Chapter 6: Disparities in Sleep Medicine Access- Diversity, Equity, and Inclusion

Learning Objectives

• By the end of this chapter, students will be able to:
• Understand the concepts and contributing factors of healthcare disparities.
• Investigate trends in the usage of sleep medicine across different populations.
• Examine national and local initiatives aimed at reducing disparities in sleep medicine.
• Propose strategies to recruit and include diverse patient and technologist populations.
• Understand sociomedical demographics and how they impact sleep care.
• Identify common comorbidities and diseases that overlap with sleep-disordered breathing.

I. The Sleep Center Patient

As the population of the United States grows, the “typical patient” in the sleep center is becoming more diverse; yet disparities in access, diagnosis, and treatment continue. What is diversity? Diversity refers to the range of human differences including race, ethnicity, gender, age, socioeconomic status, religion, language, and physical ability. Historically, the “typical patient” in a sleep lab was considered an overweight person— mostly white males— who presented with complaints from wives of snoring. Occasionally, women were added into the mix if they too were overweight and complained of sleep issues.

Equity means providing fair access to resources and care, accounting for each patient's unique barriers. Inclusion involves ensuring that all individuals feel respected, represented, and supported within healthcare systems. In sleep medicine, the concept of diversity, equity, and inclusion (DEI) applies to how providers deliver care and communicate with patients from varying backgrounds. For example, studies have shown that Black and Hispanic patients are less likely to be diagnosed with or treated for obstructive sleep apnea (OSA) than their white counterparts, despite equal or greater risk.

These disparities may stem from reasons such as provider bias, lack of culturally competent education, or systemic barriers like poor insurance coverage. To address this, sleep centers have a responsibility to proactively tailor outreach and care practices to underserved communities, ensuring equitable access to diagnostics, follow-up, and therapy.

II. Socioeconomic Factors

Socioeconomic status (SES) involves a person’s income, education, employment, and access to resources. Patients with lower SES often face significant barriers in accessing sleep medicine services. They may lack health insurance, transportation, or the flexibility to take time off work for sleep testing. Even when diagnosed, affording and maintaining PAP devices can be difficult. These economic constraints widen disparities in treatment and health outcomes.

Equity in this situation means acknowledging these limitations and responding with compassion and systemic solutions. Sleep centers can improve access by partnering with community health organizations, offering sliding-scale payment options, and supporting public health policies that expand coverage for diagnostic sleep services. Additionally, health professionals should be trained to recognize how poverty and resource scarcity impact compliance and patient engagement. DEI-informed care requires seeing beyond clinical symptoms to the social determinants affecting the patient's ability to succeed with treatment.

III. Cultural and Religious Influences

Cultural beliefs shape how individuals view health, illness, and treatment. Religion often plays a significant role in defining personal health choices and behaviors. In sleep medicine, cultural and religious norms may influence how patients perceive fatigue, snoring, or the use of medical equipment at home. Some cultures may view sleep disorders as a private or even shameful topic, which can prevent patients from seeking care.

Inclusion in healthcare involves adapting communication and treatment plans to align with a patient's cultural and spiritual values. For example, providing patient education materials in multiple languages or incorporating religious practices into scheduling (such as adjusting for prayer times or fasting periods) can build trust and compliance. Clinicians also must be careful not to impose their own cultural norms or assumptions onto people in their care. Technologists should be encouraged in practicing cultural humility, acknowledging what they don’t know and being open to learning. These practices will help to enhance rapport with patients and patient outcomes.

IV. Age and Gender Identities

Sleep health concerns and access to care vary widely across different age groups and gender identities. Older adults are at high risk for conditions like sleep apnea and insomnia but are often misdiagnosed due to assumptions that poor sleep is a natural part of aging. Meanwhile, women frequently present with more subtle symptoms of OSA and may be dismissed or misdiagnosed with conditions like depression or anxiety.

Gender identity also plays a critical role in healthcare access. Transgender and nonbinary patients may avoid medical care due to past discrimination or fear of bias. Creating inclusive sleep centers requires not only awareness but also action, such as using gender-neutral language on forms, training staff in LGBTQI+ sensitivity, and ensuring that everyone feels respected during exams and consultations. RUSH University, UChicago Medicine, Northwestern University, and the University of Illinois are Chicago area medical providers with Gender Affirming Care Programs that provide patient navigation for people who wish to find comprehensive, supportive medical care. DEI in this context refers to removing both procedural and emotional barriers so that all patients can access and benefit from sleep health services.

V. Urban and Rural Care Gaps

Geographic disparities in healthcare access are well-documented, and sleep medicine is no exception. Urban areas typically have several options for people from which to choose, including hospital-based sleep centers and private sleep centers. However, barriers still exist within these options, such as language and cultural barriers, which can create a reduction of trust and lower compliance outcomes. Poor access to first-time or follow-up appointments can result in an increase in complications or hospitalization rates. Wait times for sleep specialist appointments at urban, hospital-based sleep labs may be as far in advance as four to six months from the initial request. Often, this does not include the appointment for sleep study, which can be another four to six month wait.

While urban areas may offer a range of sleep specialists and testing centers, patients in rural or remote regions often struggle with limited access. Long distances to clinics, lack of local providers, and poor broadband coverage for telehealth are significant challenges. Because of this, rural populations go undiagnosed or untreated for sleep disorders that significantly affect quality of life.

Equity in geographic access requires innovation and community engagement. Expanding the use of home sleep apnea testing (HSAT), remote CPAP monitoring, and mobile diagnostic units can help bridge these gaps. Training local providers and technologists from rural communities also helps safeguard cultural familiarity within the community as well as long-term sustainability of a sleep program. DEI in rural care means delivering high-quality sleep services regardless of ZIP code and recognizing that rural patients may face unique cultural and logistical challenges that require tailored approaches.

Chapter Summary:

Disparities in sleep medicine access are driven by a range of social, economic, cultural, and geographic factors. Diversity, equity, and inclusion are not optional concepts; they are foundational to providing effective, ethical, and comprehensive care. Understanding and addressing these disparities enables sleep professionals to ensure that every patient receives the care they need—without bias, without barriers, and with dignity.

End-of-Chapter Reflection Questions:

1. What are the most significant barriers to sleep care you see in your community?
2. How can sleep centers be more culturally and economically inclusive?
3. What strategies would you propose to improve technologist recruitment from underrepresented communities?
4. How do social and economic categories affect access to sleep medicine treatment?
5. Name three ways that a patient’s religious or cultural views can both hinder and promote seeking help for issues of sleep?
6. Describe an instance where you observed or experienced a lack of cultural or religious sensitivity in healthcare delivery. What improvements could the healthcare provider have implemented in that situation?
7. Explain, in detail, barriers to sleep medicine for patients who live in both rural and urban areas.