key: cord-0845352-ty6spr91 authors: Zhai, Xiaobing; Zhang, Yanan; Eshak, Ehab S; Zeng, Jing; Yang, Mei; Di, Lihua; Xiang, Bing; Cao, Jinhong title: The influencing factors of sleep quality among Chinese junior and senior high school adolescents during the COVID-19 pandemic date: 2021-07-30 journal: J Trop Pediatr DOI: 10.1093/tropej/fmab069 sha: e171b7e9f8a7aa1cf991947d28c142c3bfac2847 doc_id: 845352 cord_uid: ty6spr91 BACKGROUND: Since coronavirus disease 2019 (COVID-19) outbreak, its terrible infectiousness has caused great panic, anxiety and poor sleep quality to the vulnerable adolescent populations. METHODS: This cross-sectional online survey recruited 10,569 Chinese junior and senior high school adolescents during January 31 to February 9, 2020. Basic sociodemographic information, Pittsburgh Sleep Quality Index (PSQI), Self-rating Anxiety Scale (SAS), and Fear of negative evaluation (FNE) were included in the survey. Chi-square and logistic regression analyses were used to identify factors correlated with poor sleep quality. RESULTS: The prevalence of poor sleep quality was 18.6% in the Chinese adolescent population. The average score of PSQI was 3.39 (SD = 2.64), which was significantly correlated with scores for anxiety (r = 0.50, P < 0.01), and FNE (r = 0.36, P < 0.01). Adjusted logistic regression indicated that gender (females) and education (senior high school) were associated with poor sleep quality, while living in Hubei Province and time spent on the COVID-19 information were inversely associated with poor sleep quality. Having a family member or friend infected/suspected and spending time on electronics were associated with higher odds of having poor sleep quality. Adolescents with anxiety were 8-times, and those with FNE were 3-times more likely than ones without anxiety or FNE to have poor sleep quality. In addition, the number of meals, exercise time, and diet quality were also significantly associated with sleep quality. (P <0.05). CONCLUSIONS: Poor sleep quality was common during the COVID-19 pandemic in Chinese adolescents. Understanding several factors associated with the poor sleep quality will offer some important insights into determining potential interventions to improve sleep quality during the COVID-19 pandemic. Adolescence is a critical period of transition in the life span which is characterized by tremendous changes and growth [1] . Sleep is indispensable for the growth and development of adolescents and it is also necessary for maintaining their physical and psychological health [1] . According to the previous studies, prevalence of poor sleep quality in adolescents ranged from 3.4% to 40% in various countries [2, 3] . While, the prevalence of poor sleep quality in Chinese adolescent ranged from 3.4% to 25.7% [4, 5] before the COVID-19 pandemic. Compared to Chinese adolescents with good sleep quality, those with poor sleep quality were more likely to be girls, city residence, victims of bullying, with unstable personality, senior grades, with high academic pressure, lonely, anxious, and depressed [4, 5] . The sleep theme of adolescents with poor sleep includes difficulties falling asleep, restless sleep, mid-sleep awakening for several times, and waking up too early [1] [2] [3] [4] [5] . Adolescents, who are going through an immature psychological developing period, are easily affected by external adverse factors, especially the public health emergencies [6, 7] . The emergence of COVID-19 pandemic has exacerbated anxiety globally [7] . Recent studies have shown an increased prevalence of mental health disorders; such as anxiety, depression, and posttraumatic stress symptoms with the rapid spread of and lock down caused by COVID-19 [8] [9] [10] . Among the various emergency measures taken to limit the COVID-19 outbreak, the temporarily closure of schools and keeping the students at home, rendered life style changes such as stopping the usual daily activities and spending more time on electronics [11] . Such life style changes may bear risk to the adolescent physical and psychological health by hindering peer relationships and depriving opportunities for stress regulation [11] . However, since the morbidity and mortality of COVID-19 infection were lower in adolescents than in adults [12] , the previous studies primarily focused on the mental and sleep outcomes associated with COVID-19 among the adult population [13] , especially the health care medical staff [14] , with insufficient attention on the adolescents' sleep quality [6, 7] . Therefore, it is necessary to timely evaluate adolescents' sleep quality and the related factors induced by the pandemic. This study seeks to evaluate the prevalence and influencing factors of poor sleep quality among adolescents in junior and senior high schools during the COVID-19 pandemic, which could be helpful to screen the poor sleep quality among adolescents and explore potential interventions in the current or future pandemics. By the convenience sampling method, an online cross-sectional survey that recruited 10,569 participants from 32 provinces of China was conducted through the WenJuanxing platform, a large ecommerce and information service platform that provides online health products and services in China (https://www.wjx.cn/). The detailed geographic distribution of participants was shown in Fig. 1 . The inclusion criteria for this study were as follow: (a) Age between 12 and 20 years; (b) Adolescents in junior or senior high schools; (c) volunteered to participate in the survey. The online questionnaire was designed to collect basic sociodemographic information, Pittsburgh Sleep Quality Index (PSQI), Self-rating Anxiety Scale (SAS) and Fear of negative evaluation (FNE) questionnaire from January 31 to February 9, 2020. All adolescents provided informed consent. This study was conducted anonymously and approved by the Ethics Committee of School of Medicine, Wuhan University of Science and Technology. The sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) [15] . The PSQI scale is categorized into seven dimensions: (1) subjective sleep quality; (2) sleep latency; (3) sleep duration; (4) habitual sleep efficiency; (5) sleep disturbances; (6) use of sleeping medication; and (7) daytime dysfunction. Each dimension graded on an integer score from 0 to 3, and accordingly, the PSQI score ranged from 0 to 21. Higher scores represented poorer sleep quality, and a PSQI total score > 5 defined the poor sleep quality group [6, 7, 15] . The reliability and validity of the Chinese version of PSQI was verified in previous studies in China and the Cronbach's alpha for this scale was 0.842 [16] . The Self-rating Anxiety Scale (SAS) was wildly used to assess anxiety [17] . The SAS consists of 20 self-report items on anxiety and all items are rated on a 4-point Likert scale from 1 (never) to 4 (always). A standardized scoring algorithm was used to define symptoms of anxiety, and the total score ranged from 20 to 80. Higher scores indicated higher risk of anxiety. Anxiety symptoms were defined when the total SAS score was ≥ 50 [18] . The reliability and validity of the Chinese version of the SAS was verified and the correlation between test and retest within a two-week period was 0.85 [19] . The adolescents' levels of FNE were assessed by the Brief Fear of Negative Evaluation Scale [20] . The BFNE is a 12-item self-reported questionnaire that assesses fear and distress related to negative evaluation from others, including 8 obverse-scored items and 4 reverse-scored items. A 5-point Likert scale ranging from 1 (not at all a characteristic of me) to 5 (extremely a characteristic of me) was used to rate each item. High FNE was defined when the total BFNE score was >30 [21] . The BFNE demonstrated adequate internal consistency in the current sample, and the Cronbach's alpha coefficient of the total scale was 0.813. The Statistical Package of Social Science (SPSS 25.0) was used for data analyses. Continuous variables were presented as mean (standard deviations, SD) and categorical variables were presented as frequencies (percentages). For the purpose of our study, the number of confirmed COVID-19 cases in the adolescent's city was divided into none, ≤50, 51-100, and >100. Family members or friends infected/suspected were classified as none, confirmed, and suspected. The time spent using electronics every day (h/d) was classified into five groups: <1, 1-4, 5-8, 9-12, and >12. The time spent on COVID-19 information per day was grouped into <0.5, 0.5-1, and >1 h/d. The number of meals every day, self-reported diet quality, and exercise time every day were divided into three levels: decreasing, unchanged, and increasing. The Chisquare test was used to compare the distributions of the characteristic variables between adolescents in the good and poor sleep quality groups. According to the findings of the previous studies and the established associations between sleep quality and a wide range of the collected variables [1,2], univariate analyses were conducted to assess the associations between each of age, gender, education, being a single child, living in Hubei province, home quarantine, number of confirmed COVID-19 cases in the adolescents' city, having a family member or a friend infected/suspected, time spent on electronics per day, time spent on COVID-19 information per day, number of meals and exercise time, self-reported eating quality, anxiety level, and FNE with poor sleep quality in our sample. Variables that showed significant associations with poor sleep quality in the univariate analyses were tested in multivariable-adjusted logistic regression models. Moreover, we conducted a stratified analysis by the level of education (junior high school versus senior high school) to explore potential differences in the influence of factors associated with sleep quality during COVID-19 outbreak among younger and older adolescents. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were obtained from the logistic regression models. All statistical tests were 2-tailed and values of P < 0.05 were regarded as statistically significant. The socio-demographic characteristics of the recruited Chinese adolescents according to binary categories of the sleep quality are shown in Table 1 . None of the 10,569 recruited adolescents reported symptoms of COVID-19. The number of respondents in Hubei (the epidemic area) and other regions (including Guangdong, Guangxi, and other 29 regions) were 4402 (41.7) and 6167 (58.3%), respectively. The mean age of the recruited adolescents was 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 15.94 ±1.45, and 50.3% were males. During the COVID-19 pandemic, 18.6% of adolescents had a poor sleep quality (PSQI >5). There were significant differences in all the studied factors between adolescents with and without poor sleep quality (P < 0.05). The mean, standard deviation (SD) and Pearson correlation coefficients of the sleep qualityrelated variables are shown in Table 2 . The PSQI total score was significantly correlated with the scores for anxiety (r = 0.50, p < 0.01) and FNE (r = 0.36, p < 0.01). Sleep latency was the highest PSQI domain score, and the use of sleeping medication was the lowest PSQI domain score. The mean score of the PSQI was 3.39, and the detailed seven domains' scores of sleep quality divided by age and gender are reported in Fig. 2 and Fig. 3 . Adolescents aged 16 years or more reported worse sleep quality, except for the sleep efficiency, compared with adolescents under 16 years. Furthermore, about the gender difference on sleep quality, females reported better performance at sleep efficiency, but worse performance at sleep quality, sleep latency, sleep disturbance, daytime dysfunction and total PSQI scores than males. The independent factors of poor sleep quality were shown in Table 3 . During the COVID-19 pandemic, the univariate analyses showed that being a single child and being forced to home stay during the COVID-19 pandemic were not associated with the sleep quality. Whereas, older adolescents' age, female gender, senior high education, increasing number of COVID-19 cases in the city, having a suspected or infected family member of COVID-19, the increasing daily hours spent using electronics, having anxiety, and FNE were positively associated with poor sleep quality. On the other hand, living in Hubei province, the increasing daily hours spent following or searching for COVID-19 information, unchanged number of daily meals, unchanged or increased eating quality, and unchanged or increased daily exercise time were inversely associated with poor sleep quality. In the multivariable-adjusted models, being a female, as well as a senior school student, were both associated with higher risk of poor sleep quality 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 kept their diet quality unchanged and those who increased it, during the pandemic, had ORs (95 % CIs) for poor sleep quality = 0.541 (0.463-0.632) and 0.523 (0.401-0.682), respectively. In addition, the higher category of the dichotomized anxiety score (OR: 8.269, 95% CI: 6.883-9.935) and the FNE (OR: 2.834, 95% CI: 2.341-3.430) were significantly associated with of the odds of having poor sleep quality. Factors which associated with poor sleep quality among Chinese adolescents varied by the education level as shown in Table 4 . Among senior high school students, all the studied factors, except for the number of COVID-19 cases in the city, were associated with poor sleep quality. While among Junior high school students, the number of COVID-19 cases in the city besides female gender, suspected COVID-19 in family members or friends, and diet-related factors were associated with poor sleep quality. Anxiety and FNE were associated with poor sleep quality in both levels of education. The prevalence of poor sleep quality among Chinese adolescents in junior and senior high schools during the COVID-19 pandemic period was 18.6%, and the overall average score of PSQI was 3.39. Factors that were positively associated with poor sleep quality included older age, female gender, senior high education, having an infected/suspected family member or a friend, time spent using electronics every day, anxiety, and FNE; while living in Hubei province, time spent on COVID-19 information, improving diet, and increasing daily exercise time were inversely associated with poor sleep quality. Our findings provided a data support for an accurate understanding about the Chinese adolescents' sleep quality during COVID-19 outbreak. Females were more likely to have poor sleep quality than males during the COVID-19 outbreak, which was consistent with findings of an earlier study [22] . Anxiety and FNE scores were strongly correlated with scores of the seven dimensions of PSQI in our study (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction) indicating an association between sleep quality and mental health issues [2, 23] . Recent studies have suggested that the public level of anxietyrelated symptoms increased when a major infectious disease occurred such as in SARS [24] and COVID-19 [25] . As sleep quality is sensitive to psychological status, and with the prevalent symptoms of anxiety and depression during the COVID-19 pandemic [26] , many people had suffered from poor sleep quality [6, 7, 25] . The current study showed that adolescents in junior and senior high schools with anxiety and FNE had approximately 8 and 3 times, respectively poor sleep quality rate compared to those without anxiety and FNE (p <0.05). In addition, adolescents with a family member or a friend infected or suspected to be infected with COVID-19 were more likely to develop poor sleep quality. The presence of nearby infected relatives or friends could have led to experience more anxiety and negative emotions, which can affect the sleep quality of the young individuals of the family [25, 27] . The COVID-19 has disrupted the normal learning and living conditions of the adolescent students and affected their sleep quality. Due to the outbreak of COVID-19, a large number of students had to apply social distancing or forced to isolate at home. This has led to more spare time to use various electronic devices and to stay awake later than usual. Staying awake for late or midnight time could change the circadian rhythm and slow the homeostatic sleep drive accumulation, which may lead to the decline of sleep quality in those adolescents [28] . The average time spent focusing on the COVID-19 outbreak news was found inversely associated with poor sleep quality. This result may be explained by the fact that the time of monitoring COVID-19 news could have provided the adolescents by the necessary information; such as facts, inflection data, and government measures which could have reduced their fears and anxiety and led to the better quality of sleep [29] . It is somewhat surprising that adolescents living in Hubei province, where the first COVID-19 case was detected, showed a better sleep quality than adolescents in other provinces. This could be attributed to the adequate medical resources and online psychological counseling services provided by the Chinese government to the Hubei residents [30, 31] . The results of study showed an interesting phenomenon that adolescents were more likely to get a good sleep when their physical activity levels improved or did change during the pandemic. Therefore, we recommend governments to encourage young individuals to practice more indoor exercise during epidemics. In our study, more than 80% of adolescents have not changed the number of daily meals, or their diet quality. Adolescents who did not change their frequency of eating nor decreased the quality of their diet were more likely to get a good sleep. A growing body of evidence also supports the idea that properly controlled diets can have an impact on circadian rhythms and sleep [32, 33] . Age was positively associated with poor sleep quality in our sample of Chinese adolescents, which could be reflecting the effect of the stage of education. Of note, 20.3% of senior high school students, compared to 11.6% junior high school students, had a poor sleep quality during the COVID-19 pandemic. All the studied factors showed strong associations with poor sleep quality among senior rather than juniors high school students. Senior high school students have heavier academic burdens, and being not able to attend school regularly with the potentiality to face the university entrance exam during the COVID-19 outbreak may have resulted in more 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 anxiety and worries about their chances of getting into college, which could be triggers for decreased sleep quality [6, 7, 9, 11] . This cross-sectional study has provided a comprehensive insight into factors associated with sleep quality of junior and senior high school adolescents during the COVID-19 pandemic in China. We used validated scales to assess the dependent and independent variables under the study. Moreover, we provided stratified analyses by the education level to assess the potential impact of the stage of education on the adolescents' sleep pattern response to varied factors during the COVID-19 pandemic. The study limitations include the difficulty to deduce causal associations between the outcome and exposure variables because of the cross-sectional nature of this study. However, some factors such as anxiety, FNE, and increasing time spent using electronics showed consistent strong associations in the adjusted and stratified models which suggest a potential cause-effect association. To further explore the temporal relationship between the outcome and exposure variables, we are considering to conduct a case-control study whenever the data are available. Second, the prevalence of poor sleep quality may be over-or under-estimated, and the indicated levels of sleep quality may not always be consistent with the evaluations of mental health professionals, since the study was conducted by self-reports from only one source. Third, due to the impact of COVID-19 pandemic, we conducted the survey of this study by online questionnaire rather than face-to-face investigation, which may bear certain deviation in the response population, especially with the use of convenience sampling. This was obvious for the differences in the age strata proportions; adolescents aged ≥16 accounted for a relatively large proportion, and age matching should be carried out in future studies. Therefore, the findings of the study should be cautiously applied to sleep problems among national adolescents. During the COVID-19 pandemic, poor sleep quality was prevalent in junior and senior high school adolescents in China. A variety of demographic and geopolitical factors detected to influence the adolescents' sleep quality. Sleep support is important for managing the COVID-19 emergency and improving sleep quality, and even is helpful to protect the adolescents' physical health. Therefore, more attention should be paid to sleep quality among adolescents and be ensured that they get enough rest and sleep time. 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