"Aqui Siempre Uno Sera Inmigrante" [Here One Will Always be an Immigrant]: A Qualitative Exploration of Precipitating and Perpetuating Factors of Insomnia Among Spanish-Speaking Latinx Adults

Background: Insomnia, a psychiatric disorder associated with high health, societal, and economic costs, affects approximately 19% of U.S.-based Latinx adults. Acculturation stress and ethnic discrimination, two types of sociocultural stressors, may be particularly salient precipitating and perpetuating factors (PPFs) of insomnia among Latinx adults. However, insomnia models used to inform gold-standard treatments, such as Cognitive Behavioral Therapy for Insomnia (CBT-I), have mostly focused on biological and behavioral etiological factors. To inform the cultural adaptation of a digital CBT-I program for Latinx adults, this study aims to qualitatively examine the PPFs of insomnia as described by Latinx adults with this condition.

Methods: Following the information gathering stage of Barrera and Castro’s (2006) cultural adaptation model, we conducted four focus group interviews in May 2020 using the videoconference platform Zoom with 18 Latinx adults with self-reported good/excellent Spanish speaking and reading skills, and clinically significant insomnia (Insomnia Severity Index Score [ISI]>15) for at least 3 months. The facilitators were bilingual/bicultural Latinx women with extensive experience in sleep health research. Participants were recruited from participant pools from two previous NYC based studies led by facilitators. The focus group discussions followed a semi-structure interview guide that solicited feedback on different components of a digital CBT-I program. Participants were asked to describe PPFs of their insomnia followed by a discussion of these factors in relation to their social identities. Facilitators opened focus groups by providing space for participants to discuss their experiences with the ongoing COVID-19 pandemic. The discussions were audio-visually recorded and transcribed verbatim. Thematic content analysis was used to identify major and minor themes.

Findings: Participants were on average 51.94 years old (SD=11.71) and had an average ISI score of 16.56 (SD=4.50). The majority of participants were female (52.94%), college graduates (50%), and immigrants (94.44%). Overall, psychological distress, economic instability, and health concerns were major themes that emerged when participants discussed general PPFs of insomnia. Poor sleep hygiene and environmental factors were minor themes attributed to insomnia. When participants described causal factors related to their social identities, their immigrant identity was the most salient. A sense of “starting from zero” in the U.S., loneliness due to family separation, and experiencing economic and emotional instability due to migration status constituted major themes. Participants also expressed that anti-Latinx and anti-immigrant bias negatively affected their sleep.

Conclusions: These themes suggest that PPFs of insomnia among Latinx adults span beyond biological and behavioral factors to include sociocultural, psychological, and environmental factors. Factors currently represented in insomnia models, such as poor sleep hygiene, were a minor theme. Instead, the centrality of the immigrant experience as a PPF was apparent. This study, among the first of its kind, documented the unique challenges of Spanish-speaking Latinx immigrants’ lived experience of insomnia. Participants highlighted how their immigrant identity compounded and was sometimes inextricably tied to the negative effects of other PPFs, such as economic and psychological stressors. These findings suggest culturally adapted CBT-I programs for Spanish-speaking Latinx adults should center the immigrant experience throughout treatment, particularly when discussing PPFs of insomnia.