To our knowledge, this is the first study examining sleep quality among women living in Nairobi’s informal settlements. Utilizing Bronfenbrenner’s ecological framework, our analysis illuminates the complex interactions between individual-, family, or household- and community- or environmental-level factors, enriching our understanding of the nuanced challenges these women face in obtaining restorative sleep. Approximately 29% (n = 229) of women in our study scored above five on the B-PSQI, representing poor quality sleep, consistent with other sleep studies [9, 46].

At the individual level, significant relationships were found between poor sleep quality and depression and disability. Depression was notably impactful, reflecting literature that links mood disorders to sleep disturbances [47, 48]. These conditions profoundly affect daily functioning and well-being, emphasizing the critical need for accessible mental health services in these communities. The presence of disability further exacerbates sleep issues, likely due to associated physical discomfort and psychological stress [17, 49]. While there is limited data on the causes of sleep disturbance in informal settlements, research focused on sleep and anxiety among residents in informal settlements in Dhaka city, Bangladesh, during the COVID-19 pandemic found that anxiety and sleep disturbance co-occur, with 34.5% of the sample (n = 586) experiencing both.

Research suggests that women, in general, experience higher levels of stress and anxiety than men [38, 39, 50, 51], but the effects of stress and anxiety on women’s sleep quality remain understudied. In one example, however, Boer et al. [4] found no significant gender differences in the effect stress on insomnia. Given our results, which suggest stress and disability are essential factors to consider when focusing on sleep quality among women in informal settlements, more research is needed on the link between stress and sleep quality, particularly across genders.

Studies have shown that rates of IPV and common mental health issues are much higher for women in informal settlements in Kenya than in other populations in the nation [28, 52,53,54], likely due to the political, economic, social, environmental, and climatic factors that also impact sleep quality. While IPV did not emerge as a statistically significant predictor of poor sleep quality in the quantitative analysis, its association with poor mental health and disability – both significant in our models – remains critical [55]. Additionally, our measurement of IPV, which included emotional, physical, and sexual violence, may have limited our ability to capture its full impact, particularly given that emotional IPV often requires alternative coding strategies (e.g. [64, 65]). This suggests that the association may be more apparent in cases of severe violence. These potential impacts underscore the need for further investigation and targeted interventions within healthcare and social support systems.

Moreover, food insecurity was significantly associated with poor sleep quality, indicating that basic survival concerns, such as hunger and financial stress, directly influence physiological and psychological states [56]. This finding highlights the intersection of food security, economic stability, and sleep health, suggesting interventions aimed at reducing food insecurity may also enhance sleep quality by alleviating a key stressor in women’s lives.

Residents of informal settlements are disproportionately vulnerable to the negative effects of climate change [57,58,59] and face many stressors associated with historical, political, and social marginalization, poverty, and exclusion from formal and consistent essential services and legal land tenure [15]. Our study considered whether conditions within Bronfenbrenner’s exosystem, especially extreme events like heat waves or cold snaps, impact women’s sleep. While these conditions were not statistically significant in the multivariable analysis, they were significantly associated with poor sleep quality in the bivariate analyses and were also reported qualitatively as factors disrupting sleep. This suggests that housing and community planning should consider environmental comfort to improve sleep health. Similarly, broader socioeconomic development – such as improving employment opportunities, income stability, and community resources, could indirectly enhance sleep quality by reducing systemic stressors.

Findings from women’s open-ended responses describing factors affecting sleep further emphasize the stressors identified in the study. Participants cited physical health issues, financial instability, caring for young children/infants, and family as common sources of sleep disturbance. Additional reported factors included unemployment, pregnancy, climate, grief and loss, insecurity in the community, food insecurity, and election-related fears. While these factors help to identify important individual and contextual factors affecting sleep quality, more research is needed to develop effective intervention strategies. Some research suggests that upgrading informal settlements can improve sleep quality by enhancing the physical environment and infrastructure [19, 60], but more research is needed to identify the most pertinent risk factors for sleep quality and, relatedly, the most appropriate, feasible, and effective interventions to mitigate their effects. Given the unique challenges women in informal settlements face, future research should explore direct and indirect pathways between various potential risk factors and women’s sleep quality to better inform targeted interventions.

Some research suggests that protective factors may also contribute to sleep quality among women in informal settlements, potentially mitigating some of the effects of risk factors. Our findings suggest that only 29% (n = 229) of women in our sample met the threshold for poor quality sleep, which means that despite significant challenges, most women maintain adequate sleep quality. While most studies in informal settlements focus on poor health outcomes and their contributing factors, emerging research highlights community resilience and strengths. For example, women in informal settlements often have widespread social networks, strong social ties and collective agency in addressing common problems [61]. These factors may serve as buffers against stress and should be explored further in future research to inform intervention strategies.

In addition to more research addressing structural issues, individual level interventions such as education on healthy sleep habits may also be beneficial. Several studies suggest that educational interventions focused on healthy sleep habits may enhance sleep quality and/or reduce insomnia [62, 63]. Our experience working with women in informal settlements and the dearth of research focused on sleep quality among women in these communities suggests that sleep is an under-discussed, under-considered, under-researched factor in women’s health. Raising awareness and education about sleep-promoting practices may improve sleep quality. At the very least, more awareness and education on sleep could reduce the risk of underreporting or misinterpreting the importance of sleep-related data.

More broadly, improving sleep quality among women in informal settlements may require increased access to services, especially healthcare, mental health, and sleep-specific services. There is limited access to healthcare services [9], especially mental health services, in informal settlements. Increasing access to healthcare for residents of these settlements, including specialized professionals, would enhance support for women with poor quality sleep and provide opportunities for more robust research into this critically important issue.

This initial study on sleep quality among women in rural Kenya highlights the scarcity of existing literature, the unique risk and protective factors they face, limited awareness of sleep hygiene and its health impacts, and challenges in accessing healthcare and resources. Investing in further research and comprehensive studies that help address the gaps in existing research will contribute to a better understanding of sleep quality and the development of targeted interventions to improve sleep quality and overall health among women in informal settlements.

Limitations

To our knowledge, this is the first study focused on sleep quality among women living in informal settlements; however, it was not without limitations. First, it is important to consider the potential for recall bias when reporting information about sleep. Recall bias refers to the potential for participants to inaccurately or incompletely remember events or experiences. This can lead to biased or unreliable data, as participants may have difficulty accurately recalling past events. Many studies use accelerometers, mobile phone sleep applications, or other methods of collecting more objective sleep data; however, as a preliminary study, we only collected self-reported sleep data. More research is needed to triangulate self-reported data with other methodologies of measuring sleep quality.Second, the nature of cross-sectional data does not allow for examining sleep patterns, quality of sleep, and sleep hindrances over time, which limits our ability to investigate causal pathways between various factors and sleep quality and to draw temporal conclusions associated with the significant relationships. Finally, we used the B-PSQI. Although this measure has been validated in other populations [38], it has not been widely validated in informal settlements or strictly among populations of women.