Unfair treatment may disrupt women’s sleep through unhealthy coping habits

Poor sleep is one of the most underappreciated threats to public health, and a new study suggests that the way women cope with unfair treatment may partly explain why some sleep worse than others. In an analysis of more than 31,000 women enrolled in a nationwide United States cohort, researchers found that maladaptive coping strategies such as self-blame, denial, venting, and behavioral disengagement served as a behavioral bridge linking experiences of unfair treatment based on race or ethnicity to poor sleep quality and insomnia symptoms measured years later. Adaptive strategies, including seeking emotional support and active problem-solving, did not provide the same protective buffering. The findings, published in the Journal of Behavioral Medicine, offer one of the most detailed portraits to date of how psychological responses to discrimination may shape sleep health in women, and they point to coping skills as a potential target for interventions designed to reduce sleep disparities.

The investigation drew on the Sister Study, a prospective cohort of 50,884 women across the United States and Puerto Rico enrolled between 2003 and 2009. For the current analysis, the team led by Rupsha Singh, Symielle A. Gaston, Dale P. Sandler, and Chandra L. Jackson of the National Institute of Environmental Health Sciences identified 31,443 eligible participants who identified as non-Hispanic White, non-Hispanic Black, or Hispanic/Latina and who had complete data on differential treatment, coping, and at least one sleep dimension. Participants reported whether they had ever experienced unfair treatment attributed to their race or ethnicity during a follow-up questionnaire administered between 2008 and 2012. Everyday differential treatment was assessed with items covering unfair service at stores or restaurants, being treated as less intelligent or worthy, and people acting afraid of them. Major differential treatment included unfair treatment in housing, police encounters, and employment. Sleep was assessed five to eleven years later, between 2017 and 2019, capturing habitual sleep duration, sleep disturbance, and insomnia symptoms.

The prevalence of reported differential treatment varied dramatically by race and ethnicity. Among non-Hispanic Black women, 78.6 percent reported everyday differential treatment and 57.1 percent reported major differential treatment. Among Hispanic/Latina women, the corresponding figures were 29.7 percent and 14.3 percent, while among non-Hispanic White women only 3.8 percent and 2.2 percent reported these experiences. Sleep outcomes also differed: habitual short sleep, defined as fewer than seven hours per night, was most prevalent among non-Hispanic Black women at 29.8 percent, compared with 16.2 percent of Hispanic/Latina and 10.0 percent of non-Hispanic White women. Moderate-to-severe sleep disturbance followed a similar gradient, affecting 12.2 percent of non-Hispanic Black, 11.3 percent of Hispanic/Latina, and 9.5 percent of non-Hispanic White participants. Insomnia symptoms, however, were most common among non-Hispanic White women at 43.8 percent, with 39.9 percent of non-Hispanic Black and 38.3 percent of Hispanic/Latina women affected.

Methodologically, the researchers classified coping strategies using nine items adapted from the Coping Orientation to Problems Experienced Inventory and its abbreviated version. Adaptive coping comprised five strategies: use of emotional support, active coping, acceptance, humor, and personal growth. Maladaptive coping comprised four: behavioral disengagement, denial, self-blame, and venting. Responses were measured on a four-point Likert scale and summed into composite scores. To test whether coping explained the relationship between differential treatment and later sleep, the team performed parallel mediation analyses using the Hayes PROCESS macro in SPSS, simultaneously modeling adaptive and maladaptive coping while adjusting for a battery of potential confounders including age, marital status, income, education, employment, body mass index, depressive symptoms, general health, and sleep medication use. Bias-corrected bootstrapped confidence intervals provided estimates of indirect effects, and separate models were computed for each combination of differential treatment type, sleep outcome, and racial-ethnic group.

The results revealed a consistent pattern: maladaptive coping, not adaptive coping, carried the harmful signal from differential treatment to sleep. Among non-Hispanic Black women, maladaptive coping significantly mediated the relationship between everyday differential treatment and poor sleep quality, with an indirect effect of 0.01 and a 95 percent confidence interval of 0.00 to 0.03, and between everyday differential treatment and insomnia symptoms, with an indirect effect of 0.04 and a confidence interval of 0.01 to 0.07. Notably, these mediation pathways emerged even where total and direct effects were not statistically significant, a finding the authors emphasize as valuable for intervention research, since mediators can represent actionable targets even in the absence of overall effects. Contrary to the team’s hypothesis, neither form of coping mediated the association between major differential treatment and sleep among non-Hispanic Black women.

Among non-Hispanic White women, despite the very low prevalence of reported differential treatment, maladaptive coping mediated relationships between both everyday and major differential treatment and both poor sleep quality and insomnia symptoms. For everyday differential treatment, the direct effect on later poor sleep quality was significant, and the indirect effect through maladaptive coping was also significant, while the pathway through adaptive coping was null. A parallel pattern held for insomnia symptoms. Among Hispanic/Latina women, by contrast, neither adaptive nor maladaptive coping mediated any of the associations between differential treatment and sleep, and the direct associations themselves were not statistically significant. Sleep duration showed no significant associations with either form of differential treatment or with either coping style in any group, suggesting that the coping pathway operates primarily on sleep quality and insomnia rather than on total sleep time.

The theoretical framework guiding the study is the environmental affordances model, which posits that environments impose both constraints and opportunities that shape how people cope with stress. Under this model, differential treatment acts as an external stressor that elicits coping responses, which in turn shape downstream health outcomes including sleep. In neighborhoods with limited access to healthy foods and recreational resources but greater availability of tobacco, alcohol, and illicit drugs, maladaptive coping may be both more accessible and more consequential. The authors suggest that maladaptive coping may trigger physiological stress responses that disrupt the transition from wakefulness to sleep and impair the body’s ability to achieve restorative slow-wave sleep. Psychological distress amplified by ineffective coping could create a feedback loop in which sleep disturbance deepens vulnerability to further stress, perpetuating insomnia symptoms and poor sleep quality over time.

The researchers also explored whether socioeconomic status moderated these pathways. Among non-Hispanic White women, household income significantly moderated the mediating effect of maladaptive coping: the indirect effect linking differential treatment to poor sleep quality and insomnia symptoms was weaker among women earning between 50,000 and 100,000 dollars compared with those earning less than 50,000 dollars, as reflected in significant indices of moderated mediation. Interestingly, the moderated mediation was not significant among women earning 100,000 dollars or more, indicating that the coping-mediated relationship between differential treatment and sleep was most pronounced in the lower-income group. Educational attainment did not moderate the mediation in any group, and neither income nor education moderated the indirect effects among non-Hispanic Black or Hispanic/Latina women.

The authors caution that the study has limitations. The nine-item coping measure may oversimplify a complex, context-dependent construct and did not capture culturally salient strategies such as spiritual or religious practices, mindfulness, collective or community-based coping, activism, or substance-related coping. Self-reported data on both differential treatment and sleep may introduce recall or misclassification bias, although validation studies indicate that self-reported sleep duration is overestimated across all racial-ethnic groups, meaning observed differences are unlikely to be purely artifactual. Smaller sample sizes for non-Hispanic Black and Hispanic/Latina women limited statistical precision, and the number of Puerto Rican residents was too small for separate subgroup analysis, which may partly explain the null findings among Hispanic/Latina women given geographic, cultural, and phenotypic heterogeneity within that population. The sample was also not nationally representative, and no formal correction for multiple comparisons was applied, leaving open the possibility of Type I error.

Even modest indirect effects carry public health weight when the underlying exposure is both common and persistent, the authors argue. Nearly four in five non-Hispanic Black women in this relatively high socioeconomic cohort reported everyday differential treatment, and more than half reported major differential treatment, underscoring that even women with substantial educational and financial resources routinely encounter stressors known to damage health. The identification of maladaptive coping as a mediating mechanism suggests that individually targeted interventions—particularly culturally tailored programs addressing coping skills—may help mitigate the sleep consequences of differential treatment. The authors recommend routine clinical assessment of coping strategies in patients reporting discrimination, integrated care involving sleep medicine specialists and mental health practitioners, and concurrent public health efforts to foster supportive environments that strengthen coping resources rather than merely treating symptoms. Future research, they note, should examine additional contextual factors such as support networks and cultural norms, test bidirectional relationships between coping and sleep, and employ qualitative approaches to deepen understanding of how women across different cultural contexts experience and cope with unfair treatment.