key: cord-1047403-t8zb92dt authors: Lin, Yanmei; Liu, Shuai; Li, Shuangyan; Zuo, Heming; Zhang, Bin title: Relationships Between the Changes in Sleep Patterns and Sleep Quality among Chinese People During the 2019 Coronavirus Disease Outbreak date: 2021-01-18 journal: Sleep Med DOI: 10.1016/j.sleep.2021.01.021 sha: 43ce068464e9a775d521fba415e0770505f1438a doc_id: 1047403 cord_uid: t8zb92dt OBJECTIVE: Rapidly increasing numbers of confirmed cases and deaths during the 2019 coronavirus disease outbreak (COVID-19) resulted in widespread psychological problems in the Chinese population. The purpose of this study was to investigate the sleep quality and changes in sleep patterns before and during the outbreak in the general population in China and to determine factors related to sleep quality. METHODS: This cross-sectional study was conducted using an online questionnaire from 20 February to 29 February 2020 in China. Socio-demographic data, self-designed COVID-19-related characteristics, sleep patterns, and Pittsburgh Sleep Quality Index (PSQI) scores were obtained. Single factor analysis and multivariate binary logistic regression analysis were used. RESULTS: A total of 1,897 individuals were included in our study, and 30.0% of participants reported suffering poor sleep quality (PSQI≥8). Logistic regression analysis found that the factors related to sleep quality included poor physical health (OR=3.382, p<0.001), respiratory disease (OR=1.629, p=0.008), other diseases (OR=2.504, p=0.012), suspected case of COVID-19 in the same community (OR=1.928, p=0.002), confirmed case of COVID-19 in the same community (OR=2.183, p=0.007), worry about being infected (OR=2.336, p<0.001), ≥1 hour/day spent hearing COVID-19 information (OR=1.960, p<0.001), time difference in midpoint time in bed (OR=1.230, p<0.001), and time difference in time in bed (OR=0.711, p<0.001). CONCLUSIONS: Our study revealed that more than one-fourth of the participants suffered poor sleep quality during the COVID-19 outbreak. In addition to the poor health status and COVID-19-related anxiety, delayed sleep phase and reduced time in bed impacted sleep quality in the general population in China. In December 2019, an outbreak of coronavirus disease 2019 (COVID-19), initially reported in Wuhan, Hubei Province, China, rapidly spread throughout China and around the world [1] . As of 9 September 2020, COVID-19 affected more than 27.4 million individuals and led to nearly 895.0 thousand deaths [2] . Previous studies have shown that when an epidemic breaks out, it will cause both physical damage [3, 4] and psychological problems in the population [5] [6] [7] [8] . The severe acute respiratory syndrome (SARS) in 2003, which had 8,422 confirmed cases and resulted in 916 deaths worldwide [9] , placed great pressure on individuals resulting in sleep disturbances [10, 11] . Currently, the confirmed cases and deaths of COVID-19 which will continue grow are approximately 3,300 times and 1,000 times higher than those of SARS, respectively. With the high contagiousness of COVID-19 and the shortage of protective equipment resources, the public have been experiencing mental health problems [12] . Considering that the COVID-19 outbreak was stressful [13] , the Centers for Disease Control and Prevention predicted that the public may experience changes in sleep patterns and difficulty in falling asleep [14] . Moreover, aimed at controlling epidemic spread, the Chinese government encouraged the public to practice social distancing and stay at home as much as possible to prevent droplet transmission [15, 16] . One study during the COVID-19 pandemic reported a high mean score on the Pittsburgh Sleep Quality Index (PSQI) in individuals who self-isolated, indicating poor sleep quality [17] . However, J o u r n a l P r e -p r o o f only 170 subjects were recruited, and the subjects only isolated for 14 days in that study. In addition, people tend to relax during home quarantine and may have irregular biological rhythms and altered sleep patterns, similar to changes that occur on weekend days and long-term vacation [18] [19] [20] . However, most studies about sleep status during the COVID-19 outbreak have focused on healthcare workers [21, 22] , college students[23], or self-isolated people [17] , while few studies have focused on the public. To the best of our knowledge, no study has focused on changes in sleep patterns before and during the COVID-19 outbreak to identify sleep disturbances. In this account, we aimed to investigate the sleep patterns and their potential changes before and during the COVID-19 outbreak in the general population in China and to determine the relationship of sleep quality with socio-demographics, health conditions, COVID-19-related characteristics, and changes in sleep patterns. This study was completed anonymously by "Toutiao" (ByteDance Ltd, Beijing, China) users. The participants came from 31 provinces, autonomous regions, municipalities and Hong Kong and were more than 18 years old. The cross-sectional study designed by the Chinese Sleep Research Society (CSRS) was conducted with a questionnaire on the online platform "Toutiao" from 20 February to 29 February 2020. The study was approved by the research ethics committee, Nanfang Hospital, Southern Medical University. J o u r n a l P r e -p r o o f characteristics Socio-demographics, health conditions, and COVID-19-related characteristics from the participants included age, sex, education level (senior high school or below, college or university, or master or above), employment status (unemployed or employed), per capita household income (>10,000 RMB/month or ≤10,000 RMB/month), living in Hubei Province (no or yes), living arrangements (alone, with family, or with others), self-reported physical health (good or poor), history of illness (no disease, respiratory disease, cardiovascular disease, mental disease, or others), history of personal COVID-19 infection (no or yes), history of COVID-19 infection among friends and relatives (none, suspected case, or confirmed case), history of COVID-19 infection in the same community (none, suspected case, or confirmed case), worry about being infected (no or yes), and time spent hearing COVID-19 information (<1 hour/day or ≥1 hour/day). Sleep patterns including bedtime, rise time, time in bed (rise time -bedtime), and midpoint time in bed [(rise time + bedtime)/2] before and during the epidemic (with the line of demarcation on 20 January 2020) were required. The time difference values for bedtime, rise time, time in bed, and midpoint time in bed were obtained by subtracting time before the outbreak from time during the outbreak to determine changes in sleep patterns during the COVID-19 outbreak. PSQI [24] was used to assess sleep status not only because of its simplicity, high reliability, and validity but also because of its comprehensive evaluation of sleep status from several dimensions. The scale was comprised of 18 items containing seven dimension that included sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, sleep medications, and daytime dysfunction. Each dimension was scored between 0-3, with a total J o u r n a l P r e -p r o o f score ranging from 0-21. A total score ≥8 indicated a poor sleeper, while others were recognized as good sleepers. Data were reported as the mean ± standard (SD) for continuous variable and as numbers (percentages) for categorical variables. The between-group comparisons of socio-demographics, COVID-19-related characteristics, and sleep patterns were performed using the independent t test for data with normal distribution and Mann-Whitney U test for those without normal In this study, 1,897 (94.7%) valid profiles were collected from a total sample of 2,004 individuals surveyed. The research, including 1,069 males (56.4%) and 828 (43.6%) females, showed that the mean age of these participants was 36.6±11.5 years old. The sleep quality, measured by the PSQI scale, revealed a sample mean score of 6.09±2.90. A total of 569 (30.0%) participants were considered poor sleepers. The socio-demographics, health conditions, and COVID-19-related characteristics between poor and good sleepers are shown in Table 1 Post hoc analyses on multiple category data were performed by Bonferroni correction. *significant after Bonferroni correction by using the first category as a reference. Sex, other socio-demographics, health conditions, and COVID-19-related characteristics with statistical significance in univariate analysis as well as the time difference of midpoint time in bed and the time difference of time in bed were assessed as potential related factors of sleep quality by logistic regression. As shown in Table 3 The mean score of PSQI in our study (6.15±2.90) was higher than the national norms in China (3.88±2.52) [25] . During the COVID-19 outbreak, 30.0% of individuals suffered poor sleep quality. In line with our hypothesis, the prevalence of sleep disturbance was higher than that in previous studies on COVID-19 [26] , SARS [27] , the Wenchuan earthquake [28] , and the Ya′an earthquake [29] . These differences in sleep disturbances may be related to the survey time relative to the events, respondents, and the extreme stress that the COVID-19 outbreak exerted on individuals such as uncertainty regarding epidemic control and high contagiousness. In our study, the risk of poor sleep quality among participants with case of COVID-19 infection in their communities was higher than that of participants without a community case. Transmission of the COVID-19 virus can occur via respiratory droplets and contact routes [31] . Due to the high probability of close contact with individuals infected with COVID-19 in the same community, the public may be worried about infection through droplet transmission. In addition, sharing indoor environments in public places such as elevators and stairways also increases the risk of infection [32] . Additionally, people may not have access to enough face masks, alcohol, and other protective equipment as a result of the initial resource shortage [12] . The dearth of protective equipment makes it easier to become infected. It is believed that high risk of infection makes people anxious about personal and family health, which is highly correlated with poor sleep quality. Expectedly, we found that worry about being infected was positively associated with poor sleep quality. Up to now, no vaccine for the COVID-19 has been used to prevent infection. People with COVID-19 infection have a risk for developing serious symptoms and even death. Without a curative drug, people will be anxious about their health when infected. Anxiety activates the hypothalamus-pituitary-adrenal (HPA) axis [33] and hypersecretion of stress-related J o u r n a l P r e -p r o o f hormones, thereby reducing duration of deep sleep and precipitating sleep disturbances [34] . A study of insomnia of medical staff involved the COVID-19 outbreak found that worry about being infected was related to sleep disorder [21] , which was in line with our study. Individuals who spent more time focusing on COVID-19-related information seemed to have a higher risk for poor sleep quality. Outbreak information, especially information about the individuals' cities, obviously raised awareness of danger to the public. Long-term focus on the epidemic results in repeated and excessive outbreak-related media exposure which possibly increases levels of worry, anxiety, and stress [26, 35] . Additionally, some negative feeling, expressed by individuals on social media causes public anxiety because of the nature of emotional contagion [36] . What is more, spending too much time consuming COVID-19 information, especially before bedtime, may deprive sleep time and affect sleep quality [37] . Taken together, time spent hearing about COVID-19 outbreak was relevant to sleep quality. For self-reported physical health and illness history, it seemed that poorer physical health[20], having respiratory disease [38, 39] , and having other diseases [40, 41] were all risk factors for poor sleep quality. Mental illness was not a statistically significant risk factor for sleep disturbance, probably due to the small number of subjects with mental illness in this study. Patients with underlying health conditions such as chronic lung disease, chronic renal disease, and diabetes mellitus appear to be at higher risk for severe disease or death from COVID-19 [42, 43] . High risk for severe COVID-19-associated outcomes, which makes the pandemic a greater stressor for those with underlying health conditions, facilitated poor sleep quality. Thus, patients with underlying health conditions might reduce or not follow up on regular medical care in hospitals J o u r n a l P r e -p r o o f due to the risk of infection outdoors. Disruption of maintenance treatment exacerbated negative feelings [5] . Furthermore, the sleep of patients with underlying health conditions may be disrupted by the disease itself, for example, by the emergence of physical symptoms at night or in the early morning [39] . Based on this, patients with respiratory illness may even suffer from abnormal breathing patterns resulting in difficulty initiating or maintaining sleep, increase in light sleep, and reduction of rapid eye movement (REM) sleep and micro-arousal [38, 39] . Undoubtedly, individuals with poor physical health, especially those with chronic diseases, are more likely to have poor sleep quality. The results of this study showed that more delayed midpoint time in bed was positively associated with poor sleep quality. Considering that the sleep-wake cycle is primarily regulated by the circadian rhythm, the larger delay in sleep phase results in a desynchronization with the circadian rhythm, leading to sleep pathology [44, 45] . Additionally, as light is a social zeitgebers [44] , the individuals with late midpoint time in bed may receive more indoor light before sleep in addition to their disrupted circadian rhythms, including sleep-wake rhythm and melatonin rhythm [46] . Such changes in melatonin rhythm reduce sleepiness and increase arousal at night [47] . On the whole, greater delay of the midpoint time in bed was highly correlated with poor sleep quality. As far as we know, this was the first study to explore the relationships between poor sleep quality and changes in sleep patterns during the COVID-19 outbreak among the public in China. In summary, poor sleep quality was highly prevalent among the general population in China Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia Review of the Clinical Characteristics of Coronavirus Disease 2019 (COVID-19) Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study Progression of Mental Health Services during the COVID-19 Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: Mental health consequences and target populations Psychiatric and neuropsychiatric presentations coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. The lancet Psychiatry Online mental health services in China during the COVID-19 outbreak. The lancet Psychiatry COVID-19 and SARS: Differences and similarities. Dermatologic therapy Effects of a SARS prevention programme in Taiwan on nursing staff's anxiety, depression and sleep quality: a longitudinal survey Psychosocial impact of SARS. Emerging infectious diseases Mass masking in the COVID-19 epidemic: people need guidance European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in Wuhan, China COVID-19 Outbreak Associated with Air Conditioning in Restaurant Social Capital and Sleep Quality in Individuals Who Self-Isolated for 14 Days During the Coronavirus Disease 2019 (COVID-19) Outbreak in January 2020 in China. Medical science monitor : international medical journal of experimental and clinical research Sleep Hygiene Pattern and Behaviors and Related Factors among General Population in West Of Iran The Pittsburgh sleep quality index as a screening tool for sleep dysfunction in clinical and non-clinical samples: A systematic review and meta-analysis Reliability and validity of the Pittsburgh sleep quality index Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey Investigation of College Students to the Cognition and the Mental State of SARS Sleep problems among adolescent survivors following the 2008 Wenchuan earthquake in China: a cohort study An epidemiologic study of self-reported sleep problems in a large sample of adolescent earthquake survivors: The effects of age, gender, exposure, and psychopathology Dealing with sleep problems during home confinement due to the COVID-19 outbreak: Practical recommendations from a task force of the Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient Agarwood Essential Oil Ameliorates Restrain Stress-Induced Anxiety and Depression by Inhibiting HPA Axis Hyperactivity Interactions between sleep, stress, and metabolism: From physiological to pathological conditions Social Media Spread During Covid-19: The Pros and Cons of Likes and Shares Mental health problems and social media exposure during COVID-19 outbreak The associations of long-time mobile phone use with sleep disturbances and mental distress in technical college students: a prospective cohort study Sleep quality in chronic obstructive pulmonary disease A cross-sectional survey of night-time symptoms and impact of sleep disturbance on symptoms and health status in patients with COPD. International journal of chronic obstructive pulmonary disease Sleep quality and obesity in young subjects: a meta-analysis. Obesity reviews : an official journal of the International Association for the Study of Obesity Sleep and CKD in Chinese Adults: A Cross-Sectional Study Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 -United States Clinical Characteristics of Coronavirus Disease 2019 in China Circadian rhythm abnormalities. Continuum (Minneapolis, Minn) Circadian Rhythm and Sleep Disruption: Causes, Metabolic Consequences, and Countermeasures Early versus late bedtimes phase shift the human dim light melatonin rhythm despite a fixed morning lights on time The effectiveness of melatonin for promoting healthy sleep: a rapid evidence assessment of the literature None.