Implementing mindfulness practice to advance sleep health equity among Black women

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Sleep deficiency, characterized by short sleep duration, poor sleep quality, and symptoms of insomnia, is a significant public health concern in the US. Insomnia is the most common sleep disorder but is generally undertreated. Black women have a high prevalence of clinically significant insomnia, which is associated with the risk for cardiometabolic disease and early mortality. However, there is a dearth of sleep interventions and implementation efforts for Black women. There is a growing interest in the influence of structural racism on downstream social and health inequalities, suggesting health disparities as “a special case of implementation failure.” The time lag between research discovery and uptake of evidence-based intervention is even more inflated in Black communities. The long-term goal of the proposed research is to achieve health- and healthcare equity by implementing an evidence-based, equity-focused sleep intervention to reduce stress and sleep deficiency-related cardiometabolic disease burden in Black communities. Mindfulness-based therapy for insomnia (MBTI) is an evidence-based stress management program using mindfulness meditation and behavioral therapy for insomnia. The efficacy of MBTI on stress reduction and sleep deficiency has been shown in multiple meta-analyses in the general population. Findings from our pilot MBTI study were also aligned with the evidence. Evaluating the effectiveness of MBTI and developing equity-focused implementation strategies that address social determinants of health (SDoH), unique to Black women, are urgently needed to achieve sleep health equity. To address gaps in implementation science, we propose a study guided by the NIMHD Research Framework and Equity-focused Implementation Research Framework through a community participatory approach. In phases 1 and 2, we will identify multi-level barriers and facilitators to implementing the online MBTI through an equity lens using community-engaged research with key stakeholders. Then, we will develop and refine equity-focused implementation strategies with the community advisory board, comprised of community- based organization members, African Methodist Episcopal Zion Church networks, clinicians, and community health workers (CHWs). In phase 3, we will use a Hybrid Type 1 effectiveness/implementation design with a pragmatic randomized controlled trial with MBTI and a waitlist control in Black women with insomnia. CHWs as SDoH specialists will assess and address social needs of Black women, and registered nurses will deliver the online MBTI intervention in the community settings. We will evaluate effectiveness- (insomnia severity reduction/ remission) and implementation (acceptability, feasibility, fidelity, cost, contextual factors, and sustainability) outcomes. The study will contribute to equity-focused implementation science and policy decisions by providing multi-level implementation determinants, equity-relevant metrics, and contextual factors through community- engaged research and evaluation of the outcomes.