Sleep disorders are prevalent across populations, but significant racial disparities persist. Compared with White individuals, Black and Hispanic individuals experience poorer sleep quality and higher rates of obstructive sleep apnea (OSA), with prevalence estimates ranging from 5% to 86%.¹⁻² Black patients, in particular, have higher rates of sleep apnea symptoms and are substantially underdiagnosed, with only 16.2% of those with moderate to severe OSA reporting a formal diagnosis.²
Compared with White patients, Black patients with OSA tend to have more severe disease, as evidenced by higher apnea-hypopnea indices, greater comorbidities, and increased symptom burden.³
Black Women and SleepHealth
When compared with other racial/ethnic groups, Black women, in particular, experience worse sleep health. Black women have shorter sleep duration, longer sleep-onset latency, and poorer sleep efficiency. Compared with Black men, White men, and White women, Black women score significantly higher on the Pittsburgh Sleep Quality Index (PSQI), indicating worse subjective sleep quality.4 In a 2021 study published in Sleep Medicine, researchers found that compared with White patients, Black patients, specifically Black women, were less likely to report worse self-reported sleep quality despite poorer objectively measured sleep.5
It is critical to examine the factors contributing to the higher prevalence of sleep disorders among Black patients, as well as the barriers they encounter in accessing diagnosis and treatment.
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It is critical to continue diversifying the health care workforce, so that Black patients can receive culturally competent care from providers who look like them and understand their needs.
Neighborhood and Sleep Quality
Neighborhood disadvantage contributes to poor sleep quality and higher OSA risk among minority populations. Segregation has limited access to health resources and increased exposure to environmental hazards like air pollution.² Higher obesity rates, driven by food deserts, further compound OSA risk.² Access to care is also limited, as sleep labs are often located in affluent areas, creating transportation barriers for Black patients.³
Insurance and Sleep Diagnosis Disparities
Several insurance-related barriers contribute to disparities in sleep apnea diagnosis, treatment, and follow-up among Black patients. While OSA prevalence is similar between minority-serving institutions (MSIs) and voluntary hospitals (VHs), follow-up rates differ significantly — 42% of patients at MSIs did not follow up for treatment, compared with just 7% at VHs. Many patients at MSIs are uninsured or rely on Medicaid, which covers nearly half of Black Americans, with about 10–11% remaining uninsured.
Insurance restrictions also affect treatment adherence; for example, Centers for Medicare & Medicaid Services (CMS) limits continuouspositive airway pressure (CPAP) coverage beyond 90 days without strict adherence, which disproportionately affects minority patients. Home Sleep Apnea Testing (HSAT) can improve diagnostic access — over 80% of urban Black patients prefer it — but coverage gaps, especially in Medicaid, continue to limit its availability and widen disparities.
The Lack of Diversity in Sleep Testing Criteria
Many sleep disorder diagnostic tests have been validated mainly in White patients, overlooking differences in other populations. For instance, the reduced sensitivity of pulse oximetry in detecting desaturations in people with darker skin may lead to underdiagnosis of OSA in Black patients.³ The Epworth Sleepiness Scale (ESS), widely used to assess daytime sleepiness, was developed with White populations and may not fully reflect sleepiness in Black patients, whose higher ESS scores are not well understood.³
Funke Afolabi-Brown, MD, FAASM, CEO of The Restful Sleep Place, the first Black woman-owned virtual sleep clinic, noted the importance of diversity in research testing. “People talk about BMI [body mass index], for instance. A BMI as a tool in a person that’s Black sometimes may not necessarily be the gold standard when you want to figure out if this patient is overweight. So, some of those screening tools, we really need to be more aware of the fact that sometimes they’re not necessarily controlling for race.”
Clinician-Patient Race Similarities and Better Communication
The absence of clear referral pathways from primary care providers to sleep clinics, as well as to specialists like dentists and surgeons, places an added burden on patients with sleep disorders, particularly those with limited health literacy.
The underrepresentation of minorities among sleep medicine experts further exacerbates the unclear communication between Black patients and their providers. Research has shown race similarities in patients and providers lead to better communication, improved perceptions of care, and better health outcomes among minorities.3
Doctors are often less likely to believe the severity of symptoms in their Black patients, specifically Black women. Victoria Francois, MPH and Doctor of Public Health Candidate at Penn State College of Medicine believes this can impact the quality-of-care Black women receive.
“If health care clinicians do not believe their Black patients when they are experiencing pain or other adverse symptoms due to the color of their skin, they may perpetuate harmful stereotypes,” said Francois. “It is critical to continue diversifying the health care workforce, so that Black patients can receive culturally competent care from providers who look like them and understand their needs.”
The Superwoman Schema
“The Superwoman Schema (SWS) is a framework that depicts how Black women are socialized to be strong, suppress their emotions, avoid vulnerability, and help others at their own expense,” said Francois. “While Blackness is not a monolith, this framework can be useful in describing how many Black women feel the need to over-exert themselves. SWS can help to contextualize why Black women experience poorer health outcomes.”
Research shows that this mental framework is linked to poorer subjective sleep quality in Black women and can hinder self-diagnosis, as negative stereotypes like laziness may cause patients to downplay their fatigue.³⁻⁴
Francois believes that a strong bond between patient and provider is a key in counteracting this schema. “Health care professionals can counteract health behaviors that result from the SWS by forming strong relationships with their patients that are built on trust and empathy,” she noted. “This may include listening to their patients’ symptoms, asking questions about their patients’ health, and believing their patients when concerns are raised about their health … They can build relationships by being transparent about prognoses, involving their patients in decision-making for treatments, and practicing a patient-centered approach to care.”
The introduction of patient advocates is another way to counteract this schema and foster better communication between patient and provider. In a 2024 JAMA Network Open study conducted on physician perspectives toward racism, one participant noted, “There’s a gap in communication that needs to be addressed for both parties to understand where the other is coming from and find alignment.”7
Francois expressed how, while SWS is harmful, it is not always intentional and is something health care professionals should strive to unlearn. “Some health care clinicians may unintentionally perpetuate the notion of the SWS, and not take their Black female patients seriously when they present different adverse symptoms. However, if health care clinicians can see their Black female patients as people who deserve quality care, then Black women can live healthier lives.”
The Anti-Black Ideology: Addressing The Racial Inequality of Sleep
Black patients are often unaware of the severity of their sleep disorders, with some viewing snoring as normal rather than a sign of airway obstruction, as 33% of Black participants in the Sleep Medicine study did.³ Interventions like the Tailored Approach to Sleep Health Education (TASHE) and telephone-delivered programs have improved OSA diagnosis by increasing consultations and testing.²
To address unconscious bias and poor care Black patients receive, research has explored using restorative justice processes — rooted in Indigenous practices — to counteract anti-Black racism in health care.⁷
A key point of conflict between health care professionals and patients is the defensiveness around addressing anti-Black ideology. As one participant in the JAMA Network Open study stated, “We’re quick to say race has nothing to do with it,” which leads to defensive communication.⁷
Black patients also often feel unheard and unsatisfied with standard sleep health care. Dr Afolabi-Brown believes communication and accessibility can lead to better outcomes for her patients.
“A lot of times, we just kind of work and hide in our silos and do our own thing. But outreach about the awareness of these disparities is going to be very important,” she said. “Really the best way to bridge that gap is [to] start with knowing and understanding that they exist, and then really taking actionable steps. In many practices, people are so busy, they’re not necessarily screening for sleep disorders. But, you know, sometimes just a little questionnaire incorporated into your practice may help to show that, oh wow, this patient may need more help and more support.”
Dr Afolabi-Brown also noted that while health care providers can assist in branching this disparity of sleep diagnosis in Black women, they too must take the reins of their own health journey. “You’re your biggest asset and investment,” she said, “And many of us, especially women, might feel the temptation to put others first, but you have to prioritize your own health so that you can actually thrive to be everything that you’re hoping you can.”
Francois disagrees, however, and believes it is the duty of health care professionals over the patients themselves to alleviate these disparities. “One takeaway that the clinical audience should know about Black women is that we are resilient. But many Black women are also tired. Black women have to advocate for themselves in all aspects of our lives, but the health care field is where clinicians should advocate for us too.”
