“No rest for me tonight”: A social-ecological exploration of insomnia in rural Appalachian women

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: Semistructured 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 multistage, 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.