Nearly two-thirds of surveyed rural Appalachian adults had clinically significant insomnia

Rural Appalachian communities are a federally designated health-disparity population with documented "insufficient sleep hotspots," but the prevalence of clinical sleep disorders there — and what drives it — has been poorly characterized until now. A cross-sectional study published this month in JAMA Network Open surveyed adults across economically distressed Eastern Kentucky counties to fill that gap [s1].

The design

Researchers analyzed baseline survey data collected from 2023 to 2025 as part of the Researching Equitable Sleep Time in Kentucky Communities (REST-KY) study, conducted across 12 economically distressed Eastern Kentucky counties, following the STROBE reporting guideline for cross-sectional studies [s1]. Participants were English-proficient adults recruited through print and broadcast media and community venues. The study measured three sleep outcomes: clinically significant insomnia (Insomnia Severity Index score ≥10), elevated obstructive sleep apnea risk (STOP-Bang score ≥3), and insufficient sleep duration (fewer than 7 hours per night) [s1]. Independent variables covered sociodemographic factors, health behaviors, and psychosocial factors including trauma, stress, and anxiety or depression [s1].

The cohort comprised 327 participants with a mean age of 45.3 years, 75.5% female, and 97.2% identifying as white [s1].

What it found

Among participants with complete data, 64.9% (187 of 288) had clinically significant insomnia, 51.3% (138 of 269) had elevated obstructive sleep apnea risk, and 44.8% (126 of 281) had insufficient sleep duration [s1].

The clearest pattern in the data was economic: insomnia prevalence declined from 82.9% among participants earning less than $20,000 annually to 44.4% among those earning more than $100,000 — a difference researchers describe as "a clear socioeconomic gradient" [s1]. Insomnia was also significantly associated with female sex, not working full-time, living alone, cigarette use, poorer diet quality, lower social support, poorer self-rated health, taking five or more prescription medications (polypharmacy), a history of trauma, moderate-to-severe anxiety or depression, and high stress [s1]. Elevated sleep apnea risk followed a different profile, associated instead with older age, being male, cigarette use, higher BMI, poorer self-rated health, polypharmacy, and trauma history [s1]. Insufficient sleep duration was significantly associated with lower social support [s1].

Why the divergent risk profiles matter

The study's design — measuring three distinct sleep outcomes against the same set of social and health variables — reveals that insomnia and sleep apnea risk track with different, sometimes opposite, demographic patterns within the same population: insomnia skews toward women and lower income, while elevated sleep apnea risk skews toward men and older age, patterns broadly consistent with what's known about each condition nationally but now documented specifically within a rural, economically distressed population that's rarely been studied on sleep outcomes at all [s1]. That distinction matters for how public health interventions in this region might be targeted, since a single generic "sleep health" intervention might miss the different populations actually at risk for each condition.

What this doesn't establish

This is a cross-sectional survey using convenience sampling — participants were recruited through media and community venues rather than randomly selected, which limits how confidently the 64.9% insomnia figure and other prevalence estimates generalize even to the broader Appalachian Kentucky population, let alone rural America overall. The cohort was 97.2% white and 75.5% female, reflecting who responded to recruitment rather than the region's actual demographic composition. Associations identified through Fisher exact tests describe correlations, not causal pathways — the study cannot determine whether, for instance, poor diet quality causes insomnia, insomnia leads to poor diet quality, or both stem from some other shared factor like economic stress.

What to watch

Whether these findings inform targeted sleep health interventions in Appalachian communities, and whether follow-up REST-KY data with larger and more demographically representative samples confirms the socioeconomic gradient found here. This article is not medical advice.

Sources

1. Social Determinants of Sleep Health Inequities Among Rural Appalachian Adults — JAMA Network Open, 9 April 2026