This study aims to provide fundamental information for nursing interventions that can improve sleep quality in middle-aged women by identifying the factors that affect sleep quality as well as the correlation between sleep quality and neck pain, shoulder pain and disability, physical activity, and health perception.
The present study showed statistically significant difference in sleep quality in relation to the general characteristics of middle-aged women, in relation to age, number of comorbidities, and the perceived physical difficulty of their work. The findings of this study suggest that sleep quality is worse with younger age. Among the participants, those with a job accounted for the most at 82.4%, and most of the women in their 30s took responsibility for work, housework, and childcare, and occupational stress as well as the physical burden of housework and childcare is thought to negatively impact sleep quality. Therefore, it is necessary to plan support measures for such people by extensively assessing the occupational factors as well as the environmental and situation factors. This study found that the more comorbid diseases the participants have, the worse their sleep quality is compared to those without comorbid diseases, and the participants had various comorbid diseases, such as hypertension, diabetes, arthritis, lumbar herniated disc, neck herniated disc and cancer. This finding corroborates with various preceding studies.15, 31–33 Patients with chronic low back pain are associated with poor sleep quality32 and patients with diabetes are also reported to have decreased sleep quality and sleep efficiency.31 In particular, there have been reports of decreased sleep quality in patients with diabetes being associated with symptoms such as nocturia, nocturnal hypoglycemia, and obstructive sleep apnea.33 In the case of the elderly, a higher number of chronic and comorbid diseases is associated with a higher rate of sleep disturbances and lower sleep efficiency due to persistent pain and disability. Additionally, lower sleep quality and quality of life was resulted from waking up at dawn due to night pain or having a hard time falling back asleep after having woken up once.15,34 The study is limited in that there was no comprehensive analysis of sleep quality in relation to the type of illness. Through this study, sleep quality for participants with a bigger number of comorbidities are found to be poor. Therefore, physiological health problems such as comorbidities in middle-aged women are thought to directly or indirectly affect sleep quality, which indicates that health interventions could improve not only sleep quality but also the quality of life; 31% of participants reported that their present perception of physical burden from their work is high and their sleep quality appeared to be the worst. As for women without jobs, this could be from the burden of housework and childcare and as for women with jobs, it could be from difficulty in work and job stress including burden of housework and childcare. This is consistent with a previous study that showed that compared with men, women experience burden accompanied by various changes, such as housework, childcare, work, child education, as well as hormonal changes in middle-aged women, which negatively effects sleep quality.35
The participants of this study had an average score of 8.88 (2.71) in sleep quality and 89.7% of the participants were classified as a poor sleeper with a score of >5. The result is similar to other studies that examined sleep quality in middle-aged women and obtained a score of 8.422,36 and is higher than the score of 7.76 obtained in another study conducted on middle-aged women.37 This result implies that sleep disorders among South Korean middle-aged women are common. South Korean middle-aged women have the tendency to ignore their sleep management. This could be attributed to them dismissing it as a menopausal symptom experienced in midlife or the result of neglecting one’s health and caring only for the health of the family and sacrificing for the family despite the poor health conditions subjectively felt due to the burden of childcare, housework and workplace stress. Therefore, the result of this study suggests that active interests and efforts are needed to provide health information or develop health education and sleep intervention programs to improve the sleep quality in middle-aged women of South Korean society where interest toward their sleep health is low.
Regarding the correlation between sleep quality and related variables, the present study showed positive correlation between sleep quality and neck pain and shoulder pain and disability and a negative correlation between sleep quality and health perception. As such, the more severe the neck pain and shoulder pain and disability, the higher the score for sleep quality, demonstrating a poor quality of sleep. The higher the self-health perception was, the lower the sleep quality score, hence demonstrating good sleep quality. This corroborates with previous studies38,39 that show the more severe the neck pain, the more severe the shoulder pain, and the more severe the shoulder pain, the more severe the shoulder disability and that such symptoms or disabilities worsen sleep quality.40 Women complain of chronic pain as they spend more time making repetitive movements in the same posture for a long time due to work or house chores. Since these pains negatively affect sleep quality due to the accompanying muscle dysfunction, it seems necessary to establish an intervention that can fundamentally improve health promotion through investigating their lifestyle and postures in daily life according to the area of chronic pain.
In the study’s findings, shoulder pain, perceived difficulty of one’s work, and health perception were analyzed as significant factors that affect sleep quality in middle-aged women. Similar results were obtained in a study by Bintang et al41 and Lee and Oh15 in which pain affected sleep quality and a more severe pain resulted in a higher sleep quality, supporting this study’s findings. Moreover, the perceived difficulty of one’s work can be affected by various factors, such as occupation, house chores, childcare and health concerns, and such factors can consequently affect one’s health perception and further worsen sleep quality.41 This study found no correlation between sleep quality and physical activity, and this corresponds to previous studies that also found that the level of women’s physical activity has no impact on sleep quality.42 In other words, this study found that the participants’ physiological symptoms, physical burden and health perceptions were more important factors in sleep quality than physical activity.
This study has some limitations. The first is that the subject of the study were South Korean middle-aged women who resided in Seoul; hence, the results cannot be generalized to other populations. Second, because the sleep quality in middle-aged women was assessed using self-report tools, it is different from identifying the actual sleep pattern. Lastly, this study is a cross-sectional study; hence, it is limited in that the cause and effect in between variables cannot be analyzed in various ways. Despite these limitations, in consideration of the study’s findings, middle-aged women’s shoulder pain, perceived difficulty of one’s work and health perception were found to be important factors in determining sleep quality. These results suggest that the severe physical symptoms of shoulder pain, which the middle-aged women complain of, can negatively affect sleep quality and that an intervention of sleep quality in consideration of such physical symptoms is needed. Based on the results of this study, to improve sleep quality in middle-aged women, healthcare workers should take into consideration the subject’s health and other symptoms or pain. Because perceived difficulty of one’s job and health can affect sleep quality, it is necessary to develop a health intervention strategy to provide healthcare for physical health, as well as mental and social support to lessen the burden of work, house chores and childcare to improve health promotion. For a follow-up study, based on the results of previous studies that show physical symptoms affect sleep quality and such physical symptoms not only affect individual physiological health but also mental health15,43 and the results of the present study, nurses in clinical practice should plan and provide health education and nursing intervention that enhances sleep quality in middle-aged women to ultimately improve their physical and mental quality of life. This should be done based on objectively measured data of the sleeping state, while taking into consideration their physiological symptoms in relation to their comorbidities and age.