Sleep difficulties among South Sudanese former refugees settled in Australia

Abstract

This quantitative study investigated self-reported sleep, mental health and trauma related nocturnal behaviours among South Sudanese Australians (SSA), examined sex differences in their responses, and sought to determine risk factors for insomnia in this population. Comparisons were also made to a general Australian (AUS) sample of 1,512 respondents, obtained in a previously published study using the same questions regarding sleep difficulties. Self-reports of sleep difficulties, psychological distress (Kessler Psychological Distress Scale, K10), and nocturnal post-traumatic stress symptoms (Pittsburgh Sleep Questionnaire Inventory-Addendum, PSQI-A) were obtained from 117 former refugees (aged 16–60 years) who had been resettled for a decade on average. A key finding was that SSA men (n = 62) reported many more problems compared to both SSA women and AUS men. These problems included high rates of clinical insomnia (32%), clinical-level nocturnal post-trauma symptoms (57%), restless legs (31%), daytime sleepiness (40%), fatigue (43%), and waking unrefreshed (55%). Nearly one in five SSA men had “very high psychological distress,” a rate 10 times higher than that of men in Victoria and twice as high as SSA women. Analyses suggest that for many SSA men memories and dreams of past traumas may be affecting sleep health, with some improvement over time. It was concluded that men within the South Sudanese Australian community report hitherto unrecognised significant problems with their sleep. The findings are consistent with the interpretation that unresolved pre-migration trauma stress may be affecting the sleep of about half of the South Sudanese men in Australia.

Keywords

insomnia post-traumatic stress disorder refugees sex differences sleep South Sudanese

Introduction

For South Sudanese refugees in Australia, the likelihood that the legacy of pre-migration stressful or traumatic experiences and/or post-migration difficulties may affect sleep quality is strong given the various documented links between poor sleep, negative psychological states, and/or migration (Fazel, Wheeler, & Danesh, 2005; Li, Liddell, & Nickerson, 2016; Morin, Rodrigue, & Ivers, 2003; Taylor, Lichstein, Durrence, Reidel, & Bush, 2005). Yet sleep disturbances are often overlooked in studies addressing the difficulties of people surviving war conflict and displacement. Recent reviews of mental health studies of displaced children and adolescents (Fazel, Reed, Panter-Brick, & Stein, 2012, reviewing 44 studies) and psychological treatments of post-traumatic stress disorder (PTSD) in refugees (Nickerson, Bryant, Silove, & Steel, 2011, reviewing 19 studies) include little or no mention of sleeping difficulties. Further, no sleep-related studies involving resettled Sudanese refugees could be located.

Traumatic events frequently precede forced displacement, and the South Sudanese are recognised as having high rates of trauma experiences pre-migration (Karunakara et al., 2004; Tempany, 2009). A large study of nearly 2,000 Sudanese in northern Uganda and Southern Sudan in late 1999/early 2000 concluded that the population prevalence of PTSD among the Sudanese was 46–48%, with around 50% having witnessed murders (Karunakara et al., 2004). Traumatic experiences can lead to sleep disturbances for many years (Caldwell & Redeker, 2005) and sleep difficulties are increasingly being recognised as possibly central to PTSD, rather than simply being one of its symptoms (Spoormaker & Montgomery, 2008). While South Sudanese refugees as a group are recognised as often showing positive elements of resilience and coping despite trauma and hardship (Schweitzer, Greenslade, & Kagee, 2007), the experiences of post-migration acculturation in Australia for South Sudanese includes significant potential stressors and emotional difficulties (Milner, 2010; Schweitzer, Melville, Steel, & Lacherez, 2006).

While there are over 700 studies examining relationships between traumatic event exposure, post-traumatic stress, and sleep problems (Babson & Feldner, 2010), studies of such issues as they pertain specifically to sleep and refugees or displaced persons are limited in number. Basishvili et al. (2012) studied 87 internally displaced persons from Abkhazia 15 years after displacement and found an insomnia incidence of 41.4%, mostly related to war stress. Obstructive sleep apnea prevalence was significantly elevated in post-Gulf War Iraqi immigrants (30.2%) compared to pre Gulf-war Iraqi immigrants (0.7%) (Arnetz, Templin, Saudi, & Jamil, 2012). The role of nightmares in response to trauma has received some attention for refugee adult and paediatric populations (Kovachy et al., 2013; Weaver & Burns, 2001) and in relation to treatment (Boynton, Bentley, Strachan, Barbato, & Raskind, 2009). Asylum-seeking Afghan adolescents were found to have a mean self-reported sleep onset latency of over 45 minutes, about twice as long as their US peers (Bronstein & Montgomery, 2013). Conflict-affected displaced adolescents from Georgia were found to have poorer sleep quality than controls, with family SES being an important contributing factor to their poor sleep quality (Sakhelashvili et al., 2016). Sleep paralysis in relation to culture and trauma has been featured within a small literature (see review by Carvalho, Maia, Coutinho, Silva, & Guimarães, 2016), including a special issue of Transcultural Psychiatry, (Hinton, Hufford, & Kirmayer, 2005).

Interventions that target sleep difficulties are increasingly seen as an appropriate way to manage mental health problems that are often co-morbid with poor sleep. Resettled refugee populations have high rates of depression (Fazel et al., 2005) and there is evidence that treating sleep difficulties co-morbid with mild to moderate depression will help depression remission (Watanabe et al., 2011). Treating sleep problems in those with a history of trauma and/or PTSD can be an effective and culturally appropriate way of both screening for PTSD and treating PTSD symptoms (see reviews by Babson & Felder, 2010; Bronstein & Montgomery, 2013; Kovachy et al., 2013). For example, assessment of a presenting problem of wakefulness during the night could reveal the presence of high levels of nocturnal anxiety related to past traumas; sleep-focused psychological treatment of this anxiety may yield improvements in both sleep quality and trauma-related symptoms.

Sex differences in the sleep quality and psychological health of various groups show that women in Western countries are more likely to report insomnia (e.g., Zhang & Wing, 2006) and mood disorders (e.g., Kuehner, 2003) than men. Further, a meta-analysis found women were more likely to meet the criteria for PTSD than men (Tolin & Foa 2006). A sample of 63 resettled Sudanese refugees found that women experienced greater PTSD, depression, and anxiety symptomatology than men (Schweitzer et al., 2006). However, such sex differences were not found in a sample of newly arrived Burmese refugees in Australia (Schweitzer, Brough, Vromans, & Asic-Kobe, 2011). It is important that the extent and nature of a problem is well understood before any new remediation strategies are considered. Accordingly, this study examined the prevalence and nature of self-reported sleeping difficulties in a sample of South Sudanese former refugees living in Victoria, Australia.

The South Sudanese refugee population in Australia began arriving in significant numbers around 2001, with 72.4% of the population arriving between 2001 and 2006 through the United Nations High Commission on Refugees (UNHCR) Humanitarian Program (ABS, 2011 Census). Australian Bureau of Statistics (ABS) Census data available (2011) records approximately 20,000 Sudan-born Australian residents nationally; however, this number includes those born in Sudan before South Sudanese independence in 2011. The number of South Sudanese Australians is higher if those who are born in Australia but identify themselves as being of South Sudanese heritage are included. Sudan-born men (56.7%) slightly outnumbered women (43.3%) (ABS, 2011 Census).

The main population centres for South Sudanese Australians are the state of Victoria (capital city, Melbourne) followed by Queensland (capital city, Brisbane), New South Wales (capital city, Sydney), and Western Australia (capital city, Perth) (ABS, 2011). Urban settlement in Australian capital cities is prevalent, with much smaller numbers in regional and rural locations. Australia has a strong community services infrastructure for new and recent migrants, incorporating language, housing, health, mental health, employment, education, and other social services. In the case of South Sudanese migrants, many of these services are offered through translated materials and support from interpreting and translation services in key languages for South Sudanese communities, including Dinka (South Sudan’s largest language group), Nuer, and South Sudanese Arabic (Australian Government, 2014). South Sudan has over 70 indigenous languages. Varieties of Arabic and South Sudan Arabic creoles (for example, Juba Arabic, Pidgin Arabic, and Southern Sudan Arabic) serve as lingua franca connecting different language groups for broad public and social communication purposes. The largest language groups of South Sudanese migrants in Australia are Dinka and Nuer, with smaller numbers speaking a wide variety of languages including Acholi, Anuak, Lopit, Luwo, Bari, Fur, and Shilluk (Borland and Mphande, 2006).

Objectives

This study, the first to address sleep-related issues in the SSA former refugee population, was designed to facilitate comparisons to published general Australian (AUS) data based on the same questions conducted by other Australian researchers (Hillman & Lack, 2013; State Government of Victoria, 2010). The Hillman and Lack (2013) study is a recent comprehensive survey of sleeping difficulties of Australians. Both the SSA and AUS groups are representative of their populations in Australia in terms of sex and age. The study considered four specific research questions:

(a) To examine the prevalence of a variety of sleep and daytime symptoms in SSA men and women, and descriptively compare such prevalence to data from an AUS sample. (b) Further, to obtain derived assessments of insomnia, nocturnal post-traumatic stress symptoms, and psychological distress for the SSA men and women and compare these to AUS rates.

To determine whether scores on the derived assessments (i.e., for insomnia, nocturnal PTSD symptoms, psychological distress, and sleep apnea) differ significantly between SSA men and women. In the event of finding significant sex differences within the SSA sample for insomnia, determine what the insomnia risk factors may be, especially for the group at highest risk.

To analyse key categorical demographic variables, known to potentially have a relationship with sleep quality, for each sex and determine which, if any, demographic variables are associated with insomnia severity.

To analyse key continuous variables, including the derived assessments of insomnia, nocturnal PTSD symptoms, psychological distress, age, and years in Australia/New Zealand and determine whether important correlational relationships exist, within each sex, between these variables.

Methods

Participants

Participant recruitment from within the South Sudanese former refugee community living in Victoria, Australia and occurred across metropolitan Melbourne as well as in the regional centres of Morwell, Ballarat, and Geelong. There was some geographical bias to communities living in the western suburbs of Melbourne. Recruitment venues were mainly at community centres, churches, and local cafes, and this precluded a calculation of a response rate. No clinically related venues were used.

The package was administered individually in Dinka, Nuer, English, or Arabic across Victoria by two male researchers who were PhD students from the South Sudanese Australian community. All women could request a female research assistant to administer the questionnaire but none chose to do so.

The final sample (N = 117) was aged 16–60 years and comprised 62 men and 55 women. Published Australian South Sudanese demographic data suggests a close to 50:50 split between the sexes and a distribution of age groups, as shown in Table 1 (recalculated from Australian Government, 2014). Table 1 also shows the comparative percentage, by age group and sex, for the current sample. It can be seen that the difference between the current SSA sample and the SSA population was within a 5% tolerance range for most age groups. The age profile of the SSA population is younger compared to the general Australian population (Australian Bureau of Statistics, 2014), with almost half of the SSA population being within the 35 to 64 years age band.

Table 1.

Age group, as a function of sex, for the current sample and the Australian population of South Sudanese former refugees (SSA).

	Men		Women
Age in years	% in current sample (n)	% in SSA population*	% in current sample (n)	% in SSA population*
16–21	4.8 (6)	9.6	5.5 (6)	8.1
22–26	3.2 (4)	7.0	7.4 (8)	6.7
27–36	22.6 (28)	13.1	15.7 (17)	13.3
37–51	16.9 (21)	13.3	20.4 (23)	12.8
52–66	2.4 (3)	5.2	1 (1)	3.9
67+	0 (0)	1.7	0 (0)	2.3

Notes: *Based on data recalculated from Australian Government (2014).

The average duration of living in Australia or NZ was 9.13 years (standard deviation = 2.95) for SSA men and 9.99 years (SD = 2.72) for SSA women. There was an almost equal split between Dinka and Nuer speakers (51% Nuer). Comparisons will be made with an Australian sample reported in Hillman and Lack (2013). The 1,512 survey respondents were sampled in 2010 by a national polling organisation (Roy Morgan Research). Respondents were “from all states and territories, both urban and rural, with the sampling proportionate to the populations of those areas, sex and age” (Hillman and Lack, 2013, p. S7).

In terms of age of the Australian (AUS) sample, the following details are available (14–17 year olds = 6.4%; 18–24 year olds = 11.7%; 25–34 year olds = 17.4%; 35–49 year olds = 26%; 50–64 year olds = 21.9%; 65 + year olds = 16.5%), and women were 50.6% of the sample (Hillman, personal communication, 2017). No further details about the sample such as marital status and employment were collected.

The data were collected between early December 2013 and the end of April 2014, and this coincided almost exactly with the timing of a new civil war in South Sudan, causing anguish in the local South Sudanese community. The question then arises as to what extent their responses may have been impacted by these distressing events. One open question asked them to comment “about your sleep or things that make good sleep a problem for you.” Seventy participants responded to this item but only three comments contained any reference to the current crisis/war in South Sudan.

Measures

The questionnaire¹ package included a ‘Sleep and Demographic’ questionnaire, a PSQI-Addendum for nocturnal PTSD symptoms, and the K10 (psychological distress), and was made available in hard copy and online in four languages, Dinka, Nuer, Arabic, and English (see below for further details). An Arabic K10 was available (K10 Arabic, 2012) and all the remaining questionnaires were translated using a standard translation protocol by professionally qualified and accredited translators. Significant efforts were made to ensure the translations were as valid as possible. Initially English words that may have presented problems were discussed by a small group of tertiary educated multilingual South Sudanese living in Australia. After professional translation, the materials were carefully checked by an independent translator and any differences of opinion were discussed with the original translator and a resolution obtained. The questionnaires were initially piloted for translation quality on several tertiary educated Nuer and Dinka individuals with excellent English skills and any ambiguities reviewed with accredited translators. Pilot work suggested it would be best to present all the materials to participants with each question and possible responses having both the translation and English side by side. Most questionnaires were completed face-to-face with a bilingual researcher (BK and SD, with both the Nuer and Dinka researchers themselves being accredited translators).

Sleep and Demographic Questionnaire

This first section contained sleep-related items (see Figure 1) that were the same as those used in a recent study of the Australian population (1,512 surveyed by telephone, Hillman & Lack, 2013). This was done to enable direct comparisons with the results of their study. The first 12 items had five rating scale options from “rarely or never” to “every or almost every night/day.” Further questions yielded categorical data related to sleep duration, and factors that may affect their sleep were included.

Figure 1.

Percentages of participants experiencing sleep difficulties, sleep disorder symptoms, and daytime impairments a few times a week or more, for Australians (AUS) (Hillman & Lack, 2013 data) and South Sudanese Australians (SSA), as a function of sex.

Two derived assessments were made. Firstly, an Insomnia Severity Rating (ISR) score was derived from reported sleep difficulties plus daytime impairments (seven variables with each having a frequency score range from 0 to 4). The seven variables were ratings of difficulty falling asleep, waking up a lot, waking up too early, waking unrefreshed, inadequate sleep, daytime sleepiness, and fatigue or exhaustion. Following Hillman and Lack (2013), a score >14 (out of 28) was used to describe clinical insomnia. Secondly, the presence or absence of Possible Sleep Apnea was derived by determining how many respondents snored loudly at least a few times a week and had observed breathing pauses during sleep at least a few times a month. These two questions were the same as used by Hillman and Lack (2013) and were the two questions identified as core questions in eight different sleep apnea questionnaires reviewed by Abrishami, Khajehdehi, & Chung (2010).

Nocturnal PTSD Symptoms – (Pittsburgh Sleep Quality Index-Addendum - PSQI-A)

The PSQI-A consists of seven questions on a range of symptoms over the last month. There are four frequency options and symptoms relate to hot flashes, nervousness, nightmares anxiety/panic, bad dreams, screaming during sleep, and acting out dreams. The developers (Germain, Hall, Krakow, Shear, & Buysse, 2005) found satisfactory internal consistency (0.85) and good convergent validity with two standard PTSD measures, even when excluding their sleep items. This study, and further research (Insana, Hall, Buysse, & Germain, 2013), concluded that the PSQI-A is a valid measure to detect PTSD, with a cut-off score of 4. Scores above this level are termed “clinical-level PTSD nocturnal symptoms” in the current study. Normative PSQI-A rates for nocturnal PTSD disruption are not available. Internal consistency for the current SSA sample (N = 114) was very good (0.82).

K10 – Kessler Assessment of Psychological Distress

This is a 10-item assessment devised for screening purposes (Kessler et al., 2002) that has been widely used. Scores ≥30 are considered as “very high” (State Government of Victoria, 2010). Ratings are over the last four weeks on a 5-point scale. Rates are compared here to the Victorian Population Health Survey (State Government of Victoria, 2010), which interviewed 7,535 Victorians. Internal consistency for the current sample (n = 115) was very good (0.84).

Procedure

All participants were given various options of how the questionnaire could be completed. They could (i) do the hard copy on their own, (ii) do the online version on their own, (iii) do it over the phone with a bilingual researcher, or (iv) sit with a bilingual researcher with a laptop and complete it together. No participant chose the first option and four participants completed the package orally over the phone. Most (n = 75) completed the questionnaires in a one-to-one situation with a laptop, where the researcher entered their verbal responses into the computer, with the remainder going online themselves.

Hillman and Lack (2013) note that the AUS sample were recruited in 2010 by a national polling organisation which conducted a national landline telephone survey of adolescents and adults, who were called on successive weekend evenings. No further recruitment details were provided.

Data analysis

Comparison with sleep data from 1,512 respondents comprising a representative general Australian sample (Hillman & Lack, 2013) was confined to descriptive comparisons of percentages of like variables (see Figure 1 and Table 3). Independent t-tests were used to compare continuous data across SSA men and women and also analyse for insomnia risk factors using dichotomised variables and ISR scores as the dependent variable (see Results section for details). Internal consistency calculations used Cronbach’s alpha. Correlational analyses were also completed for relevant continuous variables, within each sex group. Alpha was set at .05.

Table 3.

Percentages and frequencies of self-reported problems for South Sudanese men and women (SSA) and reported sleep durations and comparisons with published rates from broad Australian samples (AUS) as applicable.

	Measure and criteria	AUS total	AUS men	AUS women	SSA total % (n/N)	SSA men % (n/N)	SSA women % (n/N)
Clinical insomnia	Insomnia Severity Index >14	6.9%^a	5%	8.7%	21.6% (24/109)	31.6% (18/57)	11.5% (6/52)
Clinical-level nocturnal PTSD behaviours	PSQI-A ≥ 4				38.9% (44/113)	57.6% (34/59)	18.5% (10/54)
Very high psychological distress	K10 ≥ 30	2.6%^b	1.8%	3.4%	12.8% (14/109)	17.5% (10/57)	7.7% (4/52)
Possible sleep apnea	See text for criteria	4.9%^a	6.3%	3.6%	6.0% (7/117)	6.5% (4/61)	5.5% (3/54)
Sleep duration on weeknights (Sun–Thurs)	Self-reported hours	7.16^a	7.15	7.17	6.44	6.22	6.68
Sleep duration on weekends (Fri, Sat)	Self-reported hours	7.37^a	7.37	7.37	6.53	6.29	6.85
Sleep duration overall	Self-reported hours	7.22^a	7.21	7.23	6.47	6.24	6.73

Notes:^aFrom Hillman and Lack (2013). ^bfrom State Government of Victoria (2010). ISR = Insomnia Severity Rating, PSQI-A = Pittsburgh Sleep Quality Index-Addendum, K10 = Kessler 10.

Ethics

The study was approved by the institution’s Human Experimentation Ethics Board (HRE 13-130) and all participants gave formal informed consent prior to undertaking the study.

Results

Characteristics of the sample as a function of sex

Responses on a range of demographic and sleep-related categorical questions are presented in Table 2. Over 60% of participants were married and well over two thirds were parents. Over two thirds of SSA men had completed a post-high school qualification and 30% were seeking work. Men reported many more memories and nightmares related to the past (29.5%) than women (9.1%) as well as reporting more bad dreams, anxiety, or panic not related to bad memories than women.

Table 2.

Self-reported demographic and sleep-related categorical variable frequencies for South Sudanese Australian men and women.

		Men n = 62*		Women n = 55*
		Frequency N	%	Frequency n	%
Marital status	Yes, married	38	61.3	33	60.0
	No, never been married	20	32.3	11	20.0
	Divorced and not remarried	4	6.5	7	12.7
	Widowed and not remarried	0	0	4	7.3
Work status	Full time	21	34.4	11	20.0
	Part time	14	23.0	15	27.3
	No but seeking work	18	29.5	18	32.7
	No and not seeking work	8	13.1	11	20.0
Study	Yes, full time	21	34.4	28	24.1
	Yes, part time	15	24.6	38	32.8
	No study	25	41.0	50	43.1
Time of day mostly work	Afternoons/evenings	5	8.2	1	1.8
	Nights	1	1.6	1	1.8
	Daytime	20	32.8	14	41.2
	Varies across the above	13	21.3	13	21.3
	N/A as not working	21	34.4	21	34.4
Highest completed education	Did not complete high school	3	4.9	14	25.5
	Completed high school	14	23.0	3	5.5
	Technical/further education/apprentice	19	31.1	30	54.5
	University	22	36.1	3	5.5
	Other (specify)	3	4.9	5	9.1
Drink more than one cup caffeine within four hours of bed	Rarely or never	26	41.9	38	70.4
	A few days a month	12	19.4	12	22.2
	A few days a week	14	22.6	4	7.4
	Every or almost every day	10	16.1	0	0
Chew khat within four hours of bed	Rarely or never	50	80.6	53	96.4
	A few days a month	4	6.5	1	1.8
	A few days a week	5	8.1	1	1.8
	Every or almost every day	3	4.8	0	0
Drink three or more alcohol drinks within four hours of bed	Rarely or never	51	82.3	44	80.0
	A few days a month	3	4.8	9	16.4
	A few days a week	5	8.1	2	3.6
	Every or almost every day	3	4.8	0	0
Do you have children?	No children	20	32.8	9	16.4
Do you have children?	One or more children	41	67.2	46	83.6
Normal sleeping arrangement	Sleep alone	30	48.4	10	18.2
	Wife/husband/partner in bed	11	17.7	8	14.5
	Children in bed (no spouse)	6	9.7	12	21.8
	Spouse and children in bed	15	24.2	25	45.5
Current family status in community	Immediate family attachments	36	58.1	36	50.0
Current family status in community	No immediate family attachments	26	41.9	19	34.5
Issues affecting sleep	Long hours at work#	20	32.3	7	12.7
	Long hours studying#	16	25.8	5	9.0
	Lots of worries#	15	24.2	20	36.4
Events more than 1–2 times a week(3 PSQI-A questions)	Memories or nightmares related to past	18	29.5	5	9.1
	Severe anxiety/panic not related to bad memories	14	23.4	0	0
	Bad dreams not related to past memories	11	18.3	3	5.5

Notes: *May vary with some missing data for some variables. All questions are from the Sleep and Demographic Questionnaire.

#Percentages for each variable are as a proportion of the total numbers of respondents for each sex, as more than one option was possible per respondent.

Sleep and psychological variables (research question 1)

Figure 1 presents the data pertaining to research question 1a (prevalence of sleep and daytime symptoms) as a function of sex. It shows that almost two thirds of SSA respondents (men and women) self-reported inadequate sleep and these prevalence rates were more than twice that of the comparison Australian (AUS) sample. Similarly, around four in 10 SSAs (men and women) reported difficulty falling asleep, a prevalence rate nearly twice that of their Australian counterparts. For a number of other variables, SSA men had much higher rates than the other three comparison groups shown in Figure 1, and these included significant waking and daytime impairments (over 40% for SSA men on the four relevant variables related to waking, daytime sleepiness, and fatigue/exhaustion) and restless legs (over 30% for SSA men). Further noticeable differences were high rates of reported frequent or loud snoring in AUS men compared to all three other groups, higher reports of daytime sleepiness for AUS women compared to SSA women, and more irritability for SSA men compared to SSA women.

Derived assessments of insomnia (ISR), nocturnal PTSD symptoms (PSQI-A), psychological distress (K10), and possible sleep apnea were obtained for the SSA men and women and compared to AUS rates. These are shown in Table 3 (research question 1b). SSA men were six times more likely to be classified with “clinical insomnia” than AUS men, with rates almost three times that of SSA women.

Nearly one in five SSA men met the criteria for “very high psychological distress,” a rate nine times higher than found in Victorian men and over twice as high as in SSA women. Of particular concern is that 57.6% of SSA men met the criteria for “clinical-level” nocturnal PTSD symptoms, a rate more than three times that of their female counterparts. Further, comparisons of the descriptive data in Table 3 show that SSA men had the shortest sleep duration of any group.

Sex differences on derived sleep and psychological assessments (research question 1)

Table 4 shows that assessments for insomnia, nocturnal PTSD symptoms, and sleep duration showed significant sex differences between SSA men and women, with men having more difficulties. As only seven SSA participants met the self-report criteria for possible sleep apnea, no analyses for a sex difference were made.

Table 4.

Means (and standard deviations, SD) for questionnaire scores and sleep duration estimates for South Sudanese (SSA) men and women and t-test results.

	Mean (SD)		t (df = 111)	p
	SSA men (n = 59)	SSA women (n = 54)	t (df = 111)	p
Insomnia (ISR)	19.37 (4.58)	16.67 (3.81)	3.35	.001
Nocturnal PTSD behaviours (PSQI-A)	5.11 (4.33)	2.37 (2.67)	4.01	<.001
Psychological distress (K10)	21.67 (7.73)	19.81 (5.21)	1.46	ns
Sleep duration (hours)	6.24 (0.98)	6.73 (.89)	2.81	.006

Notes: ns = not significant, ISR = Insomnia Severity Rating, PSQI-A = Pittsburgh Sleep Quality Index-Addendum, K10 = Kessler 10.

Insomnia risk factors for SSA men and women (research question 3)

In order to identify possible demographic risk factors for insomnia in SSA men and women, mean insomnia (ISR) scores were compared within each sex as a function of a dichotomised demographic categorical variable using independent t-tests, where the ISR score was the dependent variable and the dichotomised demographic variable was the independent variable. Such dichotomisation allowed the use of inferential statistics. Seven demographic variables were investigated using this method, dichotomised as follows: not working and seeking work versus all other possibilities (fulltime work, part-time work, not seeking work), shift-worker (daytime or not applicable versus all other possibilities), married versus all other possibilities (never married, divorced, or widowed), have children or not, sleep with children or not (either with or without a spouse as well), have immediate family in community or not, and completed university studies versus all other possibilities of highest completed educational level (did/did not complete high school, completed technical/further education/apprentice/other). No significant differences (or trends) were yielded for these comparisons, with one exception. It was found that currently married men had higher insomnia scores than those men who were never married, currently divorced, or widowed (t (58) = 2.46, p = .017). Married men had a mean ISR score of 20.35 (SD = 5.04), while non-married men had an ISR of 17.72 (SD = 3.15).

Correlations for derived scores as a function of sex (research question 4)

Correlations sought to identify important relationships for men and women (separately) among the three derived scores, i.e., ISR, PSQI-A, and K10. Correlations were also computed for age and years in Aust/NZ. Table 5 shows three significant correlations for men (PSQI-A correlated with ISR, K10, and Years in Aust/NZ) and one for women (PSQI-A and ISR). The significant negative correlation between years in Aust/NZ and nocturnal PSQI-A symptoms suggests some improvement over time for SSA men.

Table 5.

Correlation matrix for relationships between continuous variables assessing insomnia, nocturnal PTSD symptoms, psychological distress, age, and years in Australia/New Zealand, with South Sudanese men (n = 54–59) and women (n = 51–54) correlated separately.

	ISR		PSQI-A		K10
	Women	Men	Women	Men	Women	Men
PSQI-A	r = .66, p < .001	r = .46, p < .001
K10	r = .10, ns	r = .27, p = .05	r = .00, ns	r = .51, p < .001
Age in years	r = −.10, ns	r = .14, ns	r = −.17, ns	r = −.14, ns	r = −.16, ns	r = −.15, ns
Years in Aust/Nz	r = −.17, ns	r = −.05, ns	r = −.08, ns	r = −.28, p = .04	r = −.19, ns	r = −.16, ns

Notes: ns = not significant, ISR = Insomnia Severity Rating, PSQI-A = Pittsburgh Sleep Quality Index-Addendum, K10 = Kessler 10.

Discussion

This study fills a significant gap through its reporting of the sleep difficulties and related psychological issues of South Sudanese former refugees and provides new insights about the difficulties SSA are experiencing post-migration. SSA men were found to have particularly high rates of sleeping difficulties compared to SSA women and AUS men and women. For many SSA men, memories and dreams of past traumas may be affecting their sleep and psychological health.

Group comparisons of sleep difficulties and psychological symptoms

As a group, the SSA reported much higher rates of inadequate sleep and difficulty falling asleep than the comparison AUS group. While the incidence of clinical insomnia was high across the SSA group (21.6%), the incidence was half that reported by the displaced population of Abkhazia (41.4%) still living in centres for displaced people after 15 years (Basishvili et al., 2012); a difference most likely related to their very different post-migratory experiences.

Reported sleep durations across the full week were, on average, three quarters of an hour less for SSA respondents than AUS. Many studies in Western countries have found shorter average sleep durations and more sleep problems in people of lower socio-economic status (SES) (see review by Knutson, 2013). This relationship may be confounded by unhelpful health behaviours as it is not always present once adjustments are made for co-variants such as BMI, smoking, alcohol use, physical activity, and health measures (Stranges et al., 2008). The extent to which SSA may engage in unhelpful health behaviours is unknown. While there was no evidence of widespread stimulant use (caffeine, khat, or alcohol) in the four hours before bed in the SSA group, poverty and unemployment are disproportionally present in the Australian South Sudanese community, as is acculturation stress (Milner & Khawaja, 2010). Also of relevance are the racism and discrimination which have affected South Sudanese migrants in Australia (Khawaja, White, Schweitzer, & Greenslade, 2008), as they have other African-background communities, and this trend continues. In the highly regarded Scanlon Foundation national survey published in 2016, 77% of South Sudanese reported experiences of discrimination across Australia (Scanlon Foundation, 2016). These experiences have included discrimination in housing and employment, both verbal and physical instances of race-based harassment in public settings such as shops and on the street, and racial profiling from police in interactions with South Sudanese youth (Scanlon Foundation, 2016).

Disturbingly, almost 40% of the SSA group had clinical-level nocturnal PTSD behaviours, with men being much more affected. Studies have suggested that the PSQI-A can successfully discriminate clinically diagnosed PTSD from non-PTSD conditions with an accuracy ranging from 93% (Germain et al., 2005) to 74% (Insana et al., 2013), although neither study involved former refugees. While these PTSD prevalence data found the PSQI-A compared quite well to a comprehensive PTSD clinical diagnostic process, caution is needed. Australian PTSD severity 12-month prevalence rates, based on the Composite International Diagnostic Interview for PTSD, were low at 1.33% (Creamer, Burgess, & McFarlane, 2001). While the current findings cannot directly conclude what the rate of PTSD is in the SSA population, the high rates of PTSD-like sleep disturbances, such as nightmares, bad dreams, nervousness, and panic, in SSA men are concerning and deserve further investigation.

A Canadian study of 220 recently arrived Sudanese refugees found that those experiencing post-migration economic hardship were 2.6 to 3.9 times more likely to experience loss of sleep, constant strain, unhappiness, and depression as well as bad memories, compared to those who were not experiencing hardship (Simich, Hamilton, & Baya, 2006). This suggests a possible interaction between post-migration disadvantage and the extent to which “bad memories” linger.

Sex differences in sleep difficulties and psychological symptoms

SSA men had significantly higher rates of insomnia and nocturnal PTSD behaviours than women. The SSA men’s rate of 57.6% for clinical-level nocturnal PTSD symptoms is similar to the findings of Karunakara et al. (2004) (46–48% PTSD prevalence) for refugee Sudanese in Uganda in 1999/2000, suggesting rates of post-trauma symptoms in this population may continue more than a decade after initial displacement. Caution must be applied here as the method of assessing post-trauma symptoms differed between the studies, but it does suggest an important issue for further research.

While the current findings show that SSA women were more likely to report that their sleep was affected by “lots of worries,” it was quite clear that many more SSA men were reporting frequent disturbing memories and nightmares related to the past than women (30% versus 9%). These findings warrant comparison with the Queensland (Australia) study by Schweitzer et al. (2006) of 63 Sudanese former refugees. In that study, gender was a significant predictor for PTSD, depression, and anxiety, with women being more at risk than men, and pre-migration trauma experiences and post-migration social support were important contributors to all three psychological issues.

With regard to restless legs, the self-reported rate in SSA men (31%) was much higher than the rate reported for the AUS sample of 9.4% (Hillman & Lack, 2013) and other published rates of 5–10% (Ulfberg, Nyström, Carter, & Edling, 2001). Restless legs syndrome is known to be more likely in those with PTSD (Krakow et al., 2000) and has been linked to psychiatric conditions (Ulfberg et al., 2001). Caution is needed with regard to prevalence estimates for restless legs syndrome based on surveys, with a face-to-face diagnostic interview being a much more valid and reliable methodology (Hening, Allen, Washburn, Lesage, & Earley, 2009). It is possible this is even more the case where linguistic and/or cultural differences across survey groups exist.

AUS men had higher rates of self-reported frequent or loud snoring a few times a week or more than other groups, which may be related to the higher average age of AUS men than SSA men, or may be associated, speculatively, with AUS men perhaps having higher rates of being overweight or obese or alcohol intake than SSA. Rates of possible sleep apnea, derived from self-report questions, did not differ between AUS and SSA men.

Differences in the prevalence of daytime sleepiness, occurring a few times a week or more, were found between AUS women (22.3%) and SSA women (7.3%). This was an unexpected finding that may arise in part from the lighter and more fragmented sleep associated with the increased mean age of the AUS group (Ohayon, Carskadon, Guilleminault, & Vitiello, 2004). SSA men reported themselves as being more irritable and moody than SSA women (24.2% versus 9.1%) and this may mirror the more prevalent mental health problems reported by the two groups with, for example, rates for very high levels of psychological distress being 17.5% and 7.7% for SSA men and women respectively.

Insomnia risk factors and other associations

Seven possible risk factors for insomnia were explored and six were found not be associated with insomnia. It is difficult to know how to interpret the finding that for SSA men being married was a risk factor for insomnia (compared to those men who were never married, divorced, or widowed). Members of the local South Sudanese community felt it was due to increased stress from family responsibilities. However, it may be a random significant finding, given the large number of statistical analyses that have been performed.

Both a Canadian study of recently arrived refugees by Simich et al. (2006) and the Queensland study assessing predictors of anxiety and depression in former Sudanese refugees (Schweitzer et al., 2006) found that economic hardship/unemployment were predictors of poor psychological health. The current study found that work status was not a risk factor for SSA, but other indicators of hardship were not collected. A study designed specifically to assess hardship as a risk for insomnia in SSA using regression techniques would bring more rigour to this issue.

Schweitzer et al. (2006) also found that those with more depression and anxiety symptoms had been in Australia for a longer period of time. This is at variance with the current finding that there was no correlation between years in Australia/NZ and levels of psychological distress, suggesting that post-migration stressors may not be exerting a significant influence on the mental health of the current SSA population in Victoria. Consistent with this finding, a series of correlations revealed that longer residency in Australia or NZ was associated with fewer nocturnal PTSD symptoms in men (only).

Nevertheless, high rates of clinical-level nocturnal PTSD symptoms were found in SSA men, much higher than those reported by SSA women. Perhaps women had more psychological problems and PTSD in the earlier post-migration years (as found by Schweitzer et al., 2006), while for men the nocturnal PTSD symptoms are more persistent, although they do diminish with time. Child and adolescent multi-ethnic women were found to have greater resilience, as did those that had been living in Australia longer (Ziaian, de Anstiss, Antoniou, Baghurst, & Sawyer, 2012).

The significant correlation between nocturnal PTSD symptoms and insomnia severity for both SSA sexes is consistent with the literature on the important relationship between subjective sleep disturbance and the severity of PTSD symptoms (Babson & Feldner, 2010), even when a range of potentially confounding variables are controlled (e.g., SES, alcohol, psychotropic medication, and psychiatric co-morbidities) (Belleville, Guay, & Marchand, 2009). Indeed, Caldwell and Redeker (2005) argue that sleep has been found to act as a mediator in the relationship between PTSD symptoms and health functioning and consequently interventions should focus on improving subjective sleep quality.

Among SSA men, where 57.6% were found to have clinical levels of nocturnal PTSD symptoms, these symptoms were found to correlate significantly with their scores for psychological distress. This is unsurprising given the high co-morbidity of PTSD with anxiety and depression. A study of war veterans with PTSD found about a third had this “triple comorbidity” and their longitudinal analyses over 20 years showed that PTSD predicted the development of anxiety and depression, but not vice-versa (Ginzburg, Elin-Dor, & Solomon, 2010). The lack of this correlation in SSA women warrants further exploration to determine whether it may be a “floor” effect given the lower incidences of nocturnal PTSD symptoms and psychological distress in this group.

Limitations

The most important limitation of this study is the fact that none of the questionnaires that were translated into Dinka, Nuer, and Arabic have been validated for those languages. While significant effort was taken to ensure high quality translations, there is no independent evidence of their validity, including cultural validity.

The sleep data obtained in this study from the SSA could stand alone as a descriptive, rather than comparative, study. However, it was decided that the data was more meaningful and informative from a public health point of view if the frequencies of particular sleep difficulties could be specifically compared with the sleep of the general Australian population. Thus the findings were compared to a study of 1,512 Australians from a survey that sought to be representative of the geographic, age, and sex profile of the broad Australian community (Hillman & Lack, 2013). Such a comparison raises a number of limitations that need acknowledgement. The first relates to the ages of SSA compared to AUS. The study purposefully obtained a sample that was quite closely representative of the age and sex profile of the South Sudanese former refugee population in Australia. Thus the SSA group had fewer adults aged over 50 compared to the AUS group, while the AUS group included 14–15 year olds, which the SSA group did not. The prevalence rates in this article should thus be interpreted as representative of the age and sex profile of each group, not as an age-controlled comparison of sleep difficulties. Indeed, given that sleep quality declines with age (Ohayon et al., 2004), the sleep difficulties of the South Sudanese found here may be an under-representation, were an age-controlled comparison to be made. A further important limitation of the SSA/AUS comparison arises from a lack of demographic data on factors such as marital status and education level. This data was unfortunately not collected for the Hillman and Lack (2013) study. The available literature would suggest that the AUS group would have a higher overall educational and socio-demographic level than the former refugees (Milner & Khawaja, 2010). The relationship between socio-demographic indicators, including ethnicity and poverty, and sleep quality is well documented (e.g., Patel, Grandner, Xie, Branas, & Gooneratne, 2010) and cannot be overlooked as an important contributor to the current findings on sleep difficulties in the SSA group. The extent of demographic bias arising from recruitment strategies for the SSA is unknown; there may have been, for example, some bias towards SSA who were involved in post-secondary studies. The existence of a possible bias in the responses of SSA women, given that both researchers administering the questionnaire were men, is possible. Speculatively, some women may have minimised their sleep problems in this context but there is no evidence regarding this possibility.

A further consideration is the fact that comparisons are made across different response methods, where the AUS sample answered questions over the phone while most of the SSA (75/117) completed the questionnaire in the presence of a researcher entering their verbal responses onto a laptop. Dillman et al. (2009) compared survey responses across a variety of methods and found similar outcome data across aural methods (telephone interview and interactive voice response) compared to visual response modes (mail and the web). However, their study did not examine possible differences in responses that included face-to-face interview situations.

As noted above in the Procedure section, the timing of data collection coincided with a new civil war in South Sudan, which caused distress in the Australian South Sudanese community. Although inspection of open-ended responses about “other” factors that may be affecting sleep revealed very little reference to the new events in South Sudan, the possibility that worry about people in their homeland affected participants’ sleep (and overall psychological wellbeing) cannot be ruled out. Images, news, and family stories from the new war may have re-ignited past traumatic memories, influencing responses.

Implications for treatment

Two bodies of evidence support the idea of focussing on sleep interventions to assist with nocturnal PTSD symptoms and more general sleep disturbance in former refugees from non-Western countries. The first is a review of the empirical literature showing that the “treatment of sleep disorders yields strong improvement in PTSD symptoms” (Kovachy et al., 2013, p. 504). The second is from cross-cultural psychology, arguing individuals from non-Western countries respond better to a focus on somatic symptoms and complaints rather than psychopathology as defined by the biomedical model (Sue & Sue, 2012). Similarly, a review of the research on the psychosocial wellbeing of Sudanese refugees (Tempany, 2009), cautions against the idea that mental health and wellbeing are conceptualised in similar ways across cultures and notes the importance of ‘bodily metaphors’ for a range of complaints (see also Hinton & Jalal, 2014). Consistent with this, Black African immigrants to Australia attributed sleep difficulties more to physical than psychological phenomena compared to non-immigrant Australians (Clever & Bruck, 2013). A study documenting a primary health program for Burmese refugees noted that asking about sleep opened up the conversation about emotional and mental health problems (Haley, Walsh, Maung, Savage, & Cashman, 2012). Further, while screening for sleep problems may be a less culturally disputed form of initial assessment of distress (Bronstein & Montgomery 2013), a culturally competent assessment of sleep difficulties must take into account what an individual’s interpretation of their sleeping problems may be - allowing for the possibility of spiritual attributions, for example.

In developed countries, Cognitive Behavioural Therapy for Insomnia (CBT-I) has been shown to be highly efficacious in providing treatment for sleep onset and sleep maintenance difficulties (Smith et al., 2002), including those co-morbid with psychiatric conditions such as PTSD (Taylor & Pruiksma, 2014). However, it is unknown how effective and/or acceptable these might be for the sleep health of non-Western communities and CBT-I is likely to need modification to be more culturally competent and less biomedically- orientated (Sue & Sue, 2012). Issues such as the most successful venue (e.g., clinic versus other), therapist background, and setting (i.e., individual, group, family, social, mixed gender) need to be understood. The possible interaction of sleep difficulties with trauma stress may require special sensitivities in sleep-related treatments.

Conclusion

Both men and women in the South Sudanese community had prevalence rates of self-reported inadequate sleep and difficulty getting to sleep around twice that of their Australian counterparts. In particular, men within the South Sudanese Australian community report hitherto unrecognised significant problems with their sleep and psychological adjustment. The high rates of PTSD-related disturbances to sleep and evidence of some improvement over time are consistent with the interpretation that unresolved pre-migration trauma stress may be continuing to affect the sleep of about half of South Sudanese men in Australia (assuming that trauma has not been an issue for them post-migration). Whether or not such pre-migration stress has an interaction with post-migration hardship is unknown, and warrants further research.

Studies about the most culturally acceptable and effective methods of assisting with sleep difficulties in non-Western populations are also needed.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The funding for this research from the Centre for Cultural Diversity and Wellbeing, Victoria University, is gratefully acknowledged.

Note

Dorothy Bruck, BA(Hons), PhD, is an Emeritus Professor of Psychology at Victoria University, Australia. Dr. Bruck researches a wide range of issues relating to sleep health and its impact on psychological wellbeing and she is currently Chair of the Sleep Health Foundation. She is an experienced psychologist specialising in insomnia and narcolepsy, with a particular interest in cross-cultural aspects of therapy. Dr. Bruck’s published works focus on sleep/wake behaviour, mental health, narcolepsy, chronic fatigue syndrome, sleep inertia, arousal thresholds, human behaviour in emergencies, and gut-brain relationships.

Santino Atem Deng, PhD, MEd, BA, is an experienced counsellor, educator, researcher, and trainer. Dr. Deng has some expertise in mental health, settlement issues, and family and parenting practices. His PhD study investigated changes and challenges within South Sudanese family dynamics and parenting practices in Australia by examining recent transitions in parenting practices from the perspectives of both parents and youth. Dr. Deng draws on nuanced cultural understandings and contexts to explore various challenges and transitions in parenting after resettling in Australia. Dr. Deng currently works as a Counsellor and positive parenting trainer and has held many community leadership roles and managed community programmes. His published works focus on positive parenting, mental health, acculturation, refugee resettlement, and disparities within settlement service delivery.

Bichok Wan Kot, BSSc, MSSc, PhD, is an Academic Teaching Scholar at Victoria University, Australia. Dr. Bichok researches the changing dynamic of traditional Nuaüaür gender roles and the migrant experience as a result of migration and resettlement in Australia. His research revolves around a “crisis” in masculinity experienced by Nuaüaür men as they transition from a traditional society to life in refugee camps and resettlement in Australia. Dr. Bichok is currently a lecturer as well as Convenor of Youth and Community Context and Applied Human Rights at First Year College at Victoria University.

Michele Grossman, BA, MA, PhD, is the Research Chair in Diversity and Community Resilience, Professor of Cultural Studies, and convenor of the AVERT Research Network at the Alfred Deakin Institute for Citizenship and Globalisation at Deakin University, Australia. Dr. Grossman researches community resilience strategies for countering violent extremism, and culturally diverse approaches that build resilience to social harms more generally. She is the inaugural Director of the consortium-based Centre for Resilient and Inclusive Societies (CRIS), and serves as a principal investigator on current research projects supported by Public Safety Canada, the USA’s National Institute of Justice, and the European Commission’s Horizon 2020 programme. Her recent publications focus on terrorism and violent extremism research, and resilience and vulnerability in cross-cultural contexts.

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