|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2021 | Volume
: 6
| Issue : 2 | Page : 63-69 |
|
Assessing sleep hygiene among Saudi community during COVID-19 pandemic
Hasan Saeed Alamri
Department of Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
| Date of Submission | 23-Jun-2021 |
| Date of Acceptance | 13-Aug-2021 |
| Date of Web Publication | 12-Jan-2022 |
Correspondence Address:
Hasan Saeed Alamri
4742 Morooj District, Abha 62527
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/KKUJHS.KKUJHS_27_21
Introduction: The mental health of the general public is significantly affected due to the COVID-19 pandemic. The present study aims to evaluate sleep hygiene during the COVID-19 pandemic among the general Saudi population. Subjects and Methods: A descriptive cross-sectional design was adopted to fulfil the study aim, and an electronic structured questionnaire was used to collect data from the participants. Pittsburgh Sleep Quality Index (PSQI), a self-rated questionnaire, was used to assess sleep hygiene over a month, including the quality of sleep and sleep disturbances. A total of 1597 participants completed the survey, among which 871 (54.5%) were males. The age of participants ranged between 18 and 75 years. Results: The results showed that >30 min was required for 28.5% of the participants to fall asleep since last month. The sleep efficacy was <75% among 17.9% of the study participants, and 17.9% sleep for <7 h at night. The total PSQI score ranged from 0 to 20 points with a mean score of 5.8 ± 3.4. Nearly one out of each four participants had poor sleep quality, and about one out of each five participants had to take medication to fall asleep. Conclusion: Therefore, it is concluded that changes associated with lifestyle change COVID-19 pandemic and lockdown inversely affected public mental health and sleep hygiene.
Keywords: COVID-19, pandemic, Saudi community, sleep hygiene, stress
How to cite this article:
Alamri HS. Assessing sleep hygiene among Saudi community during COVID-19 pandemic. King Khalid Univ J Health Sci 2021;6:63-9 |
| Introduction | |  |
COVID-19 influences the physical health and welfare of infected persons while noninfected persons' psychological status was hampered adversely.[1] Countries and territories around the world have imposed varying strict lockdowns, and the majority have been forced to work from home. Previous studies have shown that sleep patterns, stress, and induced anxiety were affected too in this pandemic.[2],[3],[4] According to Ahmed et al.,[5] almost 33.8% of the Saudi adults were sleeping fewer than 7 h. Similarly, sleep deprivation was commonly reported among 41.5% of Saudi residents. Furthermore, physical activity and daylight exposure, which are necessary for proper sleep, were adversely affected due to the implementation of quarantine measures.
Interacting in satisfying routine activities becomes multifaceted due to social isolation. Sleep assists in adequate functioning of the immune system along with promoting tissue repair, improving cell regeneration, improving memory, and reducing blood pressure. As per Altena et al.,[6] such modifications deteriorate nighttime sleep and elevate the risk of mental health issues. Indeed, receiving an adequate amount of sleep will result in resisting illness and injury, increasing immunity, and reducing infection risk against COVID-19.[7] On the contrary, numerous unhealthy effects, including lack of energy, unstable blood pressure, an attenuated immune system, sleepiness, mood swings, and complexity dealing with change, were driven through sleep deprivation.[8] Similarly, changes in sleep patterns lead to symptoms of sleep disorders, rousing several times at night, and not feeling rested even after the night's sleep.
Sleep quality is classified as objective and subjective; for instance, overall quality sleep is subjective sleep quality, whereas the total duration and frequency of awakening result from objective sleep quality during the night.[9] The rapid spread of COVID-19 infection resulted in individuals feeling nervous, worried, and afraid in some geographical regions. Sleep quality can be affected by modifications in routine activities due to the mandated lockdown, even in areas where the infection was well controlled. The psychophysiological well-being of the population must be investigated considering that the pandemic was not short lived, and its result might influence the community for a long-time period.
Psychological distress was further triggered due to the unprecedented risk of mortality and morbidities. Due to the COVID-19, moderate or severe psychological distress was reported by Alkhamees et al.[10] among one-fourth of the Saudi residents, with an equivalent proportion suffering from depression and anxiety. Instant behavioral changes obliging individuals are of great significance to report the change in behavior and habits, including sleep hygiene, because pandemics such as COVID-19 come unexpectedly. Therefore, the current study aims to assess the sleep pattern of the Saudi community and its consequences after enforcing the lockdown policies and direct public health to increase the focus on healthier and safer life options, especially during quarantine in pandemics. Based on the author's knowledge, it is the first large-scale study covering this issue in Saudi Arabia during the pandemic.
| Subjects and Methods | | |
The study adopted a descriptive cross-sectional design and recruited general public in Saudi Arabia aged >18 years. The study was conducted during June and September 2020. The prestructured questionnaire was used to collect data distributed electronically to the participants using different social media platforms. Literature was extensively reviewed for constructing the survey tool, along with getting consultation from the experts. Five experts were consulted for checking the social acceptability and content validity of the survey tool.
The survey tool helped gather sociodemographic details of the participants that included gender, age, education, residence, medical history, and different practices associated with COVID-19 pandemics such as contact with COVID-19 patients, quarantine, and traveling.
A self-rated questionnaire named Pittsburgh Sleep Quality Index (PSQI) was used for assessing quality and disturbances in sleep patterns of the general public during the last month.[11] Seven component scores were generated from 19 individual items; subjective sleep quality, sleep duration, sleep disturbances, daytime dysfunction, sleep latency, habitual sleep efficiency, and prescribed sleep drugs. Seven component scores are derived in PSQI, ranging from no difficulty (score 0) to severe problem (score 3). One global score is yielded by adding scores of all these seven components. The global score is added to generate a component score that ranges between 0 and 21. The total score was categorized at cutoff point 7 as those who had a global score of 7 points or less were considered to have good sleep quality, while others with a global score of more than 7 points were supposed to have moderate to bad sleep quality.
The tool was translated into Arabic and validated based on the guidelines for translating and validating a questionnaire.[12],[13] Forward translation was done by two bilingual persons from English to Arabic independently (first two authors). Then, the two versions were reviewed, and any discrepancy between the translators was resolved by consensus. Another two translators back-translated the initial translation. An expert panel of five bilingual experts, including the original translators and the principal investigator, reviewed all versions of the tool, including the original English version, translations, and back translation till the final Arabic-translated version was established. Preliminary pilot testing for the translated tool was done in the Department of Family and Community Medicine, College of Medicine, King Khalid University, through exposing both English and Arabic versions to be answered by 15 bilingual staff. Data were collected and analyzed to test for linguistic and psychometric validity of the translated tool through correlating the data for the original and translated tool. After that, a pilot panel of 30 primary health care centers (PHCCs) visitors were invited to participate in the tool validation; however, their data was not included in the study's final sample. The correlation between each item score and the total score was examined by testing the convergent validity of the translated tool. Discriminant validity was tested by comparing the first quartile average score with the third quartile average score using an independent sample t-test.[14]
A pilot study was done to check the reliability of the survey tool. A total of 35 participants were included in the pilot study, and the reliability coefficient (Cronbach's alpha) came out to be 0.71, which is acceptable.[15]
The data were revised, coded, and entered into the Statistical Package for Social Sciences (SPSS) Statistics version 22 (IBM Corp., Armonk, NY, USA). Two-tailed tests were used to conduct all the statistical analysis at the statistically significant value of <0.05. All the variables such as demographics, medical condition, and increased risk of COVID-19 were evaluated through descriptive analysis (frequencies and percentages). The distribution of sleep quality based on the personal data and other related data was assessed through cross-tabulation. However, Pearson Chi-square test was used to determine the significant associations revealed in the cross-tabulation. At last, a multiple stepwise logistic regression model evaluated the adjusted relation between participants' data and their sleep quality.
Following the Declaration of Helsinki, the study was conducted, and the Ethics and Research Committee of the College of Medicine of King Khalid University approved the protocol. Approval number was ECM#2020-237-HAPO-06-B-001.
| Results | | |
The survey was completed by 1597 participants, among which 871 participants (54.5%) were males. All participants were between 18 and 75 years old (mean age = 36.6 ± 10.8 years). [Table 1] shows the sociodemographic details of all the participants. One thousand five hundred and thirty-five participants (96.1%) were Saudi nationals, regarding educational level, 1307 participants (81.8%) were university graduated, and 783 (49%) worked in the governmental sector. One hundred and eighty-eight participants (11.8%) are employees in the private sector and 542 (33.9%) in the healthcare sector. Monthly income exceeded 10,000 SR among 54.5% of the survey respondents. The exact 69.1% of the respondents were married, and 547 (46.6%) had 3–5 children. Moreover, 9.6% of the married participants were childless. Among females, 34 (6.7%) were pregnant. As for smoking, 1114 (69.8%) never smoked, while 283 (17.7%) were smokers.
The risk of COVID-19 exposure among the participants is presented in [Table 2]. It shows that 118 of the participants (7.4%) were abroad during the last period, 38 (2.4%) had previously quarantined, and 35 (2.2%) had contacts with COVID-19 patients. Most of the participants (73.4%) with chronic health problems were healthy. The prevailing health conditions among the participants include asthma (7.5%), diabetes mellitus (7.1%), hypertension (5.8%), and immunosuppressive disorders (2.1%). | Table 2: Risk of coronavirus disease 2019 exposure among the participants
Click here to view |
[Table 3] and [Table 4] illustrate sleep quality among the public during the COVID-19 pandemic. In the past month, 28.5% of the participants needed >30 min to fall asleep each night. Sleep efficacy was <75% among 17.9% of the study participants, and 17.9% of the participants slept for <7 h at night. Four hundred and thirteen participants (25.9%) of the respondents could not rest within 30 min, while 28.4% of them get up either in the middle of the night or early morning. Moreover, 5.1% of the participants complained about breathing >3 times a week, and 23.3% used to wake up to use the bathroom three or more times a week. Regarding bad dreams, 104 of the participants (6.5%) reported experiencing three or more times a week, and 116 (7.3%) complained of pain three or more times a week. Ninety-one participants (5.7%) took medicine to help them sleep three or more times a week, and 19% had any trouble waking during driving. Generally, 287 (18%) respondents ranked their sleep quality as bad during the last month. The overall PSQI score ranged from 0 to 20 points with a mean score of 5.8 ± 3.4. 428 (26.8%) participants had scored more than 7 points, which indicated terrible sleep quality. | Table 3: Sleep quality among the public during coronavirus disease 2019 in Saudi Arabia, 2020
Click here to view |
 | Table 4: Sleep quality among the public during coronavirus disease 2019 in Saudi Arabia, 2020, continued
Click here to view |
[Table 5] shows an assessment of the distribution of sleep quality according to the participants' data. Nearly 29% of female participants had a bad PSQI score (>7 points) compared to 24.6% of males (P = 0.027). Furthermore, a bad PSQI score was detected among 29.8% of young, aged participants (<35 years) in comparison to 23.8% of the participants aged 35 years or more (P = 0.008). Regarding nationality, 38.7% of non-Saudi respondents had poor PSQI scores compared to 26.3% of Saudis (P = .031). University-graduated respondents had a higher rate of bad PSQI score than those below the secondary education level (28.3% vs. 18.5%; P = 0.015). Furthermore, 31.9% of the participants who were healthcare practitioners had a bad PSQI score, in comparison to 24.2% of others (P = 0.001). Married participants had less bad PSQI scores than others (24.6%), and 37.1% of current smokers had bad PSQI scores compared to 24.4% of nonsmokers (P = 0.001). Further, participants with chronic health problems reported higher PSQI scores than others who were healthy (33.9% vs. 24.2%, respectively; P = 0.001). 54.3% of the participants who had contact with COVID-19 patients had a lousy PSQI score compared to 26.2% of the participants with no contact with COVID-19 patients (P = 0.001). | Table 5: Sleep quality according to participant's personal data during coronavirus disease-2019, Saudi Arabia
Click here to view |
[Table 6] illustrates logistic regression model results. Among all included predictors for sleep quality, female gender, healthcare practitioner, smoking, chronic health problem, and contact with the COVID-19 case were the most significant predictors for bad sleep quality. Non-Saudi nationality was associated with a 2.3 times likelihood for bad sleep quality (odds ratio [OR] =2.3; 95% confidence interval [CI]: 1.26–4.20). At the same time, contact with the COVID-19 case was associated with tripled likelihood for bad sleep quality (OR = 3.1; 95% CI: 1.35–7.17). | Table 6: Multiple stepwise logistic regression model for determinates of sleep quality among the public during coronavirus disease 2019 pandemic in Saudi Arabia, 2020
Click here to view |
| Discussion | | |
The entire world experienced great stress of severe acute respiratory syndrome coronavirus 2 pandemic by the end of 2019, initiated in Wuhan, China. World Health Organization later renamed it COVID-19.[16] This outbreak was declared as the Public Health Emergency of International Concern in January 2020 and later pandemic in March 2020 by the World Health Organization.[17],[18]
The World Health Organization has advised people to adhere to several preventive measures to reduce the spread of infection, for example, hand washing and physical distancing to reduce close contact between individuals. Physical distancing included restrictions on traveling, quarantines, avoid gatherings, and closure of schools/universities.[19],[20],[21] The lifestyle of the general public was significantly affected amid these measures as it obligated them to modify their daily activities, living conditions, and sleep hygiene to cope with new procedures. The general public became more aware regarding personal hygiene, healthcare, and healthy lifestyle, including healthy food and behavior.[22] As the result of limited daily shopping in quarantine, a significant change in dietary habits of the individuals, such as intake of processed food (unhealthy diet), increased with lack of fresh fruits (vegetables and fruits). There is a significant association between disturbed sleep and obesity with an unhealthy diet.[23] Moreover, restless sleep is also associated with an unhealthy diet that includes low fiber and high fat intake.[24],[25]
The researchers worldwide recorded changes in public lifestyle, behavior, and ordinary daily life activities, due to the sudden hit of the COVID-19 pandemic to the whole world with the associated lockdown either partially or even totally for an extended period.[26],[27],[28] These factors were primarily due to stress and psychological drawbacks of lockdown, due to economic and social disturbances. These findings directly and indirectly affected public sleep hygiene. The current study evaluated sleep hygiene among the Saudi population due to quarantine during the COVID-19 pandemic. The results revealed that sleep quality was not markedly affected as nearly one-quarter of the study participants had bad PSQI scores. Almost three-quarters of the participants reported that their sleep quality exceeded 85%, and they fall asleep within 30 min each night. Furthermore, less than half of the study participants had terrible dreams, and only one-quarter had reasons disturbing their sleep. Taking medication to fall asleep was reported among nearly one-fifth of the participants. However, more than half of them reported having problems maintaining enough enthusiasm to complete assigned tasks but primarily unrelated to the COVID-19 pandemic. Overall, most participants (80%) said that their sleep quality was either good or very good.
Based on the literature review, the assessment of sleep hygiene and quality for the time of the COVID-19 pandemic has shown highly variable findings. Each study evaluated the problem from different sides relating sleep quality with stress, anxiety, or even social deprivation. In addition, variability in the tools used may be secondary factors explaining this verity in the estimated problem magnitude. Targa et al.[29] showed that the COVID-19 pandemic was associated with lower sleep quality. PSQI score calculated during the COVID-19 outbreak was 5.45 ± 3.14, which is concordant with the current study findings. Another study by Cellini et al.[30] assessed 1310 Italian residents and stated a poor sleep quality among them because of the COVID-19 outbreak. The disturbed sleep quality was associated with an increase in depressive stress symptoms. These results were consistent with another study reporting decrease in sleep quality among quarantined individuals in China.[31] Decreased sleep quality among these individuals has been associated with stress and anxiety. The increasing prevalence of sleep disorders was also evaluated by Yu et al.;[32] it was found that most participants experienced a decrease in sleep quality (38.3%), difficulty in falling asleep (29.8%), and shortened duration of sleep (29.1%). The participants in this study also reported increased prevalence (29.9%) of insomnia. There was a significant link of insufficient masks' stock with poor sleep quality, difficulty falling asleep, and shortened sleep duration. These findings show higher values than the current study; however, China was the initial of the pandemic with no clear information and high mortality rate than what was reported in the Saudi community, which justified the higher rates of poor sleep quality and stress.
By concerning factors affecting sleep quality, the current study showed that females had nearly doubled the risk for poor sleep hygiene than males. This is consistent with female worry nature as they are mostly more liable for stress and depression, affecting their sleep quality.[33],[34],[35] Other factors associated with poor sleep quality were considered modifiable factors associated with higher exposure or higher risk of catching the infection. These factors were healthcare workers, smokers, having a chronic health problem, or contact for confirmed COVID-19 case. These findings and identified risk factors were evidenced by other researchers on literature with more factors identified such as age, outdoor travel, and those who live alone.[6],[36],[37],[38]
Although the study holds significant importance, there are some limitations associated with this study. First, most of the participants in this study were from a young age group, thus distorting the data while comparing with other age group people. Further, data collection using an online questionnaire made most highly educated respondents with high-income levels, which may relieve stress and reduce the effect on sleep. This is the most available data collection method due to lockdown and current social distancing guidelines.
The study concluded that lifestyle changes resulting from the lockdown due to the COVID-19 pandemic adversely affected overall mental health and sleep hygiene. Nearly one out of each four participants had poor sleep quality, and about one out of each five had to take medication to fall asleep. Females and those at higher risk of catching infection due to job career, chronic health problems, or contact with a confirmed case were the most affected. More efforts are needed to improve awareness related to COVID-19 and to provide psychological support for individuals taking into account the importance of sleep for a healthy life and good immunity. The study findings play a significant role in resolving an essential aspect with the restrictive measures that need to be considered shortly.
Acknowledgments
The author thanks all participants in this study for their cooperation and time spent filling out the questionnaires.
Institutional review board statement
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by King Khalid University Research Ethics Committee (approval number: ECM#2020-237-HAPO-06-B-001) and the Research Ethical Committee at General Directorate of Health Affairs-Aseer Region, Saudi Arabia.
Informed consent statement
Informed consent was obtained from all subjects involved in the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Han J, Qian K, Song M, Yang Z, Ren Z, Liu S, et al. 92020). An early study on intelligent analysis of speech under covid-19: Severity, sleep quality, fatigue, and anxiety. arXiv preprint arXiv:2005.00096.  |
| 2. | Morin CM, Carrier J. The acute effects of the COVID-19 pandemic on insomnia and psychological symptoms. Sleep Med 2021;77:346-7. |
| 3. | Voitsidis P, Gliatas I, Bairachtari V, Papadopoulou K, Papageorgiou G, Parlapani E, et al. Insomnia during the COVID-19 pandemic in a Greek population. Psychiatry Res 2020;289:113076. |
| 4. | Vinkers CH, van Amelsvoort T, Bisson JI, Branchi I, Cryan JF, Domschke K, et al. Stress resilience during the coronavirus pandemic. Eur Neuropsychopharmacol 2020;35:12-6. |
| 5. | Ahmed AE, Al-Jahdali F, AlALwan A, Abuabat F, Bin Salih SA, Al-Harbi A, et al. Prevalence of sleep duration among Saudi adults. Saudi Med J 2017;38:276-83. |
| 6. | Altena E, Baglioni C, Espie CA, Ellis J, Gavriloff D, Holzinger B, et al. Dealing with sleep problems during home confinement due to the COVID-19 outbreak: Practical recommendations from a task force of the European CBT-I Academy. J Sleep Res 2020;29:e13052. |
| 7. | Leigh-Hunt N, Bagguley D, Bash K, Turner V, Turnbull S, Valtorta N, et al. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health 2017;152:157-71. |
| 8. | Besedovsky L, Lange T, Haack M. The sleep-immune crosstalk in health and disease. Physiol Rev 2019;99:1325-80. |
| 9. | O'Donnell D, Silva EJ, Münch M, Ronda JM, Wang W, Duffy JF. Comparison of subjective and objective assessments of sleep in healthy older subjects without sleep complaints. J Sleep Res 2009;18:254-63. |
| 10. | Alkhamees AA, Alrashed SA, Alzunaydi AA, Almohimeed AS, Aljohani MS. The psychological impact of COVID-19 pandemic on the general population of Saudi Arabia. Compr Psychiatry 2020;102:152192. |
| 11. | Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193-213. |
| 12. | Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J. Anaesth 2017;11:S80. |
| 13. | |
| 14. | Osterhaus JT, Purcaru O, Richard L. Discriminant validity, responsiveness and reliability of the rheumatoid arthritis-specific Work Productivity Survey (WPS-RA). Arthritis Res. Ther 2009;11:1-2. |
| 15. | Ponterotto JG, Ruckdeschel DE. An overview of coefficient alpha and a reliability matrix for estimating adequacy of internal consistency coefficients with psychological research measures. Percept Mot Skills 2007;105:997-1014. |
| 16. | Velavan TP, Meyer CG. The COVID-19 epidemic. Tropical Med Int Health 2020;25:278–80. |
| 17. | “Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV)”. World Health Organization. 30 January 2020. Archived from the original on 31 January 2020. Retrieved 30 January 2020. |
| 18. | “WHO Director-General's opening remarks at the media briefing on COVID-19—11 March 2020”. World Health Organization. 11 March 2020. Retrieved 11 March 2020. |
| 19. | Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. The Lancet. Infectious diseases 2020;20:631-3. |
| 20. | Parmet WE, Sinha MS. Covid-19—the law and limits of quarantine. New England Journal of Medicine 2020;382:e28. |
| 21. | Zajenkowski M, Jonason PK, Leniarska M, Kozakiewicz Z. Who complies with the restrictions to reduce the spread of COVID-19: personality and perceptions of the COVID-19 situation? Personality and individual differences 2020;166:110199. doi:10.1016/j.paid.2020.110199. |
| 22. | Del Rio C, Malani PN. COVID-19—new insights on a rapidly changing epidemic. Jama 2020;323:1339-40. |
| 23. | St-Onge MP. Sleep–obesity relation: Underlying mechanisms and consequences for treatment. Obes Rev 2017;18:34-39. |
| 24. | |
| 25. | St-Onge MP, Roberts A, Shechter A, Choudhury AR. Fiber and saturated fat are associated with sleep arousals and slow-wave sleep. J Clin Sleep Med 2016; 12:19-24. |
| 26. | Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912-20. |
| 27. | |
| 28. | Górnicka M, Drywień ME, Zielinska MA, Hamułka J. Dietary and lifestyle changes during COVID-19 and the subsequent lockdowns among Polish adults: A Cross-sectional online survey PLifeCOVID-19 study. Nutrients 2020;12:2324. https://doi.org/10.3390/nu12082324. |
| 29. | |
| 30. | Cellini N, Canale N, Mioni G, Costa S. Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy. J Sleep Res 2020:e13074. https://doi.org/10.31234/osf.io/284mr. |
| 31. | Xiao H, Zhang Y, Kong D, Li S, Yang N. 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. Med Sci Monit 2020;26:e923921-1. |
| 32. | Yu BY, Yeung WF, Lam JC, Yuen SC, Lam SC, Chung VC, et al. Prevalence of sleep disturbances during COVID-19 outbreak in an urban Chinese population: A cross-sectional study. Sleep Med 2020;74:18-24. |
| 33. | Barber SJ, Kim H. COVID-19 worries and behavior changes in older and younger men and women. J Gerontol B Psychol Sci Soc Sci 2021;76:e17-23. |
| 34. | Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976. |
| 35. | McLaren HJ, Wong KR, Nguyen KN, Mahamadachchi KN. COVID-19 and Women's Triple Burden: Vignettes from Sri Lanka, Malaysia, Vietnam, and Australia. Soc Sci 2020;9:87. |
| 36. | Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res 2020;288:112954. |
| 37. | Yang Y, Zhu JF, Yang SY, Lin HJ, Chen Y, Zhao Q, et al. Prevalence and associated factors of poor sleep quality among Chinese returning workers during the COVID-19 pandemic. Sleep Med 2020;73:47-52. |
| 38. | Gualano MR, Lo Moro G, Voglino G, Bert F, Siliquini R. Effects of COVID-19 lockdown on mental health and sleep disturbances in Italy. Int J Environ Res Public Health 2020;17:E4779. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
|
Search Pubmed for