Sleep Health 4 (2018) 565–571

Contents lists available at ScienceDirect

Sleep Health
Journal of the National Sleep Foundation

journal homepage: sleephealthjournal.org

Perceived stress and worldview influence sleep quality in Bolivian and

United States university students
Jesse Doolin, MS a,⁎, Jose Enrique Vilches, MS b, Cheryl Cooper, PhD, MSN c,
Christine Gipson, PhD c, William Sorensen, PhD, MSPH b,c
a
University of Texas Health Science Center San Antonio, San Antonio, TX
b
Universidad Autónoma Gabriel Rene Moreno, Santa Cruz, Bolivia
c
University of Texas at Tyler, Tyler, TX

a r t i c l e i n f o a b s t r a c t

Article history: Objective: This study investigated predictors of poor sleep quality among American and Bolivian students.
Received 12 December 2017 Design: A cross-sectional survey was designed and administered to undergraduate university students.
Received in revised form 11 August 2018 Setting and participants: Psychology classes from 2 public universities (Texas, USA, and Bolivia) were conve-
Accepted 15 August 2018 nience sampled (n = 80 American students; 60 Bolivian students).
Measurements: We used a sleep quality index and the Perceived Stress Scale. We added questions
Keywords:
concerning worldview, sleep hygiene, sleep deficiency, health behaviors, and demographics.
Sleep quality
College students
Results: Five variables predicted poor sleep quality: perceived stress, sleep hygiene, sleep deficiency, world-
Bolivia view, and site. Greater stress positively associated with poorer sleep in both cultures. Yet, Bolivian students
Stress reported significantly more stress than American students but experienced significantly better sleep qual-
Culture ity. Worldview, a measure of optimism or pessimism about the world, negatively associated with sleep
quality in both cultures.
Conclusion: Three variables that predict sleep quality (worldview, sleep hygiene, and sleep deficiency) did
not differ significantly between countries. Only perceived stress differed by country but contrary to the pre-
dicted direction. Thus, this work reveals new avenues for future work to the investigation of sleep in differ-
ent cultures. Lastly, we offer recommendations to ameliorate poor sleep in university students.
© 2018 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

Introduction
Stress is pervasive in college students. Lack of sleep mediated
through stress can affect both physical and mental health.1–5 Stress
can delay the onset of sleep or shorten sleeping times. Likewise,
sleep influences the stress response during waking hours. 6 A study
by Buboltz and colleagues7 determined that 73% of college students
reported occasional sleep problems and 15% had poor sleep overall.
Relatively little research has been conducted that investigates how
specific cultural contexts influence sleep behaviors.8 Worthman and
Melby9 compared the literature on sleep behavior among adolescents
across cultures in non-Western societies. They found that sleep set-
tings are generally social, sleeping in solitude is rare, and co-sleeping
⁎ Corresponding author at: Polytrauma Rehabilitation Center, 7400 Merton Minter
Blvd, San Antonio, TX 78229. Tel.: +1 832 641 8055; fax: +1 903 565 5923.
E-mail address: doolin@uthscsa.edu (J. Doolin).
with others is common. In a 2007 article, Worthman and Brown10 re-
ported on the findings from a study that explored sleep among Egyp-
tian families, with results indicating that age, sex, and co-sleeping
influence sleeping arrangements, thus impacting overall sleep quality.
Conversely, solitary sleeping is the most common practice in Western
societies.11 Therefore, assessing sleep behaviors while also considering
cultural norms, or beliefs, deserves further investigation.
We underscore “sleep behaviors” in light of recent anthropologi-
cal studies. For instance, rapid eye movement (REM) sleep, asserted
to be high-quality sleep, allows humans to stay relatively active into
the night,12 albeit a sleep debt response may ensue. 13 And cross-cul-
tural analyses from traditional societies have revealed that although 7
hours seems to be the human species’ mean for sleep duration, how
that 7 hours is distributed within the 24-hour circadian cycle is rela-
tively flexible and illustrates a significant degree of plasticity.14
Other studies in psychology have investigated coping behaviors
and their influence on stress. Coping as a means for stress reduction
can be divided into 2 broad categories: problem-focused coping,

https://doi.org/10.1016/j.sleh.2018.08.006
2352-7218/© 2018 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
566 J. Doolin et al. / Sleep Health 4 (2018) 565–571
characterized by cognitions or behaviors aimed at solving the prob-
lem or changing a situation, and emotion-focused coping, character-
ized by behaviors elicited to control the uncomfortable emotional
response caused by the problem. 15 Problem-focused coping, rather
than emotion-focused coping, is viewed as being a more effective ap-
proach for reducing stress.16–18 There is evidence that psychological
distress propels negative changes in sleep quality, particularly with
respect to the duration in REM sleep. Problem-focused behaviors re-
sult in less need for REM sleep. 19 This finding is supported from a
study of adult Japanese showing that several emotion-related behav-
iors (smoking, binge-snacking, and excessive TV/gaming consump-
tion) were positively associated with insomnia, whereas problem-
solving approaches to stress were negatively correlated with
insomnia20.
O'Connor and colleagues21 evaluated stress between Western and
Eastern lifestyles, comparing individual-oriented vs society-oriented,
or collectivist, values. Japanese university students demonstrated sig-
nificantly more stress than did British university students when mea-
sured by a Western stress instrument (Perceived Stress Scale [PSS]).
However, the researchers warned that notions of stress emerge
from Western paradigms and are therefore subject to Western bias.
Nonetheless, when Korean nursing students were measured on the
same stress scale, they demonstrated less stress than both British
and Japanese students. 22 This latter study challenges the Western/
Eastern, individualist/collectivist paradigm.
Still, Hu and colleagues 23 demonstrated that coping behaviors,
both emotional and problem focused, were not specifically associated
with either individualistic or collectivist cultural orientations. For in-
stance, coping responses that functioned as a buffer for the negative
impact of stress within a Chinese population exacerbated it within a
New Zealand population.24
Because of the prevalence of both stress and poor sleep quality
among US college populations, we explored the extent that culture
plays in students' sleep quality by surveying undergraduate popula-
tions from countries on 2 different continents, Bolivia and the United
States. Bolivia and the United States can be considered Western coun-
tries based on the historical European influence common to both coun-
tries. A few comparative countrywide statistics may indirectly relate to
stress and sleep. For example, life expectancy in Bolivia at birth is 69.5
years, whereas it is 80.0 years in the United States. The fertility rate in
Bolivia is 2.6 children per woman, whereas in the United States, it is 1.9
children per woman25 (2017 estimates). Yet their economies may be
the most influential engines that drive societal and health issues. The
purchasing power (GDP) per capita in Bolivia is $7500 with a GDP
growth rate of 4.2%. In the United States, these figures are $59,500
and 2.2%, respectively.25 Each year, Columbia University ranks coun-
tries based on an index that includes GDP per capita, social support,
life expectancy, and perceptions about freedom, generosity, and cor-
ruption. These 6 factors purportedly express societal happiness. In
2017, Bolivia ranked 58th in the world and the United States ranked
14th on this index.26 At first glance, Bolivian citizens appear to be at
a disadvantage in well-being or happiness compared to US citizens.
Would this correlate with health- or sleep-related outcomes?
Specifically, we searched for predictors of poor sleep quality and
sought to identify differences by country. We aspired to capture cul-
tural optimism or happiness, calling this construct “worldview”. Our
hypothesis is as follows: Perceived stress and worldview will influ-
ence sleep quality. From this hypothesis, we predict that:
• Perceived stress will positively associate with poor sleep quality.
• The group with higher perceived stress will show poorer sleep
quality.
• Worldview will negatively associate with poor sleep quality.
The results of this investigation led us to suggest ideas in improv-
ing students' sleep quality.
Methods
Participants
We analyzed the responses of 140 undergraduate students en-
rolled in a psychology program from either a mid-sized, public,
South-Central US university or a large, public university in Bolivia.
Their average age was 24.9 years (range 18-45).
Measures
Comfort being alone
Participants marked on a 5-point Likert scale whether they
enjoyed being alone. Scores approaching 5 indicated comfort in a sol-
itary lifestyle.
Health behavior
This component was composed of 3 health-related behavioral
questions (physical activity, smoking cigarettes, and consumption
of soda) in which the participants engaged. Scores were summed so
that very healthy and very unhealthy behaviors were reflected in
the extreme ends of the index.
Perceived health
This index was a single question asking the participants how they
perceived their own health, offering 4 categorical responses from
“Excellent” to “Poor.”
Perceived stress
The PSS index has been used in past research and assesses the de-
gree of stress in one's life.27 It is composed of 10 questions, using a 5-
point Likert scale. Our results yielded a reliability coefficient of .821,
comparing favorably with other studies, 28–30 ranging from .848 to
.870. Two of these studies were done in foreign populations. 29,30
Poor sleep quality
This index was assessed with 4 questions closely following Na-
tional Sleep Foundation (NSF) criteria of sleep quality as well as
related to 3 of 7 sleep quality domains captured by The Pittsburgh
Sleep Quality Index: Sleep Latency, Sleep Disturbances, and Day-
time Dysfunction 30,31 We refrained from investigating other
sleep quality domains such as “Use of sleeping medications” and
“Subjective sleep quality” included in the Pittsburgh Sleep Quality
Index to include a sleep hygiene measure described below. Two of
the questions were: “On an average night, how long does it usually
take you to fall asleep after you close your eyes?” and “On an aver-
age night, how many times do you wake up after falling asleep?”
To assess frequency of sleep disturbances, we asked how often
the participant has trouble falling asleep on a weekly basis. Lastly,
daytime function was assessed by asking how often the partici-
pant feels tired or sleepy during the day. 32 A higher score indi-
cated poor sleep quality. The index demonstrated a reliability
coefficient of .575.
Self-efficacy
Self-efficacy is a measure of confidence and is championed in
many health models. Participants' self-efficacy was rated based on a
question asking whether they could reduce the stressors in their
life. The response was captured on a 5-point Likert-scale.
Sleep deprivation
Sleep deprivation was computed by subtracting the number of
hours of sleep a participant reported as indispensable to function
properly from the number of self-reported hours he/she gets in an
average night's sleep. The resulting number is either positive
 J. Doolin et al. / Sleep Health 4 (2018) 565–571 567

(indicating a self-reported surplus in sleep) or negative (indicating were female (78.7%; n = 111). In the US sample, 75.9% (n = 60)
that the participant perceives he/she is sleep deprived). were female students and 85.0% (n = 51) were female students in
the Bolivian sample. A significant age difference existed between US
Sleep hygiene and Bolivian students (t = −2.827, df = 135, P = .005), with
This index was created by using 3 multiple-choice questions that Bolivians older by 2½ years (23.9 vs 26.3) on average.
inquired about sleep-promoting routines of the participants. 32 The average amount of time that all the participants had spent in
Choices ranged from “never” to “always” concerning whether the college was 4.6 years (3.9 years US students vs 5.4 years Bolivian stu-
participant (1) goes to bed at the same time every night, (2) keeps dents) (t = −6.018, df = 137, P = .000). Fifty-six participants
the same sleep schedule throughout the week and weekend, and (39.7%) reported to have moved to attend college. Of the US sample,
(3) worries about not getting enough sleep. Two of the questions spe- 37 (46.8%) reported to have moved to attend college, whereas 19
cifically reflect NSF criteria, 33 whereas all 3 also mirror questions (31.7%) Bolivians moved to college, a marginally significant differ-
from the Sleep Hygiene Index (SHI), a reliable sleep hygiene index.34 ence (t = −1.831, df = 137, P = .069; Table 1). (See Fig. 1.)
We chose these 3 questions in lieu of the full SHI both for brevity and Forty-five students reported that they were either married or liv-
to avoid cultural bias. Evaluation of the SHI indicates that it measures ing with a partner (31.9%), and 93 reported to be single (66.0%).
2 factors: sleep-disturbing behavior and environment, and irregular Within the US sample, 26.6% (n = 21) were living with a partner;
sleep wake schedule.35 As such, we excluded behavior and environ- 40.7% (n = 24) of Bolivians reported to be living with a partner. In
ment questions, limiting the cultural assumptions implicit in sleep addition, 26 (18.6%) students within the total sample reported to be
hygienic behaviors and environments. High scores indicated good taking care of another family member, whereas 110 (78.6%) were
sleep hygiene. not. Among the US students, 10 (12.5%) reported to be family
member caregivers, and among the Bolivians, 16 (26.7%) were care-
Worldview givers. This was a significantly different proportion (χ 2 = 5.086; df
Responses from nine original questions using a 5-point Likert = 1, P = .024).
scale were summed to create this index, whereby participants indi-
cated their optimism or pessimism in areas of daily living, whether
they expected things to go their way, or if people around them Health and stress indices
were supportive or selfish and greedy. It was tested for theme consis-
tency using oblique rotation factor analysis, loaded on 2 domains. The health behavior index exhibited a mean of 6.6 (SD = 1.06;
Four items were discarded through factor analysis, leaving 5 vali- range 4-8). The United States, students demonstrated significantly
dated items. One domain expressed positive (or negative) expecta- better health behavior engagement than Bolivian students (6.8 vs
tions of one's future in general, and the second expressed optimistic 6.4; t = −2.331, df = 137, P = .021). We extracted physical activity
or pessimistic beliefs about others or society. Examples of the items from the index to test it separately; physical activity did not reveal
included “I hardly ever expect things to go my way” and “Most people a difference by site, nor did it impact sleep. Not surprisingly, US and
are kind and good and don't want to intentionally hurt others.” The Bolivian students perceived their health equally (2.4 vs 2.3, respec-
worldview index yielded a reliability coefficient of .547. tively; t = −0.609, df = 138, P = .543). The perceived stress index
exhibited a mean of 30.0 overall (SD = 6.21; range 12-48). Bolivian
Procedure students reported significantly more stress than their US counter-
parts (31.3 vs 30.5; t = −2.13, df = 135, P = .035; Table 2). Sex man-
Participants were offered the opportunity to complete the paper/ ifested marginally different stress levels, with female students
pencil questionnaire by designated instructors (instructors demonstrating more stress than men (t = −1.908, df = 134, P =
volunteered their classes ahead of time). Classes were convenience .059). This was not a significant difference.
selected. The participants had to be currently enrolled undergraduate
students in a psychology program. There was no variation in how the
questionnaire was administered between classes or participants. All Table 1
subjects gave informed consent; it took participants approximately Demographics of participants, by country, n = 140
20-25 minutes to complete. Total US Bolivian P
Data analysis included descriptive analysis and bivariate analysis n (%/ave) students students value
between poor sleep quality and variables of interest either through n (%/ave) n (%/ave)
analysis of variance or regression analysis. Lastly, multiple regression Age (average, y) 137 (24.9) 79 (23.8) 58 (26.3) .005⁎⁎
analysis was performed with the significant variables from the bivar- Sex .188
iate component. Significance was set at .05. A sample size of 140 Male 28 (20.1) 19 (24.1) 9 (15.0)
Female 111 (79.9) 60 (75.9) 51 (85.0)
allowed for a margin of error of 8.5% (1/√N), sufficient for exploratory
Civil status .231
research. Married 20 (14.5) 9 (11.4) 11 (18.6)
Permission to conduct this study was approved by the Institu- Living w/ partner 25 (18.1) 12 (15.2) 13 (22.0)
tional Review Board through The University of Texas at Tyler and Single 93 (67.4) 58 (73.4) 35 (59.3)
was approved by the Department of Psychology at the Universidad Time in university 139 (4.6) 79 (3.9) 60 (5.4) .000⁎⁎
(average, y)
Autónoma Gabriel Rene Moreno. Data analysis was completed on Work (h/wk)a,b 129 (16.8) 79 (17.3) 50 (16.0) .703
IBM SPSS (version 20). Caregiver .024⁎⁎
Yes 26 (19.1) 10 (12.7) 16 (28.1)
Results No 110 (80.9) 69 (87.3) 41 (71.9)
Moved to attend university .071⁎
Yes 56 (40.3) 37 (46.8) 19 (31.7)
Demographics No 83 (59.7) 42 (53.2) 41 (68.3)
⁎ .05 b P b .10.
Eighty students (57.1%) were US citizens and 60 students (42.9%) ⁎⁎ P b .05.
were Bolivian. The 3 most prominent ethnicities were Hispanic/La- a
Independent-samples t test.
tino 43.5%, White 39.1%, and Black 8.7%. The majority of participants b
χ2 test.
568 J. Doolin et al. / Sleep Health 4 (2018) 565–571

Fig. 1. Worldview on poor sleep quality, by country.

Sleep indices Worldview

The sleep hygiene index ranged in scores from 3 to 10 and pro-
duced a mean of 7.5 (SD = 1.52). In the US sample, the average
score was 7.7; the Bolivian sample attained 7.3. This difference was
not statistically different (t = −1.267, df = 138, P = .207). The
poor sleep quality index ranged from 4 to 19 (mean = 9.5; SD =
3.57). The US sample averaged 10.4, and Bolivians averaged 8.4; US
students had significantly poorer sleep quality than their Bolivian
counterparts (t = −3.560, df = 137, P = .001). In Table 3, stress
shows a significant relationship with sleep quality. Our first predic-
tion stated that as perceived stress increases, sleep quality degrades;
our first prediction was not false. The sleep deprivation index for all
participants demonstrated a mean of −1.3 (range −7 to 5; SD =
1.74). US students showed an average of −1.1, whereas Bolivians av-
eraged −1.5; this was not a significant difference (t = −3.560, df =
136, P = .201). Of note, the average hours actually slept between
the 2 groups were nearly identical (US students 6.44 hours vs
Bolivian students 6.37 hours), but when asked “how many hours of
sleep do you need in order to function well,” the US students reported
an average of 7.6 hours and the Bolivian students 9.1 hours, still not a
significant difference (t = −1.261, df = 138, P = .212).
The worldview index ranged from 7 to 23, with an average of 16.8
for all participants. There was no difference between US students
(mean = 16.7) and Bolivian students (mean = 16.9) (t = −.459,
df = 137, P = .647). However, worldview demonstrated a significant
association with poor sleep quality (Table 3) such that the more pos-
itive world outlook one had, so too one had better sleep quality. Our
third prediction stated that worldview negatively associates with
poor sleep quality; this was not false even after controlling for coun-
try, stress, and other sleep indices (Table 4).
Other measures
Self-efficacy demonstrated a mean of 3.9 overall (SD = .91; range
1-5). US students showed significantly higher self-efficacy compared
to their Bolivian counterparts (4.0 vs 3.6, respectively; t = −2.587,
df = 138, P = .011). Comfort-being-alone scores ranged from 1 to 5,
with a mean of 3.4 for all participants (SD = 1.19). The US sample av-
eraged 3.6 and the Bolivians averaged 3.2, another significant differ-
ence (t = −2.028, df = 138, P = .045). US students were more
comfortable with solitude.

Table 2
Selected indices, differences by country⁎

Average Actual range Possible range US students (average) Bolivian students (average) P value

Perceived stress 30.0 12-48 10-50 29.0 31.3 .035⁎⁎

Heath behavior 6.6 4-8 3-8 6.8 6.5 .021⁎⁎
Perceived health 2.4 1-4 1-4 2.4 2.3 .854
Sleep quality (poor) 9.5 4-19 3-19 10.4 8.4 .001⁎⁎
Sleep hygiene 7.5 3-10 3-12 7.7 7.3 .207
Sleep deprivation −1.3 −7 to −5 – −1.1 −1.5 .201
Self-efficacy 3.9 1-5 1-5 4.0 3.6 .011⁎⁎
Comfort being alone 3.4 1-5 1-5 3.6 3.2 .045⁎⁎
Worldview 16.8 7-23 5-25 16.7 16.9 .647
⁎ .05 b P b .10.
⁎⁎ P b .05.
 J. Doolin et al. / Sleep Health 4 (2018) 565–571 569

Table 3 predictors of poor sleep quality were perceived stress, sleep hygiene,
Bivariate analysis on poor sleep quality sleep deficiency, and worldview. Among these predictors, only stress
Fa Bb P value differed significantly by country.
Demographic
Regarding stress, perceived sleep deprivation deserves consider-
Age −0.072 .232 ation. This measure was constructed by subtracting the number of
Sex 0.273 .602 hours reported as necessary for proper day-to-day functioning from
Civil status 0.200 .819 actual hours slept. Bolivian and US students reported sleeping nearly
Years in university −0.043 .812
the same number of hours each night. However, when asked, “how
Caregiver 3.047 .083⁎
Move to university 0.159 .691 many hours of sleep do you need in order to function well,” the US
Site 11.147 .001⁎⁎ students reported an average of 7.6 hours and the Bolivian students
Indexes an average of 9.1 hours. Although this difference was not significant,
Worldview −0.490 .000⁎⁎ we think that this might be an important factor. Although neither
Health behavior −0.096 .740
group gets the minimum number of hours recommended by the
Perceived health 1.078 .361
Self-esteem 0.276 .893 NSF (at least 7 hours), the perceived deprivation by Bolivians is
Sleep deprivation −0.501 .004⁎⁎ about 2 times that of US students (2.3 and 1.2 fewer hours, respec-
Sleep hygiene −0.816 .000⁎⁎ tively). The perception that one is not getting enough sleep, whether
Comfort being alone 0.433 .433
real or not, can result in concern or worry, which may increase stress.
Stress 0.045 .000⁎⁎
If this gap produced worry in Bolivian students, it might account for
⁎ .05 b P b .10.
their increased stress as compared with their US counterparts.
⁎⁎ P b .05.
a
Analysis of variance.
Bolivian students were more likely to report being a caregiver for
b
Regression. a family member, a task that would surely increase stress. However,
this variable was removed through multiple regression iteration.
How did Bolivian students sleep better while being more stressed?
Perhaps Bolivians are more resilient36,37 in moments of stress or en-
Variables that showed significant association to poor sleep quality
gage in better coping skills15–18 (note that some emotion-focused be-
through bivariate analysis (Table 3) were placed into a multiple re-
haviors such as smoking or watching television, when performed
gression model to control for each other. The significant variables
before bed, are in direct contrast to NSF sleep hygiene suggestions
emerging from the model, which were predictors of sleep quality,
to promote sleep quality and may partially account for the negative
were site, perceived stress, sleep hygiene, sleep deficiency, and
relationship between emotion-focused coping approaches and sleep
worldview (Table 4). Our second prediction stated that the site
quality). A third explanation could be that stress, like depression or
with the highest perceived stress indicates poorer sleep quality.
anxiety, may be understood as debilitating across cultures but is
This was shown to be untrue; the site with the highest stress had bet-
expressed differently by different cultures. 38
ter sleep quality.
Worthman 13 asks: why do populations from developed coun-
tries, those who can best control sleep debt responses, suffer so
much insomnia? She suggests that although natural threats have
Discussion
mostly disappeared (and with them cues to safety or insecurity),
humans' nighttime arousal ability has not correspondingly disap-
Overall, we found support for 2 out of 3 predictions based on our
peared. Therefore, our biologically wired expectations for cues
hypothesis. First, perceived stress positively associated with poor
may have become emotionally internalized. This paradigm ad-
sleep quality for both sites, which supports our first prediction and
dresses not only the negative aspects of emotion-focused coping
corroborates with previous work. 5 However, we found that stress
but also the internalization of remote threats that one endures
accounted for only 15% of the variance in poor sleep quality in univer-
from a globalized media. Unfortunately, this idea would not ad-
sity students (data not shown), whereas Lund and colleagues 5 found
dress differences between Bolivian and American undergraduate
that stress accounted for 24% of the variance in sleep quality. Sec-
psychology students if we assume that they consume the same
ondly, worldview was negatively associated with poor sleep quality
quantity of media. Nor can we account for any qualitative differ-
for both sites (ie, those who had a negative worldview also had
ences in media between them. Future researchers may want to ex-
poor sleep quality), supporting our third prediction. A central finding
plore this idea.
of our study is that sleep quality was significantly different between
Could a mental construct such as attitude, self-efficacy, or opti-
the 2 sites, with Bolivian students reporting better sleep quality
mism affect sleep? And if so, to what extent? This study's data sup-
than US students while also reporting greater stress. This runs con-
port the third prediction: worldview is significantly associated with
trary to our second prediction. Other than site, the significant
sleep quality. Worldview affected sleep quality no matter which cul-
ture was involved, while also controlling for perceived stress. World-
view did not differ significantly between the sites. Higher worldview
Table 4 scores indicate trust in one's society; with more optimistic social atti-
Multiple regression analysis on poor sleep quality⁎
tudes, one has less stress and has better sleep quality. Other studies
P value B SE T P value support the effects of positive world outlook on decreasing stress
(unadjusted) (adjusted)a and good sleep quality. 39,40 Optimism is a cognitive mood that
Site .000⁎⁎ −2.590 0.531 −4.882 .000⁎⁎ reflects peoples' generalizations of favorable future expectancies. 41
Caregiver .767 – – – – It is associated with several positive health and social outcomes,
Stress .005⁎⁎ 0.141 0.049 2.894 .004⁎⁎
some of which are a sense of well-being in times of difficulty (ie,
Sleep hygiene .013⁎⁎ −0.463 0.183 −2.526 .013⁎⁎
Sleep deprivation .022⁎⁎ −0.342 0.148 −2.314 .022⁎⁎ experiencing civil strife,32 during treatment for a chronic illness, 41,42
Worldview .003⁎⁎ −0.304 0.100 −3.045 .003⁎⁎ or persistence in educational efforts 43,44). Carver and colleagues 41
⁎ .05 b P b .10. hypothesized that an association between optimism and physical
⁎⁎ P b .05. health may be explained by the ability to deflect stress, thus avoiding
a
After 2 iterations. physiological wear and tear on one's body. We claim that optimism is
570 J. Doolin et al. / Sleep Health 4 (2018) 565–571
similar to worldview, which, in our study, protects against both stress
and poor sleep quality.
According to the earlier cited happiness index, 26 Bolivian citizens
were decidedly less happy than US citizens, with ranks of 58 and 14,
respectively. This could explain our data showing relatively more
stress among Bolivian students relative to the US group. That is, stress
could be a mediating factor between happiness and sleep quality.
However, to test that, one would have to look specifically at happi-
ness scores among college students.
Some limitations of this study exist. First is the nonrandom selec-
tion of participants, exposing the study to bias. Also, the self-reported
items in the survey tool incur threats of validity by recall bias. In ad-
dition, our results are not easily generalizable to people globally. On
the other hand, our participants are well-educated individuals who
study cognitive assessments in their discipline; their skills in survey
inspection would incline their responses toward objectivity and cut
down potential bias. Our sample size was moderate. Despite limita-
tions, validity was demonstrated by consistency in results from
other studies.
We found that stress and worldview predict poor sleep quality in
both cultures. But we are challenged to find clear cultural signals be-
hind a mechanism to explain this, as worldview is similar in both cul-
tures. The figure suggests that one may miss detection of culturally
sensitive predictors of sleep quality in educated populations but
may pinpoint them with lower worldview scores, on average. That
is, worldview may surface as a cultural measure in less educated
populations.
Our research indicates that, for both cultures, sleep hygiene prac-
tices are positively related to sleep quality. This implies that interven-
tions aimed at improving sleep hygiene might yield favorable results
in sleep quality. Among the sleep hygiene best practices suggested by
the NSF is stress reduction before bed. 33 This may be accomplished
through meditation or mindfulness techniques. 45,46 Another ap-
proach to improve sleep quality is to address worldview. Worldview
may be modifiable through therapeutic methods such as cognitive
behavioral therapies (CBTs). CBT challenges and reshapes basic as-
sumptions about the self, others, and the perceived world that result
from cognitive distortions. CBT may produce 2-fold results: More
positive social beliefs may emerge, and it may reduce stress. Either re-
sult shows promise in increasing sleep quality.
Disclosure
Mr Doolin has nothing to disclose.
Dr Vilches has nothing to disclose.
Dr Cooper has nothing to disclose.
Dr Gipson has nothing to disclose.
Dr Sorensen has nothing to disclose.
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571
Glossary
Culture: Shared practices, norms, and values demarcated by a group of people that re-
flect a common set of beliefs and attitudes.47
Insomnia: The presence of 1 of the 3 following sleeping disturbances: (1) difficulty ini-
tiating sleep, (2) difficulty maintaining sleep characterized by frequent awakenings or
problems returning to sleep after awakening, or (3) early-morning awakening with in-
ability to return to sleep.48
Sleep disturbance: Interruption in sleep which produces distress or impairment in
social, occupational, academic, behavioral, or other important areas of functioning.
It must occur at least 3 nights per week, be present for at least 3 consecutive
months, occur despite adequate opportunity for sleep, not be associated with
substance abuse or medications, and not be better explained by another sleep-
wake disorder.48
Sleep hygiene: An array of habits that are necessary to have good nighttime sleep
quality. 33 Sleep hygiene recommendations include avoiding stimulants before
bed, limiting daytime naps to 30 minutes, getting adequate exercise, establishing
a regular relaxing bedtime routine, making sure that the sleep environment is
pleasant, avoiding foods that can be disruptive before sleep, and ensuring that
lighting is not intrusive.33
Sleep quality: The NSF lists 4 key determinants of this concept: (1) sleeping at least
85% of the time while in bed, (2) falling asleep within 30 minutes of laying down, (3)
waking up no more than once a night, and (4) being awake for 20 minutes or less after
initially falling asleep.31
Stress: One's response to perceived tension and strain.49
Worldview: Defined as a set of beliefs about the state of the world, other individuals,
and their relation to the self.50 This is likened to optimism.