleep. All models poorly discriminated WOCBA
based on their sleep quality with areas under the ROC curve below the 70% threshold (53).

Discussion
Adequate sleep duration and quality sleep were both significantly associated with demographic and
behavioral variables, suggesting that certain WOCBA would be more at risk for short or poor sleep
and that some health behaviors would be associated with sleep. Ethnicity, parity, geographical
location, and smoking were significant correlates of sleep duration, while ethnicity, level of educa-
tion, the presence of mood disorders, geographical location, FV intake, and alcohol consumption
were significant correlates of sleep quality among WOCBA. Common correlates of sleep duration
and quality were ethnicity and geographical location, suggesting ethnic disparities in sleep and that
WOCBA living in urban areas would be more at risk for short and poor sleep.
Demographic variables exerted the strongest influence on sleep duration among WOCBA. The
present results suggest that ethnic minorities, such as Asian, Black, and Arab WOCBA, would be
more at risk for short sleep and may make important targets for sleep interventions. These results
mirror those of previous studies that reported ethnic disparities in sleep duration among adults
(Grandner et al., 2016; Jackson et al., 2015; Laposky et al., 2016; Malone et al., 2017; Walsemann
 BEHAVIORAL SLEEP MEDICINE 7

Table 2. Individual correlates of adequate sleep duration (≥ 7 hr per night).

Variables Odds ratio (p value) and 95% confidence interval
Step 1 Step 2 Step 3
Age 0.99 (p = 0.3141) 0.99 (p = 0.2633)
0.98, 1.01 0.98, 1.01
Ethnicity
● White Reference Reference
● Asian 0.70 (p = 0.0324) 0.67 (p = 0.0129)
0.51, 0.97 0.49, 0.92
● Black 0.54 (p = 0.0038) 0.51 (p = 0.0025)
0.35, 0.82 0.33, 0.79
● Latin American 1.17 (p = 0.5874) 1.09 (p = 0.7682)
0.67, 2.03 0.63, 1.88
● Arab 0.38 (p = 0.0011) 0.37 (p = 0.0009)
0.22, 0.68 0.21, 0.67
● Other 0.70 (p = 0.4716) 0.69 (p = 0.4469)
0.26, 1.86 0.26, 1.81
Level of education
● Less than high school diploma 0.97 (p = 0.8247) 1.01 (p = 0.9513)
0.70, 1.33 0.73, 1.40
● High school diploma 0.81 (p = 0.0804) 0.84 (p = 0.1500)
0.64, 1.03 0.66, 1.07
● Some postsecondary studies 0.82 (p = 0.1909) 0.85 (p = 0.2777)
0.61, 1.10 0.63, 1.14
● Postsecondary certificate/diploma or university degree Reference Reference
Household income 1.00 (p = 0.3506) 1.00 (p = 0.4778)
1.00, 1.00 1.00, 1.00
Mood disorders 0.78 (p = 0.0818) 0.81 (p = 0.1547)
0.59, 1.03 0.61, 1.08
Number of children 0.91 (p = 0.0175) 0.90 (p = 0.0085)
0.83, 0.98 0.83, 0.97
Geographical location
● Urban Reference Reference
● Fringe 1.00 (p = 0.9876) 1.03 (p = 0.9232)
0.55, 1.81 0.56, 1.89
● Rural 1.67 (p < 0.0001) 1.71 (p < 0.0001)
1.36, 2.06 1.39, 2.10
Fruit and vegetable intake 1.005 (p = 0.0203) 1.00 (p = 0.0859)
1.001, 1.009 0.999, 1.01
Physical activity 1.02 (p = 0.9311) 1.17 (p = 0.4410)
0.70, 1.47 0.79, 1.73
Smoking 0.82 (p = 0.0299) 0.80 (p = 0.0321)
0.68, 0.98 0.66, 0.98
Alcohol status 1.25 (p = 0.0553) 0.96 (p = 0.7178)
0.995, 1.56 0.75, 1.22
Area under the ROC curve 56.1 52.9 56.9
−2 log likelihood 11,694.37 12,770.64 11,611.12
Note. Numbers in bold are statistically significant (p < 0.05)

et al., 2017; Whinnery et al., 2014). WOCBA with many children were at higher risk for shorter sleep
duration. Similarly, the results of a previous study conducted among U.S. women between the ages
of 18 and 55 years indicated that parity (i.e., 0 versus ≥ 1 children) was negatively associated with
reporting adequate sleep (Kachikis & Breitkopf, 2012). Data from the BRFSS 2009 also suggested that
increased household size was associated with insufficient sleep in adults (Grandner et al., 2015).
Another variable associated with increased risk for short sleep duration among WOCBA was living
in urban areas compared to living in rural areas. Data from the BRFSS 2009 had identified
geographical differences in sleep duration across the United States (Grandner et al., 2015).
Neighborhood safety in cities could be one factor explaining the association between geographical
location and sleep duration, since living in an unsafe neighborhood has been previously linked to
short sleep among U.S. adults (Simonelli et al., 2017). Consistent with previous studies (Jaehne et al.,
8 L.-A. VÉZINA-IM ET AL.

Table 3. Individual correlates of quality sleep (none/little sleep problems).

Variables Odds ratio (p value) and 95% confidence interval
Step 1 Step 2 Step 3
Age 1.01 (p = 0.1402) 1.01 (p = 0.1609)
0.997, 1.02 0.997, 1.02
Ethnicity
● White Reference Reference
● Asian 1.06 (p = 0.7408) 1.00 (p = 0.9920)
0.76, 1.46 0.72, 1.39
● Black 1.15 (p = 0.5177) 1.09 (p = 0.7073)
0.75, 1.75 0.71, 1.66
● Latin American 1.46 (p = 0.1912) 1.40 (p = 0.2805)
0.83, 2.57 0.76, 2.55
● Arab 0.53 (p = 0.0744) 0.45 (p = 0.0302)
0.26, 1.06 0.22, 0.93
● Other 0.81 (p = 0.6494) 0.74 (p = 0.5169)
0.33, 2.01 0.29, 1.86
Level of education
● Less than high school diploma 0.75 (p = 0.0938) 0.78 (p = 0.1741)
0.53, 1.05 0.55, 1.11
● High school diploma 0.78 (p = 0.0316) 0.80 (p = 0.0630)
0.62, 0.98 0.64, 1.01
● Some postsecondary studies 0.68 (p = 0.0061) 0.70 (p = 0.0118)
0.51, 0.90 0.53, 0.92
● Postsecondary certificate/diploma or university degree Reference Reference
Household income 1.00 (p = 0.2637) 1.00 (p = 0.3477)
1.00, 1.00 1.00, 1.00
Mood disorders 0.20 (p < 0.0001) 0.21 (p < 0.0001)
0.14, 0.27 0.15, 0.29
Number of children 0.96 (p = 0.2570) 0.95 (p = 0.1668)
0.88, 1.03 0.88, 1.02
Geographical location
● Urban Reference Reference
● Fringe 0.98 (p = 0.9536) 1.01 (p = 0.9777)
0.58, 1.68 0.58, 1.74
● Rural 1.21 (p = 0.0605) 1.23 (p = 0.0396)
0.99, 1.47 1.01, 1.49
Fruit and vegetable intake 1.01 (p = 0.0022) 1.01 (p = 0.0291)
1.002, 1.01 1.001, 1.01
Physical activity 0.86 (p = 0.4659) 0.82 (p = 0.3578)
0.57, 1.29 0.55, 1.25
Smoking 0.75 (p = 0.0019) 0.86 (p = 0.1223)
0.63, 0.90 0.70, 1.04
Alcohol status 0.92 (p = 0.4535) 0.78 (p = 0.0404)
0.74, 1.15 0.61, 0.99
Area under the ROC curve 57.3 56.0 59.0
−2 log likelihood 11,899.30 13,058.80 11,801.12
Note. Numbers in bold are statistically significant (p < 0.05)

2012; Riedel et al., 2004), smoking was negatively associated with adequate sleep duration. Thus,
smokers may need to be targeted for interventions promoting adequate sleep duration. Our results
on sleep duration thus suggest that ethnic minorities, WOCBA with many children, those living in
urban areas, and smokers would be at higher risk for short sleep duration.
Similar to sleep duration, sleep quality appears to be more influenced by demographics as
four (out of six) of the individual correlates of sleep quality (i.e., ethnicity, level of education,
mood disorders, and geographical location) were nonbehavioral variables. The results of this
study suggest ethnicity and level of education may need to be considered when developing
interventions aimed at improving sleep quality among WOCBA. WOCBA with mood disorders
were also more at risk for poor sleep quality, which is concordant with the scientific literature in
adults (Cox & Olatunji, 2016; Medina et al., 2014; Murphy & Peterson, 2015). Similar to the
 BEHAVIORAL SLEEP MEDICINE 9

results on sleep duration, living in urban areas was associated with lower chances of having
quality sleep. Noise exposure and low neighborhood safety, which can be associated with living
in urban areas, have been linked to poorer sleep quality among U.S. adults (Simonelli et al.,
2017). Living in urban areas could also explain the relationship between the presence of mood
disorders and sleep quality, as living in urban (versus rural) areas has been associated with a
higher prevalence of mood disorders (Peen, Schoevers, Beekman, & Dekker, 2010). FV intake
and alcohol consumption were behavioral correlates of sleep quality. FV intake was positively
associated with sleep quality, while smoking was negatively associated with sleep quality.
Previous evidence had already identified FV intake as a behavior positively related to sleep
quality in adults (Duke et al., 2017; Patterson et al., 2016; St-Onge et al., 2016). Previous studies
reported that alcohol negatively affected sleep quality among adults (Feige et al., 2006;
Geoghegan et al., 2012; Thakkar et al., 2015).
The present study has a number of strengths and limitations. Strengths include the large
sample size, the inclusion of sleep duration, and quality, as both are important aspects of sleep
and the novelty of the population, since few studies have been conducted among Canadian
WOCBA. The main limitation is the cross-sectional design precluding causal inferences or
statements about the direction of associations, particularly for behavioral variables. The hier-
archical logistic regression models poorly discriminated WOCBA based on their sleep duration
or quality, with areas under the ROC curve below 70% (Hosmer & Lemeshow, 2000), suggesting
that other variables not measured in the present study, such as stress, employment status, and
acculturation, might be better to distinguish risk of short or poor sleep among this population
and possible residual confounding. All variables were self-reported, which can result in bias and
random measurement errors. The measure of sleep quality available in the CCHS had a low
reliability coefficient with a Cronbach’s alpha < 0.70 (Nunally, 1978); it did not assess all seven
components of sleep quality of the PSQI (Buysse et al., 1989) and thus might not have been a
comprehensive measure of sleep quality. Behavioral measures of FV intake, PA, smoking, and
alcohol consumption did not include timing, and timing of these behaviors can be important in
relation to sleep (Arias, Madinabeitia-Mancebo, Santiago, Corral-Bergantino, & Robles-Garcia,
2016; Bulckaert et al., 2011; Gallant, Lundgren, & Drapeau, 2014; Kredlow et al., 2015; Murray
et al., 2017). The present results also cannot be generalized to all Canadian WOCBA as the
CCHS, 2011–2014, did not sample respondents from all provinces of Canada, since the items on
sleep were part of the optional content of the survey, but they are representative of the seven
Canadian provinces and territories surveyed.
Our findings suggest that certain WOCBA may be more at risk for short or poor sleep based on
their ethnicity, level of education, mood disorders, parity, and geographical location. Some health
behaviors, such as FV intake, smoking, and alcohol consumption, were correlates of sleep duration
or quality. Given that the results differ according to which aspect of sleep was measured, this
suggests the need to investigate both separately. These results identify which WOCBA may benefit
most from sleep interventions and guide the development of behavioral sleep interventions.
However, additional studies among this population are needed to confirm the findings, and future
studies should preferably adopt a longitudinal or experimental design and use both self-reported and
objective measures of sleep and behavioral variables.

Funding
The first author is recipient of a fellowship award from the Canadian Institutes of Health Research. This material is
based upon work supported by the U.S. Department of Agriculture, Agricultural Research Service under Agreement
No. 58-3092-5-001.
10 L.-A. VÉZINA-IM ET AL.

ORCID
Lydi-Anne Vézina-Im http://orcid.org/0000-0001-9769-9847

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