Provider Perspectives on Sleep as a Determinant of Health and Housing Outcomes among Veterans Experiencing Homelessness: An Exploratory, Social-Ecological Study

Abstract

Sleep problems are common among United States (U.S.) veterans and are associated with poor health, mental health, and functioning. Yet, little is known about insufficient sleep and factors contributing to sleep disparities among veterans experiencing homelessness. We conducted semi-structured interviews to better understand the clinical, environmental, and structural factors contributing to insufficient sleep among veterans and to improve care for this population. Interviews were conducted with 13 providers caring for veterans experiencing homelessness, including physicians, psychologists, nurses, social workers, and peer support specialists. Providers worked at a West Coast VA institution serving a large population of veterans experiencing homelessness. Interviews were analyzed for themes pertaining to sleep using the social-ecological model as a framework. On an individual level, factors influencing sleep included psychiatric disorders and use of substances. On an interpersonal level, factors included safety concerns while sleeping. On an environmental level, factors included noise and proximity to others as barriers to sleep. On the organizational level, logistical issues scheduling sleep clinic appointments and lack of transportation to attend sleep clinic appointments were identified as treatment barriers. These findings can inform future research studying the impact of sleep on health and housing outcomes and interventions addressing sleep among veterans experiencing homelessness.

Sleep health inequities in vulnerable populations: Beyond sleep deserts

“…Permanent supportive housing (PSH) is considered a permanent solution to homelessness. Contrary to expectations, however, the sleep disturbances suffered by PEH do not end with the attainment of PSH and the end of homelessness [ 24 , 29 ]. For example, in a study of 237 formerly homeless adults, 28% had moderate or severe sleep disturbance measured by the PROMIS scale [ 29 ].…”

“…There are many environmental barriers to sleep among PEH, such as feeling the need to remain alert to protect oneself from others while sleeping [ 21 , 24 ]. Additionally, the environment may hinder treatment of sleep disorders in PEH [ 24 ]. For example, limited electrical outlets, storage, and cleaning can make it difficult to properly use PAP machines.…”

“…For example, limited electrical outlets, storage, and cleaning can make it difficult to properly use PAP machines. Further, the city and shelter policies that require PEH to vacate certain areas or shelters during certain times, consequently, prohibit the storage of personal property, which can present challenges to maintaining PAP machines, and therefore untreated sleep disorders and disrupted sleep [ 24 ].…”

“…Sleep patterns differ between sheltered and unsheltered PEH by way of environmental factors. For instance, noise levels of others and disruptive shelter schedules are a barrier to sleep for PEH living in a homeless shelter [ 21 , 24 ]. Despite unsheltered sleep being affected by outdoor noises and weather challenges, some unsheltered outdoor locations may be preferable over sheltered areas due to decreased noise and more privacy [ 21 ].…”

“…For example, in a study of 237 formerly homeless adults, 28% had moderate or severe sleep disturbance measured by the PROMIS scale [ 29 ]. Moreover, mental health problems can remain unresolved even after obtaining PSH, which can further exacerbate sleep problems [ 24 ]. These findings support the importance of screening for sleep disorders not only in PEH but also those in PSH programs and to provide them with supportive services.…”