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Sleep deprivation in two Saskatchewan First Nation communities: a
public health consideration
Chandima P. Karunanayake
a
,
*
, Mark Fenton
b
, Robert Skomro
b
, Vivian R. Ramsden
c
,
Shelley Kirychuk
a
,
b
, Donna C. Rennie
d
, Jeremy Seeseequasis
e
, Clifford Bird
f
,
Kathleen McMullin
a
, Brooke P. Russell
a
, Niels Koehncke
a
,
b
, Thomas Smith-Windsor
g
,
Malcolm King
h
, Sylvia Abonyi
h
, Punam Pahwa
a
,
h
, James A. Dosman
a
,
b
a
Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 2Z4, Canada
b
Department of Medicine, University of Saskatchewan, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8, Canada
c
Department of Academic Family Medicine, University of Saskatchewan, West Winds Primary Health Centre, 3311 Fairlight Drive, Saskatoon, SK S7M 3Y5,
Canada
d
College of Nursing, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 2Z4, Canada
e
Community A, PO Box 96, Duck Lake, SK S0K 1J0, Canada
f
Community B, PO Box 250, Montreal Lake, SK S0J 1Y0, Canada
g
Victoria Hospital, Prince Albert, SK S6V 4N9, Canada
h
Department of Community Health &Epidemiology, College of Medicine, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada
article info
Article history:
Received 29 November 2020
Received in revised form
15 March 2021
Accepted 21 May 2021
Available online 2 June 2021
Keywords:
Sleep duration
Sleep deprivation
First nations
Adults
abstract
Objectives: Sleep deprivation is a common problem in Canada and is associated with many health
problems. More than a quarter of Canadians get fewer than the recommended sleep hours (<7 h). This
paper examines the prevalence and risk factors for sleep deprivation in two First Nation communities in
Saskatchewan, Canada.
Methods: The baseline cross-sectional survey was completed between 2018 and 2019 in collaboration
with the two Cree First Nation communities in Saskatchewan, Canada. There were five hundred and
eighty-eight participants participated in the survey from two communities. A Multivariate logistic
regression model was used for analysis.
Results: The prevalence of sleep deprivation (<7 h of sleep) was 25.4%. The multivariate logistics
regression revealed that middle and older age groups, visible mold in the house, and being male with
nighttime insomnia symptoms were significantly associated with a higher risk of sleep deprivation
among study participants in the study.
Conclusions: In these two First Nation communities, a higher proportion of the participants reported
having sleep deprivation. This was a unique study, which evolved from ongoing research collaboration
with two First Nation communities in Saskatchewan, Canada. Findings will be helpful in the manage-
ment of patients with sleep deprivation in these communities; as well as for co-creating policy with the
communities and future research priorities.
©2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Sleep deprivation is a common problem in Canada. More than a
quarter (26%) of Canadians get fewer than seven hours of sleep
[1,2]. Sleep deprivation is associated with sociodemographic and
socioeconomic risk factors, lifestyle factors, non-communicable
diseases/chronic health conditions and factors related to the sleep
environment. Socioeconomic positioning was a robust determinant
of sleep deprivation [3e7]. In Canada, people aged 18 to 64 with
*Corresponding author. Fax: þ1 306 966 8799.
E-mail addresses: cpk646@mail.usask.ca (C.P. Karunanayake), mef132@mail.
usask.ca (M. Fenton), r.skomro@usask.ca (R. Skomro), viv.ramsden@usask.ca
(V.R. Ramsden), shelley.kirychuk@usask.ca (S. Kirychuk), donna.rennie@usask.ca
(D.C. Rennie), jccquasis@willowcreehealth.com (J. Seeseequasis), c.bird@sasktel.
net (C. Bird), kathleen.mcmullin@usask.ca (K. McMullin), bpr053@mail.usask.ca
(B.P. Russell), niels.koehncke@usask.ca (N. Koehncke), dr.tom@sasktel.net
(T. Smith-Windsor), malcolm.king@usask.ca (M. King), sya277@mail.usask.ca
(S. Abonyi), pup165@mail.usask.ca (P. Pahwa), james.dosman@usask.ca
(J.A. Dosman).
Contents lists available at ScienceDirect
Sleep Medicine: X
journal homepage: www.elsevier.com/locate/sleep
https://doi.org/10.1016/j.sleepx.2021.100037
2590-1427/©2021The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/
).
Sleep Medicine: X 3 (2021) 100037
higher household education and income were more likely to report
sleeping 7e9 h per night, compared with those with less education
and lower incomes [3]. A recent study reported that male gender,
older age, low social status, and high coffee intake was associated
with objectively determined short sleep duration [4]. Another
study reported that short sleep duration was associated with
sociodemographic or socioeconomic factors and further described
that those with lower levels of education, low household income
quartiles and employment status of ‘unemployed’and ‘disability
retirees’were the most likely to report shorter sleep durations
(5h)[5]. The prevalence of short sleep was increased for the
lowest household income quintile, those with less than high school
education, and among African Americans (compared with Whites)
[6]. Ehlers et al. reported that American Indian ethnicity, being
older than 30 years, having only a high school diploma were pre-
dictive factors for sleep deprivation [7].
Studies have shown an association between lifestyle factors and
sleep deprivation. Zhu et al. [4] reported that an inverse ‘U-shaped’
relationship between objective sleep duration and physical activity
level and observed that the most physically active slept between
6e7 h. Kline [8] showed that intervening on physical activity levels
has been shown to improve sleep efficiency and sleep duration.
Another study reported that exercise promoted increased sleep
efficiency and duration regardless of the mode and intensity of
activity [9]. A meta-analysis investigating the association between
portable screen-based media devices and sleep outcomes found
that bedtime media usage was associated with insufficient sleep
duration and poor sleep quality [10]. However, another meta-
analysis found no association between television watching and
sleep duration but did find that computer use was associated with a
shorter total sleep duration [11]. A report by Hysing et al. [12]
indicated that daytime and bedtime use of electronic devices were
both related to sleep measures, with an increased risk of short sleep
duration, long sleep onset latency and increased sleep deficiency. A
doseeresponse relationship observed between sleep duration and
use of electronic devices specifically the association between per-
sonal computer use and risk of less than 5 h of sleep compared with
the recommended sleep hours [12]. One study reported that short
sleepers (6 h) were more likely to smoke tobacco than adequate
sleepers (7h)[13]. The findings of Hamidovic et al. [14 ] suggested
that sleep loss may increase the likelihood of smoking during
abstinence because of the potential of nicotine to reduce subjective
sleepiness. Nakata et al. [15] reported that exposure to passive
smoking at work was associated with short sleep duration in men
and current smoking or non-traditional use of tobacco related to
various subtypes of sleep disturbances (difficulty awakening in the
morning and difficulty initiating sleep) in both men and women.
Angarita et al. [16] reported that acute exposure to substance drug
use was associated with sleep disruption by affecting sleep latency,
duration, and quality. Evaluating the empirical evidence, Irish et al.
[17] presented several common sleep hygiene recommendations,
including regular exercise, stress management, noise reduction,
sleep timing regularity, and avoidance of caffeine, nicotine, alcohol,
and daytime napping.
Sleep deprivation or insufficient sleep duration leads to many
health problems [18e54]. Some authors have shown a relationship
with short duration of sleep and increased risk of mortality
[19e21]. Mullington et al. [22] summarized findings of the effects of
insufficient sleep on cardiovascular risk factors including blood
pressure, glucose metabolism, hormonal regulation and inflam-
mation. Another study by Hall et al. [23] reported that the preva-
lence of the metabolic syndrome and its components were elevated
in short sleepers.
Research has shown that when a person sleeps less than 7 h a
night there was a doseeresponse relationship between sleep loss
and obesity, that means the shorter the sleep was cause of the
greater the obesity [24e34]. Also, Taheri et al. [28] reported that
sleep insufficiency was associated with lower levels of leptin, a
hormone produced by an adipose tissue hormone that suppresses
appetite, and higher levels of ghrelin, a peptide that stimulates
appetite. Another Canadian study reported that short sleep dura-
tion sleepers were 35% more likely to experience a 5 kg weight gain
[35]. It is known that people who have a short sleep at night are less
able to process glucose compared to those who get enough sleep
and have increased chance of developing type 2 diabetes [36,37]. In
the Sleep Heart Health Study, which was a community-based
cohort, adults who reported 5 h of sleep or less were 2.5 times
more likely to have type 2 diabetes, compared with those who slept
7e8 h per night [38]. An experimental study supported the rela-
tionship between shorter sleep times and impaired glucose toler-
ance [39]. Possible mechanisms for how short sleep duration and
sleep restriction predispose to obesity and type 2 diabetes have
been discussed by McNeil &Chaput et al. [29] and Reutrakul et al.
[40]. Authors suggested that short sleepers have may have an in-
crease in insulin release and showed the evidence that short sleep
enhances susceptibility to food stimuli for energy-dense, high-
carbohydrate foods which may lead to obesity and diabetes.
Sleep deprivation leads to high blood pressure, inflammation,
and other bodily stress reactions. Two large epidemiological studies
reported that sleep loss and sleep complaints are associated with
heart attacks and stroke [41,42]. Adults who sleep less than 6 h a
night have a 48% greater chance of developing heart disease and a
15% greater chance having a stroke [37]. Grandner et al. [43]pre-
sented the association between long or short sleep durations and
cardiovascular disease, via several mechanistic pathways. A review
by Nagai et al. [44] reported that the short or long sleep duration is
independently associated with an increased likelihood of coronary
events.
There was sufficient evidence that short sleep duration acts as a
risk factor for hypertension [45]. Sleep durations of 5 h per night
was associated with a significantly increased risk of hypertension in
participants between the ages of 32 and 59 years, and the increased
risk continued to be significant after controlling for obesity and
diabetes [46]. Another study by Grandner et al. [47 ] reported that
both short and long sleep duration are associated with increased
hypertension risk across most age groups. Faraut et al. [48], Hwang
et al. [49] and Kumar et al. [50] reported that compared with the
recommended sleep duration of 7 h, a sleep duration of less than
5 h per day/night had an increased prevalence of hypertension.
Several studies reported an association between sleep depriva-
tion and impaired neurobehavioral performance [30,51e54]. Al-
Abri [51] reported that there is a strong bi-directional relation-
ship between sleep deprivation/disturbance and depression [51].
Author mentioned that chronic sleep deprivation may lead to
depression due to the neurochemical changes that occur in the
brain and on reverse, depression may lead to distributed sleep or
sleep deprivation. Sun et al. [53] reported that participants with
short sleep duration (<5 and 5e6 h) had a higher risk of depression
onset and recurrent depression compared to participants with
recommended sleep durations (7e8 h). They also reported the
bidirectional relationship between sleep duration and depression.
That is, conversely, depression induced short sleep durations. A
review by Wu et al. [54] reported that potential association be-
tween sleep and circadian rhythm with stress granule formation
associated with development of the Alzheimer's disease. In addi-
tion, there was a link between accidents [55]; injury [56e59]; poor
work performance [60,61] and sleep deprivation.
Several studies reported the prevalence of sleep deprivation
among American Indian/Alaska Native populations [7,62,63]. Ehlers
et al. [7] reported that the sleep deprivation prevalence in American
C.P. Karunanayake, M. Fenton, R. Skomro et al. Sleep Medicine: X 3 (2021) 100037
2
Indian/Alaska Native populations was about 30%. Chapman et al.
[62] reported in the 2009e2010 Behavioral Risk Factor Surveillance
Survey that insufficient sleep rates were higher among American
Indian/Alaska Native peoples compared with non-Hispanic Whites
(34.2% vs. 27.4%). A study from the 2014 Behavioral Risk Factor
Surveillance System reported that the age-adjusted prevalence of
healthy sleep duration (a7 h) was lower among American Indians/
Alaska Natives (59.6%) compared with non-Hispanic Whites
(66.8%) [63].
This information was available for other populations, but little
was known about the prevalence of sleep deprivation or insuffi-
cient sleep among First Nations peoples in Canada. Also, there
were no studies reported in the literature about risk factors and
their possible associations with sleep deprivation in First Nations
peoples. In this study, we examined prevalence and possible as-
sociations between sleep deprivation in two Cree First Nation
communities in Saskatchewan using the data from a community-
based cross-sectional study. First Nations are one of the three
groups of Indigenous peoples in Canada who are the descendants of
the original inhabitants of Canada (the other two being Inuit and
M
etis). First Nations peoples have unique cultures, languages and
ceremonies [64,65]. All Indigenous peoples in Canada are impacted
by colonization that produces inequities in social and structural
determinants of health [66]. The residential school experience in
particular negatively impacted the health and wellbeing of survi-
vors as well as their children and grandchildren. This experience
attempted to expunge their cultural identity including Indige-
nous language and cultural customs, their ways of life including
consuming traditional foods, and their Indigenous knowledge and
family ties linking the youth and Elders [66e68]. Other major im-
pacts from residential school attendance included physical, sexual
and emotional abuse, witnessing abuse and isolation from family
[67] with intergenerational reverberations. First Nation commu-
nities in Canada also frequently report generally poor housing
conditions [69e71]. Studies have shown associations between
dampness, exposure to visible mould at home and sleep problems
[72,73]. To bridge a part of the gap in this current research, this
paper examined the prevalence of sleep deprivation and its risk
factors and possible associations in two Cree First Nation commu-
nities in Saskatchewan, Canada.
2. Material and methods
2.1. Study sample
The baseline survey of the First Nations Sleep Health Project
(FNSHP) collaboration was completed between 2018 and 2019 in
collaboration with the two Cree First Nation communities (Com-
munity A and Community B) in Saskatchewan, Canada. The overall
goal of the FNSHP was to study the relationships between sleep
disorders and risk factors and co-morbidities, and to evaluate local
diagnosis and treatment. Ethics approval was obtained from the
University of Saskatchewan's Biomedical Research Ethics Board
(Certificate No. Bio #18e110) and followed Chapter 9 (Research
Involving the First Nations, Inuit, and Metis Peoples of Canada) in
the Tri-Council Policy Statement: Ethical Conduct for Research
Involving Humans [74]. Individual participants gave their written
consent in this research collaboration with the two Saskatchewan
First Nation communities.
2.2. Data collection
Research assistants were hired from these communities and
trained to conduct the baseline surveys in their respective com-
munity. Adults 18 years and older were invited to the Community
Health/Youth Centre to participate in baseline survey. Data were
collected via interviewer-administered questionnaires and clinical
assessments. A pamphlet describing the study and an invitation to
participate in the baseline survey were distributed by the research
assistants by door-to-door canvassing and also during local com-
munity events such as ‘Treaty Days’. Simultaneously, the commu-
nity members were invited through a social media campaign to
participate in the survey. The survey collected information on de-
mographic variables, individual and contextual determinants of
sleep health, self-reported height and weight, and objective clinical
measurements. This manuscript is based on data from the ques-
tionnaires. Demographic information about participants including
age, sex, body mass index, education level, money left at the end of
the month, life-style factors, sleeping environment, medical his-
tory, and sleep health information was obtained from the survey
questionnaire.
Information collected on ever diagnosed non-communicable
diseases/chronic conditions were: diabetes; high blood pressure;
heart problems; stroke; atrial fibrillation; chronic obstructive pul-
monary disease/emphysema; asthma; chronic bronchitis; sleep
apnea; acid reflux; hypothyroidism; depression, anxiety, post-
traumatic stress disorder; Parkinson's disease; chronic pain; kid-
ney disease and restless legs syndrome. Other factors considered
were: prescription medication use; sleep medication; and tradi-
tional medicines which are used to assist with sleeping.
2.3. Definitions
2.3.1. Sleep duration and sleep deprivation
Sleep duration was calculated using questions about the par-
ticipant's usual sleep habits during the past month: “When have
you usually gone to bed?”; When have you usually gotten up in the
morning?”;“How long has it taken to fall asleep each night?”.
Taking the difference of the first two questions, the time in bed at
night was calculated and then time to falling asleep was subtracted
to obtain the actual sleep duration. Recommendations of optimal
sleep duration hours were based on those from the National Sleep
Foundation [75]. Sleep deprivation was defined as the participants
with sleep duration of less than 7 h per night (less than the rec-
ommended optimal sleep duration per night).
2.4. Statistical analysis
Statistical analyses were conducted using SPSS software (IBM
Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0.
Armonk, NY: IBM Corp.). Descriptive statistics, mean and standard
deviation (SD) were reported for continuous variables and p-values
of t-tests were reported for comparing the means of two samples.
For categorical variables, frequency and percentage (%) were re-
ported. Chi-square tests were used to determine the bivariable
association of sleep deprivation prevalence with the independent
variables of interest. Logistic regression models were used to pre-
dict the relationship between a binary outcome of sleep depriva-
tion (yes or no) and a set of explanatory variables. A series of logistic
regression models were fitted to determine whether potential risk
factors, confounders, and interactive effects contributed signifi-
cantly to the prevalence of sleep deprivation. Based on bivariable
analysis, variables with p <0.20 and less than 25% missing variables
were included in the multivariate model. All variables that were
statistically significant (p <0.05), as well as important clinical
factors (sex, age and body mass index (BMI)), were retained in the
final multivariable model. Interactions between potential effect
modifiers were examined and were retained in the final model if
the p-value was <0.05. The strength of associations were presented
by odds ratios (OR) and their 95% confidence intervals (CI) [76].
C.P. Karunanayake, M. Fenton, R. Skomro et al. Sleep Medicine: X 3 (2021) 100037
3
3. Results
There were five hundred and eighty-eight participants partici-
pated in the baseline survey, 418 individuals from Community A
and 170 individuals from Community B. The mean age ±SD of the
588 study participants was 40.0 ±15.3 years with a range being
from 18 to 78 years. There were 44.2% male and 55.8% females that
participated in this study. Sleep duration was available for 567 in-
dividuals. The mean sleep duration was 8.18 ±2.28 h. The preva-
lence of sleep deprivation was 25.4% (144/567).
Table 1 depicts the bivariate associations with sleep deprivation
and determinants. Significantly more males were sleep deprived
compared to females. Adults who attended residential school were
more likely to report sleep deprivation compared to those that did
not attend residential school. The same significant association was
not observed between if study participant's parents and grand-
parents had attended residential school and sleep deprivation. In-
dividuals that engaged in non-traditional use of tobacco/current
smokers had a higher prevalence of sleep deprivation than those
that did not use/smoke. There was a significantly lower risk of sleep
deprivation amongst those who consumed one drink per week
compared with those that did not drink. There was a higher prev-
alence of sleep deprivation in individuals who had sleep apnea
compared with those that reported not having diagnosis of sleep
apnea. Participants exposed to adverse housing conditions such as
visible mold and moldy smell were significantly associated with a
higher prevalence of sleep deprivation compared to individuals not
exposed to these housing conditions. In addition, “afraid to sleep in
your home”,“waking up during the night due to terrifying dreams
or nightmares or flashback to a traumatic event”and “trouble going
to sleep or stay asleep (nighttime insomnia symptoms)”were
significantly associated with sleep deprivation. No associations
were observed between use of prescription medications, sleep
medication or traditional medicines and sleep deprivation.
Multivariate logistic regression results are presented in Table 2.
It was observed that those in the middle age group (age group
40e49: OR ¼2.21; 95% CI (1.16, 4.23)) and older age group (age
group 60þ:OR¼2.53; 95% CI (1.24, 5.17)), had visible mold in the
house (OR ¼1.72; 95% CI (1.12, 2.64)), and males with nighttime
insomnia symptoms were associated significantly with a higher
prevalence of sleep deprivation compared to without nighttime
insomnia symptoms (Fig. 1) after adjusting for other factors.
Mean predicted probability of sleep deprivation and trouble
going to sleep or staying asleep (nighttime insomnia symptoms) by
sex is presented in Fig. 1. Mean predicted probability was higher for
males who had nighttime insomnia symptoms compared with
those who did not have nighttime insomnia symptoms. There was
no significant difference for females with and without nighttime
insomnia symptoms.
4. Discussion
Sleep deprivation occurs when a person is not able to get the
recommended number of hours of sleep. The prevalence of sleep
deprivation among participants in two Cree First Nation commu-
nities in Saskatchewan was 25.4%. This prevalence of sleep depri-
vation was lower (25.4%) when compared with North American
Indians/Alaska Native populations reported by Ehlers et al. (30%)
[7] and Chapman et al. (34.2%) [62], but very close (26%) to the
general population in Canada [1,2]. The results of this study
demonstrated that those in the middle and older age groups, visible
mold in the house, and males with nighttime insomnia symptoms
were associated significantly with a higher prevalence of sleep
deprivation after adjusting for other factors.
The amount of sleep needed to feel refreshed, and function well
depends upon the individual and varies across the age groups [37].
In Canada, 1 in 4 adults aged 18e34 years; 1 in 3 adults aged 35e64
years and 1 in 4 adults aged 65e79 years are not getting the rec-
ommended sleep hours [2], which implies that compared to the
middle aged groups, the older age group has a lower risk of sleep
deprivation. One study suggests that older adults may actually be
more tolerant of sleep deprivation than younger age groups [77].
However, the authors commented that further research was
needed to clarify whether older adults were actually more resistant
to the effects of sleep loss than younger adults. In this study, pre-
sented herein, it was observed that the middle age groups (30e39
years and 40e49 years) and older age group (60þyears) had an
increased prevalence of sleep deprivation. There was a linear dose-
dependent relationship between age and prevalence of sleep
deprivation except for the age group 50e59 years. The prepon-
derance of evidence showed that sleep quality and duration
decreased with age [78,79].
As mentioned in the Introduction, housing conditions were poor
in First Nation communities in Canada [69e71]. In the current
study, 55.7% reported dampness, 51.9% reported visible mold and
49.9% reported moldy smell in the house in the two First Nation
communities. Several studies suggest that living in damp or
mouldy home environments in the house may be associated with
sleep problems. In a cross-sectional study among adults in England,
participants living in damp buildings were more likely to report
sleep problems [72]. Another study of children reported increased
risk for sleep problems in children exposed to visible mould or
dampness in the house. Results were significant for any sleep
problems (OR ¼1.77 (1.21, 2.60)), and short sleep time (OR ¼1.6 8
(1.09, 2.61)) [73]. In this study, it was found that there was an
increased prevalence for sleep deprivation in adults exposed to
visible mold (OR ¼1.72 (1.12, 2.64)). This finding is very important,
and points to further public health interventions on poor quality
housing stock in First Nation communities. Housing in these com-
munities is funded through federal transfer and has long been
considered to be underfunded [80].
Several suggestions have been made by other authors for the
possible mechanisms related to exposure to mold and sleep
deprivation or disruption. One possible explanation is that damp
and moldy environments (which contain beta-glucan) may cause
fatigue [81,82], irritation and inflammation in mucus membranes
or airways [83]. Another explanation is that moldy environments
with higher levels of microbial volatile organic compounds
(MVOCs) [84e86] can cause nasal inflammation [82,84,85,87,88], a
well-known risk factor for sleep disturbances [89,90]. In addition,
mold odors or unpleasant smells that are related to humid envi-
ronments can impair sleep [82,91].
Finally, the multivariate results revealed that males who had
nighttime insomnia symptoms compared to without nighttime
insomnia symptoms were associated with significantly higher
prevalence of sleep deprivation. The observed sex differences in
sleep deprivation outcome is compelling, but not surprising in light
of these associations. Other studies, did not report a sex effect on
sleep-related outcomes in adults from Indigenous communities
residing in the United States [7,92] or Canada [93]. Sabanayagam
et al. [92] reported no significant difference in the reported average
sleep duration between older (aged 55 years) Indigenous adult
men and women. A few studies have reported a relationship be-
tween sleep deprivation and insomnia [94,95]. It has been sug-
gested that objective measured short sleep duration was a risk
factor for development of chronic insomnia from poor sleep
defined by moderate to severe complaint of difficulty falling asleep,
difficulty staying asleep, early awakening, or unrefreshing sleep
[94]. The objective which measured short sleep duration was
C.P. Karunanayake, M. Fenton, R. Skomro et al. Sleep Medicine: X 3 (2021) 100037
4
Table 1
Bivariable associations between sleep deprivation and risk factors (n ¼567).
Variables Total Sleep Deprivation Unadjusted OR (95% CI) P value
n (%) Yes n (%) No n (%)
Demographics
Sex (n ¼567)
Male 248 (43.7) 76 (52.8) 172 (40.7) 1.63 (1.12,2.39) 0.012
Female 319 (56.3) 68 (47.2) 251 (59.3) 1.00
Age group, in years (n ¼567)
18-29 170 (30.0) 36 (25.0) 134 (31.7) 1.00
30-39 139 (24.5) 35 (24.3) 104 (24.6) 1.25 (0.74, 2.13) 0.406
40-49 94 (16.6) 29 (20.1) 65 (15.4) 1.66 (0.94, 2.94) 0.082
50-59 98 (17.3) 23 (16.0) 75 (17.7) 1.14 (0.63, 2.07) 0.663
60þ66 (11.6) 21 (14.6) 45 (10.6) 1.74 (0.92, 3.28) 0.088
Body Mass Index (BMI) (n ¼529)
Obese 247 (46.7) 66 (49.6) 181 (45.7) 1.32 (0.80, 2.17) 0.275
Overweight 148 (28.0) 38 (28.6) 110 (27.8) 1.25 (0.72, 2.17) 0.427
Neither obese or nor overweight 134 (25.3) 29 (21.8) 105 (26.5) 1.00
Education level (n ¼561)
Less than secondary school graduation 209 (37.3) 50 (35.5) 159 (37.9) 0.91 (0.58, 1.44) 0.687
Secondary school graduation 169 (30.1) 44 (31.2) 125 (29.8) 1.02 (0.63, 1.64) 0.940
Some university/completed university/technical school 183 (32.6) 47 (33.3) 136 (32.4) 1.00
Employment status (n ¼553)
Social assistance/unemployment insurance 129 (23.3) 35 (25.2) 94 (22.7) 1.01 (0.60, 1.71) 0.954
Unemployed 143 (25.9) 29 (20.9) 114 (27.5) 0.69 (0.41, 1.18) 0.180
Other including retired or home makers 117 (21.2) 31 (22.3) 86 (20.8) 0.98 (0.57, 1.68) 0.950
Employed (full-time, part-time, self-employed) 164 (29.7) 44 (31.7) 120 (29.0) 1.00
Shift Worker (n ¼567)
Yes 56 (9.9) 14 (9.7) 42 (9.9) 0.98 (0.52, 1.85) 0.943
No 511 (90.1) 130 (90.3) 381 (90.1) 1.00
Money left at the end of the month (n ¼561)
Not enough money 324 (57.8) 91 (64.1) 233 (55.6) 1.30 (0.79, 2.13) 0.295
Just enough money 120 (21.4) 24 (16.9) 96 (22.9) 0.83 (0.45, 1.55) 0.565
Some money 117 (20.9) 27 (19.0) 90 (21.5) 1.00
Attend residential school (n ¼567)
Yes 190 (33.5) 58 (40.3) 132 (31.2) 1.49 (1.01, 2.20) 0.047
No 377 (66.5) 86 (59.7) 291 (68.8) 1.00
Parents or grandparents attended a residential school (n ¼567)
Yes 488 (86.0) 122 (84.8) 366 (86.5) 1.13 (0.54, 2.36) 0.738
No 35 (6.2) 12 (8.3) 23 (5.5) 1.77 (0.66, 4.78) 0.257
Do not know 44 (7.8) 10 (6.9) 34 (8.0) 1.00
Life-style factors
Smoking Status/Non-Traditional Use (n ¼561)
Current smoker 402 (71.7) 119 (82.6) 283 (67.9) 1.75 (1.00, 3.06) 0.049
Ex-smoker 66 (11.8) 7 (4.9) 59 (14.1) 0.49 (0.19, 1.26) 0.141
Never smoker 93 (16.6) 18 (12.5) 75 (18.0) 1.00
Marijuana Use (n ¼562)
Regularly 162 (28.8) 43 (30.3) 119 (28.3) 1.16 (0.75, 1.79) 0.512
Occasionally 85 (15.2) 24 (16.9) 61 (14.5) 1.26 (0.73, 2.16) 0.402
No use 315 (56.0) 75 (52.8) 240 (57.2) 1.00
Alcohol consumption per week (n ¼397)
More than 1 per week 149 (37.5) 42 (41.2) 107 (36.3) 0.92 (0.55, 1.55) 0.752
One-per week 121 (30.5) 22 (21.6) 99 (33.6) 0.52 (0.29, 0.95) 0.032
Non-drinker 127 (32.0) 38 (37.3) 89 (30.2) 1.00
Non-medical drugs (n ¼563)
Yes 36 (6.4) 9 (6.3) 27 (6.4) 0.99 (0.45, 2.15) 0.975
No 527 (93.6) 133 (93.7) 394 (93.6) 1.00
Physical activities at least 3 weeks (n ¼528)
Yes 290 (54.9) 75 (57.3) 215 (54.2) 1.13 (0.76, 1.69) 0.537
No 238 (45.1) 56 (42.7) 182 (45.8) 1.00
Screen time-2 hours or more (n ¼431)
Yes 284 (65.9) 73 (64.0) 211 (66.6) 0.89 (0.57, 1.40) 0.626
No 147 (34.1) 41 (36.0) 106 (33.4) 1.00
Non-Communicable Diseases/Chronic Conditions
Diabetes (n ¼534)
Yes 98 (18.4) 28 (20.6) 70 (17.6) 1.21 (0.74, 1.98) 0.436
No 436 (81.6) 108 (79.4) 328 (82.4) 1.00
High blood pressure (n ¼513)
Yes 161 (31.4) 48 (37.5) 113 (29.4) 1.44 (0.95, 2.20) 0.086
No 352 (68.6) 80 (62.5) 272 (70.6) 1.00
Heart problems (n ¼531)
Yes 59 (11.1) 17 (12.8) 42 (10.6) 1.24 (0.68, 2.27) 0.479
No 472 (88.9) 116 (87.2) 356 (89.4) 1.00
Stroke (n ¼548)
Yes 16 (2.9) 3 (2.2) 13 (3.2) 0.69 (0.19, 2.47) 0.571
No 532 (97.1) 133 (97.8) 399 (96.8) 1.00
(continued on next page)
C.P. Karunanayake, M. Fenton, R. Skomro et al. Sleep Medicine: X 3 (2021) 100037
5
Table 1 (continued )
Variables Total Sleep Deprivation Unadjusted OR (95% CI) P value
n (%) Yes n (%) No n (%)
Atrial fibrillation (n ¼524)
Yes 12 (2.3) 3 (2.3) 9 (2.3) 1.03 (0.27, 3.87) 0.963
No 512 (97.7) 125 (97.7) 387 (97.7) 1.00
Chronic obstructive pulmonary disease/emphysema (n ¼530)
Yes 17 (3.2) 5 (3.8) 12 (3.0) 1.25 (0.43, 3.63) 0.677
No 513 (96.8) 128 (96.2) 385 (97.0) 1.00
Asthma (n ¼540)
Yes 66 (12.2) 19 (14.0) 47 (11.6) 1.23 (0.70, 2.19) 0.472
No 474 (87.8) 117 (86.0) 357 (88.4) 1.00
Chronic Bronchitis (n ¼541)
Yes 33 (6.1) 10 (7.4) 23 (5.7) 1.33 (0.62, 2.88) 0.465
No 508 (93.9) 125 (92.6) 383 (94.3) 1.00
Sleep apnea (n ¼513)
Yes 36 (7.0) 14 (11.2) 22 (5.7) 2.09 (1.04, 4.24) 0.039
No 477 (93.0) 111 (88.8) 366 (94.3) 1.00
Acid Reflux (n ¼545)
Yes 51 (31.0) 51 (37.0) 118 (29.0) 1.44 (0.96, 2.16) 0.081
No 376 (69.0) 87 (63.0) 289 (71.0) 1.00
Hypothyroidism (n ¼530)
Yes 43 (8.1) 9 (6.8) 34 (8.5) 0.78 (0.36, 1.68) 0.530
No 487 (91.9) 123 (93.2) 364 (91.5) 1.00
Depression (n ¼524)
Yes 162 (30.9) 50 (36.8) 112 (28.9) 1.43 (0.95, 2.16) 0.087
No 362 (69.1) 86 (63.2) 276 (71.1) 1.00
Anxiety (n ¼525)
Yes 168 (32.0) 45 (33.8) 123 (31.4) 1.12 (0.74, 1.70) 0.600
No 357 (68.0) 88 (66.2) 269 (68.6) 1.00
Post-traumatic stress disorder (n ¼529)
Yes 57 (10.8) 16 (11.9) 41 (10.4) 1.17 (0.63, 2.16) 0.615
No 472 (89.2) 118 (88.1) 354 (89.6) 1.00
Parkinson's disease (n ¼541)
Yes 7 (1.3) 2 (1.5) 5 (1.2) 1.18 (0.23, 6.16) 0.843
No 534 (98.7) 135 (98.5) 399 (98.8) 1.00
Chronic pain (n ¼544)
Yes 128 (23.5) 38 (28.1) 90 (22.0) 1.39 (0.89, 2.16) 0.146
No 416 (76.5) 97 (71.9) 319 (78.0) 1.00
Kidney disease (n ¼545)
Yes 23 (4.2) 3 (2.2) 20 (4.9) 0.44 (0.13, 1.50) 0.189
No 522 (95.8) 133 (97.8) 389 (95.1) 1.00
Restless legs syndrome (RLS) (n ¼542)
Yes 189 (34.9) 56 (41.5) 133 (32.7) 1.46 (0.98, 2.18) 0.064
No 353 (65.1) 79 (58.5) 274 (67.3) 1.00
Sleep environment
Dampness (n ¼562)
Yes 313 (55.7) 84 (58.3) 229 (54.8) 1.15 (0.79, 1.69) 0.460
No 249 (44.3) 60 (41.7) 189 (45.2) 1.00
Visible mold (n ¼561)
Yes 291 (51.9) 89 (62.2) 202 (48.3) 1.76 (1.19, 2.60) 0.004
No 270 (48.1) 54 (37.8) 216 (51.7) 1.00
Moldy smell (n ¼563)
Yes 281 (49.9) 84 (58.3) 197 (47.0) 1.58 (1.08, 2.31) 0.020
No 282 (50.1) 60 (41.7) 222 (53.0) 1.00
Smoke inside house (n ¼560)
Yes 242 (43.2) 70 (49.0) 172 (41.2) 1.37 (0.93, 2.00) 0.109
No 318 (56.8) 73 (51.0) 245 (58.8) 1.00
Crowding (n ¼556)
>1 person/bedroom 406 (73.0) 106 (74.1) 300 (72.6) 1.08 (0.70, 1.66) 0.730
1 person/bedroom 150 (27.0) 37 (25.9) 113 (27.4) 1.00
Place of sleep (n ¼435)
Bedroom 326 (74.9) 83 (72.8) 243 (75.7) 0.77 (0.23, 2.56) 0.668
Living room 52 (12.0) 13 (11.4) 39 (12.1) 0.75 (0.19, 2.85) 0.673
Basement 44 (10.1) 14 (12.3) 30 (9.3) 1.05 (0.28, 4.00) 0.943
Other 13 (3.0) 4 (3.5) 9 (2.8) 1.00
Sleeping arrangement shared with (n ¼558)
Child 114 (20.4) 31 (21.8) 83 (20.0) 0.87 (0.45, 1.68) 0.682
Spouse or partner 174 (31.2) 42 (29.6) 132 (31.7) 0.74 (0.40, 1.38) 0.345
Alone 200 (35.8) 48 (33.8) 152 (36.5) 0.74 (0.40, 1.35) 0.323
Other family member/Other 70 (12.5) 21 (14.8) 49 (11.8) 1.00
Afraid to sleep in your home (n ¼566)
Yes 58 (10.2) 24 (16.8) 34 (8.0) 2.31 (1.32, 4.04) 0.004
No 508 (89.8) 119 (83.2) 389 (92.0) 1.00
C.P. Karunanayake, M. Fenton, R. Skomro et al. Sleep Medicine: X 3 (2021) 100037
6
associated with a significantly higher prevalence for persistent
insomnia as compared to normal sleep with an odds ratio of 3.19
[95]. Further studies are needed to confirm the relationship or in-
fluence of sex on insomnia or sleep deprivation.
This study considered potential associations between several
co-morbidities and sleep deprivation but, none were significantly
associated with sleep deprivation. In this study, several bivariate
associations (p <0.10) with sleep deprivation such as high blood
pressure (hypertension), acid reflex, depression, sleep apnea and
restless legs syndrome were observed but not retained in the
multivariate regression model. There was sufficient evidence
that short sleep duration acts as a risk factor for hypertension
[45,49,50]. Also, others have reported an association between short
sleep duration and a high risk of depression [51,53,96]. In addition,
Sun et al. [53] identified a bidirectional relationship between sleep
duration and depression. One study reported that sleep deprivation
increased the number and length of apneic events in patients with
sleep apnea and induced apnea in patients who snore [97]. This
study did not identify any relationships between obesity [24e34],
diabetes [29,36e40], heart problems [22,37e44] and sleep depri-
vation, in contrast to other authors.
Most of the associations between circumstances and sleep
deprivation reported in this paper were located as mid-level or
proximal determinants of health, poor housing conditions in on
reserves communities have been widely reported as having an
impact on the health of First Nations peoples [98,99]. Participants
from the two Saskatchewan First Nation communities in this study
reported poor housing conditions with more than 50% noting
dampness, visible mold, and crowding. Our research suggests other
situations within the home are also implicated in sleep deprivation,
such as being afraid to sleep. More proximally, participants re-
ported high rates of overweight (28%) and obesity (46.7%). In total,
about 75% of the population were considered to be overweight or
obese. While not significantly associated with sleep deprivation in
Table 1 (continued )
Variables Total Sleep Deprivation Unadjusted OR (95% CI) P value
n (%) Yes n (%) No n (%)
Waking up during the night due to terrifying dreams or nightmares or flashback to a traumatic event (n ¼564)
Yes 263 (46.6) 80 (56.3) 183 (43.4) 1.68 (1.15, 2.47) 0.008
No 301 (53.4) 62 (43.7) 239 (56.6) 1.00
Trouble going to sleep or stay asleep (n ¼562)
Sometimes/most of the time/all of the time 391 (69.6) 115 (80.4) 276 (65.9) 2.13 (1.34, 3.37) 0.001
Never/Rarely 171 (30.4) 28 (19.6) 143 (34.1) 1.00
Prescription medication use (n ¼559)
Yes 253 (45.3) 67 (46.5) 186 (44.8) 1.07 (0.73, 1.57) 0.723
No 306 (54.7) 77 (53.5) 229 (55.2) 1.00
Medication use for sleep (n ¼558)
Yes 66 (11.8) 20 (13.9) 46 (11.1) 1.29 (0.73, 2.27) 0.375
No 492 (88.2) 124 (86.1) 368 (88.9) 1.00
Traditional medication use for sleep (n ¼559)
Yes 30 (5.4) 7 (4.9) 23 (5.5) 0.87 (0.37, 2.07) 0.755
No 137 (95.1) 392 (94.5) 1.00
Odds ratios that are significantly different from zero (p <0.05) are shown in bold.
Table 2
Adjusted odds ratios for associations between sleep deprivation and covariates.
Variable Multivariate Logistic Regression
Adjusted odds ratio (95% CI) p value
Demographics
Sex
Male 0.76 (0.32, 1.83) 0.539
Female 1.00
Age group, in years
18-29 1.00
30-39 1.69 (0.93, 3.07) 0.085
40-49 2.21 (1.16, 4.23) 0.016
50-59 1.63 (0.84, 3.17) 0.151
60þ2.53 (1.24, 5.17) 0.011
Body Mass Index (BMI)
Obese 1.32 (0.78, 2.25) 0.298
Overweight 1.08 (0.59, 1.95) 0.795
Neither obese or nor overweight 1.00
Sleep environment
Visible mold
Yes 1.72 (1.12, 2.64) 0.013
No 1.00
Trouble going to sleep or stay asleep
Sometimes/most of the time/all of the time 1.12 (0.57, 2.22) 0.741
Never/Rarely 1.00
Interaction: Trouble going to sleep or stay asleep and Sex (See Fig. 1)
Male X Sometimes/most of the time/all of the time (Ref: Never/Rarely) 4.50 (2.17, 9.32) 0.001
Female X Sometimes/most of the time/all of the time (Ref: Never/Rarely) 1.41 (0.57, 2.22) 0.741
Odds ratios that are significantly different from zero (p <0.05) are shown in bold.
C.P. Karunanayake, M. Fenton, R. Skomro et al. Sleep Medicine: X 3 (2021) 100037
7
this study, others have reported an association between sleep loss
and an increased risk of obesity [32,33]. More than half of the study
participants were in the age groups of 18e29 years and 30e39
years, with more than 26% unemployed. More than half reported
not having enough money left at the end of the month, a marker for
poverty. These factors could be reasons for some of the findings
observed in this study that showed the associations with sleep
deprivation. Young adults may be more vulnerable to acute sleep
deprivation than older adults [100]; as well, the use of electronic
devices were found to be higher in younger adults [12]. It is
important to note that these results also point to the significant
influence of more upstream social and structural circumstances
which are of particular relevance to Indigenous peoples in Canada.
Residential school attendance was significantly associated with
sleep deprivation in the bivariable analysis. This specific circum-
stance is a marker for historical and contemporary structures of
colonization policy that have long been implicated in inequitable
access to resources for the attainment of optimal health and in
poorer health across numerous outcomes compared to the Cana-
dian population overall [67,68,101e103].
This study has several strengths including: the number of par-
ticipants from the two First Nation communities participating in
this study; detailed information about sleep and sleep duration in
the community; social and structural information including envi-
ronmental housing conditions; and exploring medical histories.
According to the Statistics Canada Census Profiles [10 4], overall,
42% (588/1397) of individuals participated in this cross-sectional
study, which would be considered to be a very good participation
rate. In Community A, the 18þyears population was 752 and 418
(56%) individuals participated. In Community B, the 18þyears
population was 645 and 170 (26%) individuals participated. Ac-
cording to the Canadian Census of 2016 [104 ], the participants had a
similar age distribution to the general population of these com-
munities while there were more females who participated in this
study and therefore, results may not be generalized to populations
of these communities. Further studies are needed to confirm the
relationships observed in this study on sleep deprivation.
However, several limitations also existed in this study. First, as
these are cross-sectional observations, causation can only be spec-
ulative. Another potential limitation is that this study was based on
self-reported data and therefore, there is potential for recall bias.
Other potential limitations are: residual confounding due to addi-
tional confounding factors such as, details about ventilation, traffic
noise, household illumination that were not collected in this study;
misclassification of ever diagnosed non-communicable diseases/
chronic disease conditions due to recall bias; and small sample cell
sizes for some of the reported chronic conditions. An objective
assessment of sleep quality and duration was not obtained. Results
cannot be generalized to any other First Nations although the tools
and applications used could be transferrable.
5. Conclusions
In these two First Nation communities, 25% of the participants
reported sleep deprivation. Associated risk factors were older age
group, visible mold in the house, and males with nighttime
insomnia symptoms. This was a unique study, which evolved with
two First Nation communities in Canada, and will be helpful in the
management of patients with sleep deprivation in these commu-
nities; as well as for co-creating policy with the communities and
future research priorities.
Author contributions
Conceptualization, J.A.D., S.A., M.K., P.P., D.R., S.K., N.K., M.F., R.S.
and the First Nations Sleep Health Project Team; Data curation,
B.P.R., K.M.; Formal analysis, C.P.K.; Funding acquisition, J.A.D., S.A.,
M.K. and P.P.; Investigation, J.A.D., S.A., M.F., M.K. and P.P.; Meth-
odology, J. A. D., P.P., S. A., M. K., C.P.K., M. F.; Project administration,
P.P.; Resources, J.S., C.B., R.S., M.F., T.S.; Supervision, J.A.D. and P.P.;
Visualization, S.A., J.S., C.B. and V.R.R.; Writingdoriginal draft,
C.P.K., J.A.D., P.P.; Writingdreview &editing, J.A.D., C.P.K., B.P.R.,
K.M., S.A., D.R., S.K., N.K., J.S., C.B., V.R.R., M.F., M.K., T.S., and P.P.
Funding
This research was funded by a grant from the Canadian In-
stitutes of Health Researchd“Assess, Redress, Re-assess: Address-
ing Disparities in Sleep Health among First Nations People”, CIHR
MOP-391913-IRH-CCAA-11829-FRN PJT-156149.
Acknowledgments
The First Nations Sleep Health Project Team consists of: James A
Dosman, MD (Designated Principal Investigator, University of Sas-
katchewan, Saskatoon, SK Canada); Punam Pahwa, PhD (Co-Prin-
cipal Investigator, University of Saskatchewan, Saskatoon SK
Canada); Malcolm King, PhD (Co-Principal Investigator, University
of Saskatchewan, Saskatoon, SK Canada), Sylvia Abonyi, PhD (Co-
Principal Investigator, University of Saskatchewan, Saskatoon, SK
Canada); Co-Investigators: Mark Fenton, MD, Chandima P Kar-
unanayake, PhD, Shelley Kirychuk, PhD, Niels Koehncke, MD,
Joshua Lawson, PhD, Robert Skomro, MD, Donna Rennie, PhD,
Darryl Adamko, MD; Collaborators: Roland Dyck, MD, Thomas
Smith-Windsor, MD, Kathleen McMullin, MEd; Rachana Bodani,
MD; John Gjerve, MD; Bonnie Janzen, PhD; and Vivian R Ramsden,
RN, PhD; Gregory Marchildon, PhD; Kevin Colleaux, MD; Project
Manager: Brooke Russell; Community Partners: Jeremy Seesee-
quasis, BA; Clifford Bird; Roy Petit; Edward Henderson; Raina
Henderson; Dinesh Khadka. We are grateful for the contributions
from Elders and community leaders that facilitated the engage-
ment necessary for the study, and all participants.
Abbreviations
FNSHP First Nations Sleep Health Project
BMI Body Mass Index
SD Standard Deviation
OR Odds Ratio
CI Confidence Interval
Fig. 1. Mean Predicted probability of sleep deprivation and trouble going to sleep or
stay asleep by sex.
C.P. Karunanayake, M. Fenton, R. Skomro et al. Sleep Medicine: X 3 (2021) 100037
8
Conflict of interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper. The funders
had no role in the design of the study; in the collection, analyses, or
interpretation of data; in the writing of the manuscript, or in the
decision to publish the results.
The ICMJE Uniform Disclosure Form for Potential Conflicts of
Interest associated with this article can be viewed byclicking on the
following link: https://doi.org/10.1016/j.sleepx.2021.100037.
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