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Léger D, Beck F, Richard JB. Sleep Loss in the Homeless—An Additional Factor of Precariousness: Survey in a Group of Homeless People. JAMA Intern Med. 2017;177(2):278–279. doi:10.1001/jamainternmed.2016.7827
Sleep is a key component of good health.1 Sleeping less than 6 hours per night is associated with increased risk of obesity, type 2 diabetes, cardiovascular disease, depression, anxiety, pain, and accidents.2 Being homeless makes sleep particularly difficult. Homeless facilities are often closed at night, and homeless people face inclement weather, darkness, and fear for their personal security. Owing to limited resources, many facilities limit the number of nights per individual. Thus, many homeless persons have no regular access to a safe and warm bed at night.
This survey was approved by both the CNIS (Conseil national de l’information statistique) and the French National Institute for Demographic Studies (INED) ethics committee. Participants who agreed to participate were informed by interviewers at the moment of the survey, but written informed consent was not required by the committees for this epidemiological survey. To better characterize this problem, we collected information on sleep from a health survey conducted by the French National Institute on Statistics and Economic Studies and the INED.3 We surveyed 3741 persons who met the definition of homeless (attending sites that offer free meals, associated with social and medical assistance services, and in French cities with more than 20 000 inhabitants). After excluding 288 incomplete questionnaires, we analyzed responses from 3453 individuals; 2068 men and 1385 women, with a mean age of 39.8 years. At the time of the survey, 197 respondents were living on the street, 447 were in collective short-term shelters (housing for <1 week), 1320 in collective long-term shelters (housing for >1 month), 240 in small social services paid hotels, and 1249 in individual facilities (1 or 2 bedrooms for homeless persons with children).
The questionnaire asked about total sleep time at night and over the 24 hours prior to the interview; insomnia defined by the International Classification of Sleep Disorders, Third Edition; whether drugs or alcohol were used to promote sleep, and whether the participant experienced frequent daytime fatigue. We compared homeless persons to age-, sex-, and location-matched controls enrolled in the 2010 National Health Barometer, a large representative survey of the French adult population that asked similar questions on sleep.3
Homeless persons reported significantly shorter total sleep time than the general population (6 hours 31 minutes vs 7 hours 9 minutes) (Table). Among the homeless, 8% reported less than 4 hours of total sleep time over the past 24 hours compared with 3% of the general population; homeless women were twice as likely as men to report that they slept less than 4 hours. Insomnia was reported by 41% of homeless individuals compared with 19% of controls. Daytime sleep duration averaged only 30 minutes per day, yet 33% of homeless persons complained of daytime fatigue compared with 15% of the general population. Among the homeless persons, 25% reported that they regularly took a drug to help them sleep vs 15% of controls.
Our survey shows that in France, homeless people sleep less and are more likely to have insomnia and daytime fatigue than persons in the general population. Sleep is important for good health1,2 and necessary to the ability to work and successfully perform daily activities. Improving the quality and duration of sleep in the homeless may, therefore, improve alertness, health, and the ability to face daily tasks.
We believe that improving sleep deserves more attention in this vulnerable group. We strongly support strategies other than hypnotic agents to improve sleep in the homeless, including more careful control of noise, lighting, heating, and air conditioning at night. Facilities could provide residents with sleep aids, such as earplugs, eye sleep masks, and pillows. Screens between beds could offer some sense of privacy, even in collective dormitories, and addressing issues of personal security should promote better sleep. Ideally, housing facilities would provide individual rooms, but collective shelters might be better organized with specific architecture and schedules to promote sleep.4
Corresponding Author: Damien Léger, MD, PhD, Assistance Publique Hôpitaux de Paris (APHP), Hôtel Dieu, Centre du Sommeil et de la Vigilance, 1 place du Parvis Notre Dame, 75181 Paris CEDEX 04, France (firstname.lastname@example.org).
Published Online: December 27, 2016. doi:10.1001/jamainternmed.2016.7827
Author Contributions: Dr Beck had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Leger, Beck.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Leger, Beck.
Critical revision of the manuscript for important intellectual content: Beck, Richard.
Statistical analysis: Beck, Richard.
Administrative, technical, or material support: Beck.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank volunteers and professional organized by the INED and INSEE who had realized the extensive survey on homeless, and we thank the homeless participants who responded to the study on sleep. We also thank Karen Pickett, PhD, who provided the English wording for narrating this perspective with respect for the people involved in the study.
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