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Published in final edited form as: Behav Sleep Med. 2025 Aug 11;23(6):883–892. doi: 10.1080/15402002.2025.2544178

Sleep Health Barriers and Facilitators Among African American Family Caregivers

Elliane Irani a, Heba Aldossary a,b, Uva Sri V Dasari c, Glenna S Brewster d, J Daryl Thornton c,e,f, Carolyn Harmon Still a, David B Miller g, Ronald L Hickman Jr a, Stephanie Griggs a,*
PMCID: PMC12859754  NIHMSID: NIHMS2127502  PMID: 40787750

Abstract

Objective:

The cultural and historical experiences of African American family caregivers increase their risk for poor sleep health. Limited research representation hinders the development of effective sleep interventions for their unique needs. The purpose of this study is to explore the barriers and facilitators to sleep health in African American family caregivers and describe participants’ preferences and recommendations for sleep health interventions.

Method:

Using a qualitative descriptive approach, African American family caregivers of community-dwelling adults with chronic or disabling conditions were recruited via community-based methods. Twenty-four caregivers participated in semi-structured in-person, telephone, or videoconference interviews. Transcribed interviews were analyzed using conventional content analysis.

Results:

Participants were on average 58 years old, mostly female (87.5%), and caring for a parent (79.2%). Caregivers reported significant sleep health barriers due to caregiving responsibilities, various sources of stress, and personal health problems such as anxiety or sleep apnea. Caregiving responsibilities disrupted sleep due to irregular sleep timing, night time interruptions from care recipients’ needs, and hypervigilance to ensure care recipient safety. Sleep facilitators included accessing caregiving resources such as self-initiated proactive strategies to address care recipient needs and caregiving support from other family members. Caregivers also described how daytime activities, relaxation strategies, and natural or prescribed sleep aids helped improve their sleep. Lastly, caregivers suggested topics for intervention sessions and shared their preferences for intervention delivery.

Conclusion:

Our findings inform the cultural adaptation of sleep health interventions for African American family caregivers to address stress reduction, caregiving support, and sleep apnea risk and treatment.

Introduction

Family caregivers are family members, close friends or neighbors who provide assistance to individuals with chronic conditions and often experience poor sleep health, which can negatively impact their overall well-being (Byun et al., 2016). The demands of caregiving frequently disrupt sleep due to stress, hypervigilance, nighttime awakenings to assist care recipients, and irregular schedules (Irani et al., 2023; Maun et al., 2020; Polenick et al., 2018). Limited opportunities for self-care further contribute to poor sleep health among family caregivers (Gonzalo-Ciria et al., 2024; Secinti et al., 2022). Despite the well-documented impact of caregiving on sleep, existing research may not fully capture the unique sleep challenges faced by African American family caregivers.

African American family caregivers face heightened risks for poor sleep health due to the combined impact of unique caregiving experiences (Alexander et al., 2022; Irani et al., 2024) and systemic health inequities that drive existing racial sleep disparities (Chen et al., 2015; Jean-Louis et al., 2015; Johnson et al., 2019). African American caregivers frequently encounter poor interactions with healthcare providers (Alexander et al., 2022), provide more intensive care than their White counterparts, and experience greater financial strain – often leaving the workforce to provide full-time care (AARP & National Alliance for Caregiving, 2025; Reinhard et al., 2019; Skufca & Raineville, 2021). Limited use of community-based resources, such as adult day centers, further impacts their mental well-being and, in turn, their ability to maintain healthy sleep patterns (Irani et al., 2024; Parker & Gitlin, 2021). Additionally, other systemic factors such as experiencing discrimination and living in disadvantaged neighborhoods have been linked to poor sleep outcomes in African American populations (Nguyen et al., 2024; Troxel et al., 2018).

Sleep perceptions and behaviors among African American caregivers may be shaped by their broader sociocultural context (Williams et al., 2015). This includes cultural expectations around caregiving, disparities in access and use of caregiving resources, and historical and ongoing experiences of systemic racism (Alexander et al., 2022; Irani et al., 2024; Kim et al., 2024). These factors operate at multiple socio-ecological levels – individual, interpersonal, community, and societal – contributing to how caregivers approach rest and perceive the value and feasibility of prioritizing sleep (Grandner, 2017).Previous studies found that Black women are more likely to hold inaccurate or unhelpful sleep-related beliefs, compared to White women (Grandner et al., 2013), and that Black American adults perceive some maladaptive coping strategies (such as electronic use)as sleep facilitators (Barber et al., 2025).

Recent systematic reviews highlight the promise of existing sleep interventions for family caregivers (Cooper et al., 2022; Fernández-Puerta et al., 2022; Pignatiello et al., 2022). However, few interventions consider cultural attitudes toward sleep, particularly within the African American caregiving population. To develop effective and sustainable sleep health interventions, community-engaged approaches are essential for identifying key sleep health barriers, facilitators, and participant preferences (Epps et al., 2024). Assessing these factors is a critical first step in designing tailored interventions that recognize the lived experiences of African American caregivers, ultimately improving engagement, intervention efficacy, and long-term implementation. Therefore, the purpose of this qualitative descriptive study is to explore the barriers and facilitators to sleep health in African American family caregivers and describe their preferences and recommendations for sleep health interventions.

Methods

Sample

Participants were recruited for a parent study about social determinants of sleep and cardiovascular health among African American caregivers using community-engaged approaches. Inclusion criteria were: (a) identify as Black or African American and be at least 18 years old, (b) provide care for a community-dwelling relative or friend with a chronic or disabling condition for at least six months, and (c) be able to speak, read, and understand English. Exclusion criteria were: (a) caring for someone with a terminal illness or in hospice, (b) having a history of atherosclerotic cardiovascular disease, (c) working night or rotational shifts, or (d) being pregnant. These criteria were set to align with the parent study’s focus on sleep health and cardiovascular risk. A subsample of 24 participants completed qualitative interviews about their personal sleep experiences. Participants provided written informed consent before data collection. The study was approved by the Case Western Reserve University Institutional Review Board.

Data collection

Qualitative interviews were conducted via Zoom (n = 17), in person (n = 4), or over the phone (n = 3) based on participants’ preferences, using a semi-structured interview guide (see Supplemental Table). Interviewers asked participants to describe their bedtime routine, sleep barriers and facilitators, and suggestions for a sleep intervention. Interviews lasted on average 62 minutes and were audio-recorded. Sociodemographic, caregiving, and sleep characteristic data were collected in the parent study. Sleep quality was self-reported using the Pittsburgh Sleep Quality Index, with a global score greater than 5 reflecting poor sleep quality (Buysse et al., 1989).

Data analysis

Qualitative interviews were transcribed verbatim, deidentified, then analyzed in NVivo 14 using conventional content analysis, which is an inductive approach where codes and categories are derived directly from the raw data (Graneheim & Lundman, 2004; Hsieh & Shannon, 2005). This inductive coding approach was not guided by a preexisting theoretical framework or predetermined categories based on the interview guide questions. The first author, an expert in qualitative methods, coded eight randomly selected transcripts to develop the codebook and then met with another team member to discuss initial coding. Both team members then independently coded a subset of transcripts and met to refine the codebook and reconcile any coding discrepancies. The remaining transcripts were divided for coding. After coding all interviews, the initial first-level codes were condensed then grouped into categories and subcategories to address the study objectives. The research team discussed and resolved any discrepancies before approving the final findings (Graneheim & Lundman, 2004). An audit trail documented all coding and analytical decisions (Koch, 2006).

Results

The average age of participants was 58 years (SD = 10.1). The majority were women (87.5%), caring for a parent or parent-in-law (79.2%), and living with the care recipient (79.2%). Half of the participants were caring for a person with dementia. Most (79.2%) had poor perceived sleep quality and 37.5% self-reported a sleep apnea diagnosis. Detailed participant characteristics are presented in Table 1. Sleep health barriers and facilitators are summarized in Table 2 and described in detail in the following sections, along with intervention considerations.

Table 1.

Sample characteristics (N = 24).

Participant Characteristics n (%) M (SD)
Age (in years) 58 (10.1)
Gender (female) 21 (87.5)
Education 1 (4.2)
 High school degree or less 2 (8.3)
 Associate degree 10 (41.7)
 Some college but no degree 11 (45.8)
 College degree
Employment status 11 (45.8)
 Full time 4 (16.7)
 Part time 9 (37.5)
 Unemployed or retired
Perceived household income adequacy a 8 (33.3)
 Do not have enough 12 (50)
 Have enough to make ends meet 3 (12.5)
 Comfortable, have more than enough
Relationship to care recipient 19 (79.2)
 Child or child-in-law 1 (4.2)
 Spouse 1 (4.2)
 Grandchild 3 (12.5)
 Other (parent, friend, etc.)
Living with the care recipient 19 (79.2)
Care recipient’s conditions 15 (62.5)
 High blood pressure 15 (62.5)
 Arthritis 12 (50)
 Dementia 7 (29.2)
 Diabetes 5 (20.8)
 Chronic kidney disease 5 (20.8)
 Cardiovascular disease (i.e., coronary artery disease, heart failure, stroke)
 Cancer 3 (12.5)
 Psychiatric or emotional problem 2 (8.3)
Caregiving hours per week 8 (33.3)
 1–20 hours 5 (20.8)
 21–40 hours 11 (45.8)
 41 hours or more
Self-reported sleep quality 19 (79.2)
 Poor sleep quality (PSQI > 5) 5 (20.8)
 Good sleep quality (PSQI ≤5)
Self-reported sleep apnea diagnosis 9 (37.5)
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Note. Percentages and n are presented for categorical variables. Means and standard deviations are presented for continuous variables. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI).

a

n = 23 for perceived income adequacy variable.

Table 2.

Sleep health barriers and facilitators.

Sleep Health Barriers Sleep Health Facilitators
• Caregiving responsibilities and nighttime interruptions
• Stress and bedtime worry
• Existing physical health conditions
• Environmental disruptions		 • Internal and external resources for caregiving support and assistance
• Daytime activities
• Relaxation strategies
• Natural sleep aids and medical treatment
• Environmental modifications
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Sleep health barriers

Caregiving responsibilities

Caregivers reported difficulties with sleep timing, with some experiencing extended late-night hours and others waking up earlier than desired to manage caregiving and personal obligations. One caregiver shared, “I couldn’t go to bed at a more reasonable time. I would work all day, then come home and take care of her, so I couldn’t go to bed earlier than I would have liked.” Caregivers also described changes in their sleep due to a change in the care recipient’s condition. For example, one caregiver noted, “After chemo treatment, the accidents are more, the confusion is more, the incontinence is more, the vomiting is more. And altogether is more. I knew whatever noise I heard [at night], was run downstairs because she’s too weak to do anything.”

Caregivers described how daytime and nighttime tasks affect their sleep. Some caregivers discussed the need to organize daytime activities for care recipients because the lack of daytime engagement for care recipients frequently resulted in restless nights. One caregiver observed, “When she has nothing to do, and she’s in the house and just sitting all day, it’s a bad night for me.” Some caregivers tried to keep the care recipient engaged during the day or restricted daytime napping to mitigate nighttime awakenings. Nighttime disruptions were common when the care recipient was at an increased fall risk, exhibited wandering behaviors, and had other health needs such as bathroom visits, vomiting, pain, or distress. As a result of the potential nighttime disruptions, caregivers described being in a state of continuous hypervigilance to keep care recipients safe and redirect them in cases of confusion. One caregiver said, “Some evenings, she’s wired up. What kind of night is this gonna be? I need to sleep on alarm. Maybe I’m still sleeping upstairs in the bedroom. Maybe sleep down in the living room so I can watch or hear her when she comes down.”

Stress

Caregivers reported worry and stress related to general and caregiving-specific concerns, which interfered with their ability to have a relaxing bedtime routine and restorative sleep. One caregiver explained, “I play the day over in my head while sleeping, and it’s like I’m not resting.” Caregivers also reported financial burdens, family conflicts, difficulty balancing responsibilities, and caregiving overload as sources of stress. One participant described his caregiving experience, “I started taking care of my mom. It’s four siblings, but I’m the only one she really depends on [. . .] Has it been a lot of sleep? No, because being dependent upon morning and night. . . it tends to be a little bit of stress.” Conflicts with the care recipient, especially when managing behavioral symptoms of dementia in the evening, were another source of stress.

Health factors

Existing physical health conditions such as chronic pain, anxiety, and sleep apnea affected caregivers’ ability to sleep well, further complicating their caregiving challenges. One caregiver shared, “I have fibromyalgia, so I’ve always had a problem with sleeping. I think the extra stress just made it worse.” Some participants also experienced frequent nighttime awakenings to use the bathroom. Many reported symptoms of insomnia, including difficulty maintaining sleep and anxiety about their inability to fall asleep without identifying a specific barrier.

Sleep health facilitators

Caregiving resources

Caregivers used internal and external resources to manage their responsibilities and improve sleep. Internal resources included self-initiated proactive strategies to address care recipient needs like establishing structured routines to reduce nighttime interruptions. For example, one caregiver adjusted her mother’s evening water intake to prevent frequent bathroom trips at night. External resources involved family support and assistive devices such as hospital beds and bedside commodes. One participant noted, “We got the bedside potty so that he doesn’t have to walk to the bathroom. So that kind of eases that up a little bit.” Family support also allowed caregivers to prioritize their health. One caregiver described how her sleep improved when her niece was visiting: “She slept with my mother. So, she was the one that was able to get up and do the things if [my mom] needed it. She would get up and go and do it and I’m like, fine, thank you.” Others shared that splitting nighttime caregiving with family members helped them rest more when they were not with the care recipient.

Daytime activities

Daytime activity levels and social engagement influenced caregivers’ sleep health. One caregiver reflected on her recent vacation: “I was sleeping better. I think that was because I was out with my friends, like every day, we went to two museums, so it was pretty busy [. . .] but now that I’m getting back to my daily routine my sleeping is not as great, so I’ve got to get my exercise regimen back in place.” Other participants also reported better sleep after tiring days.

Relaxation strategies

Some caregivers engaged in calming bedtime routines such as reading, journaling, and rock painting, and others adopted relaxing daytime activities like massage and meditation. One participant used meditation apps, “I use their sleep stories to help calm from the stuff I got to do tomorrow. ‘I got to do this, I got to do that.’ If I focus on this story, then I can go to sleep easily.” These strategies helped create a relaxed state conducive to sleep.

Sleep aids

Some participants used natural sleep aids like melatonin and herbal tea, while others relied on prescribed medications for sleep disorders. However, these aids were not always effective. One caregiver shared, “I’ll take my sleeping medicine so I can lie down. But my mind is always racing, so I really don’t go to sleep until probably around 1 to 3 o’clock in the morning.” Caregivers with sleep apnea were advised to use CPAP machines. One caregiver emphasized its importance: “Ever since I started using my CPAP consistently, I can’t sleep without it. My sleep is much better now.” However, most did not follow these recommendations due to limited information and difficulty incorporating the CPAP device into their routine.

Environmental modifications

Caregivers optimized their sleep environments by maintaining a quiet, dark room, using white noise or earplugs, and regulating room temperatures. These modifications also helped address environmental barriers to sleep health. One participant shared, “The only way I can sleep is if it’s dark and I have white noise going, like a fan, or some sound like that. That’s the only way that helps me be calm.” Half of the participants mentioned sleeping with the television on: “The TV doesn’t distract me. It’s my company-keeper, and if I cut it off, that’s my distraction.” Some relied on the TV to fall back asleep during the night, while others set a timer for it to turn off.

Intervention considerations

Caregivers expressed interest in learning about the importance of sleep and what constitutes healthy sleep as illustrated in this quote: “Is a solid seven, eight hours optimal? Or it doesn’t matter if it’s cumulative? Three hours here, an hour there. Is that equally as beneficial if it adds up?” Some expressed a desire to adopt new habits, such as reducing screen time at bedtime and starting an exercise routine. They were interested in non-pharmacological methods for improving their sleep, including relaxation techniques, meditation, and guided imagery. Some caregivers had experience with these strategies but encountered challenges in sustaining them over time. They recommended learning how to how to put their intentions into action and integrate relaxation strategies into everyday routines to ensure long-term use.

Besides sleep-related topics, caregivers mentioned the need for caregiving support, self-care, and stress management. They emphasized the significance of learning about and engaging with community-based services. Caregivers also wanted to learn how to formulate self-care plans and organize their schedules to designate time for enjoyable activities, while providing attention and care to the care recipient. One caregiver said: “Making sure that people know to make time that you set aside for yourself, not think about the person you’re caring for. Just let it go because that person will be there when you’re done.” Lastly, they underscored the necessity for financial planning resources and emotion regulation strategies to manage difficult caregiving situations.

In terms of intervention delivery, caregivers suggested integrating individual and group sessions to accommodate varying preferences and needs, while benefiting from individual tailoring of the intervention as well as the group dynamics and support from other caregivers. Most indicated a preference for remote delivery methods due to the time limitations imposed by caregiving duties with the potential for periodic face-to-face sessions.

Discussion

We explored the sleep barriers and facilitators experienced by 24 African American family caregivers and described their recommendations for sleep health interventions. Our participants reported significant sleep health barriers due to their caregiving responsibilities, stress, and personal health issues. Sleep health facilitators included internal and external resources for caregiving support, engaging in daytime activities, relaxation strategies, using natural or prescribed sleep aids, and making environmental modifications. Caregivers suggested topics for intervention sessions and shared their preferences for intervention delivery, which will guide intervention adaptation.

Our findings are in line with other studies about the individual and social determinants of sleep health in the context of caregiving and in African American communities. In a qualitative study with caregivers of persons with dementia, sleep barriers included increased vigilance, stress from balancing responsibilities, and personal sleep issues (Lee et al., 2023). Similarly, for low-income African American mothers, internal worry and external factors like work commitments contributed to poor perceived sleep quality (Zambrano et al., 2016). In a qualitative investigation about sleep health in African American adults, Baron et al. (2019) described various internal (stress, physical discomfort) and external (noise, caregiving, work schedule) barriers to sleep. Common facilitators across studies include time management, family support, sleep hygiene, regular exercise, and relaxing activities (Baron et al., 2019; Lee et al., 2023; Rottapel et al., 2020; Zambrano et al., 2016). Therefore, sleep health interventions can address various behavioral and contextual factors at different socio-ecological levels to optimize sleep health in African American caregivers (Grandner, 2017).

One of our overarching findings was about care recipient’s health needs. Caregivers described using personal strategies and external support systems to address care recipient needs, which helped facilitate sleep. This is in line with a recent study that found caregiving benefits, including caregiving confidence and satisfaction that the care recipient is well cared for to be positively associated with caregiver sleep quality (Petrovsky et al., 2024). Our caregivers reported feeling satisfied and relaxed during the night when the care recipient’s needs were met. On the other hand, unmet care recipient needs and fall risk were a sleep barrier because they led caregivers to be vigilant at nighttime, particularly when caring for persons with dementia. Other studies using a nationally representative sample of dementia caregivers found that providing more nursing tasks and caring for those with higher fall risk are associated with caregivers’ sleep disturbance and nighttime awakenings (Leggett et al., 2018; Polenick et al., 2018).

Caregiver sleep interventions should include caregiver training tailored to care recipients’ health needs to manage nighttime stressors. Caregivers can learn fall risk management, including safety supervision and modifications to the physical environment, such as adding floor lighting or a bedside commode to prevent nighttime falls (Zhou et al., 2022). Caregivers should be also guided to accept that sleep interruptions when caring for persons with dementia is part of the caregiving trajectory and provided with strategies to facilitate falling back asleep.

Our participants did not report culture-specific sleep barriers and facilitators. The perception of resilience in the African American community, the cultural emphasis on strength and perseverance, and the expectation of caring for others, may lead some caregivers to prioritize productivity or caregiving responsibilities over sleep. While cultural sleep perspectives did not emerge from our data, sleep interventions should be tailored for African American caregivers, as cultural values and norms shape how and why they provide care, subsequently influencing sleep behaviors. It is important to integrate culturally-tailored approaches for stress reduction and caregiving support resources, which was reported as a sleep facilitator. Some of our participants accessed internal and external resources to reduce stress and nighttime demands. Care recipients benefit from daytime activities to improve their sleep (Hodgson et al., 2024), which can alleviate caregivers’ nighttime sleep interruptions. These activities can be offered through community programs, such as adult day services (Larsson Ranada & Österholm, 2022). However, few caregivers in the African American community rely on community supports for respite care (Kim et al., 2024). There is a need for culturally-sensitive approaches to disseminate information about community-based caregiving resources through trusted community sources. Community leaders can join researchers as study team members or facilitators to engage with African American caregivers and help bridge the gap in accessing these resources (Hebert et al., 2006).

Lastly, interventions should address sleep apnea risk and treatment. Some participants reported a sleep apnea diagnosis but were not using CPAP treatment, which is also a concern in the broader African American community (Wallace et al., 2018). Untreated sleep apnea may limit the benefits derived from behavioral sleep interventions. Tailored recommendations for African American family caregivers with sleep apnea are needed to ensure access to treatment and improve CPAP adherence. Intervention sessions can include education on sleep apnea and the importance of screening to increase awareness for those without a diagnosis. Caregivers would also benefit from a behavior modification plan to sustain behavior change, using effective reinforcement strategies like keeping a personal diary or checking in with a partner (Abraham & Michie, 2008).

Our study has some limitations. We recruited a convenience sample in partnership with three community organizations. Our participants had to meet the eligibility criteria of the parent study (e.g., we excluded those with cardiovascular disease, pregnant caregivers, night shift workers) and most had high levels of education. Therefore, our findings may not be transferable to the wider population of African American family caregivers who may be less open to research participation. While we asked participants about sleep health barriers, facilitators, and intervention recommendations, we did not specifically inquire about their attitudes and cultural perspectives on sleep health. Consequently, our insights into cultural beliefs and attitudes are based solely on the examples that caregivers voluntarily shared. Future work is needed to uncover specific cultural attitudes toward sleep in the African American caregiving population to further inform sleep intervention tailoring.

Our study is among the first to explore sleep barriers and facilitators in African American family caregivers. We identified intervention targets to address sleep challenges, particularly stress and caregiving responsibilities, and expand on caregivers’ existing strengths to optimize sleep. Integrating sleep facilitators, such as caregiving supports and relaxation strategies, can help with navigating caregiving demands, thereby improving sleep and overall health. Future research is needed to develop and test culturally-sensitive interventions that increase sleep health knowledge and enhance caregiving skills and capacity. These interventions have the potential to empower African American caregivers to lead a healthy and balanced life through their caregiving journey.

Supplementary Material

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/15402002.2025.2544178

Acknowledgments

We are grateful to all our caregiver participants for their time and dedication. We also appreciate the instrumental support of our community partners: Fairhill Partners, McGregor PACE, and the Northeast Ohio Black Health Coalition, throughout the study period.

Funding

This work was supported by the National Institute on Minority Health and Health Disparities under Grant [U54MD002265], Involving Communities in Delivering and Disseminating Health Disparity Interventions, Investigator Development Core Pilot Program, in partnership with the Center for Health Equity, Engagement, Education, and Research at the MetroHealth System. Dr. Stephanie Griggs is funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), [R01DK136604]. Dr. Glenna Brewster is funded by the National Institute on Aging (NIA), [K23AG070378]. Dr. Thornton is funded by the National Center for Advancing Translational Sciences (NCATS), [R25TR004517] and [UM1TR004528] and the National Heart, Lung, and Blood Institute (NHLBI), [R01HL169588]. Dr. Carolyn Harmon Still is funded by the National Nursing Research Institute (NINR), [R01NR019585], [1R21NR020489-01A1].

Footnotes

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material
NIHMS2127502-supplement-Supplementary_Material.docx (16.7KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

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