Sleep and Society
Abstract and Keywords
This chapter demonstrates how sleep is inextricably linked to “society.” Part 1 illustrates how sleep and its disorders are historically and culturally divergent and that “where,” “why,” and “how” we sleep differ depending on the society in which we live. Part 2 focuses in more detail on the “private” nature of Western sleep. Sleep is affected by the social context where it occurs and is thus influenced by household composition, gender, social roles, power, and life course position. We examine sleep in caregiving and institutional contexts, where sleep is not only “observed,” but may be disturbed by those undertaking care or surveillance at night. Sleep is also socially patterned with those who are socially disadvantaged most likely to report sleep problems.
In his classic text Some Must Watch Whilst Some Must Sleep, the eminent sleep scientist William C. Dement suggested that the “anthropological and sociological implications of sleep are vast and complex” (1972, p. 2). He was undoubtedly correct. Sleep, as we argue here, is more than a shared biological universal. How, where, and when we sleep also depends on the type of society in which we live.
This chapter synthesizes the growing body of literature on sleep and society. It is framed around three main sections and focuses on both the macro and the micro aspects of the sleep and society link. In Part 1 of the chapter we illustrate how, at the highest level (the macro), societies have cultural rules and norms about sleep timing and patterns. Western sleep, for example, has shifted from being a very public affair to become something that is carried out behind closed doors in household bedrooms. These rules and norms should not be considered “natural” or “inevitable,” but are historically and culturally contingent.
We then move to examine how sleep and society link at the micro level. Parts 2 and 3 illustrate how the influence of Western society infiltrates sleep in private households. Even behind closed doors, the ways in which individuals understand and carry out sleep reflect broader social inequalities, power dynamics, gender relations, and life course positions. Thus, women’s sleep is more likely to be negatively influenced by their role as primary caregivers (both for children and older parents). The social patterning of sleep relates to not only gender and age but also social class and income, with more disadvantaged groups in society reporting higher levels of disturbed sleep.
Part 1: Sociological perspectives on sleep
This part of the chapter illustrates how “sleep” is inextricably linked to “society.” Our argument proceeds in three steps: i) we begin by outlining what we mean when we say that “sleep” is connected to “society”; ii) we then move to evidence our argument by showing that there are, as Williams (2005, p. 111) suggests, “convergence and divergence, (p. 224) within and between sleeping cultures over time.” Once this is accepted, it becomes apparent that where, why, and how we sleep are all sociocultural matters. From here we iii) counter the claim that differences in sleeping cultures simply result from the absence or presence of scientific knowledge about sleep. We do this by introducing some key themes and debates found within contemporary sociological discussions of (Western) sleep. These include issues surrounding the medicalization of sleep, attitudes toward sleep, and changing work ethics.
Sleep and society: Introducing terms
When people think about sleep, they tend to hold one of three positions. Occupying the first position (or far left of the continuum) are those who view sleep purely as a physiological process. Professional sleep researchers who hold this view may well see a link between sleep and society, but they try to “control” or adjust for any societal influences. For example, at the same time as acknowledging that social factors (such as alarm clocks and work timing) are a “major determinant of sleep–wake behaviour” (Dijk & von Schantz, 2005, p. 281) clinical trials on circadian and homeostatic processes are often designed to eradicate these “external” influences.
The second position that can be occupied is one where “society” begins to become something of direct interest. For example, Bliwise (1996) reports how the National Commission on Sleep Disorders Research “has documented the pervasive lack of concern for and interest in sleep in contemporary American Society” (p. 462). Similarly, Kryger (1995) describes how many people want to sleep less because they view sleep as a waste of time. Much epidemiological writing on sleep falls within this category. This literature tells us that those working shifts are more likely to complain of fatigue and anxiety and report a reduction in quality and quantity of sleep (Harrington, 2001, p. 69). It also tells us that high work demands and physical effort at work are risk indicators for disturbed sleep (Åkerstedt et al., 2002) and that teachers with high job strain report poorer sleep quality (Cropley, Dijk, & Stanley, 2006). See also Williams (2005) for a discussion of how the prevalence of sleep problems may differ by occupation.
Within this second position there is a tendency to revert back to a physiological focus. Thus, when epidemiological studies examine gender they are, for all intents and purposes, examining biological sex. Similarly, when epidemiologists examine aging and sleep they retain an explanatory framework that prioritizes the physical and physiological changes associated with age, and less weight is given to life course changes such as retirement, divorce, or the death of a partner.
The third (and final) position when researching sleep takes society as its central focus. This position suggests that when, where, and how we sleep are all “to a considerable degree, socio-cultural matters, including processes of social scheduling and management in our waking lives. This in turn is dependent on history and culture, time and place” (Williams, 2002, p. 178). It also suggests that sleep has been bestowed with moral and social connotations and that the social norms of nightly sleep play a necessary role in social order (Aubert & White, 1959a, 1959b; Schwartz, 1970).
This is the position we take when we talk about sleep and society. As mentioned above, the first step in evidencing this position is to demonstrate that how, when, and where we sleep are all historically and culturally contingent.
Differences within and between sleeping cultures over time
If we traveled around the globe today we would find sleep being practiced in numerous different ways. For example, in a discussion primarily concerned with when we sleep, Steger and Brunt (2003, p. 15) suggest that there is a threefold typology of sleep cultures: monophasic, biphasic, and polyphasic. Northern Europe and North America can be described as monophasic, as within these cultures there is a normative idea that sleep should occur within a single block or period. Within these societies norms also require this single block of sleep to occur at night “and therefore to conform to the general pattern of sleep time, unless legitimate social circumstances, such as work arrangements depict otherwise” (Williams & Bendelow, 1998, p. 182).
Biphasic sleep cultures, that is cultures where it is normative to have two periods of sleep, can be found in those societies where the “siesta” is common, such as Spain and societies with Spanish cultural influence (Steger & Brunt, 2003). In contrast, polyphasic cultures can be described as “napping cultures” and, as Steger and Brunt (2003) identify, can be found in every continent. They are also heterogeneous. In some polyphasic societies napping takes on a distinct social form, embedded within a complex set of norms and rules. Steger (2003), for example, examines napping in Japan (inemuri) (p. 225) during public, observable working situations. Steger concludes that the degree to which this napping is accepted “is influenced by the power relations between the persons involved since those relations largely determine who defines the situation as one where sleeping is or is not acceptable” (2003, p. 181).
As well as cultural differences in when we sleep, there are also differences in how and where we sleep. Within the Western world, norms and rules suggest that we should “sleep in a bed, or similar device, in a private place, away from public view, in proper attire (i.e., pyjamas, nightdress etc.)—the latter is not an absolute requirement and indeed, is increasingly being circumvented if not flouted” (Williams & Bendelow, 1998, p. 182). Yet, as Richter (2003, p. 24) identifies, visitors to China would note people sleeping in public, “sometimes in the most surprising postures and locations.” India is similar, with daytime sleep being abundant and everywhere to be seen (Brunt, 2008, p. 153). Further to this, as Williams (2005, p. 108) writes, in some societies, people “rest” in fields standing like storks: “the Paraguayan Aches apparently sleep on mats, whilst the South Venezuelans favour hammocks. As for the Kung! in North West Botswana, they sleep on the ground. The Efe in Zaire, however, go one better and sleep on thinly strewn leaves.”
In essence, in every society there are norms and rules surrounding sleep that prescribe what is acceptable and what is not (see also Aubert & White, 1959a, 1959b). Transgressing or breaching these norms can bring repercussions—whether this is embarrassment, shame, stigma, or criminalization. For example, within the UK there is a complex rhetoric surrounding “rough sleeping.” On the one hand, recent legislation, such as the Housing Act 1996, gives (some) homeless people the right to be housed. This legislation sits alongside a recent publication by the UK government (No One Left Out, 2008), which outlined 15 action points for reducing “rough sleeping.” These action points include introducing effective housing policies, supporting best practice, and developing training programs for those who support rough sleepers. Yet, on the other hand, the Vagrancy Act 1824 still makes it a criminal offense to sleep on the streets (see Renson, 2003, for a discussion of sleeping rough in Amsterdam).
The final area addressed in this section is how these norms and rules come into being. Even societies with similar sleep cultures may have arrived at these via quite different historical trajectories. For example, it is only recently that Western European societies emphasized the private nature of sleep. As Crook suggests, “within the West itself the spaces and technologies associated with sleeping have changed over time and it has not always been a private experience requiring comfortable accessories” (2008, p. 16). In medieval society, sleep was a very public affair, and it was common for people to receive visitors in the bedroom and for many people to spend the night in the same bed (Elias, 1978). Amongst 19th century Breton farmers, for example, all family members and servants usually slept in one large bed, and passing travelers were often invited to join the same shared bed (Borbély, 1986; see also Montijn, 2008, for a discussion of the history of Dutch bedrooms).
Further to this, it was not always the case that Western European sleep patterns were monophasic. In his book At Day’s Close: A History of Nighttime, Roger Ekirch explains how “until the close of the modern era, Western Europeans on most evenings experienced two major intervals of sleep bridged by up to an hour or more of quiet wakefulness” (2005, p. 300). So common was this occurrence that it provoked little comment, and sleep became routinely described in terms such as the “first” and “second” sleep. Thus, the diarist Robert Sanderson arose after his “first sleepe” to sit and smoke a pipe or to tend to his wife. Similarly, Tobias Venner urged “students that must of necessity watch and study by night, that they do it not till their first sleep” (cited in Ekirch, 2005, p. 305). For Ekirch, the catalyst for the shift from the era of “first” and “second” sleep to one defined by a single block of “consolidated” sleep was the introduction of artificial light. Indeed, Ekirch (2005) suggests that if we were to deprive ourselves of artificial light we would revert back to nights filled with “first” and “second” sleeps (see also Williams, 2005, p. 45).
Historical variations in the timing, length, and practices of sleep are not limited to Western Europe. Li (2003, p. 45), for example, highlights how the Chinese radically changed their attitudes toward napping in the last two decades of the 20th century. During the 1980s, there was widespread criticism of the Chinese practice of having a three-hour break in the middle of the day. This criticism peaked in 1984 when the Chinese government announced an official change in the work schedule and implemented the one-hour break for lunch. During the late 1980s to mid-1990s the debate shifted again, with many Chinese challenging the merits of the changes and arguing that midday napping should largely be a matter of individual choice.
(p. 226) Understanding sleep in contemporary western societies
There are, then, many different ways to “do” sleep. Once this is accepted, the logical question for each society becomes “why do we sleep in this way”? Within the UK and other Western societies, the standard answer found within popular texts on sleep normally involves two threads; the first thread links modern sleep practices with the rise of sleep research and sleep medicine. There now exists a well-rehearsed history of sleep research and sleep medicine, which usually begins by stating that “more has been learned about sleep in the past 60 years than in the preceding 6000” (Hobson, 1989, p. 1). This history identifies key moments in recent (Western) history, such as the first electroencephalogram (EEG) recording by Hans Berger in 1928 and the discovery of REM sleep (Aserinsky & Kleitman, 1953). It also highlights the importance of the late 1960s and early 1970s, when sleep apnea was discovered, benzodiazepines were introduced, several symposia were organized that looked at “abnormal” sleep (Dement, 2005), and the first sleep center opened (Todman, 2008). There was also a growth in medical “investigation” of sleep problems, as Kroker suggests, “tonight, thousands of patients around the world will have their sleep observed in a laboratory” (2007, p. 3).
The second component of the usual (Western) answer to the question “why do we sleep in this way” emphasizes a prima facie paradox. At the same time as knowledge about sleep medicine is said to be increasing, the world is turning us all into “sleep sick” individuals. Debates now rage about whether we are sleeping less in an epoch that is increasingly characterized as a 24-hour society (Williams, Arber, & Meadows, 2010). We now live in a globalized world, where advances in technology have broken down geographical barriers. We can travel from the United Kingdom to Japan in a little over 12 hours. We can instantly communicate with others, regardless of location, using telephones and computers. As Moore-Ede (1993, p. 8) puts it, “all that now separates us are the time zones.”
But here, we are told, lies the problem (Moore-Ede, 1993, p. 8). An increasing number of people are now working longer hours, or working night shifts, to keep the global economy going: “hustle and bustle, decisions, deals and opportunities occur continuously, because it is always daytime somewhere in the global village. And those working in that daytime create a demand for instant attention from others who must work by night on the other side of the world” (Moore-Ede, 1993, p. 8). It is perhaps not a great surprise, then, to find that a plethora of internet sites1 and popular sleep books now exist that address sleeping problems.
Sociologists, and others who occupy the third position identified above, do not necessarily disagree with these two threads of explanation. Rather, they engage critically with them, in particular they probe more deeply the idea that current sleep practices are a result of a tension between increased time pressures found within globalized societies (Williams et al 2010). Below we outline four key lines of inquiry that sociologists have focused on when exploring the organization of sleep in contemporary western societies: namely (1) the shift from public to private sleeping, (2) the relationship between work and sleep, (3) sleep within consumer societies, and (4) the medicalization of sleep. Throughout this discussion, it will become apparent that power and class divisions are implicated within many of the norms and rules surrounding sleep.
The shift from public to private—“civilizing” sleep
Drawing on historical books of etiquette, Elias (1978) explains the (Western) shift from public to private sleeping through redress to the emergence of “a web of interdependency” as people became more and more dependent on one another. Behavior became more predictable (and refined) and intimate functions were secluded and hidden away within the private sphere (Vaughan, 2000). In essence, a “progressive socialization, rationalization and individualization of the body” (Shilling, 2003, p. 143) occurred that saw an increase in body (self) monitoring and control. Thus, whereas in medieval society it was common for many people to sleep in one room and there was little or no shame associated with nudity, Elias suggested that in contemporary society the nuclear family “remains as the only legitimate, socially sanctioned enclave for [sleep] and many other human functions. Its visible and invisible walls withdraw the most ‘private,’ ‘intimate,’ repressively ‘animal’ aspects of human existence from the sight of others” (1978, p. 163). For Elias (1978), then, the shift from public to private sleeping was linked to a general “civilizing” process and the ever-increasing thresholds of shame. However, Elias does note that things may have changed somewhat (since the Second World War) and that sleep may have become less intimate and hidden (Fontaine, 1978, p. 248). This, it is argued, is because people have become so “civilized” and (p. 227) restrained that rules can occasionally be breached without this having a major consequence for social order (van Krieken, 1998, p. 113).
As Williams (2007a) suggests, Elias’ writings have limitations. Etiquette books and historical treatises on “manners” were written by and for the upper classes—meaning that they tell us little about sleep within the lower classes. Crook’s (2008) work provides a useful addendum here. He suggests that, between 1500 and 1800, the body was subjected to two processes. The first reflects Elias’ discussion of “civilizing processes.” However, some bedchambers did retain a social function (so were not strictly private) and for many, especially the poor, a single bed and a distinct bedroom remained an unaffordable luxury.
The second process relates to disciplinary techniques and mechanisms. According to Crook (2008) a different kind of spatialization of sleep was pioneered in institutions, such as prisons, army barracks, and hospitals. Medical and disciplinary critiques drew attention to the fact that mingling bodies give rise to “pestilential” atmospheres and sites of “moral contagion”; on the basis of such critiques these institutions underwent a (protracted) period of reform that resulted in the provision of individual sleeping arrangements. These individual sleeping arrangements, and the social isolation they entailed, were also thought to increase self-control and aid surveillance. The prison cell, for example, was designed to encourage self-reflection, and the separation of prisoners into specific cells enabled the collection of detailed records and individual “profiling” (see Crook, 2008).
For Crook (2008), the 1830s saw an increasing interest in “social investigation,” focused particularly on the working classes. Recalling the earlier concerns surrounding institutions, graphic descriptions of mingling bodies were offered and both moral and physical health was emphasized: “in such cramped circumstances, all manner of bad habits and social ills flourished” (Crook, 2008, p. 20). Working-class dwellings caused anxiety to the middle classes because of issues surrounding moral and physical health and because of ideals surrounding the “nuclear family.” People sharing sleep spaces were often from different families, and fathers and daughters, for example, were often found sharing the same bed. This raised issues surrounding interfamily promiscuity as well as incest. In essence, the working class were seen as requiring what the middle class already had: private bedrooms (see Crook, 2008).
“Civilized” Sleep In The 21st Century?
These notions of civilizing sleep and shame and the distinction between biological and social aspects of sleep have been applied to contemporary sleeping arrangements by Meadows, Arber, Venn, and Hislop (2008a) and by Williams (2007a). In their qualitative study of 40 heterosexual couples, Meadows et al. (2008a) examined situations where couples felt shame or were embarrassed about their sleep practices. Their findings supported the idea that normative conventions require people to sleep in private and only with “appropriate people.” However, they also found the existence of further norms and rules that apply, even if sleep is occurring behind closed doors and in a private space. At the beginning of an intimate relationship couples do feel waking embarrassment about certain, “unruly” bodily acts committed while they were asleep, and these individuals may go to bed after their partner is asleep in an attempt to hide their potentially embarrassing sleep behaviors. The authors conclude that sharing a bed may blur the divisions between public and private spaces.
Williams (2007a) touches upon many of these arguments in his study of the social uses and abuses of sleep. A person may, for example, feign sleep in order to listen to conversations about himself or herself. He or she may also be an inconsiderate or selfish sleeper. As Williams (2007a, p. 321) suggests, if I leave my tired partner to clear up after a dinner party, on the pretext that I need my sleep, then I am clearly opening myself up to the charge of being inconsiderate or selfish. Although I am not actually a sleeper at this point, for all intents and purposes, I am being an inconsiderate or selfish sleeper as I am prioritizing my own sleep over my partner’s.
Snoring raises relevant issues here. The snorer cannot easily be thought inconsiderate or selfish, as he or she is asleep when the snoring occurs. Yet, as Williams (2007a, p. 322) suggests, where a bed partner is present (and long suffering), snoring may raise questions of shame, embarrassment, and stigmatization, particularly for women. These issues about snoring are examined in Part 2 of this chapter. For now, suffice it to say that the work of Elias (1978), Meadows et al. (2008a), and Williams (2007a) reinforces the idea that there are shifting normative expectations and moral messages that accompany where, when, and how we sleep and with whom.
The relationship between work and sleep
Western societies are said to be characterized by long work hours and comprised of individuals who (p. 228) have little regard for sleep: “the more conventionally successful you are, the less time you will probably have free. Having nothing to do is seen as a sign of worthlessness, while ceaseless activity signifies status and success” (Martin, 2002, p. 5). This is certainly the view in popular culture. For example, in science fiction literature the prospect of a sleepless society has been mooted (see Steinberg, 2008), and in his novel The House of Sleep, Jonathan Coe has one of his main characters (Dr. Dudden) state that:
Napoleon was a light sleeper too. And Edison. You’ll find it’s true of many great men. Edison despised sleep, we’re told, and in my view he was right to do so. I despise it, too. I despise myself for needing it. (Coe, 1997, p. 176)
Similarly, an article in the New Statesman suggested that “there is a macho culture of sleeplessness—sleep is for wimps who can’t take the pace. The tough and the motivated like to brag about how little sleep they need” (Appleyard, 2002). In their examination of the UK media, Boden, Williams, Seale, Lowe, and Steinberg (2008) point to the Daily Mail, which ran a story in 2002 suggesting that Britons now take their work to bed with them. Similarly, in 2000 the Mirror suggested that long work hours mean that Britons are too tired for sex—even when on holiday.
Empirical studies add support to these arguments. Allison Pugh (2000), for example, offers an illustration of how notions of “long hours” and “negating sleep” form part of the bedrock mythology of the information technology revolution. Pugh suggests that sleep is now seen as “unsalvageable time” and a “waste of time” because it cannot be devoted to work. Other dominant attitudes toward sleep include “eschewed sleep is a form of modern pioneerism,” “sleep is a traitor to the body,” and “sleep is a form of self-care (and, as such, it is to be spurned).” It is perhaps unsurprising, then, to find that, alongside the work/sleep conflict, there has been an increase in the number of people using sleeping pills to fall asleep and stimulants, such as caffeine and wake-promoting pills, to stay awake.
Given the arguments above, it is also unsurprising that patients’ explanatory models of insomnia revolve around paid “work.” A US study of 24 patients (19 female and 5 male) who were receiving treatment for insomnia found that “work” was reported as the primary cause for the development of their insomnia, the primary reason for needing good sleep, the reason for seeking medical help, and the reason why individuals complied with medical regimens (Henry, McClellen, Rosenthal, Dedrick, & Gosdin, 2008). As the authors identify, “even retired informants couched their illness experience in terms of work, further evidencing the powerful internalizing role of labor in experiences of insomnia, and the long-term impact of contemporary working lifestyles on sleep” (Henry et al., 2008, p. 724).
Work/Sleep Balance: The Rise Of Protestantism
The relationship between sleep and work (described above) is a recent historical phenomenon, associated with the rise of capitalism and the development of a particular work ethic (Thompson, 1967; Giddens, 1981). Weber (1974), for example, suggests that the rise of Protestantism in the West “promoted an ethically informed rational action that possessed a substantial affinity with the ‘spirit of modern capitalism’” (Shilling & Mellor, 2001, p. 79). What Weber means here is that capitalism could not have developed without the existence of a particular attitude, or spirit, toward work. For Weber, this attitude looked very much like a secularized form of Protestantism. Protestantism, or more specifically Calvinism, believed in predestination and required some kind of sign by which the chosen could be known. This “sign” became associated with self-control in relation to material pleasures and the constructive use of time. Ironically, the constructive use of time has placed “time” under further threat. Industrialization and the associated work ethic led to the creation of technological advances (such as the phone, the Internet, and the airplane), which meant that “time” became even more fluid and work was no longer simply associated with daylight hours. As Swingewood (2000, p. 98) suggests, the counter to this was that idleness and excessive sleep became seen as negative things, associated with “imperfect grace”.
Work/Sleep Balance: Are We Beginning To Witness A Shift In Attitudes?
According to Kroll-Smith (2008), the nature of work is changing still and we now live in a world organized around cerebral labor and a fading boundary between work and home: “If fatigue was the primary problem of working bodies in the era of muscle labor, it is safe to say that drowsiness, defined as the absence of mental acuity, is the primary problem of working bodies in the era of flexible work and the expansion of cerebral labor” (p. 590).
Although sleep deprivation may remain a badge of honor for many, a new cultural frame is also said to be emerging. As Boden et al. (2008) suggest, sleep is now “being more positively construed as the (p. 229) ultimate performance and productivity enhancer for workers and/or the perfect antidote to the speeding up and urgency of everyday life” (pp. 551–552). There are numerous articles discussing “workplace naps” and calls for companies to create special “nap rooms” (see Baxter & Kroll-Smith, 2005, for a critical discussion of this phenomenon). Boden et al. (2008) found that media coverage of the workplace nap was largely positive, although linking to our earlier discussion of the “private” nature of sleep, one napper suggested that they felt “embarrassed” to sleep in front of colleagues.
This complex mix of “work ethic” and “sleep as performance enhancer” was found in a qualitative study of heterosexual, coupled men. Meadows, Arber, Venn, and Hislop (2008b) identified how four core assumptions underpinned the men’s understandings of sleep: “sleep is something my body needs”; “my body needs change and are changeable”; “my body needs are specific to me”; and “sleep is necessary for functioning.” These four assumptions, many of which can be found in sleep health promotion literature, were intertwined to create a “function/non-function” balancing act. The men believed that they should get just enough sleep to be able to function (especially in paid employment), but not so much that it reduced the time they had awake to perform work roles and other valued activities.
Sleep within consumer societies
The previous section was concerned with production, capitalism, work, and (negative) attitudes toward sleep. This section is more concerned with consumption. For many scholars, society has undergone a shift from modernity to post-modernity that, at the economic level, equates to a shift from “an emphasis on productive capacity and output to one on consumer goods, competition and customer service” (Bury, 1998, p. 4). Although there remains great debate over the actualities of this shift, several authors have identified components of this developing consumer culture that are directly linked to sleep.
One of these relates to changes in the nighttime economy. As Hobbs, Lister, Hadfield, Winlow, and Hall (2000) suggest, the shift from manufacturing, production, and lifetime employment to the provision of (consumer) services and a flexible workforce has spawned an increasingly complex mass of nighttime leisure options. This new nighttime economy means that work is now conducted at times that would previously have been considered “unsocial.” As Hobbs et al. (2000, p. 702) suggest, “many young men and women now experience their first taste of employment on a part-time basis in bars and clubs, only some of which the State will become aware of. Working in a bar on a part-time basis can be combined with part-time daytime employment, which is far easier to find than full-time labor.” See also Kraftl and Horton (2008) for a discussion of geographies of sleep, Melbin (1978) for an early discussion of changes to “the night,” and Brunt (2008) for a discussion of Indian nights.
Writings on consumer culture also speak to sleep in a more direct way. Williams and Boden (2004), for example, ask whether sleep is, itself, becoming a consumer “good.” In answering this question, they identify how sleep is being “capitalized” upon within the domains of health and beauty, leisure and pleasure, and in the workplace itself (through the avocation of workplace naps). There is now an abundance of sleep-related information that can be consumed, and a cursory glance in any shopping center will illustrate the multitude of herbal remedies, special pillows, and bedding on offer. In addition, sleep has become part of the “entertainment businesses,” whether through films such as Nightmare on Elm Street, programs based around sleep-deprived contestants (such as the UK Channel 4 series Shattered), or documentaries depicting the plight of those suffering from sleep disorders (see Williams & Boden, 2004).
Sleep, then, would appear to be facing in two opposed directions. On the one hand, it would seem that work ethics have left us all “negating sleep,” while on the other hand, a burgeoning sleep business has developed that seeks to sell us sleep-promoting products. As Williams and Boden (2004) put it, how does the increasing consumption of sleep square with notions of the 24-hour society and negative attitudes toward sleep (discussed above)? In addition, class and power may intersect here, not least because some people may not have the financial resources available to “consume” sleep. Taylor suggests that there are “contingent influences on the meanings attached to sleep” and the ways in which sleep is “commonsensically conceived will relate to an individual’s social location and economic function” (Taylor, 1993, p. 468). Those who see sleep as a leisure pursuit are liable to have attained a certain socioeconomic status, whereas “hard-working peasantry” are more likely to view sleep as respite from labor (Taylor, 1993, p. 468).
Medicalization, the media and sleep
The discussion above brings us to another key question currently being debated within sociological circles: is sleep being “medicalized”?
(p. 230) Medicalization involves “defining a [social] problem in medical terms, using medical language to describe the problem, adopting a medical framework to understand a problem, or using medical intervention to ‘treat’ it” (Conrad, 1992, p. 18). Proponents of the medicalization thesis often point to the development of new medical categories for conditions previously thought to be variations of “normal behavior”—for example, attention deficit/hyperactivity disorder (ADHD), anorexia and eating disorders, and repetitive strain injury (Conrad & Potter, 2000)—and examine how these variations became constructed as medical diseases.
Medicalization And The Social Construction Of Sleep Disorders
Discussions of the medicalization of sleep have focused on several different aspects of our dormancy. For example, authors have examined the social construction of sleep “disorders.” For sleep medicine to come into being, sleep had to shift from being a “matter of fact” to a “matter of concern,” and new conceptions of “normal” and “pathological” were required (Wolf-Meyer, 2008). When these shifts occur, histories are (re)written to make them seem the consequence of a heightened, more accurate state of scientific awareness while divergences are ignored.
A key concern within discussions of the medicalization of sleep disorders is the contemporary relevance of the doctor–patient relationship. In their examination of media constructions of insomnia and snoring, Williams, Seale, Boden, Lowe, and Steinberg (2008b) suggest that issues surrounding medicalization may differ depending on the sleep disorder under study. Insomnia, for example, is portrayed through a “psychologized” discourse that draws upon notions of stress and anxiety. These discourses also emphasize personal responsibility: insomniacs are often portrayed as their own worst enemy and are seen as individuals who exaggerate their plight, which exacerbates their sleeping problems. In contrast, snoring provided a different picture. Media coverage frequently drew on members of the sleep community, alerting people to the links between snoring and sleep apnea and emphasizing the public health risks that this entails. Williams et al. (2008b, p. 266) therefore suggest that the doctor–patient relationship is still important (at least with respect to snoring): “the media are still by and large conveying and relaying, amplifying and disseminating concerns and discourses circulating within the sleep science and sleep medicine communities.”
Kroll-Smith (2003) highlights the importance of electronic and print media and suggests that they are now bypassing the traditional doctor–patient relationship. More specifically, he emphasizes the “conspicuous influence of newspapers, magazines and the Internet in shaping a persuasive cultural directive to become conscious of soporific states and their possible deleterious consequences” (p. 625). In essence, as Kroll-Smith succinctly puts it in a later paper there is now a “new truth” being told about sleepiness and what was once considered a private, “routinely occurring state of partial consciousness deprivatized” has become “linked to public health vernaculars, and transformed into a reprobate condition.” (Kroll-Smith & Gunter, 2005, p. 346). This “new truth,” played out within the media, has led to an increase in people self-diagnosing with sleep problems and a chasm between the number of individuals reporting insomnia-like symptoms and the number actually being diagnosed with insomnia.
Medicalization And Responses To Sleep Problems
Discussions of the medicalization of sleep have also examined the way sleep problems are dealt with. In one of the first sociological, empirical studies of sleep, Hislop and Arber (2003b, 2004) investigated midlife women’s sleep and sleep management. The authors conclude by suggesting that medicalization plays only a small role in women’s sleep management. Women, it is argued, “have developed a range of personalized strategies over time to manage their sleep without recourse either to externally invoked healthy lifestyle practices or medical intervention” (Hislop & Arber, 2003b, p. 822).
Gabe and Bury (1996) studied the controversies surrounding Halcion, a sleeping pill that was subjected to intense media and legal scrutiny. The authors highlight how medical authority is increasingly becoming questioned in contemporary society. Expert knowledge and information now circulate through numerous professional and lay circles, and greater coverage is given to the fact that experts do not agree. People now have greater access to expertise while, at the same time, the idea that the medical profession is the dominant source of expert knowledge is being undermined (see also Abraham & Sheppard, 1999).
These positions have, however, been critiqued and extended by others. Seale, Boden, Williams, Lowe, and Steinberg (2007) studied coverage of sleep (disorders), and notions of productivity and risk in both tabloid and “serious” UK newspapers. (p. 231) Unlike Hislop and Arber (2003b), Seale et al. (2007, p. 429) suggest that many of the personalized strategies employed by midlife women are “discussed and debated in the popular public forum of the Daily Mail [one of the UK papers the authors investigated], so they are far from being wholly private [or personalized] solutions.”
Williams et al. (2008a) examined the ways in which modafinil/Provigil (a wake-promoting drug) is described in the media, identifying four key themes within UK newspaper coverage of modafinil. The earliest newspaper stories (uncritically) discussed the expanding list of conditions for which modafinil was prescribed, such as narcolepsy, shift work sleep disorder, and attention deficit/hyperactivity disorder. The newspapers raised many more concerns when discussing non-clinical reasons for using the drug. They found that media coverage of modafinil exemplified the blurring of the line between treatment and enhancement. This led the authors to suggest that there are limitations in the medicalization thesis, and that what is actually happening is a pharmaceuticalization rather than the medicalization of alertness, sleepiness, and every day/night life. Therefore, the concern is more to do with the transformation, treatment, or enhancement of the human condition using pharmaceutical interventions. Returning to themes discussed above, modafinil may embody the Protestant work ethic (cf. Williams et al., 2008), providing individuals with a means to stay alert and productive in a time when capitalism has sped up and our means of escaping it (via sleep) are being reduced.
Part 2: Sleep across the life course
We now examine sleep across the life course, which throws into sharp relief issues of power and control at different stages of life: childhood and youth, parents and couples, and later life. Issues related to gender roles and the household context across the life course continue to impact on sleep quality. As Pahl (2007)points out, sleep that takes place within households is a shared (in)activity and is therefore complicated by negotiations surrounding the timing of sleep (who goes to bed when), the place of sleep (sleeping together or apart), and who is responsible for dealing with disturbances (a crying child, outside noises). The following sections discuss such issues by examining the social influences that impact on sleep at different stages of the life course, and within varying household contexts.
Children, young people and sleep in the household context
There is no doubting the importance of sleep for children and adolescents, in terms of health, development, and well-being, with sleep comprising a significant part of the daily lives of children, particularly for the very young (Kryger, Roth, & Dement, 2000). Because of its importance, there has been considerable research on how to improve the quantity and quality of children’s sleep, by focusing primarily on sleep problems and sleep outcomes (Wiggs, 2007; Stores, 2008; Durand, 2008).
Yet there has not always been a focus on improving children’s sleep. Prior to modern times in the West, both adult and children’s sleep and bedtimes were less rigid and were certainly not the focus for specialists offering advice on how to improve sleep. However, during the early 20th century, popular manuals on how to “rear” children started to address the matter of sleep and bedtime issues (Fass, 2003; Stearns, Rowland, & Giarnelli, 1996). The imposition of bedtime and sleep rituals were also synony (p. 232) mous with what was called the “socialization” of children, where parents were expected to assert their authority and power by encouraging their children to have specific bedtimes and wake times, to sleep in their own bed, and ultimately, where feasible, in a different space from their parents.
There is a general perception that for young children and adolescents, the nighttime is largely a time of silence and non-activity once children are put to bed. By listening to children and young people’s narratives of sleep and bedtime, sociological studies have revealed that their bedtime is not devoid of activity, but rather is subject to a number of interjections from other household members, revealing, as Moran-Ellis and Venn (2007) call it, an “arena of action” or a “night-world.”
For children, sleep and bedtime often commence through a series of impositions and negotiations, with parents, with siblings, and with themselves. Bedtime impositions, as would be expected, are more likely with very young children, but with the increasing autonomy that children experience as they grow older and become more independent, the time of settling down to go to sleep is more likely to be a decision made by the child or young person themselves (Moran-Ellis & Venn, 2007). Recent research has demonstrated how one marker of young people’s transition into adulthood is the establishment, where feasible, of their own bedroom as a private space, a space that is not accessible to parents but from which they can continue with their social networks (Hodkinson & Lincoln, 2008; Moran-Ellis & Venn, 2007). As young people delay leaving home, or, as is increasingly occurring, periodically return as young adults to live at home, their expectations of increased autonomy, as reflected in a lack of rules governing bedtimes, have consequences for all members of the household (Mitchell & Gee, 1996). Thus sleep, or rather bedtime, offers insights into the development of agency for children in terms of how they negotiate the power struggles that can take place surrounding how, and when, bedtime takes place.
A number of writers (Moran-Ellis & Venn, 2007; Williams & Williams, 2005; Wiggs, 2007), have suggested that during their “sleep” time, children and young adolescents attempt to regularly maintain contact with the “real” waking world. For young children this is largely through lights and parental contact, and for adolescents through mobile phones and the Internet. Younger children’s negotiation of lighting levels at night is an area that may demonstrate power struggles between parents and their children, with children arguing for sufficient light to reduce fear, and parents most often determining the “appropriate” level of darkness to facilitate sleep (Moran-Ellis & Venn, 2007).
Staying Connected: Young People And Mobile Phones At Night
The adjunct of greater autonomy surrounding bedtime, and the recognition by parents of the bedroom as “private space,” allows older children to have greater access to their mobile phones at night. The use of mobile phones amongst teenagers and young people has been well documented, with the emphasis on how mobile phones mediate their social relationships but may also disrupt their sleep (Taylor & Harper, 2001; Williams & Williams, 2005). Venn and Arber (2008) found that the maintenance of young people’s social relationships disrupted their sleep, with many using their mobile phones to communicate with school friends until late at night, first thing in the morning, and even during the night. Phones were left on “just in case” a message was received. There was a perceived need to be available at all times to communicate with friends, and checking mobile phones for messages was often the first action upon awakening (even before getting out of bed), in case someone had contacted them during the night, as illustrated by Helen (aged 13), “It [mobile phone] wakes me up, but I like to leave it on in case someone does call me really early in the morning, so I would know” (Venn & Arber, 2008, p. 121).
Van den Bulck’s (2007) study of 1,656 schoolchildren living in the Netherlands (average age 13.7 years) found that only 38% never used their mobile phones after lights out. Of cultural interest here is the contrast with the perception of mobile phones in terms of sleep in Japan (Kaji, Shigeta, & Takada, 2007). Kaji et al. argue that mobile phones are perceived by young people in Japan as items that assist sleep, rather than interrupt it, by offering reassurance and security.
The Changing Context Of Children’S Sleep
The structure of households has undergone significant change in recent years, with trends indicating that families are becoming more complex, often comprising children, siblings, stepsiblings, and other household members (Ermisch & Murphy, 2006). Additionally, more young people are remaining in the family home until their 20s and 30s, delaying the transition to adulthood. It is therefore (p. 233) important to contextualize household sleeping arrangements in the UK in terms of the increasing trend toward teenagers and young adults living with their parents for longer periods.
Studies on children’s sleep need to be seen within the context of the changing nature of households and contemporary childhood because the complex construction of modern families and households has the potential to complicate sleeping arrangements. For example, when parents are divorced or separated, children may have access to two sleeping places, one with each parent. Sleeping arrangements can then be further complicated when there are stepsiblings and other family members in each separate household, and decisions have to be made about who sleeps where, when, and with whom. This may vary depending on the hierarchy of the child within the household. For example, a child may be the eldest in the father’s home, but the youngest in the mother’s, and as such, his or her access to bedrooms and sleep may have varying precedence depending on which household the child is in (Williams, 2007).
The next section also focuses on sleeping within a household context, but examines in more detail how bed partners negotiate their sleep needs.
Couples, bed partners, and sleep
The history of two people exclusively sharing one bed in their own private bedroom is short. In medieval times, for example, hardly anybody ever slept alone. Beds and bedrooms (which were also used for other purposes) were shared not only by married couples and their children but also by relatives and servants (Klug, 2008); see Part 1. It was not until the 18th century that the bedroom became a more private and intimate space, where practically and financially feasible (Martin, 2002). Today, most adults do not sleep alone (Martin, 2002), yet even with the potential for sleep disturbance caused by a bed partner in the form of snoring, sleepwalking, or nightmares, evidence suggests that the psychological and emotional benefits of sleeping with a partner outweigh the disadvantages (Pankhurst & Horne, 1994).
Negotiating The Night
Meadows (2005) emphasizes that sleep is not only a natural, biological phenomenon but is also a social phenomenon, suggesting that individuals negotiate their sleep needs firstly with themselves, and then with their partner. Sleep, Meadows (2005) argues, is not simply governed by sleep–wake cycles but is subject to “a negotiation between individual expectations, desires and social roles, and the expectations, desires and social roles of others” (p. 243).
However, far from sleeping with a bed partner always being comforting and reassuring, Hislop and Arber (2003a, 2003b) suggest that for midlife and older women the bedroom may be a “battleground” and argue that, from a woman’s perspective, their male partners may act as “gatekeepers” to their partner’s sleep by, for example, waking them up in the night to discuss problems, or insisting the light is turned off. Some women reported being able to re-engage with their own sleep needs once they no longer shared a bed:
It’s nice to be able to please yourself … I love having the bed to myself and I sleep diagonally, and when he went (divorced), I bought lots of extra pillows. You can leave books lying around. (Hislop & Arber, 2003a, p. 704)
Hislop (2007) has also likened the way couples negotiate sleep to a form of “stage management” where couples manage, over the period of their relationship, how their sleep needs and those of their partner will be met, with the ultimate sleep “performance” taking place in the double bed. These negotiations may be explicit, as in open discussion, or tacit, as in evolving over time through compromise or acquiescence. The setting of the couples’ bedroom is also subject to negotiations that encompass issues such as which side of the bed to sleep on, whether to have the window open, whether to have the light on, and, more particularly, when to go to bed and when to get up (Hislop, 2007).
Studies of couples’ sleep, therefore, have demonstrated an (uneasy) balance between the comfort and reassurance of sharing a bed with another adult and disturbances arising from bed sharing; one of the most commonly mentioned disturbances is snoring.
Managing Snoring And The Snorer
Although snoring is often the subject of laughter and ridicule, it can have a serious effect on not only the snorer and his or her partner, but also on the couple’s relationship (Madani, 2001). With 15 million people reported as snoring in the UK, and one-third of those being women (Beninati, Harris, Herold, & Shepard, 1999; Hu, 2000; British Snoring and Sleep Apnea Association, 2006), it is a widespread problem that has been the subject of extensive research by sleep scientists. Most studies on snoring and sleep apnea, though, have focused on the snorer, and only rarely have they recognized the potential problem to the snorer’s partner (Sharief, (p. 234) Silver, Goodwin, & Quan, 2008). When the impact of snoring on a partner is addressed, the focus has primarily been on women’s sleep being disturbed by their male partners’ snoring, with little attention being paid to women who snore. For example, Rosenblatt’s (2006) exploration of co-sleeping in the U.S. showed only how women developed strategies to deal with the practicalities of sleeping with a snoring (male) partner, while Ulfberg, Carter, Talback, and Eding (2000) found that women whose partners snored were three times more likely to report symptoms of insomnia than those whose partners did not snore.
Venn’s (2007) qualitative interviews with 40 couples highlight two other potentially damaging effects of snoring: (a) on the couples’ relationship, where one or both partners snore, and (b) on the self-esteem of the snorer. This study included women’s and men’s strategies about partner snoring and also raised awareness of the stigma that women experience because of their snoring. Women who snored were reluctant to say so, largely because they felt that their snoring was “unfeminine,” a perception that arises out of social and cultural norms that snoring “is what men do” and therefore not what women do. Moreover, the women’s reluctance to acknowledge that they snored was compounded by their partners revealing to others outside their relationship that their wife did, in fact, snore, thereby engendering a sense of betrayal in the partnership.
The strategies women developed to cope with their partners’ snoring, such as prodding (but not waking their partner), laying and listening, and moving out of the bedroom, were very much in line with normative expectations of femininity, of women being adaptive and passive (Coppock, Haydon, & Richter, 1995). By subjugating their own sleep needs to those of their partner, the women were reflecting an uneven gender/power balance within couples.
While the women sought to find reasons for their partner’s and their own snoring, the male respondents did not feel the need to justify their own snoring. The stigma of “being” a snorer for women was embarrassing and de-feminizing, whereas “doing” snoring for men was simply what men do. By playing down the significance of the disruption to women’s own sleep caused by their husbands’ snoring, the women were protecting the integrity of their relationship, an honor that was not reciprocated by the men within these couples.
That couples should continue sharing a bed throughout their relationship is regarded as a normative convention. Therefore, the integrity of the couple relationship is deemed to be at risk when partners relocate to a different bed or bedroom. Venn’s (2007) study of couples demonstrated that, no matter how long the couple had been together, there was a need to assert that relocation was a last resort, and not something either partner wished to do. However, it was mainly women who relocated, whether they or their husbands snored. For women, though, this led to a dilemma between being unselfish in helping their husbands achieve a good night’s sleep, while recognizing that moving out of the shared bed has potential implications for the representation of their relationship to others.
A review of articles on partners’ co-sleeping highlights the very limited amount of research on couples’ sleep (Troxel, Robles, Hall, & Buysse, 2007). Importantly, they suggest that such research “provides conditional support for the hypothesis that relationship quality is importantly implicated with sleep and vice versa” (Troxel et al., 2007, p. 401). Since most adults do not sleep alone, it is essential to recognize the largely dyadic nature of sleep, and that it takes place within a social context. As such, social factors such as socioeconomic status, gender, social roles, and normative expectations surrounding sleep needs and rights all influence how a couple negotiate and experience sleep. Troxel et al.’s (2007, p. 401) advice that “incorporating such knowledge into both clinical practice and research in sleep medicine may elucidate key mechanisms in the etiology and maintenance of both sleep disorders and relationship problems and may ultimately inform novel treatments” is therefore timely and salient.
This section has shown how sleeping with a partner is a negotiated experience between the needs and requirements of the individual and with the partner. Continuing the theme of sleeping within a household context, the next section addresses in more detail how gender, and particularly women’s social roles, impact on their sleep and sleep disturbance.
Gender, social roles, and women’s sleep
Advice given to cope with sleep disturbance is often focused on improving sleep through addressing sleep “hygiene” or habits, such as maintaining routines of going to bed and getting up at the same time every day and cutting out coffee (Horrocks & Pounder, 2006; Smith & Battagel, 2004). However, although there is much important practical advice available to help with sleep disturbance, such advice largely ignores the impact that gender and social roles have on an individual’s sleep. A woman may reduce her caffeine intake to help her to sleep, (p. 235) but her sleep may still be disturbed by her concerns as a mother for a crying child, or as a daughter worrying about her sick and elderly parent. Sleep is influenced by many aspects of an individual’s life, including their gender, social role, health, and changes that occur across the life course, such as having children or returning to paid employment (Hislop & Arber, 2003a). This section reviews recent sociological research on the influence of gender roles on sleep.
Hislop and Arber’s (2003a, 2003b, 2003c) research into the meanings and experiences of sleep in women over 40 years of age, through focus groups, interviews and audio sleep diaries, highlighted how significantly their social roles impact on their sleep. The multiple roles that women in mid to later life have, such as mother, partner, caregiver, and worker, can serve to create, for women, an invisible “workplace” at night. Hislop and Arber (2003c) suggest that this invisible workplace at night is a reflection of the gendered division of labor that typifies the household during the day, where the undertaking of “caring” roles result in women’s own needs being subjugated to those of other family members. Over time this disturbed sleep for women may become the norm. That is, as they propose:
Midlife women in our study see disturbed sleep as a “woman’s lot,” a source of frustration, annoyance, and fatigue, but nevertheless an everyday reality over which they have little control. While for some women these disturbances may become problematic, for the majority of women they become normalized over time. (Hislop & Arber, 2003c, p. 232)
Arber, Hislop, Bote, and Meadows (2007) assessed the relative importance of several factors that impact on women’s sleep by analysing the UK Women and Sleep Survey. Three factors were most significant in disturbing women’s sleep: how their partners’ slept, how their children slept, and their own worries. This study also showed the influence of disadvantaged socioeconomic status and ill health on sleep; also see Part 3. Women who were living in more disadvantaged socioeconomic circumstances reported poorer-quality sleep, and the strongest correlation was between women’s level of educational qualifications and their quality of sleep. These findings therefore reinforced Hislop and Arber’s (2003a) earlier work on the impact of gender inequalities on not only everyday life, but also on women’s sleep.
Couples With Children: Impact On Sleep
Sleep and the negotiations surrounding sleep are made more complex by living within a household context, especially in a household with children, and more especially for women in a caregiving role. Research on couples with children living at home revealed the (largely) different ways that men and women respond to interruptions to their sleep associated with children (Venn, Arber, Meadows, & Hislop, 2008). This research highlighted how physical and emotional care for young children at night was mainly provided by women, disturbing women’s own sleep. In particular, there was a lack of explicit negotiation between partners about who provided this care, with mostly tacit understandings that women would get up in the night to deal with, for example, nappy (diaper) changing or settling anxious children. Even when women returned to employment or full-time education, they continued to undertake most of the child care at night.
Thus, considerably more women than men carried on working during the evening (domestic chores) and the night (changing nappies, settling children). In addition, many women reported undertaking in the night what Mason (1996) contends is “sentient activity,” that is thinking about and anticipating the needs of their family. This resulted in women not only having their sleep disturbed by the physical needs of their children, but also by waking up worrying about their children’s and partner’s needs and demands. As a consequence, and echoing Hislop and Arber’s work (2003a), women were more likely to subjugate their own sleep needs to those of their family. Within the Venn et al., (2008) study, fathers did not, in general, engage in worrying and thinking about family members at night. Those that did were more apt to be the fathers of older teenage and adult children who were staying out until late at night. The focus of fathers’ concerns was for the safety and welfare of their older children. Whereas fathers of young children were less likely to have their sleep disturbed, the fathers of older children reported having difficulty getting to sleep when their children were out at night, particularly when they were out driving or being driven. Venn et al. (2008) therefore concluded that women’s propensity within the household to undertake caring roles, such as wife and/or mother, leads to them having greater family-related sleep disturbance.
The theme of the gendered nature of caring roles impacting on sleep is evident in Bianchera and Arber’s (2007) work on sleep and caring in midlife and older Italian women. Societal pressure, lack of state welfare, and close family networks in Italy place the burden of care for children and for frail older relatives on women, which in turn adversely (p. 236) affects their sleep (see discussion of “informal care” for family members in Part 3).
Sleep is also a time of vulnerability, which is put into stark relief for women living in abusive relationships, as explored by Lowe, Humphries, and Williams (2007). Qualitative interviews with women who had suffered from domestic violence showed how the women’s fear of violence led to them having to manage how, when, and even whether they slept, and that sleep deprivation was used by the perpetrators of the violence to exert control over women (Lowe et al., 2007). Additionally, the women expressed guilt over their perceived inability to protect their children from the effects of the violence, as manifested by the children having recurring nightmares, wetting the bed, and being afraid of going to sleep.
Talking to women and men about sleep within the context of their everyday lives affords an opportunity to place the study of sleep within the real, lived, and experienced social world. Studying sleep within its social context also provides the opportunity to better understand how gender is played out in parent–child and other household relationships, within families, and within couples.
Sleep and aging
This final section on sleep across the life course addresses sleep in later life. The majority of recent research on sleep and older people has focused on investigating the changes that take place to sleep architecture during aging (Goldman et al., 2008; Ancoli-Israel, Ayalon, & Salzman, 2008). Recent studies have shown that as we age the amount of time spent in deep, slow-wave sleep diminishes, along with a decrease in REM (dreaming) sleep, and the time spent in lighter stage 1 and stage 2 sleep increases. The result is that older people may find that it takes longer to get to sleep, have more fragmented sleep, and wake up earlier (Bliwise, 2005). There is also an ongoing debate about whether the change in nighttime sleep experienced by older people leads to a propensity for daytime napping (Münch, Cajochen, & Wirz-Justice, 2005), or has no effect on whether older people sleep during the day or not (Klerman & Dijk, 2008). Similarly, in terms of daytime sleep, there are debates about whether daytime napping benefits older people by increasing the overall time spent asleep during a 24-hour period (Campbell et al., 2005), or is detrimental in terms of reducing nighttime sleep quality and duration following a nap (Boden-Albala et al., 2008). It is therefore unsurprising that older people themselves are often confused as to whether they need less sleep, more sleep, or should experience no change in their sleep as they age.
Napping And Daytime Sleep
Recent work conducted by researchers on the meanings and experiences of poor sleep for older people (as part of the multidisciplinary SomnIA project, University of Surrey www.somnia.surrey.ac.uk)2 shows that older people have complex attitudes toward daytime sleep. Some older people regarded napping as beneficial, some resisted it at all costs because of its implication of time wasting or laziness, and yet others regarded it as a “necessary evil” to enable them to carry on with their daily activities (Venn & Arber, 2011).
Even the language of daytime sleep has different meanings for older people. The implicit meaning of the word “nap” is not only sleep that takes place during the day, but also sleep that is intentional, controlled, planned for, and clearly delineated with a beginning and an end, such as “to take a nap.” “Power” napping, for example, is recommended for office workers to improve productivity; “siestas” are the (acceptable) cultural equivalent of a nap in Mediterranean countries; and “inemuri” or napping during work in Japan, is acceptable because of its implication that an employee is working hard (see Part 1). Different terms, however, are used to describe unplanned or unacknowledged daytime sleep, such as dozing, nodding off, dropping off, or catnaps. For some older people, the moral connotations of the former type of daytime sleep (napping) have different, more negative implications than the latter (dozing), in that napping hints at laziness and is seen as a signifier of aging (Venn & Arber, 2011).
Older People’S Subjective Views About Their Sleep
Measuring sleep objectively, through polysomnography and/or actigraphy, alongside subjective measures of sleep quality has highlighted contradictions between the poor quality of older people’s sleep demonstrated by objective measures and the subjective assessment that older people give to their sleep quality. For example, Davis, Moore, and Bruck’s (2007) study of older women found that a majority could be classified as “poor” sleepers, according to their overall Pittsburgh Sleep Quality Index (PSQI) score (> 5, poor sleep) (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989), and yet many of these older women self-categorized themselves as (p. 237) “good” sleepers (Davis et al., 2007). Similarly, Arber and Meadows (2011) show that older people are less likely than younger age groups to self-report their sleep as ‘bad/fairly bad’, despite reporting greater sleep maintenance problems and taking more sleeping medication.
Recent sociological investigations have indicated that older people are likely to adjust their personal expectations about the quality of their sleep in later life by taking into account the influence of age, health, and other factors. In the SomnIA project, 54% of older people (65+) who completed the PSQI had a global score of >5, signifying clinically poor sleep, whereas over 80% subjectively rated their sleep as good, or very good (n = 1,058). In-depth interviews with 62 older people with poor sleep (PSQI >5 ) revealed that older people often rated their sleep as good or very good because they had different expectations of how their sleep should be in later life. The older people interviewed sought to position and justify their current poor sleep with reference to (a) how their sleep used to be, or (b) their perception of what is “normative” sleep, that is, how their sleep should be, both of which were influenced by how their sleep was currently expected to be—taking into account their increasing age (Venn & Arber, 2011). This positioning ultimately led them to accept poor sleep as a natural outcome of the aging process. In this light, their poor sleep was now categorized as good, or as good as can be expected.
Aging, Sleep Disturbance And The Household
Quite apart from physical factors that may disturb sleep, such as pain from arthritis, diabetes, and taking medications prescribed for health problems, social roles may also affect the sleep of older people. The influence of sleeping within a household context is as significant for older people as it is for younger people. Older women often undertake caregiving for grandchildren or partners, and men too may be caring for their ill partners (Arber & Venn, 2011) or grieving for partners who have died. Older people in particular are often disturbed at night by worries concerning their future, or fears for their safety (Hislop & Arber, 2003a). Social influences on sleep may be compounded by older people reporting an increase in needing to go to the toilet. In the SomnIA research, for example, more than 62% of older people reported being woken up three or more times a week to go to the toilet, and interviews with older people revealed that many of them went to the toilet several times a night. Similarly, Bliwise et al. (2008) have reported that frequent urination in the night is so commonplace in older people that it is often neglected as a potential reason for poor sleep in later life. Once woken by the need to go to the toilet, older people in the SomnIA study explained that it was often difficult to get back to sleep because of worries and concerns playing on their mind.
Finally, it is also important to be aware that sleep problems in later life may not necessarily have originated in later life. Morgan and Clarke (1997) have highlighted how poor sleep in later life may actually have its roots in previous poor sleep, and that often the sleep problems that older people report are not related to aging but are a consequence of prior psychiatric, somatic, or lifestyle factors.
Part 3: The social organization and social patterning of sleep
Sleep not only takes place in a social context but may be constrained and influenced by the actions of others or constraints of that context. As discussed in (p. 238) Part 2, a mark of the transition toward independence is that children become responsible for their own sleeping time and are “allowed” to sleep within the privacy of their own rooms—“a necessary rite of passage of growing up is therefore the right to be left alone unobserved when sleeping” (Taylor, 1993, p. 466). Privacy, autonomy, and personal control are therefore fundamental normative dimensions of adult sleep.
The following two sections discuss the circumstances under which adults may have their sleep observed by others: because they have medical conditions that require care or monitoring by caregivers at night, or because they reside in an institutional context, such as older people living in a care home. In these contexts the individuals’ sleep may be not only “observed” at night, but also disturbed by those undertaking care, monitoring, or surveillance at night. In institutional settings the individuals’ sleep is no longer private and under their own control, but takes place in the workplace of strangers. Such individuals therefore lose power over their own sleeping context and sleeping body. The final section turns to broader structural issues. We examine the ways that social disadvantage, such as low social class, may be implicated in poor sleep quality, and to what extent socioeconomic factors may be one explanation for gender differences in sleep.
Ill health, disability, informal caregiving, and sleep
We all know that during illness, e.g., flu or a stomach upset, our nighttime sleep is likely to be affected, and we may value the additional attention of family members “caring” for us during periods of acute ill health. However, people with chronic or disabling illnesses may have their sleep adversely affected by pain or medical symptoms for long periods, and routinely require care or support at night. An individual with a disabling condition may find it more comfortable to sleep in an armchair or on the sofa rather than in a bed, but may receive criticism from caregivers for this practice (Martin & Bartlett, 2007). This illustrates the moral imperatives underlying taken-for-granted sleep practices regarding the spatial location of sleep, particularly where and how we sleep (Williams, 2005); see Part 1.
A major reason for poorer sleep quality with increasing age is because chronic ill health causes pain and discomfort at night, resulting in sleep complaints and difficulties (Davidson, MacLean, Brundage, & Schulze, 2002; Stewart et al., 2006; Vitiello, Moe, & Prinz, 2002). For example, Happe and Berger (2002) report that 74%–98% of patients with Parkinson’s disease have sleep disturbance involving sleep fragmentation, nocturnal cramps, pain, nightmares, and impaired motor function during the night. People with dementia have poor sleep quality because of disruption of circadian rhythms, with a less clear diurnal pattern of nighttime sleep and more sleep during the day (Bliwise, 1993; Van Someren, 2000). For these groups of people, not only is their sleep likely to be disturbed by their health condition, but also the sleep of their family members and caregivers.
Research examining how caregiving impacts on caregivers’ sleep has been largely “disease-specific,” focusing on patients with particular health conditions or disabilities; e.g., Carter and Chang (2000) studied caregivers for patients with cancer, finding that 95% had severe sleep problems; Happe and Berger (2002) studied Parkinson’s disease patients, reporting that their caregiving spouses had high levels of sleep disturbance; and Smith, Ellgring, and Oertel’s (1997) research on Parkinson’s disease spouse pairs found higher sleep disturbance among female than male spouse caregivers. Many studies have shown that caring for a person with dementia has adverse effects on the caregivers’ sleep quality (Lee et al., 2007; Wilcox & King, 1999; Beaudreau et al., 2008).
Qualitative research with caregivers can provide insights into the nature of the impact of caregiving on sleep quality. Care at night may include helping an older person to use the toilet, cleaning an older person (and/or changing their bed) following incontinence, turning or repositioning, and administering medication. In addition, the care recipients’ nighttime activities or behaviors may disturb the caregivers’ sleep, e.g., if they wander or get disoriented at night, yell, experience pain, or need comforting (Arber & Venn, 2011). These nighttime “disruptions” or disturbances for the caregiver may engender varying levels of stress/anxiety (Beaudreau et al., 2008) and thereby influence the ease with which the caregiver returns to sleep following the disruption.
Chronically ill or demented care recipients may be considered “vulnerable” or a danger to themselves at night, and require the caregiver to be involved in “surveillance,” “monitoring,” or “maintaining nighttime vigilance” (Martin & Bartlett, 2007). Askham et al.’s qualitative study of caregivers for persons with dementia illustrates how caregivers’ perceived need to undertake surveillance was problematic to all caregivers and prevented them from “getting a good night’s sleep” (2007, p. 13).
(p. 239) Numerous studies have examined the burdens of caregiving and the constraints imposed on the caregivers’ life (Zarit, Reever, & Bach-Peterson, 1980; Beaudreau et al., 2008). Caregiving leads to stress, reduced psychological well-being, reduced quality of life, and higher levels of depression among caregivers (Lee, Morgan, & Lindesay, 2007; Livingston, Manela, & Katona, 1996; Cannuscio et al., 2002). What is rarely considered is whether one of the mechanisms underlying the link between caregiving and stress/depression is through poor sleep quality. Reductions in sleep quality/duration may be an intermediary factor between the nature of caregiving roles and caregivers’ depression/stress (Beaudreau et al., 2008).
Extensive research has shown that family (or informal) caregivers are more likely to be women than men (Arber & Ginn, 1991; Wolff & Kasper, 2006; Sims-Gould, Martin-Matthews, & Rosenthal, 2008). This gender inequality in caregiving means that women’s sleep is more likely to be adversely affected by direct care provision at night. In addition, women are more likely to perform “emotional labor” (James, 1992; Hochschild, 1990) associated with anticipating the needs of the care recipient and worrying about his or her well-being (Mason, 1996); see also Part 2. This engagement with the emotional needs of the care recipient is a factor in the higher sleep complaints reported by female than male caregivers.
Based on qualitative research with Italian women about their sleep, Bianchera and Arber (2007, 2008) developed a fourfold typology of how caregiving can disrupt caregiver’s sleep. First, providing care to attend to the nighttime needs of the care recipient, including monitoring/surveillance, and experiencing nighttime disruptions from the care recipient; second, anticipation of having to provide care, which may keep the caregiver awake or result in “light” sleep, so they remain alert and do not obtain deep, restorative sleep; third, sleep may be disrupted by “emotional labor” in the form of worries, thoughts, and anxieties linked to the nighttime needs of the care recipient, or more generalized worries about his or her well-being; and fourth, the legacy of caregiving that may continue to disrupt sleep for long periods after the caring has ended, with some caregivers haunted by painful images of caregiving, the suffering of their relative, or feelings of guilt about not having provided adequate care. This typology has been further elaborated by drawing on interviews with older caregivers in England (Arber & Venn, 2011).
Therefore, ill health and disability leads to disrupted sleep of both the individual and his or her caregivers. Since caregiving is more likely to be undertaken by women than men, nighttime care provision, which involves practical tending, emotional labor, and surveillance/monitoring at night, is more likely to adversely affect women’s sleep quality, continuity, and duration.
Sleep in institutional contexts
Most sleep takes place in the privacy of an individual’s home. As discussed in Part 1, in contemporary Western society, household bedrooms are construed as private and intimate spaces (Elias, 1978). In contrast, sleep is highly controlled and therefore likely to be disturbed within “total institutions.” Goffman (1961) suggested that in “normal” adult life an individual “sleeps, works, and plays” in different places with different sets of other social actors. However, in “total institutions,” these activities all tend to occur in the same setting, with the same group of others, operating according to timetables laid down by the institution rather than under the personal control of the individual. Thus, residing in a “total institution” reduces autonomy and control, and inmates are likely to lack power over many aspects of their everyday lives, including the temporal and spatial aspects of their sleep. This occurs in the most extreme form in prisons, with the degree of constraint over the social organization of sleep varying in different types of institutional settings (Williams, 2005).
It is well known that hospitals are not conducive to sleep; patients are woken early according to the requirements of the shift schedules and routines of the staff. Sleep may be disturbed by proximity to other patients who are in pain, snoring, or moaning, and the environment is generally noisy at night (Ersser et al., 1999; Williams, 2005). However, patients are usually in the hospital for only short periods and look forward to returning home and getting a good night’s sleep.
In 2001, 5% of people over age 65 in Britain, rising to 12% of men and 23% of women over age 85, lived in a communal establishment (Arber & Ginn, 2004). For these older people, the vast majority of whom are women, a nursing or residential home is their “home” for the rest of their life. Care homes exemplify the interface between the public and private and the impact that the public/private distinction has on sleep practices. In Britain, residents generally have their own “private” bedroom, which is also the workplace of care staff, while (p. 240) other areas of the care home are “public” to staff, other residents, and visitors. Sleeping in a care home is a frequent daytime activity. Gubrium’s (1975) ethnographic research of a U.S. nursing home found that staff evaluated residents’ sleep during the day differently depending on where it took place, with sleep in “public” places, such as the lounge, being more legitimately disturbed by staff and other residents.
Nursing home residents are found to have poor sleep quality (Ancoli-Israel, Parker, Sinaee, Fell, & Kripke, 1989; Fetviet & Bjorvatn, 2002). Our research, involving day- and nighttime observations in 10 care homes and interviews with staff and residents as part of the SomnIA project2, provides insights into social factors influencing the sleep quality of residents. Care home residents frequently do not have control over the time they go to bed or are woken up in the mornings (Luff, Ellmers, Eyers, Cope, & Arber, 2011). The routines of the home and timing of staff shifts take precedence in determining residents’ sleep timing, especially for residents who are more physically disabled, e.g., requiring a hoist to get them into and out of bed, and/or are more cognitively impaired. Luff et al. (2011) showed that the mean time residents spent in bed each night was 10 hours 50 minutes. Thus, residents lack control and agency over this critical aspect of their everyday life.
Although most residents have their own “private” room, they lack control over who enters their room and experience sleep disruptions by staff coming into their room at frequent intervals during the night. Staff routinely enter resident rooms at night to administer medication, give nighttime drinks, and change incontinence pads, often waking the resident for these purposes (Kerr, Wilkinson, & Cunningham, 2008). Thus, sleep is “observed” and no longer private (Taylor, 1993). Care homes are “risk averse” environments, with night staff reporting high levels of “what if” anxiety (Kerr et al., 2008), reflecting staff concerns about possible falls, incontinence, breathing problems, and ill health at night. One of the practices employed to reduce risk is the routine checking of residents at night, which involves staff going into bedrooms at set intervals, usually hourly, to check on residents. The issue of risk may be a central concept in whether older people have control and choices (Bernard, 2007). Our SomnIA research suggests that resident surveillance through routine checks during the night, together with changing incontinence pads and associated changes in lighting levels and noise of doors opening, often seriously disturbs residents’ sleep (Luff et al., 2011). Thus, in care homes there is a tension between staff concerns for “risk” and the routine surveillance this engenders, which conflicts with residents’ privacy, autonomy, and control at night (Martin & Bartlett, 2007).
Our qualitative interviews with care home residents and staff have highlighted that the everyday matter of sleep represents an area over which residents have little basic control regarding either their sleeping environment or their sleeping bodies (Luff et al., 2011). Care homes adopt regular and routine monitoring and observation of residents’ sleeping bodies during nighttime. This contrasts with the normative expectations of most adults that sleep is a time of privacy and intimacy (Martin & Bartlett, 2007). The notions of “observed sleep” and the control of the sleep environment by care home staff, rather than by individuals themselves, demonstrate unequal power relations and undermine resident choice and independence in the most basic aspects of residents’ everyday lives.
Socioeconomic circumstances and inequalities in sleep
It is well known that sleep is socially patterned by age and gender (see Part 2). However, fewer researchers have addressed the social patterning of sleep by socioeconomic characteristics, such as education, income, unemployment, and housing, or whether socioeconomic inequalities may be one explanation for reported gender differences in sleep quality. Sociologists have studied numerous areas of social inequality in society, including inequalities in health and educational attainment, but hitherto have neglected to what extent social variations in sleep reflect structural disadvantage and social inequalities.
Research has documented poorer sleep quality associated with lower educational qualifications (Gilles et al., 2005; Hartz et al; 2007; Moore, Adler, Williams, & Jackson, 2002; Arber & Meadows, 2011), unemployment (Hartz et al., 2007; Paine, Gander, Harris, & Reid, 2004; Rocha, Guerra, Fernanda, & Lima-Costa, 2002; Arber & Meadows, 2011), and low income (Hartz et al., 2007; Hall, Bromberger, & Matthews, 1999), but there has been little attention to understanding these patterns. As Rocha et al. (2002) note, it is important to assess whether relationships between sleep quality and socioeconomic status (SES) variables are confounded by poor health among those with lower SES.
(p. 241) Ses And Gender Inequalities In Sleep
Women report higher levels of sleep complaints than men (Groeger, Zilstra, & Dijk, 2004; Sekine, Chandola, Martikainen, Marmot, & Kagamimori, 2006; Zhang & Wing, 2006). The predominant explanations relate to biological or physiological sex differences (Chen, Kawachi, Subramanian, Acevedo-Garcia, & Lee, 2005; Dzaja et al., 2005) and psychological factors (Lindberg et al., 1997). Although women have higher levels of depression and anxiety (Piccinelli & Wilkinson, 2000; Ustun, 2000), gender differences in sleep quality remain after removing the effects of women’s higher rates of psychiatric morbidity (Lindberg et al., 1997; Zhang & Wing, 2006).
Chen et al. (2005) found that the gender difference in sleep disturbance was reduced after controlling for women’s social roles (marital status, employment status, number of children). However, women’s sleep quality still remained significantly poorer than men’s, suggesting the need for research on gender differences using more detailed measures of social roles and socioeconomic status (SES). Sekine et al. (2006) found that the gender difference in reported sleep quality among Japanese civil servants could be entirely explained by gender differences in work characteristics, domestic roles, and family–work conflicts.
Our research based on a representative sample of over 8,000 British men and women aged 16–74 showed that worries were implicated in the gender difference in self-reported sleep problems (Arber, Bote, & Meadows, 2009), with women’s sleep more likely to be disturbed by worries. Women’s worries are particularly linked to their role as mothers or wives, and their concern for the well-being of family members (Hislop & Arber, 2003a; Arber et al., 2007); see Part 2. Previous sleep research has tended to view “worries” as a mark of anxiety or psychological problems, rather than embedded within gender roles and responsibilities. In this British survey, worries and concerns were important predictors of self-reported sleep problems, retaining an independent effect after controlling for health and depression (Arber et al., 2009). However, differences between men and women in their physical and psychological health did not explain gender differences in sleep problems.
The gender difference in self-reported sleep problems was halved after adjustment for socioeconomic characteristics (education, income, employment status, and housing), indicating that a major reason for women’s greater sleep problems related to their more disadvantaged socioeconomic circumstances (Arber et al., 2009), in line with Sekine et al.’s research (2006). These findings therefore cast doubt on the importance of a physiological basis for the gender difference in reported sleep quality, while supporting explanations associated with the differential social roles and socioeconomic characteristics of men and women.
Understanding Socioeconomic Inequalities In Sleep Problems
Arber et al. (2009) found strong independent associations between self-reported sleep problems and multiple measures of socioeconomic disadvantage, namely low income, low educational qualifications, living in public housing, and not being in paid work, confirming the link between low education and sleep problems among women (Arber et al., 2007). Several types of mechanisms may underlie these associations between social disadvantage and reported sleep problems:
i. Structural disadvantage. Living in disadvantaged material circumstances leads to direct adverse effects on sleep quality. In crowded households, family members may disturb each other’s sleep. Low SES is associated with living in smaller, poorer-quality housing, e.g., with fewer and more shared bedrooms. Poor-quality housing, e.g., in flats with insubstantial walls, may lead to nighttime noise disturbance from neighbors, which is unlikely in areas of detached housing. Low SES is also associated with living in disadvantaged neighborhoods (Paine et al., 2004) and areas with greater problems of noise, crime, antisocial behavior, safety, and security, which may directly compromise sleep quality.
ii. Psychological distress associated with structural disadvantage. Low SES, particularly being unemployed, living in poor housing, living in disadvantaged neighborhoods, lacking access to transportation, and living on a low income, are likely to increase worries, anxieties, and psychological distress, which in turn impact on sleep quality. Thus, there are indirect effects of SES on sleep quality through the mediating factors of worries and psychological distress.
iii. Education and knowledge of sleep-promoting strategies. The educational gradient in sleep problems may be associated with differential knowledge about “sleep hygiene” practices and awareness of strategies that can be used to improve sleep. A plethora of media information is available (p. 242) about sleep (see Part 1), and the more educated may have greater access to varied information sources.
iv. Lifestyle–individual behaviors. Low SES is linked to individual lifestyle behaviors (such as smoking, alcohol consumption, poor diet, and less exercise), which may in turn adversely affect sleep quality. However, studies by Lallukka, Rahkonen, Lahelma, & Arber (2010) and Arber et al. (2009) found no evidence that lifestyle factors had a role in mediating the association between SES and sleep complaints.
As discussed in other chapters, sleep is important for health and well-being. The relationship between disadvantaged socioeconomic circumstances and higher levels of ill health and mortality is well known. Some researchers (Friedman et al., 2007; Hall et al., 1999; Van Cauter & Spiegel, 1999) argue that part of the mechanism underlying this link between low SES and poor health may be through the intermediary pathway of poor sleep quality. Thus, disrupted sleep may potentially be one mechanism through which social class leads to health inequalities.
This chapter has shown that sleep is inextricably linked to society. Within Western societies, cultural rules and norms suggest that we should sleep in private and alone with intimate others. Our everyday experience of sleep is influenced by this normative expectation, as well as wider social inequalities and gendered expectations. Changing societal attitudes toward work, consumption, medicine, and pharmaceutical interventions are all influencing the quality of our sleep and our sleeping patterns. In essence, sleep involves “negotiating” between physiological needs, agency, and social constraint. The parameters of this negotiation are linked to time and place and can alter depending on our role as father, mother, caregiver, and as we move through the life course. Caregiving adversely affects not only the sleep of the caregiver, but also the nature of care provision, surveillance, and monitoring impact on the care recipient’s sleep. This is brought into sharp relief in public and institutional contexts where sleep is “observed,” constrained, and disturbed. It is well known that sleep is socially patterned by gender and age, but less attention has been paid to socioeconomic circumstances, and that more socially disadvantaged groups in society have a greater likelihood of reporting poor sleep.
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(2) The SomnIA (Sleep in Ageing) research project conducted at the University of Surrey (2006-11) was funded by the UK New Dynamics of Ageing initiative, a multidisciplinary research program supported by the AHRC, BBSRC, EPSRC, ESRC, and MRC (RES-339–25-0009).