“No Rest for Me Tonight”: A Social-Ecological Exploration of Insomnia in Rural Appalachian Women

Abstract

Objectives:

Insomnia disproportionally affects women and is prevalent among rural Appalachian adults at higher rates than in the general US population. Given the strong, bi-directional relationship between sleep and health, a better understanding of insomnia in this health-disparate population is critical. The present study focused on the sex (females), gender (women), and age group (45+) at highest insomnia risk and explores the social determinants of sleep that contributed to insomnia.

Methods:

Semi-structured telephone interviews were conducted to understand factors associated with insomnia among rural Appalachian women who self-reported insomnia symptoms ≥3 nights per week for ≥3 months. Interviews were recorded with permission and transcribed. We used a multi-stage, inductive and deductive coding process aided by NVIVO 12.0 software.

Results:

Participants were 46 cisgender women in rural Appalachia who met the criteria for insomnia. The social-ecological model was our interpretative framework. Findings illuminate individual (e.g., rumination, menopause, pain, depression), social (e.g., family roles, grief, caregiving, financial concerns), and societal (e.g., gender norms, technology use) factors that likely contribute to insomnia among middle-aged rural Appalachian women.

Conclusions:

Across levels of the social-ecological model, factors of female sex (e.g., menopause) and gendered behaviors, roles, and norms (e.g., caregiving close and extended kin) played a central role in the precipitation and perpetuation of insomnia in this population. Attending to the regional cultural norms of heightened self-sufficiency, domestic work, and inter-generational familial care may aid healthcare providers and policy makers aiming to address insomnia among rural Appalachian women as well as other rural populations.

INTRODUCTION

Insomnia, defined as difficulty falling / staying asleep or early awakening, has well-established linkages to excess morbidity (e.g., depression, breast cancer) and is differentially distributed across populations.^1,2 Women have a 40% higher insomnia risk compared to men, and this gap widens with age.³ It is estimated that 59% of U.S. perimenopausal women suffer insomnia.⁴ The higher prevalence of insomnia among women is partially due to biological/hormonal factors.⁵ However, research demonstrates that gender-specific stressors, like caregiving, strongly correlate with insomnia, with effects varying across different life stages.^6–9

Insomnia rates also differ by place. Grandner and colleagues¹⁰ identified United States (U.S.) “hotspots” of insufficient sleep (i.e., 25–58% of adults slept ≤6 hours per night most nights) of which insomnia is a leading cause. Of counties reporting sleep duration, the largest number of “hotspot” counties were in Appalachia. Within Appalachia, the state of Kentucky ranked first (and worst), with 22 of 54 Appalachian counties identified as insufficient sleep “hotspots.”¹⁰

Although Appalachia is well known for its beautiful terrain and strong traditions of family connectedness and community support, Appalachian adults are an NIH-designated health disparity population who experience limited healthcare access and excess rates of disease and death.^11,12 Compared with the U.S. overall, Appalachian Kentucky residents have twice the percentage of poverty (28% versus 12.3%), more than twice the premature death rate (12,028 versus 5,317 per 100,000), and substantially higher percentages of obesity. Exacerbating these problems, nearly 80% of the 54 Appalachian counties in Kentucky are healthcare professional shortage areas.¹¹

Given the region’s health and socioeconomic circumstances, its high rates of insufficient sleep are perhaps unsurprising, but the specific causal factors are unknown. Although biological factors undoubtedly contribute, the social determinants of sleep - an umbrella term encompassing myriad factors in the environment where people are born, live, learn, work, play, worship, and age¹³ - complicate the picture of who is sleeping, for how long, and how well. The present study focuses on a socio-cultural group (Appalachian Kentuckians) who self-reported experiencing insomnia (a leading cause of insufficient sleep) and explored social determinants of sleep in the sex (female), gender (women), and age group (45+) most likely to experience insomnia.^14,15

As demonstrated by foundational prior scholarship, gender is a particularly salient social determinant of sleep, particularly for women in mid-life.^8,16,17 Women’s “performance of physical and emotional labor” for family members “often curtails their right to a good night’s sleep” (p. 709).⁸ Socio-cultural constraints may further complicate gendered roles. Appalachian women inhabit what anthropologists have described as a regional moral economy of “self-sufficiency, work, and mutual family care”¹⁸ (p84). These norms translate into strictly enforced self-sufficiency that often inhibits women from seeking or accepting help, even as they routinely bear the mental load of all the thinking, planning, and organizing of the household and its occupants as well as the emotional labor of caring for everyone else.¹⁹ Regional challenges, including poor economic and educational opportunities and the toll of the opioid epidemic, complicate family structures.^20,21 Some nuclear families in the region split and reconfigure as grandfamilies wherein grandparents fill the caregiving gap left by children who are deceased, departed, or struggling with substance use.²² Grandfamilies may also be more prevalent as the extended family unit has high cultural value,²³ with women invariably taking on more of the caregiving.²⁴

To better understand the complex circumstances and factors impacting Appalachian women’s sleep, we asked them what kept them awake or disrupted their slumber. Although quantitative methods can assess causality, qualitative studies complement quantitative research by adding depth, context, and the voices of marginalized groups.²⁵ Qualitative work is also vital for informing subsequent intervention or prevention efforts using culturally- and community-informed approaches.^26,27

The present study adds depth and nuance to our prior quantitative research with Appalachian women with insomnia^28,29 and frames interview themes within the context of Grandner’s social-ecological model of sleep.³⁰ This multi-level model considers the outcome of interest (sleep) in three embedded, interrelated contexts: individual (i.e., factors located within, or originating from, the individual), social (i.e., built and social environments, roles, and identities), and societal (i.e., macro-level contextualizing factors such as policy, economy, norms, etc.). For further detail and examples, please see Figure 1. The present paper answers the call to add clarity to the model by elucidating unique and combined influences at the individual, social, and societal levels.³⁰

Figure 1. The Social-Ecological Model of Sleep.

Adapted from Grandner (2019) “Social-ecological model of sleep health.”

METHODS

As part of a larger study of a multiple method, 6-week insomnia intervention among Appalachian women, the first author and a research assistant conducted semi-structured qualitative interviews (pre- and post-intervention) asking women to describe their insomnia experience, as well as contributing factors (see Appendices 1 and 2). All procedures, including the informed consent process, were approved by the University of Kentucky (UK) IRB.

Participants were recruited with the assistance of UK’s Center of Excellence in Rural Health and snowball sampling. Our project coordinator distributed paper and electronic flyers to the UK North Fork Valley Community Health Center, other local health clinics, Facebook, and ResearchMatch.org. Eligible participants were Appalachian women ages 45+ with regular Internet access who self-reported difficulty falling/staying asleep ≥3 nights a week for ≥3 months and prior or current use of prescription or over-the-counter sleep aids. Exclusion criteria were self-reported obstructive sleep apnea, dementia, Alzheimer’s disease, Cushing’s disease, or bipolar disorder with psychosis.

Prospective participants (N=68) used the contact information from the recruitment materials to contact study personnel and were screened for eligibility over the phone. Forty-six eligible participants completed the online intake survey and semi-structured intake interview. Thirty-eight of the original 46 completed post-intervention interviews; data from all interviews are reported here.

Semi-structured interviews were conducted by the first author or research assistant, recorded with permission, and professionally transcribed. Participants were offered the option of telephone or in person interviews; all participants chose telephone interviews. Interviews lasted approximately 30 minutes each and covered a range of questions related to participants’ sleep experiences. Transcribed interviews were coded with the aid of NVivo 12.0 qualitative analytic software.³¹ We used a multi-stage coding process that was both inductive and deductive in nature,³² allowing us to focus our analytic gaze on women’s sleep experiences and incorporate the structure of the social-ecological model of sleep while remaining open to tangential and emergent themes.²⁵ The PI and research assistant coded a subsample of transcripts, then met regularly for the purposes of code generation and reconciliation. Once strong levels of intercoder reliability were attained (i.e., kappa ≥ .80)³³the remaining transcripts were independently coded.

Our interdisciplinary research team approached this qualitative study of insomnia among Appalachian women acknowledging our positions as academic researchers. While none of our predominantly female team members experience chronic insomnia, situational insomnia is a near-universal experience. Study participants – all white cisgender Appalachian women – primarily interacted with the study PI (a white, cisgender Southern woman) and our Eastern Kentucky-based project coordinator (a white, cisgender man born and raised in Appalachia); the latter’s established community position proved instrumental in recruitment and retention. We recognize that our positionality influences every aspect of our research, and centered participant voices and experiences throughout our research process.^34,35

RESULTS

All participants (N=46) identified as cisgender women and, consistent with the demographics of Appalachian Kentucky, most (95.6%) self-identified as White, non-Hispanic. The average participant age was 55 years (SD=6.2). The majority reported living as married, having full-time employment, and completing less than two years of college. For demographics, see Table 1.

Table 1.

Participant Characteristics

Characteristic: Mean (SD)/ N (%)	Non-Completers (n=8)	Completers (n=38)
Age	58 (7.9)	55 (6.2)
Education
< HS	1 (12.5%)	0 (0.0%)
HS/GED	2 (25.0%)	10 (26.3%)
Some College	2 (25.0%)	11 (28.9%)
Vocational Training	0 (0.0%)	2 (5.3%)
Associates	1 (12.5%)	5 (13.1%)
Bachelors	0 (0.0%)	6 (15.8%)
Some Graduate/Masters	2 (25.0%)	1 (2.6%)
PhD./M.D./Professional	0 (0.0%)	3 (7.9%)
Ethnicity
White/Caucasian	8 (100.0%)	36 (94.7%)
Black	0 (0.0%)	1 (2.6%)
American Indian	0 (0.0%)	1 (2.6%)
Private Insurance	3 (37.5%)	35 (92.1%)
Medicare	3 (37.5%)	4 (10.5%)
Medicaid	2 (25.0%)	1 (2.6%)
Marital Status
Married	4 (50.0%)	28 (73.7%)
Living as married	1 (12.5%)	2 (5.3%)
Divorced	1 (12.5%)	6 (15.8%)
Widowed	1 (12.5%)	1 (2.6%)
Separated	1 (12.5%)	0 (0.0%)
Single, never married	0 (0.0%)	1 (2.6%)
Employment Status
Self-Employed	0 (0.0%)	1 (2.6%)
Full-time	4 (50.0%)	29 (76.3%)
Homemaker	0 (0.0%)	2 (5.3%)
Not working (disability)	3 (37.5%)	2 (5.3%)
Retired	1 (12.5%)	1 (2.6%)
No Response	0 (0.0%)	3 (7.9%)

HS, High School. GED, General Educational Development.

Although responses are clustered by levels of the social-ecological model, these contexts are embedded within one another, and overlap occurs. Quotes reported here are representative of thematic findings. All names in this manuscript are pseudonyms. Participants had the option to choose their own, or be assigned, pseudonyms. Viewed separately, each level provides insight into factors contributing to insomnia as reported by participants. Viewed as a whole, a nuanced picture emerges of the multi-layered social determinants of sleep influencing this health disparate population. For a visual representation of factors contributing to Appalachian women’s insomnia embedded in the social-ecological model of sleep, see Figure 2.

Figure 2. Factors Contributing to Appalachian Women’s Insomnia in the Social-Ecological Model of Sleep.

Adapted from Grandner (2019) “Social-ecological model of sleep health”

Individual level factors

Rumination (i.e., repetitive thinking about the present or past), worry (i.e., future concerns),³⁶ menopause, pain, and depression were frequently cited as individual-level insomnia factors. Women described racing, recurring thoughts that stole their ability to “shut down.”

Well, when [my insomnia] first started, I just could not turn my brain off. I would lay there, and I would start thinking about something and then it would just roll into a big old ball and be all out of proportion. I’d say, ‘There ain’t no rest for me tonight’

(Penny).

Other women fell asleep quickly, but then experienced early awakenings. The temporal and thematic focus of stress-related thoughts varied. Some women worried about uncertain futures influenced by strained finances or family struggles. Others ruminated on painful memories of loss and grief. Lauren told us that in a four-year period her brother, father, and best friend had passed away and “a lot of times when I do wake up, that’s what I’ve got on my mind.”

At the individual-physiological level, menopause and pain were rife in this sample. Women told us that when they entered menopause or perimenopause, their “sleep pattern changed completely.” Participants often naturalized the idea that sleep issues were an expected part of the menopausal process. Tammy said “I know that when you’re menopausal that you have problems sleeping at night. Or so I’ve been told.” Healthcare providers played a role in naturalizing the connection between menopause and insomnia. Beth said her providers “didn’t seem to think it was something that was bothersome. It was just part of life, basically.”

Participants’ physical pain ranged from “aches and pains,” to spinal surgery, to kidney disease. Sometimes, physical pain co-occurred with painful thoughts or memories. Maggie said: “… I got things on my mind about the grandchildren and my dad passing away, and issues like that and stuff when I try to rest. And then of course as I get older, I have pain issues. My back hurts and shoulder and stuff hurts.”

Participants didn’t complain about these issues, instead they naturalized ideas of sleep loss resulting from stress, menopause, or pain. This finding is reminiscent of research that describes Appalachian women’s naturalization of their depression experiences.¹⁸ Indeed, depression was a common thread in many conversations.

Women spoke of “down” or “depressed” emotional states that pervaded their days and impacted their nights; several shared diagnoses of clinical depression. When asked what caused her insomnia, Danielle said “I think it was mostly the depression, and then I was sleeping all the time anyway because I didn’t want to do anything. And then I didn’t sleep when I did go to bed.” Indeed, lack of sleep is a well-documented precursor to or exacerbator of depression.³⁷and participants noted that “the lack of sleep makes [depression] worse.”

Social level

The aforementioned rumination and depression were associated with family relationships and caregiving responsibilities located at the social level. The death of family members was a very common theme. Many participants’ children had died from complications related to illness, accidents or substance use (e.g., overdose). Mara noted “I started getting bad sleep when my son passed away.” The nested nature of the social level (family loss) and the individual level (rumination) was made crystalline in these discussions as the perpetuating factor of rumination was common. For instance, Tina lamented, “[N]ow, it’s just when I wake up, I always think about my daughter that I lost. Then I just get up. I just can’t go back to sleep because that’s all I do is think.”

Caregiving responsibilities, particularly for grandchildren or other young kin, emerged as another social factor that undermined sleep. Oftentimes, participants’ adult children had died or were unable to care for their children due illness (e.g., cancer, substance use disorder) or outmigration (e.g., seeking opportunities elsewhere). Indeed, grandparents in Central Appalachia are approximately twice as likely to be their grandchildren’s primary caregiver, compared to the rest of the U.S.²² Some participants were full-time caregivers for children and grandchildren who had moved back home and others shared this responsibility with their offspring. Carla told us: “Sometimes I take care of my grandson. …and I have to keep him six weeks at a time because [my daughter] can’t lift him and care for him.”

Women’s caregiving responsibilities encompassed both very close kin in their household and beyond.

I’m actually raising my great-niece… She’ll be 13 years old next month. I’ve been raising her for almost 11 years. And I live too far away from my brother to help care for him or I would be doing that. But actually, my brother-in-law and father-in-law, they live about five minutes from me. I help with their care. I go over there and clean house, cook for them, go to the store, go shopping for them, and things like that….And sometimes I take care of my grandson.

(Sophie)

Beyond and directly connected to family structure and responsibilities, the region’s economic deprivation, employment uncertainty,²¹ and impacts of the opioid epidemic²⁰ created stressors that impacted participants’ ability to fall or stay asleep. Taylor said, “I’ve been the only one working for years, and it’s very stressful… My husband had a job there for a while, but never on a steady accountable basis. So, I constantly have that worry.” Claudia shared that her husband developed a substance use disorder after he was prescribed opioids for a back surgery.

I can’t go to sleep at night because you can’t. Well, if you have $50 in your purse, it’s easier [for him] to steal it. You have to take his debit card and his credit card, and you can’t have any cash, and you monitor his phone because you think you can stop it. You think you can find a way to stop it, but the truth is you can’t. … So those are my reasons

[for not sleeping].

Although she described her husband’s substance use disorder as initiating her insomnia, his death brought no relief, particularly as Claudia went “from two incomes to one” and had two children to raise. She believed uncertainty and financial stress, compounded with grief, fueled her insomnia for nearly two decades.

Societal Level

Societal factors were the least likely to be explicitly discussed in sleep conversations. Nevertheless, two primary themes emerged. First was the use of technology. Despite the rurality of the region, technology use was ubiquitous. Women described being “addicted” to their phones, “playing with devices” in bed, or “needing” the “background noise” of a bedroom television to help them get to sleep.

When asked about the major causes of her issues with sleep, Suzanne noted that “stress” was her primary issue but said her secondary issue was “my electronics.”

I was thinking that I was doing really, really well and really getting rest because I was going to bed early. But I was laying in bed on, either on my phone or on my laptop. That was kind of shooting myself in the foot because once I did decide that’s it’s time to get to sleep then I was all wired up because I had been looking at a laptop or a smart phone.

Some women claimed – despite evidence to the contrary^38,39 – that technology helped them sleep. Many said watching TV helped them “get sleepy.” Morgan said, “For me, if I go and get on a computer for a little while, that makes me sleepy to stare at the screen. And if I can go right then, I can fall asleep. But if there is any delay or distraction, then I’m awake.”

Lauren who, as previously mentioned, had lost several loved ones in a four-year period, told us that she used technology to escape her grief. “I got to where I couldn’t sleep because my mind would dwell on that stuff. So, I got in the habit of turning the TV on and then I would try and watch the TV to get my mind off that.” While participants framed their nighttime technology use as a personal choice, their descriptions of scrolling social media and streaming shows at bedtime highlighted how individual sleep habits intersect with both widespread mobile technology adoption and evolving social norms around nighttime device use.

The second societal level theme was gender norms. Although kinship care norms are well-documented in the region and complicated by the fracturing factors of the opioid epidemic and economic deprivation, the naturalization of caregiving numerous family members across generations could not exist without societal gender norms. Deeply-ingrained gendered norms shaped participants’ waking – and sleepless – hours.

I do everything for everybody. In the morning, I mean, the breakfast is made, the lunches are packed, their clothes are laid out for them. I even sweep, mop, and do the laundry before I go to work. Everything is done for them. All they have to do is get up, go to work, come in, eat, because I do that too, and then do their homework and go to bed. Other than showering themselves, pretty much everything is done for them.

(Maggie)

Women’s mental load – combined cognitive and emotional labor in service of the household – was heavy.¹⁹ Participants described ruminating about children, spouses, parents, work, finances, “daily life” and worrying about “what is around the next corner.” Josie told us that unease about her estranged mother kept her up at night. “I worry a lot about her because …she’s alienated all of her children and all of her grandchildren.” Although these worries were created at the social level (e.g., family role) and manifest at the individual level (e.g., rumination), it is our societal level gender norms that enable the normalization of unpaid caregiving and the resulting excess mental load.

DISCUSSION

Sleep is increasingly recognized as a key domain of health, particularly for women⁴⁰ and – given the strong bidirectional relationship between sleep and heath – it is vital to address in health disparate populations.⁴¹ Prior, important work has found that social determinants of sleep include neighborhood light, noise, and crime and perceived attitudes, beliefs, and barriers to sleep may vary by race / ethnicity.^26,42,43 The present study builds on this foundational research, largely conducted in urban populations, by focusing on a rural population. We build upon established scholarship that identified how gendered roles and responsibilities shape and disrupt women’s sleep, particularly in middle age,^8,16,17 while revealing how these patterns manifest within Appalachia’s distinct socio-cultural context. Our findings contribute to a growing body of research acknowledging the community and cultural contexts of sleep disparities^26,27,43 as we address knowledge gap surrounding the causes of Appalachian sleep disparities.^10,44 Embedding our findings in the social-ecological model of sleep³⁰ offers a strong conceptual framework that illuminates individual-level factors, social relationships, and societal structures that may contribute to insomnia among middle-aged Appalachian women.

At the individual level, participants reported that physiologic (i.e., pain) and psychological (i.e., worry) problems kept them up at night, or ruined their ability to return to slumber. Participants had difficulty “turning off” their brains and rumination was rampant. Given the strong relationship between rumination and depression,³⁶ it is perhaps unsurprising that depression was frequently mentioned. Indeed, many of our participants were highly stressed and depressed as assessed qualitatively here and as reported elsewhere, quantitatively.^28,29 Moreover, the naturalization of suffering from physical sex-based processes (menopause) or mental illness (depression) was common among participants. These data are consistent with prior research characterizing increased prevalence of sleep disturbance and depression among perimenopausal and menopausal women.⁴⁵ However, rates of depression among Appalachian women are higher than the national average, and Appalachian women’s depression struggles include reticence to seek help.¹⁸

Women’s narratives located the causes of stress and depression at the social level. The opioid epidemic, while nationwide, has ravaged Appalachia,⁴⁶ evident in numerous participant narratives of prematurely losing friends and family. Participants also noted the uncertainty of the local economy as it related to financial and employment concerns. These factors are inextricably linked to the most oft-reported insomnia causes: family roles and structure. Most participants actively cared for multiple family members. Familial care typically occurred at home with close kin but often extended into caring for kin nearby (e.g., in-laws).

Many Appalachian women take pride in, and derive meaning from, their myriad familial responsibilities and family care norms are considered their most powerful influences.⁴⁷ These norms are central to and integrate with both support and stress^47,48 and it is impossible to ignore the clear and consistent connections our participants drew between their insomnia experiences and their unpaid caregiving. These insights align with the prior findings of Venn and colleagues that women’s bedrooms become “‘invisible workplaces’ in which women’s sleep needs are compromised by the unpaid physical and emotional labor necessary for the well-being and maintenance of their family”⁸ (p703). However, Appalachian women’s cultural and family contexts added complexity to their “invisible workplaces.” For instance, insomnia often began after the death of a family member. Caregiving stress and the daily mental and financial strains of raising that kin’s offspring were perceived to perpetuate insomnia.

Using the social-ecological model as a guide, we posit that societal level factors informed both social and individual level behaviors. For instance, our participants’ individual gender roles are influenced by commonly held social-familial expectations, which are in turn informed by the societal structure of patriarchy. Living in patriarchy means that women are expected to care for others and carry an often-crushing mental load of cognitive tasks and emotional labor⁴⁷ that may, quite literally, keep them up at night. Venn and colleagues identified this gendered nighttime sleep disruption as women’s “fourth shift” rooted in longstanding patriarchal structures.¹⁶ Our findings not only confirm this patriarchal influence but also reveal how it manifests distinctly within Appalachian culture, as it intertwines with regional norms of self-sufficiency, domestic labor, and mutual family care.^18,49

Some women turned to technologically-facilitated means of entertainment (e.g., “binge-watching” shows or scrolling social media) as a way to ease their mental load, even if only temporarily. This aligns with research suggesting that nighttime mobile phone use is considered an “escape” and a way to reclaim “personal time”⁵⁰ (p94). Like caregiving, technology at bedtime - a known sleep disruptor^38,39 - appears to be an individual choice. However, social media scrolling would not exist without the adaptation of mobile technology (societal level) and shifts in social norms around mobile technology use (social level).⁵⁰

These interviews suggest that Appalachian women attribute insomnia to largely situational (though persistent) factors related to sex and gender. For example, the factors most closely related to insomnia are physical changes or sensations (e.g., menopause) or situational emotional states (e.g., caregiving stress). In Spielman’s 3-P model of insomnia⁵¹ the condition develops because of predisposing, precipitating, and perpetuating factors. Predisposing factors include individual characteristics that may create the conditions for insomnia to develop and are either static (e.g., genetics) or otherwise generally out of an individual’s control (e.g., age). Precipitating factors are situational events that lead to sleeplessness by directly increasing arousal (e.g., pain).

Although most cases of acute insomnia resolve spontaneously⁵² some cases persist and become chronic, due to perpetuating factors. Principally, these factors contribute to a conditioned arousal to the bed, bedroom, and/or act of falling asleep.^51,52 This conditioned arousal – learned, paired associations between arousal and sleep attempts – is the primary contributor to chronic insomnia.⁵² The present study shows that Appalachian women readily identify precipitants to insomnia but may be unaware of the behaviors and associations that facilitate the transition between acute and chronic insomnia. A better understanding of the factors that comprise predisposing, precipitating, and perpetuating factors in this population may lead to more effective interventions.

We acknowledge limitations in this study. First, placing factors into one “level” over-simplifies the intersections that contribute to the complexity of insomnia. However, as a heuristic device, the social-ecological model of sleep enables us to understand the relationship between these factors. While interview duration averaged (a relatively short) 30 minutes and all participants opted for telephone rather than in-person interviews, prior research supports telephone interviews as methodologically valid, offering comparable quality while improving accessibility.^53,54 The shorter duration reflected our effort to minimize participant burden, as the study also included a 6-week insomnia intervention and pre/post surveys. Most participants lived 2.5 hours from the research site, making telephone interviews a practical choice. Additionally, although most participants reported having two years of college or less, such educational attainment exceeds that of most rural Appalachian woman, as does their rate of private insurance. These characteristics may lead our sample to have greater access to financial and other resources than others in the region. However, all Appalachian women are considered members of a health disparity population due to their geographic location, limited healthcare access, rural environment, regional poverty, sparse resources, and excess rates of morbidity and mortality.^11,55 Future research should endeavor to further elucidate – objectively, subjectively, and longitudinally - the causes and consequences of sleep disparities in this and other rural populations.

CONCLUSIONS

Appalachian Kentucky contains the largest number of known hotspots for insufficient sleep, of which insomnia – a sleep disorder disproportionately impacting women - is a major contributor. Our findings offer insight into multi-level, interrelated factors that may be influencing the high prevalence of insomnia in Appalachian women. Across levels of the social-ecological model, factors of female sex (e.g., menopause) and gendered behaviors, roles, and norms (e.g., caregiving) played a central role in the predisposing, precipitating, and perpetuating of insomnia. Identifying understudied factors in this rural population offers the opportunity for policy makers, health providers, and researchers to target relevant factors (e.g., adverse coping strategies, gendered caregiving responsibilities, depression) via culturally tailored interventions. Given that Appalachian women strongly identify as rural and share characteristics with other rural U.S. populations (e.g., poverty, workforce shortages^46,56), our findings may be relevant to other rural women.