key: cord-0790583-fkn47wxl authors: Wright, L.; Steptoe, A.; Fancourt, D. title: Are adversities and worries during the COVID-19 pandemic related to sleep quality? Longitudinal analyses of 45,000 UK adults date: 2020-06-04 journal: nan DOI: 10.1101/2020.06.02.20120311 sha: f6eaecd699d62fefb0be0a731abbd679987e6188 doc_id: 790583 cord_uid: fkn47wxl There are concerns that both the experience of adversities during the COVID-19 pandemic and worries about experiencing adversities will have substantial and lasting effects on physical and mental health. One pathway through which both experience of and worries about adversity may impact health is through effects on sleep. Psychosocial stress can reduce sleep length and increase sleep disturbance, which can in turn reduce individuals ability to cope and respond to stressors, and worsen health outcomes. Therefore this study explored whether either worries about adversities during the pandemic or the experience of adversities were associated with impaired sleep. We used data from 45,109 adults in the COVID-19 Social Study assessed weekly from 01/04/2020-11/05/2020 in the UK during the pandemic. We studied six categories of adversity including both worries and experiences of: illness with COVID-19, financial difficulty, loss of paid work, difficulties acquiring medication, difficulties accessing food, and threats to personal safety. We used random-effect within-between models that automatically account for all time-invariant confounders. Both the total number of adversity experiences and total number of adversity worries were associated with lower quality sleep. Each additional experience was associated with a 1.17 (95% CI = 1.11, 1.24) times higher odds of poor quality sleep while each additional worry was associated with a 1.20 (95% CI = 1.17, 1.23) times higher odds of poor quality sleep. When considering specific experiences and worries, all worries and experiences were significantly related to poorer quality sleep except experiences relating to employment and finances. Having a larger social network offered some buffering effects on associations but there was limited further evidence of moderation by social or psychiatric factors. Results suggest that poor sleep may be a mechanism by which adversities are affecting mental health and highlight the importance of interventions that seek to reassure individuals and support adaptive coping strategies during the pandemic. The global pandemic of coronavirus disease 2019 (COVID-19) is leading to increasing experience of adversities. These adversities are both arising from the virus itself (i.e. infection, illness, and possibly death from the disease) and resulting from efforts to contain the disease, such as financial shocks following the loss of employment and income, challenges in accessing food, medication or accommodation, and adverse domestic experiences such as abuse [1] [2] [3] [4] [5] [6] [7] . Similar experiences have been reported in previous epidemics [8] [9] [10] [11] [12] [13] [14] [15] , but the scale of measures implemented and the long time-frames being projected for the COVID-19 pandemic are causing concern that we face manifold public health crises in the years to come 2, 16, 17 . In particular, there are concerns that adversity experiences will have substantial and lasting effects on physical and mental health 17, 18 . Studies suggest that intimate partner violence 19 and socio-economic adversities such as poverty 20 , job loss 21 , economic recession 22, 23 , and job insecurity 24 , have lasting impacts on mortality and physical and mental health outcomes. Further, it is not just the experience of these stressors, but also worries about the potential experience of these stressors that can affect mental health, increasing levels of stress and affecting depression and wellbeing 25, 26 , as well as affecting physical health such as cardiovascular outcomes 27 . One pathway through which both experience of and worries about adversity may impact health is through effects on sleep 28 . Studies have related adversity to psychosocial stress 29 , which is known to impair sleep [30] [31] [32] , while worrying has also been associated with shorter sleep length and greater sleep disturbance 33, 34 . Impaired sleep is in turn related to worsened health outcomes, such as cardiovascular disease, weight gain, and mortality 35, 36 . Further, inadequate sleep may reinforce the impact of adversity by reducing individual's ability to . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint respond effectively to stressors, leading to a maladaptive psychophysiological cycle [37] [38] [39] [40] . It is therefore essential to understand whether adversities experienced during the COVID-19 are leading to sleep problems. While adversity may be related to poorer sleep quality on average, there are several factors that could protect against such effects. First, social support may buffer against stress through the provision of informational or tangible assistance or emotional support 41 . A large body of literature shows that social support is associated with better sleep 42 and with improved physical and mental health outcomes, including lower mortality rates 43 . Further, improved sleep has been identified as a pathway through which social support may affect health 44 . However, decreased face-to-face contact and the increasing prevalence of adversity throughout populations may have reduced the availability and quality of social support during the pandemic 7 . Further, the novel nature of several adversities faced may have reduced the efficacy of informational or tangible assistance aspects of social support. Therefore, an unresolved question is whether social support buffers the association between adversity and sleep quality during lockdown. A second factor that may be important for the link between adversity and sleep is existing mental health. Studies show that individuals with pre-existing mental health issues may be disproportionately affected psychologically by stressful events. For example, anxiety and depression can predispose individuals (especially men) to greater stress reactivity 45 , while anxiety sensitivity can moderate the relationship between exposure to traumatic events and post-traumatic stress 46 . Further, in previous studies of epidemics, there has been some indication that pre-existing psychiatric conditions are a risk factor for poorer psychological outcomes 8 . However, when considering the link between psychological experiences and sleep, it is possible that individuals with existing mental health conditions may already have . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint poorer sleep, leading to a ceiling effect, such that adversity may not have any further material detrimental effect on sleep 37, 47, 48 . To explore these issues further, the present study used data from a large, longitudinal study of the experiences of adults during the early weeks of the lockdown due to COVID-19 in the UK to explore the time-varying longitudinal relationship between (i) worries about adversity, and (ii) experience of adversity and quality of sleep. Further, it sought to ascertain whether the relationship between adversity and sleep quality was moderated by social support and existing mental health diagnoses. We use data from the COVID-19 Social Study; a large panel study of the psychological and social experiences of over 50,000 adults (aged 18+) in the UK during the COVID-19 pandemic. The study commenced on 21 March 2020 and involves online weekly data collection from participants for the duration of the pandemic in the UK. Recruitment into the study is ongoing. The study is not random but does contain a well-stratified sample. Participants were recruited using three primary approaches. First, snowballing was used, including promoting the study through existing networks and mailing lists (including large databases of adults who had previously consented to be involved in health research across the UK), print and digital media coverage, and social media. Second, more targeted recruitment was undertaken focusing on (i) individuals from a low-income background, (ii) individuals with no or few educational qualifications, and (iii) individuals who were unemployed. Third, the study was promoted via partnerships with third sector organisations to vulnerable groups, including adults with pre-existing mental health conditions, older adults, carers, and people . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. Our questions asked about experiences of adversity in the last week, so we focused on data from 1st April 2020 (one week after lockdown commenced) to 11 th May 2020, limiting our analysis to participants who were interviewed on two or more occasions during this period (n = 47,482, observations = 196,902; 79.4% of individuals interviewed between 1 April -11 May). We used complete case data, excluding participants with complete data in fewer than two interviews (n = 2,373; 5% of eligible participants). This provided a final analytical sample of 45,109 participants (186,794 observations). We studied six categories of adversity: illness with COVID-19, financial difficulty, loss of paid work, difficulties acquiring medication, difficulties accessing food, and threats to personal safety. Adversity experiences were measured weekly as follows. Illness with COVID-19 was measured as suspected or diagnosed illness (including recovery). Personal safety was measured as reporting being physically harmed or psychologically harmed by someone else on at least one day over the past week. Financial problems were measured as experiencing a major cut in household income (in sensitivity analysis, we alternatively operationalised this as inability to pay household bills), while loss of paid employment was measured as reporting having lost a job or having been unable to do paid work. Inability to access sufficient food or required medication were measured using two self-report items. We constructed a weekly total adversity experiences measure by summing the number of adversities present in a given week (range 0-6). For adversities that are likely to be continuing (i.e. once experienced in one . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. week, their effects would likely last into future weeks), we counted them on subsequent waves after they had first occurred. This applied to experiencing suspected/diagnosed COVID-19, loss of paid work, major cut in household income, and abuse victimisation. Adversity worries were captured from two questions that asked participants to select which of a list of items had caused them (a) stress (however minor) in the past week, or (b) significant stress in the past week. Participants were prompted that "significant" stress could involve something being constantly on their mind or keeping them awake at night. We used the items "catching COVID-19", "your own safety/security", "finances", "losing your job/unemployment", "getting food, and "getting medication" as analogues to the adversity experiences described above. We constructed a weekly total worries measure by summing the number of items reported as worries in a given week (range 0-6). We considered each to be one-off events and counted them only in the weeks they were reported. Sleep quality was elicited using a single item on sleep over the past week (five categories: very good, good, average, not good, very poor), which we dichotomised into a binary variable for not good or poor vs average or better sleep. We measured social support at first interview using four separate variables for loneliness, perceived social support, social network size, and living alone. Loneliness was measured using the 3-item UCLA-3 loneliness, a short form of the Revised UCLA Loneliness Scale (UCLA-R). Each item is rated with a 3-point rating scale, ranging from "never" to "often", with higher scores indicating greater loneliness. We used the sum score measure (range 3-9). Perceived social support was measured using an adapted version of the six-item short form of Perceived Social Support Questionnaire (F-SozU K-6). Each item is rated on a 5-point scale . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint from "not true at all" to "very true", with higher scores indicating higher levels of perceived social support. We used the sum score measure (range . Minor adaptations were made to the language in the scale to make it relevant to experiences during COVID-19 (see Supplementary Table S1 for a comparison of changes). Social network size was measured as number of close friends, with numbers capped at 10+. We included this as a continuous variable. We defined psychiatric illness as reporting a clinically diagnosed mental health problem (depression, anxiety, or other mental health condition) at first interview. We used random-effect within-between (REWB) models 49 (also known as hybrid models 50 ) to explore the association between within-person change in adversity experiences and adversity worries and the likelihood of poor quality sleep 50 . Our basic model can be expressed as follows: is the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. We estimated several models. In Model 1, we regressed sleep quality on the total number of adversity experiences and total number of adversity worries, both (a) separately and (b) jointly, using the fixed effects estimator to account for time-invariant heterogeneity across participants. In Model 2, we regressed sleep quality on adversity experiences and adversity worries separately for each category of adversity in turn (finances, personal safety, etc.). In Model 3, we repeated Model 1a including interactions between adversity measures and each social support variable, for each social support variable in turn. In Model 4, we repeated Model 1a including interactions between adversity measures and baseline mental health. We adjusted for day of week (categorical) and days since lockdown commenced (continuous) in each regression (person-specific means and deviations from these means). To account for the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint non-random nature of the sample, all data were weighted to the proportions of gender, age, ethnicity, education and country of living obtained from the Office for National Statistics 51 . We carried out several sensitivity analyses to test the robustness of our results. First, we reestimated Model 3 using inability to pay bills, rather than major cut in household income, as our measure of experienced financial adversity. Second, we repeated each analysis using the sleep item as a continuous variable to test whether results were robust to variable measurement. For these regressions, we used the linear fixed effects estimator which controls for time-invariant confounding by design. Third, we repeated regressions using both the linear probability fixed effect estimator and the fixed effects logit estimators. We did not use the fixed effects logit estimator in the main analysis as the estimator uses information from those whose sleep quality changes only, which may bias results towards those whose sleep is most responsive to adversity. Fourth, we repeated our main REWB model for the subset of individuals whose sleep quality changed and compared results against those from the fixed effect logit estimator to assess the possibility of confounding due to time invariant heterogeneity in our main analysis. Analyses were carried out in Stata version 16.0 (Statacorp, Texas) and R version 3.6.3. Descriptive statistics are shown in Table 1 . There was within-variation in each of the measures, suggesting REWB was a valid approach. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. Both the total number of adversity experiences and total number of adversity worries were associated with lower quality sleep ( Figure 1 ). The inclusion of experiences and worries in the same model slightly reduced the effect size of experiences and had little effect on the effect size of worries. In models including both experiences and worries, each additional experience was associated with a 1.17 (95% CI = 1.11, 1.24) times higher odds of poor quality sleep while each additional worry was associated with a 1.20 (95% CI = 1.17, 1.23) times higher odds of poor quality sleep. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint worries were entered into separate models. "Experiences and worries" meant that experiences and worries were entered simultaneously into the same model, so were mutually adjusted for one another. Analyses were further adjusted for day of the week and time since lockdown began. When considering specific experiences and worries, worries were significantly related to poorer quality sleep in every category of adversity ( Figure 2 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. There was little clear evidence that social support moderated the relationship between sleep quality and adversity experiences (Figure 3 ; see Table S3 in the supplementary information for interaction term coefficients). For adversity worries (Figure 3) , there was evidence that the association between poor quality sleep and adversity worries was weaker among those . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. (Table S3) . There was also no evidence of differences in the relationship between worries and sleep quality in people with and without a diagnosed mental illness (Figure 4) . There was limited evidence of moderation by mental health for adversity experiences, with larger effects found among those with diagnosed psychiatric conditions (OR = 1.111 [0.991, 1.246]). . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint perceived social support at baseline interview. Estimates are from REWB models, with experiences and worries entered into separate models. Analyses were further adjusted for day of the week and time since lockdown began. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint The results from sensitivity analyses are displayed in the Supplementary Information. Point estimates suggest that inability to pay bills was more highly related to poor sleep quality than reporting a major cut in household income ( Figure S1 ). Results using the fixed effects linear probability estimator were qualitatively similar to those from REWB models (Figures S2-S5 ). An increase in adversity experiences or adversity worries was association with a ~2% point increase in the probability of poor sleep ( Figure S2 ). Results using the fixed effects logit estimator, which, as noted above, only uses data from those whose sleep quality changed, were also qualitatively similar to those from REWB models, but produced stronger effect sizes ( Figures S6-S9 ). An increase in adversity experiences or adversity worries was association with a ~ 4-5% point increase in the probability of poor sleep ( Figure S6 ). Moderation analyses produced similar effect sizes to those from REWB models (Figures S8-S9 and Table S3 ). When limiting analyses to individuals whose sleep quality changed, similar results were produced by the REWB and fixed effects logit estimators ( Figure S10 ), suggesting our main results are not biased due to time invariant heterogeneity. When analysing sleep quality as a continuous measure, the main findings were qualitatively also similar, with both experiences and worries related to poorer sleep ( Figure S11-14) . However, there was no clear evidence of a moderating role of social support in the association between adversities experiences or worries and sleep ( Figure S13 ). There was still a moderating role of mental health in the association between adversity experiences and sleep quality ( Figure S14 and Table S3 ). . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint In this study, we explored the relationship between worries and experience of adversities and quality of sleep during lockdown due to COVID-19. Cumulative number of worries and experience of adversities were both related to lower quality sleep. When considering specific types of adversities, all types of worries explored were associated with poorer sleep quality, while only specific experiences such as abuse, inabilities to pay bills, access food or medication, and catching COVID-19 were showed clear associations with poorer sleep. Effects sizes were small: additional adversity experience or worries were related to approximately a 2% point higher likelihood of poor quality sleep, on average. Having more close friends helped to moderate the relationship between worries and sleep but there was weaker evidence that other social factors had any clear protective buffering effects. This study supports findings from emerging research on COVID-19, which has suggested that sleep is being adversely affected amongst people in isolation 52 . The clear relationship between both specific and cumulative worries and poor sleep echoes findings about the adverse effects of stress on sleep from a number of previous studies [30] [31] [32] . However, it is notable that only specific experiences were related to poor sleep. These related specifically to difficulties in accessing food and medication, experience of abuse, and contracting COVID-19. In particular, experience of domestic violence has previously been well-researched in relation to sleep, with studies notably suggesting that fear of future abuse and nightmares can disrupt sleep 53 . There has also been increasing research focus on the neuropsychiatric effects of coronavirus infections, with suggestions that sleep disturbance can follow from infection 54 , which could explain the findings showing a relationship between having COVID-19 and impaired sleep. However, notably we didn't find a clear relationship between experiencing loss of work or cuts in household income and impaired sleep, although worry about these things was associated with poorer sleep. It is possible that consequences may take time to . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint arise. For instance, loss of paid work or cuts in income may impact sleep only following repeated rejections during job search or when reduced incomes begin to impact living standards 55, 56 . Financial adversities may also have been anticipated such that effects were felt in anticipation of the financial adversities, and high strain work may itself have adversely impacted sleep 32 . The effect of job loss on stress may also have been counterbalanced by increased leisure time 57 . Our results also found only limited evidence of buffering of these associations by social factors. Having more close friends appeared to buffer the association between stressors and sleep, which aligns with previous research on social support as a moderator of the relationship between occupational stress and sleep 58 This study has a number of strengths including its large, well-stratified sample, which was weighted to population proportions for core socio-demographic characteristics. Further, the study collected data covering the entire period from the start of lockdown in the UK on a weekly basis, providing an extremely rich dataset with longitudinal data. This data allowed us to estimate the relationship between adversity and change in sleep within individuals, rather than rely on cross-sectional variation, which would likely be confounded by time-invariant . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint heterogeneity across individuals. However, the study has several limitations. First, we are unable to confirm causality. Whilst is appears logical that poor sleep itself cannot cause adverse experiences, there is likely a bidirectional relationship between worries and poor sleep, and worries may pre-date experiences. But our analyses suggest that both worries and experiences are independently associated with poor sleep. Additionally, we used a single item five-category self-report measure of sleep quality, which may have lacked sufficient variation and validity to accurately estimate effects. However, single item sleep scales have been shown to possess favourable measurement characteristics to lengthier sleep questionnaires and are widely used in research 59 . It is possible that individuals experiencing worries or adversities may have perceived their sleep to be worse, but without substantial variation in the core qualitative parameters of sleep. Further, our sampling was not random. Although we deliberately sampled from groups such as individuals of low socio-economic position and individuals with existing mental illness, it is possible that more extreme experiences were not adequately captured in the study. It is also possible that individual experiencing particularly extreme situations during the lockdown withdrew from the study. While our statistical method means their data is still included, we would lack longitudinal follow-up on their changing experiences. Social support was measured at first interview, which for many was after lockdown began. Responses to these questions could have been affected by adversities experienced already. We also focused on just six types of adversities, including those relating to health, safety, finances and basic needs. However, many other types of adversity were not included in the study, including those relating to interpersonal relationships, displacement, and bereavement. Finally, our study only followed individuals up over a period of weeks. It remains for future studies to assess how experience of adversities during the COVID-19 pandemic relates to sleep -and to health -long-term. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint Results suggest that poor sleep may be a mechanism by which adversities are affecting mental health during the pandemic. Worries about adversities were related to poorer quality sleep over time during lockdown in the UK. Cumulative load of adverse experiences was also associated with poorer quality sleep, but only specific adversities such as those relating to personal safety, catching COVID-19, or challenges in accessing food and medication showed clear associations with poor sleep on their own. These results were relatively consistent amongst those with and without a diagnosed mental illness. Having a larger social network had some protective effects, but other social factors had more limited moderating effects on the relationship. These results suggest the importance of interventions that seek to reassure individuals and support adaptive coping strategies. Given the challenges in providing mental health support to individuals during the lockdown, these findings highlight the importance of developing online and remote interventions that could provide such support, both as COVID- is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2020. . https://doi.org/10.1101/2020.06.02.20120311 doi: medRxiv preprint