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Systematic Review

Addressing Sleep Health in Refugee Populations: A Systematic Review of Intervention Effectiveness and Cultural Adaptation

by
Jaclyn Kirsch
1,*,
Christine E. Spadola
1,
Kabir Parikh
1,
Kristen Kerr
1 and
Hrayr Attarian
2
1
School of Social Work, The University of Texas at Arlington, Arlington, TX 76019, USA
2
Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
*
Author to whom correspondence should be addressed.
Soc. Sci. 2025, 14(8), 485; https://doi.org/10.3390/socsci14080485
Submission received: 23 April 2025 / Revised: 26 July 2025 / Accepted: 2 August 2025 / Published: 7 August 2025
(This article belongs to the Section International Migration)
Browse Figure
Versions Notes

Abstract

Refugees experience disproportionately high rates of sleep disturbances due to trauma, displacement, and resettlement stressors. Sleep health is critically linked to both physical and mental well-being, yet remains an underexplored area of intervention for refugee populations. This systematic review aimed to (1) identify interventions implemented to improve sleep health among refugees, (2) assess their effectiveness, and (3) evaluate the extent of cultural adaptation in their design and implementation. A comprehensive search of peer-reviewed literature from 2004 to 2024 identified nine studies focused on adult refugees in high-income countries. Interventions included psychoeducation, music-assisted relaxation, guided imagery, and nightmare-focused therapies. Several demonstrated improvements in sleep quality, insomnia severity, and nightmare frequency. Music-based interventions and sleep health education stood out as accessible, non-stigmatizing strategies that may be particularly well suited to refugee contexts. However, cultural adaptation emerged as the most significant gap. Using the 4-Domain Cultural Adaptation Model (CAM4)—which assesses adaptation across context, content, delivery, and engagement—most studies showed only surface-level modifications. Few incorporated community voices, and none validated sleep assessment tools for cultural relevance. Future research should prioritize co-creation with refugee communities to ensure interventions are not only evidence-based, but also culturally grounded, trusted, and sustainable across diverse refugee populations.

1. Introduction

The connection between trauma and sleep disorders is well documented, with research indicating that traumatic experiences significantly contribute to sleep disturbances (Kajeepeta et al. 2015; Milanak et al. 2019; Slavish et al. 2022). Insufficient sleep not only affects immediate well-being but also has profound implications for both mental and physical health, impeding trauma recovery and hindering adaptation to new environments (Chattu et al. 2018). Refugees, defined by the United Nations High Commissioner for Refugees (UNHCR) as individuals forced to flee their country due to persecution, war, or violence, are a population that often experience significant trauma (Blackmore et al. 2020) and are particularly vulnerable to sleep-related health challenges. Refugees face compounded stressors that frequently manifest as sleep disturbances—an often underrecognized but prevalent health concern (Baskaran et al. 2023).
Refugees who are resettled in high-income countries frequently arrive with significant psychological trauma from conflict, persecution, or forced displacement (Porter and Haslam 2005). Many have fled ongoing or protracted crises in countries such as Syria, Afghanistan, Venezuela, Ukraine, and South Sudan, conflicts that continue to drive large-scale, often violent, displacement. As of the end of 2024, more than 11.5 million refugees were hosted by high-income nations, highlighting the global scale of this issue (UNHCR 2025). Yet resettlement does not mark the end of adversity. In host countries, refugees often face additional stressors including systemic discrimination, social exclusion, gender-based violence, and instances of police and institutional trauma, which further exacerbate their psychological distress and potentially disrupt sleep patterns (Salhi et al. 2021). The cumulative impact of these past and ongoing traumatic experiences has been shown to impact refugees’ sleep health, highlighting an urgent need to develop and implement interventions that recognize sleep as a vital component of comprehensive well-being and mental health.
Sleep disturbances among refugees, encompassing sleep disorders defined as problems with the quality, timing, and amount of sleep that impair daytime functioning (Thorpy 2020), are increasingly recognized as a critical public health issue (Baskaran et al. 2023; Richter et al. 2020). While insomnia affects approximately 11.3% of the general population (Aernout et al. 2021), rates among refugees are significantly higher, ranging from 32.6% to 73.3% (Baskaran et al. 2023). Studies from the United States and Australia underscore the widespread nature of these problems: in the United States, sleep disorders are the second most common neurological diagnosis among resettled refugees (Parvez et al. 2023), while a study in Australia found over 75% of refugees reported moderate to severe sleep disturbances (Lies et al. 2019). Although insomnia is the most frequently studied sleep condition, other sleep disorders such as sleep paralysis, the temporary inability to move or speak when falling asleep or waking, also show elevated prevalence; for example, 42% of Cambodian refugees reported experiencing at least one episode within a year (Hinton et al. 2005). Even long after resettlement, refugees continue to face high rates of insomnia, fatigue, and nocturnal post-trauma symptoms, including anxiety and distressing dreams (Bruck et al. 2021). These findings highlight the urgent need for targeted, culturally informed interventions to improve sleep health in refugee populations.
Sleep health is deeply intertwined with trauma, forming a bidirectional link with both mental and physical health outcomes. For refugee populations, trauma can simultaneously disrupt sleep and contribute to poor health more broadly. For example, among refugees in Sweden, researchers found a significant association between self-perceived health and sleep quality (Mangrio et al. 2020). Similarly, among Syrian female refugees in Jordan, a strong positive correlation was observed between fibromyalgia diagnoses and the severity of insomnia (Gammoh et al. 2020). Sleep disturbances have also been tied to mental health diagnoses; for instance, posttraumatic stress disorder (PTSD) and panic attacks significantly increase the likelihood of developing sleep disorders such as sleep paralysis (Hinton et al. 2005). In addition, poor sleep can exacerbate mental health symptoms and hinder trauma recovery. In a study of Syrian refugees in the United States, sleep disturbances were identified as the strongest predictor of PTSD symptomatology (Sankari et al. 2023). Although research remains limited, available studies suggest that improving sleep health can enhance refugees’ overall functioning and increase the effectiveness of PTSD treatments (Sandahl et al. 2021a). While these findings underscore the complex and reciprocal relationship between sleep and well-being among refugee populations, little is known about effective strategies for improving sleep health in these groups.

1.1. Cultural Adaptation in Refugee Interventions

Cultural adaptation has become a critical consideration in the development and implementation of behavioral health interventions, particularly for refugee populations whose sociocultural backgrounds, displacement histories, and patterns of help seeking often diverge from those of majority populations (McCleary and Horn 2024). This is especially relevant in the context of sleep health interventions, which are often rooted in Western biomedical models that may not align with culturally grounded understandings of distress, rest, or recovery (Jeon et al. 2021). Standardized approaches that emphasize individual symptom management may overlook the communal, spiritual, or structural interpretations of sleep disruption that many refugees hold. Research has shown that refugee youth, for example, often associate health with external conditions such as legal status, family unity, and safety rather than internal psychological symptoms (van der Meer et al. 2023). Middle Eastern refugee women tend to describe mental distress through somatic or spiritual frameworks, rarely naming it in Western clinical terms (Tahir et al. 2022), while Bhutanese refugees emphasize harmony within the family and community as central to mental well-being (Maleku et al. 2022). These cultural differences shape how refugees interpret symptoms, including sleep disturbances, seek help, and engage with interventions.
Addressing sleep health has been proposed as a culturally appropriate and non-stigmatizing entry point for screening and treatment of trauma-related symptoms, including posttraumatic stress disorder (PTSD), in refugee populations (Bruck et al. 2021). Unlike direct questioning about mental illness or trauma—which may be hindered by stigma, fear of institutional consequences, or differing cultural frameworks—conversations about sleep are often viewed as less threatening and more acceptable across cultures. Framing distress through sleep problems may thus allow providers to initiate therapeutic engagement and symptom screening without requiring immediate disclosure of trauma or psychiatric symptoms. This approach is especially important for refugee populations, where stigma around mental illness and unfamiliarity with Western diagnostic labels can deter help seeking and limit the effectiveness of conventional clinical intake processes.
Without intentional cultural adaptation, even well-established interventions risk being misunderstood or rejected. For instance, a study evaluating a digital sleep intervention for refugees in Germany found that participants were more likely to engage when the content reflected their lived experiences and avoided culturally incongruent assumptions (Blomenkamp et al. 2025). Similarly, refugee patients have reported that emotional safety and cultural understanding are essential for participating in health services, including mental health or sleep-related care (Radl-Karimi et al. 2022). These findings underscore the importance of integrating culturally informed design elements, such as language, narrative framing, and delivery format, into sleep health interventions.
Despite growing attention to cultural adaptation, multiple scoping reviews have noted that no single framework has been widely adopted as best practice in the literature (Leung et al. 2025; McCleary and Horn 2024; Thier et al. 2020). This lack of consensus, coupled with inconsistent documentation of adaptation processes, limits the ability to determine which strategies are most effective or appropriate. As McCleary and Horn (2024) point out, this gap is particularly evident in emerging intervention domains such as sleep health, where cultural considerations are often secondary or absent altogether. Given that sleep disturbances in refugee populations are shaped not only by trauma and displacement but also by cultural understandings of health, distress, and healing, the absence of culturally adapted approaches may significantly reduce the accessibility and impact of sleep-focused interventions.

1.2. The Current Study

While previous systematic reviews have highlighted the high prevalence of sleep issues among refugee populations (Baskaran et al. 2023; Richter et al. 2020), there remains a limited understanding of efficacious sleep health interventions and culturally informed best practices for addressing sleep health within this group. Sleep is closely tied to both physical and mental health, and this relationship is bidirectional—poor sleep can worsen trauma symptoms, while psychological distress can disrupt sleep quality (Slavish et al. 2022). Despite this, the evidence base on targeted interventions for improving sleep among refugees is sparse and fragmented, and there is even less known about whether these interventions are culturally adapted in ways that improve relevance and acceptability.
Given the emerging nature of this literature, often dispersed across disciplines and settings, a systematic review is the most appropriate methodological approach to rigorously and transparently identify, appraise, and synthesize the existing evidence. To our knowledge, no prior review has specifically examined both the types and effectiveness of sleep health interventions designed for refugee populations and the extent to which cultural adaptations have been incorporated. Understanding both what has been done and how culturally responsive these interventions are is critical for guiding future research and practice. As refugee populations continue to grow globally and more resettled individuals seek care in high-income countries, it is vital that interventions are not only evidence-based but also culturally meaningful.
This review is therefore guided by the following research questions: (1) What interventions have been implemented to promote sleep health among refugee populations? (2) What evidence exists regarding the effectiveness of these interventions on sleep-related outcomes? and (3) How have these interventions been culturally adapted to enhance their relevance and acceptability?

1.3. Theoretical Framework

To guide the analysis of cultural responsiveness in sleep health interventions, this review draws on two complementary frameworks. First, we adopt the widely cited definition of cultural adaptation by Bernal et al. (2009), which refers to the systematic modification of evidence-based interventions to ensure compatibility with the client’s cultural patterns, meanings, and values. This definition emphasizes the necessity for intentional, structured adjustments in content and delivery that accurately reflect the lived experiences of the target population. In the context of refugee populations, such modification goes beyond language translation or imagery—it involves deep structural alignment with sociocultural beliefs, family dynamics, and historical trauma.
Second, we apply the 4-Domain Cultural Adaptation Model (CAM4) developed by Sorenson and Harrell (2021), which offers a structured framework for evaluating cultural adaptation across four domains: (1) context, referring to broader sociopolitical and historical conditions; (2) content, including language, symbols, and metaphors; (3) delivery, which addresses the format, setting, and personnel involved in implementation; and (4) engagement, focused on trust building, relational dynamics, and participant empowerment. Together, Bernal’s definition and the CAM4 model enable a comprehensive and theoretically grounded assessment of whether and how existing sleep interventions for refugees are responsive to the cultural and contextual factors that shape their effectiveness.

2. Methods

2.1. Search Strategy

A comprehensive search was completed in February 2024 using the following databases: Academic Search Complete, PsycInfo, Global Health, Health Source, MEDLINE, Psychology and Behavioral Sciences Collection, and Social Work Abstracts. The search included the following terms, used in a variety of combinations: ((“sleep” or “insomnia” or “nightmares”) AND (“intervention” or “therapy” or “treatment”) AND (“refugee” or “asylum*” or “migrant*” or “displace*)).

2.2. Inclusion and Exclusion Criteria

Studies were included if they were peer-reviewed journal articles published between 2004 and 2024, written in English, and focused on adult refugees in high-income countries. Eligible studies needed to examine an intervention aimed at improving sleep health and to report empirical data. Studies were excluded if they were not published in a peer-reviewed journal, such as book chapters or dissertations, or if they fell outside the specified publication range. Articles written in a language other than English or those that focused on non-refugee populations, including voluntary migrants and non-immigrants, were also excluded. Additionally, studies that did not assess an intervention targeting sleep health, those evaluating solely pharmacological interventions, or those taking place in low- or middle-income were not considered. Low- and middle-income countries were excluded due to the vast differences in resources, needs, and circumstances between refugees in high-income and low- and middle-income settings, ensuring a more focused and contextually relevant synthesis of interventions applicable to high-income countries. Conceptual papers, program descriptions, and intervention study protocols without reported implementation results were also excluded. Given the inclusion of both qualitative and quantitative studies, a uniform risk of bias assessment using a single standardized tool was not feasible or appropriate.

2.3. Data Extraction

Two team members independently screened all articles using Covidence, a platform designed for systematic reviews. Screening was conducted in two stages: first by evaluating titles and abstracts, followed by a full-text review. Any disagreements were resolved through team discussions, ensuring consensus on final study inclusion. As illustrated in Figure 1; 1592 studies were initially imported for screening, with 74 removed as duplicates. Of the remaining studies, 42 were deemed eligible for full-text review, while 476 were excluded as irrelevant. After full-text assessment, nine studies met the inclusion criteria and were included in the final analysis.

3. Results

3.1. Study Characteristics

Table 1 summarizes the study and participant characteristics. The participants came from a wide range of countries of origin, reflecting the global diversity of refugee populations. Studies were conducted in various countries, including Denmark, the United States, Sweden, South Korea, and Germany. Most samples included both men and women, with interventions delivered primarily one-on-one, though some used group formats. Research designs varied, including quantitative, qualitative, and mixed methods approaches. Sleep outcomes measured included sleep quality, insomnia, nightmare severity, falling asleep, and fear of sleep. Studies also assessed non-sleep outcomes such as trauma symptoms, general well-being, social functioning, anxiety, depression, quality of life, and overall level of functioning.

3.2. Intervention Outcomes

Sleep Quality. Five studies assessed changes in overall sleep quality, primarily using the Pittsburgh Sleep Quality Index (PSQI), with two reporting significant improvements. In a non-controlled pilot study, Beck et al. (2018) implemented a trauma-focused Guided Imagery and Music (GIM) intervention with refugees diagnosed with posttraumatic stress disorder (PTSD). The participants showed a notable reduction in PSQI scores from pre-intervention (M = 16.1, SD = 3.7) to post-intervention (M = 10.9, SD = 5.4; p = 0.002), indicating an improvement in sleep quality. Similarly, Jespersen and Vuust (2012) evaluated the effects of listening to relaxing music through a pillow-embedded music player. In their two-group pre-test/post-test design, participants in the intervention group showed significant improvements in sleep (mean PSQI reduction of 3.3 points; p = 0.012), while no change was observed in the control group (p = 1.00). In contrast, Sandahl et al. (2021b) assessed sleep quality as part of a large randomized controlled trial (RCT) comparing Imagery Rehearsal Therapy (IRT) and pharmacological treatment to treatment as usual. They found no significant improvements in sleep quality across groups (PSQI: p = 0.97; DDNSI: p = 0.83). While Spanhel et al. (2022) also measured sleep quality using the PSQI, they focused primarily on feasibility and did not report statistically significant results.
Insomnia Severity. Three studies used the ISI to evaluate insomnia symptoms. Leiler et al. (2020) included a session on sleep hygiene and stimulus control within a six-session psychoeducational group mental health intervention. They found a significant reduction in insomnia symptoms, with Insomnia Severity Index (ISI) scores dropping from 16.0 (SD = 6.0) to 11.0 (SD = 5.0; p = 0.011). Spanhel et al. (2022) tested a culturally adapted online self-help intervention (eSano Sleep-e) and observed a modest decrease in ISI scores in the intervention group (mean reduction = 2.18), though this did not reach statistical significance (p = 0.09).
Nightmares and Sleep Disturbances. Two studies specifically targeted nightmares using Imagery Rehearsal Therapy (IRT), assessed with the Disturbing Dreams and Nightmare Severity Index (DDNSI). Sandahl et al. (2021b) did not find any significant differences in nightmare severity between groups following the intervention. Poschmann et al. (2021), using a smaller case series design, noted reductions in nightmare frequency and improvements in sleep quality and daytime functioning, though no formal statistical analysis was conducted due to the limited sample size (n = 5).
General Sleep Outcomes. Wagner et al. (2023) used both actigraphy and self-report to examine sleep parameters such as total sleep time, maintenance efficiency, and variability in sleep timing. Although their Eat, Walk, Sleep (EWS) intervention incorporated sleep education, no significant changes were found in sleep outcomes across groups. However, participants who reduced variability in sleep timing saw modest reductions in hemoglobin A1c (HbA1c), suggesting potential indirect benefits. Two qualitative studies also reported subjective improvements in sleep. Madsen et al. (2016) found that participants using Basic Body Awareness Therapy (BBAT) reported falling asleep more easily, though outcomes were based on anecdotal feedback. Zehetmair et al. (2020) explored the use of guided imagery via audio files and found that participants widely endorsed improved sleep and reduced arousal. The “Inner Safe Place” technique emerged as particularly helpful in managing bedtime anxiety.

3.3. Cultural Adaptation

To assess the cultural adaptation of interventions for refugees, we applied the CAM4 model developed by Sorenson and Harrell, which includes four domains: (1) Cultural Identity and Worldview, (2) Cultural Stressors and Protective Factors, (3) Culturally Congruent Engagement Strategies, and (4) Cultural Meaning of Health and Symptoms. Across the included studies, consideration of cultural factors varied substantially. While several interventions incorporated surface-level adaptations, few meaningfully addressed all four domains of the CAM4 model.
Cultural Identity and Worldview. This domain focuses on whether interventions are aligned with participants’ cultural beliefs, values, and traditions. Only Wagner et al. (2023) fully engaged with this domain by co-developing the EWS program with the Cambodian American community and embedding Buddhist health principles related to balance and well-being. Other interventions, such as Madsen et al. (2016), which employed BBAT, were designed with refugee populations in mind but did not incorporate specific cultural worldviews. The remaining interventions, including those by Beck et al. (2018) and Spanhel et al. (2022), were based on Euro-American clinical frameworks and did not clearly reflect the cultural identity of their target populations.
Cultural Stressors and Protective Factors. This domain evaluates whether interventions recognize the migration-related stressors and culturally grounded coping mechanisms affecting refugees. While most studies acknowledged the role of trauma in sleep disturbances, few explicitly incorporated cultural stressors or protective factors into intervention design. An exception is Spanhel et al. (2022), who conducted a systematic review and exploratory qualitative study to tailor content to refugees’ lived experiences, including chronic stress and disrupted routines. Zehetmair et al. (2020) designed guided imagery to foster psychological stabilization, aligning with participants’ coping needs. However, interventions rarely drew on culturally specific strengths, such as spirituality, family cohesion, or collective identity. This gap limits the ability of these interventions to resonate fully with the holistic experiences of displaced populations.
Culturally Congruent Engagement Strategies. Engagement strategies that reflect cultural norms and practices were inconsistently applied. Wagner et al. (2023) most clearly embodied this domain, using bilingual and bicultural community health educators from the target population to deliver the EWS intervention. Other studies engaged in more limited or one-time efforts. Leiler et al. (2020) involved interpreters who also served as cultural brokers during psychoeducational sessions and modified materials based on refugee feedback. Jespersen and Vuust (2012) pre-tested music selections with participants from diverse refugee backgrounds to ensure cultural acceptability. Several studies adapted visual materials (Beck et al. 2018; Leiler et al. 2020), modified session length (Poschmann et al. 2021), or expanded psychoeducation content (Poschmann et al. 2021), but most retained Western-led facilitation models. Facilitators across studies were primarily psychologists, graduate students, or therapists from outside the target communities who relied on interpreters or offered content in dominant host-country languages (e.g., Spanhel et al. 2022 required fluency in German or English). One study did not report how language needs were addressed (Jespersen and Vuust 2012), and only Wagner et al. (2023) used a facilitation approach grounded in community knowledge and relational trust.
Cultural Meaning of Health and Symptoms. This domain examines how health, sleep, and trauma symptoms are understood within the cultural context. Across studies, sleep disturbances were primarily framed within Western biomedical models. No study reported integrating local or cultural conceptualizations of distress, nor did any measure whether refugee participants viewed the interventions as relevant to their understanding of sleep problems. While many studies used translated versions of assessment tools (e.g., PSQI, ISI), none described community involvement in validating or modifying these tools for cultural relevance. Several studies employed trauma and mental health measures developed for refugee populations, including the Harvard Trauma Questionnaire (HTQ) and the Refugee Health Screener-15 (RHS-15; Beck et al. 2018; Leiler et al. 2020; Poschmann et al. 2021; Sandahl et al. 2021a; Spanhel et al. 2022). Two studies used the Hopkins Symptom Checklist-25 (HSCL-25; Poschmann et al. 2021; Sandahl et al. 2021b). However, all sleep-specific assessment tools were developed in Western contexts, and none were adapted to reflect cultural understandings of sleep or insomnia, underscoring a persistent gap in measurement.
Community Collaboration. In alignment with the CAM4 emphasis on participatory design, community collaboration was notably limited. Wagner et al.’s (2023) study was the only one to use a community-based participatory research (CBPR) model, involving Cambodian American stakeholders in all phases of development and implementation. Other studies demonstrated more modest forms of community engagement. Leiler et al. (2020) adapted intervention content based on participant feedback, and Spanhel et al. (2022) incorporated formative research with refugees to inform digital content. Jespersen and Vuust (2012) involved participants in pre-testing musical materials. However, most interventions were designed and implemented by academic or clinical teams without sustained input from refugee communities, limiting both cultural responsiveness and ecological validity.

4. Discussion

This review aimed to identify interventions designed to improve sleep health among refugees, assess their effectiveness, and evaluate the extent of cultural adaptation using the CAM4 framework. The findings reflect an emerging but limited body of work in this area, with several promising intervention approaches—particularly low-threshold options, such as music-assisted relaxation and psychoeducation—demonstrating potential to improve sleep-related outcomes in refugee populations.
In addressing the first objective, to identify interventions that have been implemented to promote sleep health among refugee populations, a range of interventions was identified, including guided imagery, music therapy, psychoeducational sessions, digital tools, and nightmare-focused therapies. These varied in structure and delivery format; yet most were grounded in behavioral or psychosocial approaches. Music-based interventions and sleep health education stood out as accessible, non-stigmatizing strategies that may be particularly well suited to refugee contexts (Beck et al. 2018; Jespersen and Vuust 2012; Leiler et al. 2020). Evidence outside of the final sample further suggests that trauma-focused therapies—such as narrative exposure therapy—can yield secondary improvements in sleep by reducing PTSD symptoms (Park et al. 2020). In addition, although not part of the reviewed studies, emerging literature highlights the importance of social and community support in mitigating insomnia symptoms among refugees (e.g., Singh et al. 2024), suggesting that future interventions may benefit from embedding individual strategies within broader relational contexts. This is consistent with prior findings showing that community support is significantly associated with better sleep quality and fewer trauma-related symptoms in refugee populations (Bruck et al. 2021).
Regarding the second objective, to assess the evidence on the effectiveness of these interventions on sleep-related outcomes, the findings were mixed and often modest. Only three studies demonstrated statistically significant improvements in sleep outcomes. Several others reported non-significant or qualitative improvements, while others showed no measurable change. The diversity of sleep domains measured—including sleep quality, insomnia severity, nightmares, and sleep timing—made it difficult to compare results across studies. Some formats, such as digital and self-guided interventions (Spanhel et al. 2022; Zehetmair et al. 2020), may reduce language or stigma barriers but appeared limited by low engagement or cultural misalignment. Ultimately, the effectiveness of intervention was difficult to interpret consistently, particularly due to limitations in outcome measurement.
The third objective—evaluating cultural adaptation—revealed the most consistent and significant gaps. Using the CAM4 framework, we found that most interventions relied on surface-level adaptations, such as translated materials or occasional use of interpreters. Deeper engagement across the domains of context, content, delivery, and engagement was rare. Only one study (Wagner et al. 2023) demonstrated comprehensive adaptation through community co-development, integration of cultural health concepts, and delivery by bilingual, culturally aligned facilitators. Most other interventions retained Western clinical frameworks and facilitators from outside the target communities. Few studies engaged in sustained trust building or participatory design, limiting both acceptability and ecological validity.
Perhaps most critically, none of the studies validated their sleep outcome measures within the refugee communities they served. Instruments such as the PSQI, ISI, and DDNSI were developed and normed in Western populations and, while they may have been validated in numerous languages, were used without adaptation. This presents a significant barrier to interpretation, as these tools may fail to capture culturally relevant experiences or expressions of sleep disturbances. Without validation in the target populations, it remains unclear whether observed changes—or lack thereof—reflect actual intervention effects or measurement misalignment. This issue is particularly consequential in studies focused on sleep, where subjective experience is central and deeply shaped by cultural norms (Jeon et al. 2021). The exclusive use of Western-derived clinical tools may also reinforce biomedical models of sleep and distress that are misaligned with how many refugee communities understand and discuss suffering (Maleku et al. 2022; Tahir et al. 2022).
Ultimately, the review highlights the significance of acknowledging heterogeneity within refugee populations. While this study focused on adults in high-income countries for methodological clarity, the included studies primarily involved refugees from the Middle East, Southeast Asia, and Africa. Notably, none included Latin American refugees—a particularly important gap given the growing number of forced migrants from this region. As migration histories, cultural frameworks, and systemic barriers differ across regions, findings from one group may not generalize to others. This highlights the need for future research to include diverse refugee populations and to tailor interventions accordingly. In addition, important logistical considerations such as gender or ethnic group matching were rarely addressed, despite evidence that culturally homogeneous groups can facilitate engagement, particularly for trauma-affected communities (Block et al. 2018; Philipps et al. 2022; Greenfield et al. 2013). Some studies noted the use of interpreters or translated materials, but details were often minimal, and several studies did not report language accommodations at all.
Participatory frameworks, such as CAM4, offer valuable guidance for designing and implementing culturally responsive interventions. The EWS intervention (Wagner et al. 2023) demonstrated that community-based participatory research can yield contextually grounded and culturally resonant interventions. Incorporating community voices enhances not only cultural fit but also relevance, trust, and sustainability (Dick 2017; Wong-Parodi 2022; Turin et al. 2021). Despite this, most studies in the review were developed and delivered by academic or clinical teams with minimal refugee engagement, limiting their cultural responsiveness and ecological validity.

4.1. Limitations

This review has several limitations that should be considered when interpreting the findings. First, the small number of eligible studies and substantial heterogeneity in intervention type, delivery format, and outcomes make it difficult to draw broad conclusions. Many studies lacked control groups, standardized outcome measures, or long-term follow-up, limiting assessments of effectiveness and sustainability. Second, most interventions targeted only a narrow set of sleep problems—primarily insomnia and nightmares—leaving other common sleep disorders unaddressed. Third, cultural adaptations were generally superficial, and no study validated sleep assessment tools within the populations studied. This represents a significant limitation, as using unadopted tools developed in Western contexts increases the likelihood of measurement bias and limits the interpretability of the findings. Fourth, the studies inconsistently reported the use of interpreters or language supports, and none addressed group composition considerations (e.g., gender or ethnic matching), which may have impacted engagement.

4.2. Conclusions

This review emphasizes the importance of future sleep interventions for refugee populations that are not only evidence-based but also culturally responsive and contextually grounded. While several interventions demonstrated promise and warrant additional research—particularly low-threshold interventions like music-assisted relaxation and sleep health psychoeducation—few addressed the structural and cultural barriers that shape sleep health for refugee populations. Interventions for refugee populations should incorporate community perspectives, align with cultural health frameworks, and ensure the validity of outcome measures. Future interventions and research should prioritize co-development with refugee communities, adopt structured frameworks like CAM4 to guide cultural adaptation, and validate assessment tools within the populations served. Scalable, low-barrier delivery models—particularly those that reduce language or stigma-related challenges—should be further explored. By embedding cultural and contextual relevance into intervention design, delivery, and evaluation, sleep health interventions can better support trauma recovery, promote health equity, and improve long-term outcomes for refugee populations.

Author Contributions

Conceptualization, J.K. and C.E.S.; methodology, J.K. and C.E.S.; software, J.K., K.P., K.K.; validation, J.K. and C.E.S.; writing—original draft preparation, J.K., C.E.S., K.P.; writing—review and editing, J.K., C.E.S., K.P., K.K., H.A.; visualization, J.K. supervision, J.K.; project administration, J.K. All authors have read and agreed to the published version of the manuscript.

Funding

No external funding.

Data Availability Statement

No new data were created or analyzed in this study.

Conflicts of Interest

All authors declare no conflicts of interest.

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Socsci 14 00485 g001
Figure 1. Identification of studies.
Figure 1. Identification of studies.
Socsci 14 00485 g001
Table 1. Study characteristics.
Table 1. Study characteristics.
Author (Year)Study CountryParticipant COO Sample SizeIntervention ModalityStudy DesignSleep OutcomeSleep Measure Non-Sleep Outcomes Non-Sleep Measures
Beck et al. (2018)DenmarkIraq (8), Afghanistan (3), Syria (4), Iran (1)16GIMNon-controlled pre-test/post-test pilotSleep qualityPSQITrauma symptoms, well-being, social function, and intervention satisfaction HTQ-IV, WHO-5, GAF-F
Jespersen and Vuust (2012)DenmarkIran (2), Sri Lanka (1), Afghanistan (3), Syria (3), Kosovo (1), Vietnam (2), Iraq (3) 15Music listeningTwo-group pre-test/post-test experimental designSleep qualityPSQITrauma symptoms and well-beingPTSD-8, HDYF
Leiler et al. (2020)SwedenMost from Afghanistan, several different countries in the Middle East25AMINTwo-group pre-test/post-test intervention trialInsomniaISIAnxiety, depression, PTSD, quality of life, and catastrophizing of symptoms RHS, WHOQOL-BREF, SCS
Madsen et al. (2016)DenmarkNot mentioned 3BBATPhenomenological Falling asleep/sleep qualityNANANA
Poschmann et al. (2021)DenmarkIraq (2), Iraq (Kurdistan) (2), Syria5IRTTwo-group pre-test/post-test interventionNightmares and sleep disturbancesDDNSI, PSQI PTSD, level of functioning, and quality of lifeHTQ-IV, HSCL-25
Sandahl et al. (2021b)DenmarkAfghanistan (26), Iran (73), Lebanon (15), Syria (58), Other (35)219IRTRCTSubjective sleep qualityPSQI, DDNSI PTSD, depression and anxiety, quality of life, and functional impairment, global functioning HTQ, HSCL, WHO-5, SDS, GAF-S, WHODAS 2.0, HAM-D, HAM-A
Spanhel et al. (2022)GermanySyria (39), Afghanistan (6), Turkey (3), United Arab Emirates (3), Iraq (2), Nigeria (2), Gambia (2), Sierra Leone (2), Lebanon (2), Iran, Eritrea, Somalia, Egypt, Sudan66eSano Sleep-eRandomized controlled pilot trialInsomnia severity, sleep quality, and fear of sleepISI, PSQI, FOSI-SFFatigue, depression, well-being, and mental health literacyMFI, PHQ-9, RHS-15, MHLQ
Wagner et al. (2023)United StatesCambodia188EWSRCTMean nighttime total sleep score, sleep maintenance efficiency, mean nighttime wake after sleep onset, SD of 24-h TST, and SD of sleep timingMeasured using actigraphy and subjectively with self-reportNutrition/food eaten, and physical activitySelf-reported food diary, actigraphy for physical activity
Zehetmair et al. (2020)GermanyMiddle East, Balkan Peninsula, North Africa, Sub-Sahara Africa42Guided Imagery QualitativeNANANANA
AMIN = Amir Intervention; BBAT = Basic Body Awareness Therapy; CBT = Cognitive Behavioral Therapy; CHE = Community Health Educator; COO = Country of Origin; DDNSI = Disturbing Dreams and Nightmare Severity Index; EWS = Eat, Walk, Sleep; FOSI-SF = Fear of Sleep Inventory–Short Form; GAF-F = Global Assessment of Functioning–Social Function; GAF-S = Global Assessment of Functioning–Symptoms; GIM = Guided Imagery and Music; HAM-D HAM-A = Hamilton Depression and Anxiety scales; HDYF = How Do You Feel; HSCL = Hopkins Symptom Checklist; HSC-25 = Hopkins Symptom Checklist-25; HTQ-IV = Harvard Trauma Questionnaire Part IV; IRT = Imagery Rehearsal Therapy; ISI = Insomnia Severity Index; NET = Narrative Exposure Therapy; MFI = Multidimensional Fatigue Inventory; MHLQ = Mental Health Literacy Questionnaire; PHQ-9 = Patient Health Quesionnaire-9; PSQI = Pittsburg Sleep Quality Index; PTSD = Posttraumatic Stress Disorder; PTSD-8 = Posttraumatic Stress Disorder-8; RHS = Refugee Health Screener; RHS-15 = Refugee Health Screener-15; SDQ = Strengths and Difficulties Questionnaire; SCS = Symptom Catastrophizing Scale; SDS =Sheehan Disability Scale; WHODAS 2.0 = World Health Organization Disability Assessment Schedule; WHOQOL-BREF = World Health Quality of Life–Brief Version; WHO-5 = World Health Organization Five Well-Being Index.
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MDPI and ACS Style

Kirsch, J.; Spadola, C.E.; Parikh, K.; Kerr, K.; Attarian, H. Addressing Sleep Health in Refugee Populations: A Systematic Review of Intervention Effectiveness and Cultural Adaptation. Soc. Sci. 2025, 14, 485. https://doi.org/10.3390/socsci14080485

AMA Style

Kirsch J, Spadola CE, Parikh K, Kerr K, Attarian H. Addressing Sleep Health in Refugee Populations: A Systematic Review of Intervention Effectiveness and Cultural Adaptation. Social Sciences. 2025; 14(8):485. https://doi.org/10.3390/socsci14080485

Chicago/Turabian Style

Kirsch, Jaclyn, Christine E. Spadola, Kabir Parikh, Kristen Kerr, and Hrayr Attarian. 2025. "Addressing Sleep Health in Refugee Populations: A Systematic Review of Intervention Effectiveness and Cultural Adaptation" Social Sciences 14, no. 8: 485. https://doi.org/10.3390/socsci14080485

APA Style

Kirsch, J., Spadola, C. E., Parikh, K., Kerr, K., & Attarian, H. (2025). Addressing Sleep Health in Refugee Populations: A Systematic Review of Intervention Effectiveness and Cultural Adaptation. Social Sciences, 14(8), 485. https://doi.org/10.3390/socsci14080485

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