Several studies have shown that there

Several studies have shown that ABT there is a positive association between financial hardship and various negative health outcomes and health-damaging behaviors, including research studies showing that financial hardship is associated with poor sleep health (Hill et al., 2009; Magee et al., 2014; McHale et al., 2011). Our findings are consistent with these studies. However, our study differs from previous research conducted investigating the relationship between financial hardship and sleep health. In particular, our study examines the association exclusively on individuals who identify as MSM in France. Previous research examining the relationship between financial hardship and sleep health has predominantly focused in the U.S., paying little attention to European populations. The association found between financial hardship and poor sleep health may be due to psychological distress (which can include depression and anxiety) and/or drug use that financial hardship causes, including perhaps the stress of seeking employment. Additionally, lower socioeconomic status individuals may be unable to afford to move to a safer and quieter neighborhood, which can contribute to better sleep compared to higher socioeconomic status individuals. Both chronic and acute stress, which is directly affected by their neighborhoods, could then lead to sleep difficulties and disturbances (Cunningham, Wheaton, & Giles, 2015; Johnson, Lisabeth, Lewis, Sims, & Hickson, 2016). Financial hardship may also result in the need for individuals to increase working hours, which could reduce the actual amount of time someone can sleep. However, the pathway by which financial hardship influences different health outcomes has not yet been fully elucidated. Future research should continue to examine financial hardship, including multiple forms of financial hardship, among sexual and gender minorities. These studies should examine various lesbian, gay, bisexual and transgender (LGBT) populations, including MSM and transgender women, as these groups are often at higher risk for negative health outcomes due to social discrimination (; Badgett & Frank, 2007; Badgett et al., 2007; Laurent & Mihoubi, 2012), yet are understudied in research, relative to heterosexual populations. These studies can have multiple approaches. First, qualitative methodologies can offer the advantage of grounding the exposure within a historical context, providing insights that elude statistical measurements. Second, quantitative studies that utilize longitudinal study designs would allow the establishment of causation between the exposure and the outcome. Further, these studies could benefit by incorporating more objective measures of sleep health as well as examining potential mechanisms. As discussed, one potential pathway is that financial hardship may cause psychological distress (Tucker-Seeley et al., 2013). Research to understand the pathway(s) in which financial hardship affects health outcomes, such as stress, can use self-reported methods as well as objective measures.
Limitations The current study has several noteworthy limitations. Specifically, the data are self-reported and may suffer from both recall bias and social desirability bias, which may lead to inaccurate responses from the participants. Additionally, the study may suffer from same-source bias because both the exposure and the outcome in this study were measured using self-report measures (Roux, 2007). While the Pittsburgh Sleep Quality Index (PSQI) is a well-known and validated measure of sleep health, this same source bias could be avoided by using actigraphy to collect data on sleep timing, quality and duration. Notwithstanding sleep efficiency, sleep fragmentation, or wake after sleep onset derived from actigraphy are viewed as objective measures of sleep quality, but the PSQI is good and useful, as Polymorphism is a measure that has been validated in many studies among different populations (Aloba, Adewuya, Ola, & Mapayi, 2007; Beaudreau et al., 2012; Buysse et al., 1989; Spira et al., 2011). Furthermore, the study is limited in that in relies upon a single item to ascertain financial hardship. Rather, multiple items should have been used to measure financial hardship to better capture a range of hardships, as done some previously in research that has examined a range of hardships (Abel et al., 2016). The range of financial hardships could be examined in a variety of ways, including by analyzing multiple specific financial hardships, such as food insecurity (Chi & Tucker-Seeley, 2013). Moreover, given the cross-sectional design utilized in this study, reverse causation and residual (unmeasured) confounding variables are a possibility. We indeed cannot provide evidence for a causal relationship between financial hardship and sleep health due to the nature of the design of our study. Reverse causation is possible: having poor sleep health may lead to poorer job performance, being fired, and in turn financial hardship. Unfortunately, the survey used did not include an item to measure night shift work, thus could not control for it. In addition, the assessment of employment status only allowed for the selection of either a student or employed, which may not ideal. Moreover, the sample was recruited from an application that has the purpose of meeting other MSM. Consequently, part of the recruited sample may be heavily involved in nightlife activities, given their willingness to meet other individuals by taking part in this application. This involvement in nightlife activities can be a confounding variable affecting their difficulties to stay awake during the day, as well as influence employment circumstances, thus influence both sleep quality and financial hardship. We acknowledge the limited generalizability of the study sample, which focused on individuals who identified as MSM in Western Europe who used a single geo-social networking application. Finally, while the survey targeted users of the popular app in the Paris metropolitan area at the time of broadcasting, we do not know if the participants were currently living in Paris,