Multiple Pathways, Persistent Disparities: How Fundamental Social Causes Shape Sleep Health in Rural Appalachia

• In Event: Medical Sociology Section Roundtables
  In Refereed Roundtable (90 minute): Table 24. Health Knowledge, Behaviors, and Practices

Abstract

Background: Despite recognition of sleep's centrality to health, rural Appalachian communities – a designated health disparate population - remain critically understudied in sleep research. This study applies fundamental cause theory (FCT) to examine associations between sleep health and socioeconomic position, demographics, and health behaviors in this persistently marginalized population.

Methods: Using cross-sectional survey data from 327 Appalachian adults (2023-2025), enrolled in the REST-KY (Researching Equitable Sleep Time in Kentucky Communities) Study, we examined prevalence and determinants of clinically significant insomnia (Insomnia Severity Index score 10), elevated obstructive sleep apnea (OSA) risk (STOP-BANG score 3), and insufficient sleep duration (<7 hours). We analyzed bivariate associations between sociodemographic characteristics, health behaviors, social conditions, and sleep outcomes. We used t-tests for continuous variables and Fisher's exact tests for categorical variables.

Findings: Findings reveal substantial sleep deficiencies exceeding national prevalence rates: 64.9% met criteria for clinically significant insomnia (vs. 10-20% nationally), 44.8% reported insufficient sleep (vs. 33.2% nationally), and 51.3% had elevated OSA risk (vs. 9-38% nationally). Consistent with FCT, insomnia prevalence declined from 82.9% among those earning <$20,000 annually to 44.4% among those earning >$100,000. However, differential patterning emerged across outcomes: insomnia showed strong associations with psychosocial factors (e.g., depression, social support) and socioeconomic position; insufficient sleep demonstrated weaker sociodemographic patterning; and OSA risk associated primarily with demographic and health factors (e.g., age, smoking).

Discussion: Our results extend FCT beyond traditional mortality outcomes to illuminate how fundamental social causes operate through multiple mechanisms to shape sleep health. The distinct risk profiles across sleep outcomes demonstrate FCT's core insight: that socioeconomic position determines access to flexible resources deployable across diverse pathways—from stress management and social support affecting sleep quality to work schedules affecting sleep quantity. Results underscore limitations of individualized interventions absent structural change and highlight urgent need for upstream approaches addressing social determinants.

Authors

• Mairead Eastin Moloney, University of Miami

• Emily Slade, University of Kentucky

• Joon Chung, University of Miami

• Maliha Mehnaz Mitu, University of Kentucky

• Michael Grandner, University of Arizona

• Daniela Moga, University of Kentucky