Appalachia has a legacy of making the most with limited resources, but there's one thing that there's no way to stretch: sleep.
Researchers at the University of Kentucky, in partnership with colleagues at the University of Miami and the University of Arizona, discovered that adults living in rural Appalachian communities face a significantly higher burden of sleep disorders than previously understood. This confirms something many living in the region already see and feel every day - bad sleep leads to hardship, and hardship leads to bad sleep. Sleep disorders are part of a stark gap in healthcare outcomes shaped by economic and social factors.
The ongoing research project, REsearching Sleep Time in Kentucky Communities (REST-KY), found that 64.9% of participants suffered from clinically significant insomnia. This rate is more than six times higher than the 10% national average.
"It's not just, 'I cannot sleep.' There's a significant impact of mental health driving these high rates," said Daniela Moga, Ph.D., co-lead on the study, assistant dean for research and the Larry H. Spears Endowed Chair in Pharmacogenetics at the UK College of Pharmacy.
The socioeconomic gradient of insomnia
Recently published in JAMA Network Open, the study highlights how social determinants of health fundamentally shape sleep quality in underserved regions. The research team identified a "steep socioeconomic gradient" regarding insomnia.
According to the data, the prevalence of insomnia reached 82.9% among participants earning less than $20,000 annually. In contrast, the rate dropped to 44.4% for those earning more than $100,000. Beyond income, the study found that insomnia was significantly associated with being female, living alone, cigarette use, poor diet quality and trauma history.
"Sleep is not just a personal health behavior. It is structured by the social and economic conditions of people's lives," said Mairead E. Moloney, Ph.D., assistant professor at the University of Miami Miller School of Medicine and the lead author of the study. "Our findings show that in rural Appalachian Kentucky, poverty, social isolation and lack of employment are driving rates of insomnia that are six times the national average. Until we address those upstream conditions, we cannot meaningfully improve sleep health in these and other rural communities."
Although insomnia was the most prevalent issue, the REST-KY study took a comprehensive look at several sleep deficiencies. Approximately 51.3% of participants faced an elevated risk of obstructive sleep apnea (OSA), compared with a national average of roughly 38%. Additionally, 44.8% of those surveyed reported insufficient sleep duration, which is defined as getting less than seven hours of sleep per night.
The risk factors for these conditions often overlapped. For example, an elevated OSA risk was specifically linked to older age, being male, cigarette use, a higher body mass index (BMI) and polypharmacy - the concurrent use of five or more medications by a single patient. Meanwhile, insufficient sleep was most closely tied to lower levels of social support.
The data also revealed that 37.1% of participants suffered from moderate to severe anxiety or depression and 62.1% reported moderate to high stress. Additional data from REST-KY, published last year in the Journal of Affective Disorders, found that greater social support was associated with lower insomnia severity, and this relationship was mediated by depressive symptoms (69%), anxiety symptoms (64%) and perceived stress (78%).
"What makes this study especially important is that it focuses on a population that hasn't been well represented in sleep research," said Emily Slade, Ph.D., associate professor at the UK College of Public Health and one of the study's authors. "By taking a closer look, we're able to better understand the unique combination of factors that influence sleep in these communities. One of the most meaningful findings is how closely sleep is connected to broader life circumstances, such as financial stability, overall health and social support. That gives us clearer direction for how to support better sleep in ways that are realistic and community-informed."
The burst approach
To capture these data, the UK team recruited 327 participants from 12 economically distressed Eastern Kentucky counties: Adair, Bell, Estill, Jackson, Knott, Letcher, Lincoln, Perry, Pike, Rockcastle, Russell and Whitley.
The REST-KY study goes beyond traditional one-time surveys by following participants for two years. Every six months, participants complete a detailed survey and a two-week intensive tracking period known as a "burst." During these bursts, they complete daily surveys on their mobile phones and wear a fitness tracking device to record their sleep patterns in real time.
"This gives us a detailed picture of what is happening in their lives and impacting their sleep," Moga said.
Researchers initially intended to compare six "hotspot" counties - areas previously identified in 2015 as having excess sleep deficiency - with six nonhotspot counties. However, the results revealed that sleep deficiencies were pervasive across the entire region, regardless of previous labels.
"We couldn't even do analyses separating by hotspot and nonhotspot because they look very much alike," Moga said. "The problem is actually more prevalent and it's not just in some counties."
Health up the holler
Because healthcare access, cost and travel time are significant barriers in rural Appalachia, the researchers are focusing on interventions that do not require a visit to a physical clinic.
In a previous study funded by the Building Interdisciplinary Research Careers in Women's Health program, Moloney and Moga tested a cognitive behavioral therapy intervention delivered via an app to women aged 45 and older in Eastern Kentucky.
"We were able to show that not only did they improve their sleep outcomes, they also reduced the use of medications to help with treating insomnia," Moga said.
The team has since submitted a grant to bring a similar app-based intervention, called Somryst, to the counties involved in the REST-KY study. These digital tools are designed to address both sleep and mental health while overcoming the stigma and transportation burden sometimes associated with seeking traditional care.
Her new Kentucky home
The study's success relied heavily on one of the study coordinators, Jennifer Malan, who lives in the region.
"She has been able to make this possible because she knows the people," Moga said. "She knows how to talk to them, how to convey the message that we are there for them, to learn from them and to really try to help them in a way that they welcome."
Meeting Kentuckians in a way that feels authentic is important to Moga. She's originally from Romania, but like many people who relocated to Kentucky, she was blown away by how quickly the community embraced her. She didn't know much about Kentucky and Appalachia before moving here 14 years ago, but since then has learned to love the region and its people.
"I'm coming from a small country, and I could see lots of similarities between rural Romania and Appalachia," Moga said. "I grew to be invested in this region, and I appreciate the opportunity to really showcase our research because it's really not research for the sake of research. It really is trying to help the people there."
Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under award number K12DA035150 and the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award number R01MD016236. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
