Prevalence of Sleep Disturbances During COVID-19 Pandemic in a Nepalese Population: A Cross-Sectional Study

Article information

J Sleep Med. 2021;18(3):145-153

Publication date (electronic) : 2021 December 31

doi : https://doi.org/10.13078/jsm.210012

Avinash Chandra^1,2, Pooja Prakash³, Nabina Sharma⁴, Ayush Chandra^,5,6

¹Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal

²Department of Neurology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal

³Gandaki Medical College and Teaching Hospital, Pokhara, Nepal

⁴Laurentian University, Sudbury, Canada

⁵Multiple Sclerosis Society Nepal, Kathmandu, Nepal

⁶Department of Clinical Medicine, Tianjin Medical University, Tianjin, China

Address for correspondence Ayush Chandra, MBBS Department of Clinical Medicine, Tianjin Medical University, Tianjin 300070, China Tel: +977 9840149436 E-mail: ayushchandra1995@yahoo.com

Received 2021 April 21; Revised 2021 June 24; Accepted 2021 August 9.

Abstract

INTRODUCTION

Sleep (or at least a physiological period of quiescence) is a highly conserved behavior that occurs in animals ranging from fruit flies to humans [1]. As a result, a substantial proportion of the human lifespan is spent in this mysterious state. Sleep is vital to human health and critical for neurobehavioral, cognitive, memory consolidation [2], nociception [3], appetite regulation, and immune and hormonal functions [4]. The American Academy of Sleep Medicine and Sleep Research Society stated that sleeping less than 7 hours or more than 9 hours per night is associated with health risks [5]. Sleep disruptions can indicate or even cause more serious underlying medical conditions.

Sleep quality and disturbances have strong correlations with indices such as occupational activities, physical and psychological well-being, and even death [6]. The increase in sleep difficulties is more common among people with a higher level of depression, anxiety, and stress symptomatology associated with a feeling of time dilatation [7]. A systematic review and meta-analysis reported that, during the pandemic, about one-third of participants suffered from psychological symptoms, including a 43% prevalence of stress, 37% prevalence of anxiety, 43% prevalence of depression, and 43% prevalence of sleep disturbances [8]. A survey of an Indian population revealed a 9% prevalence of insomnia and 30% prevalence of occasional insomnia [9]. Insomnia is characterized by difficulty falling asleep, difficulty staying asleep, waking too early, or feeling unrefreshed upon waking. There are clear reciprocal dependencies between sleep duration, quality, and immune responses against viral, bacterial, and parasitic pathogens, the latter of which alter sleep patterns. An improved sleep quality and duration in a population may mitigate the propagation and severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection [10].

Infectious disease epidemics affect the physical health of patients as well as the psychological health and well-being of the non-infected population. Previous studies demonstrated that the prevalence of novel infectious diseases, such as SARS, can increase anxiety, depression, and stress levels in the general population, all of which directly affect sleep [11]. A systemic review stated that most patients (54%) with SARS or Middle East respiratory syndrome during the previous pandemic exhibited insomnia [12]. A post-SARS patient in Ontario, Canada, had symptoms of pre- and post-sleep fatigue, sleep instability, and difficulty sleeping [13]. Survivors of an Ebola epidemic in Africa reported feeling anxiety (14%), depression (15%), and insomnia (22%) [14]. The sleep problems arising during the coronavirus disease (COVID-19) outbreak are severe and affect approximately 40% of people [15]. SARS-CoV-2 was first identified in December 2019 in Wuhan city, central China [16]. As of May 12, 2020, the World Health Organization (WHO) reported a total of 4,006,257 confirmed cases globally with a mortality rate of 278,892 and 88,891 new cases and 4,531 deaths in the previous 24 hours; unfortunately, the numbers are only increasing [17]. The Nepalese Ministry of Health reported more than 400 confirmed COVID-positive cases as of May 20, 2020, a number that is expected to rise sharply [18]. The government of Nepal announced a nationwide total lockdown on March 24, 2020 in a bid to stop COVID-19 from spreading out of control. The lockdown halted the movement of people and prompted the shutdown of industry, schools, and the majority of institutions.

During the pandemic and lockdown period, reduced physical activity and disrupted routines became the main threats to sleep patterns [19]. Thinking about the COVID-19 crisis and watching news about it cause stress among people, becoming a primary cause of insomnia. Reducing TV time, increasing physical activity levels, following the pre-lockdown work routine, and keeping a positive attitude will improve an individual’s sleep quality [20]. An estimated 33.24% of people from Bangladesh reported sleep disturbances during the COVID-19 lockdown, and the associated risk factors were family members being infected with COVID-19, working from home, regular use of the Internet for more than 5 hours, unemployment, being at high risk of COVID-19 infection, and following a disturbed sleeping schedule [21]. In India, 62% of patients with COVID-19 complained of sleep disturbances [22]. A study from Nepal reported that 33.9% of health workers had symptoms of insomnia during the COVID-19 pandemic [23].

Many studies have assessed the impact of COVID-19 on sleep disorders [24]. Psychological and sleep problems have increased during interpersonal isolation due to COVID-19 among Chinese people, including 16% suffering from insomnia [25]. A survey on COVID impact, lockdown that disrupted sleep patterns among 1,500 respondents in India reported that 67% of those who worked from home had an altered sleep schedule, 50% believed that their sleep pattern had been disrupted, and 81% felt their sleep schedule would get better after the lockdown [20]. In Italy during the COVID-19 lockdown, sleep timing markedly changed, with people going to bed and waking up later, spending more time in bed, and paradoxically reporting a lower sleep quality [7].

Sleep disturbances, including insomnia, can be precipitated by stressful events [26]. In rural areas of Peru, 29% of middle-aged and older adults had poor sleep patterns before the COVID-19 pandemic, which increased to 49% at the pandemic’s peak [27]. In China, symptoms of insomnia were reported in 36% of people in addition to higher levels of other health issues; for instance, 87.1% of patients with insomnia symptoms reported also having depression [28].

Based on previous research evidence, we have reason to speculate that the psychological condition and sleep disturbances of the public may also be affected during the COVID-19 outbreak in Nepal. Therefore, this web-based cross-sectional study aimed to assess sleep disturbances during the COVID-19 pandemic in a Nepalese population. We hope that our study findings will provide data support for targeted interventions on psychological and mental health in the Nepalese public during the outbreak.

METHODS

RESULTS

Demographic characteristics and insomnia prevalence and severity

A total of 206 Nepalese residents were recruited, of whom 96 (46.6%) were female and 110 (53.4%) were male. The mean age of the subjects was 29.5±9.8 years (Table 1). As per the ISI, there was significant variation in sleep quality among Nepalese residents before and during the pandemic (Table 2). The prevalence of insomnia before the COVID-19 pandemic was 36.9%, which increased to 47.1% during the pandemic. Similarly, before the onset of the pandemic, the prevalence of subthreshold insomnia was 33%, and 3.9% of the subjects had moderate to severe insomnia that changed significantly during the pandemic period and subsequent lockdown. The prevalence of subthreshold insomnia decreased to 29.6%, while the number of people with moderate insomnia increased to 34 (16.5%) and no change was noted in the severity of clinical insomnia (n=2 [1%]). The mean ISI scores before and during the COVID-19 pandemic were 6.35±4.65 and 8.01±6.01, respectively (Table 3).

Table 1.

Socio-demographic variables of Nepali residents who completed self-administered questionnaires

Table 2.

Comparison of prevalence of insomnia between before and during COVID-19 pandemic among Nepali residents based on ISI (n=206)

Table 3.

Sleep disturbances before and during COVID-19 pandemic (n=206)

The present study revealed that subjects had severe difficulty with sleep onset (4.9%), severe difficulty with sleep maintenance (2.9%), very severe awakening problems (3.4%), and very severe dissatisfaction with sleep patterns (1.5%) even before the COVID-19 pandemic. Before the COVID-19 outbreak, 6 (2.9%) subjects felt that their sleep quality had adversely impaired their quality of life, 9 (4.4%) were worried about sleep problems, and 14 (6.8%) experienced sleep-related interference with their daily functioning. During the pandemic period and lockdown phase, 11.7% of subjects had severe difficulty with falling asleep, 5.3% had difficulty with sleep maintenance, and 12.6% had severe awakening problems. In addition, 16% of the subjects were dissatisfied with their sleep pattern, 7.8% had an impaired quality of life, 3.9% were very worried about their sleep problems, and 11.7% reported disturbed daily living function (Table 2).

Association between demographic characteristics and ISI scores

The current study showed that the prevalence of insomnia was more common among females (21.87%); similarly, less than 45 years of age had clinically severe insomnia. Table 4 shows that there was a significant association between age and sleep quality during the COVID-19 pandemic (χ²=19.91) as well as interference with daily functioning such as daytime fatigue, mood, ability to function at work, and concentration (p<0.01 for all). In this study, female respondents faced more problems than male respondents with waking up too early during the pandemic, that is, a 25% higher frequency, a phenomenon that was significantly associated with sleep disturbances (χ²=10.31). Similarly, interference with daily functioning (χ²=11.08) and distress related to current sleep problems (χ²=15.27) were reported more frequently by female participants and directly associated with sleep disturbances (p<0.05) (Table 5).

Table 4.

Association of age and ISI score during COVID-19 pandemic (n=206)

Table 5.

Association of sex and ISI score during COVID-19 pandemic (n=206)

The study showed that sleep disturbances during the COVID-19 pandemic had a poor negative correlation with age (Table 6). However, sleep disturbances were positively correlated with female sex. Difficulty falling asleep was directly related to sleep disturbances (p<0.05). Similarly, facing difficulty staying asleep, awakening problems in the early morning, distress or worry about current sleep problems, and interference with daily activities were significantly associated with the COVID-19 pandemic (p≤0.01). The obtained ISI scores during the COVID-19 pandemic were positively correlated with the different sexes (p≤0.01). Female participants (21.87%) reported more severe sleep disturbances than male.

Table 6.

Correlation of age, sex with sleep disturbances during COVID-19 pandemic (n=206)

DISCUSSION

The COVID-19 pandemic in 2020 is a paradigm of a new emerging zoonotic disaster [32] that has caused significant medical, psychological, and social issues worldwide. This study used ISI scores to determine the sleep disturbances of Nepalese residents before versus during the COVID-19 pandemic. These findings suggest that Nepalese people were more prone to sleep disturbances, including insomnia, during than before the COVID-19 pandemic. The sleeping pattern of the general population was affected, and significant differences were found before versus during the pandemic. These findings are consistent with those of a previous study in which 30%–40% of respondents from Hong Kong felt their sleep had worsened and there was a high prevalence of insomnia during the COVID-19 pandemic [33].

Insomnia is highly prevalent and associated with COVID-19 pandemic–related psychological reactions and poor sleep hygiene [34]. Our study showed that the prevalence of insomnia was 36.9% before the COVID-19 pandemic versus 47.1% during the pandemic, a pattern consistent with that of a study in Italy that reported an increase from 40.5% to 52.4% [7]. A study from China that aimed to assess changes in sleep and psychological reactions during the COVID-19 pandemic reported that the prevalence of insomnia increased significantly i.e. 26.2% to 33.7% [34]. Another study conducted in the Netherlands contradicted this finding, suggesting that sleep quality during the COVID-19 pandemic is correlated with pre-pandemic sleep quality. One-quarter of those participants reported improved sleep quality, although 20% of good pre-pandemic sleepers reported worse sleep during the lockdown measures [35]. The study also reported that 11.7% of the general population had difficulty falling asleep, 5.3% had difficulty staying asleep, and 12.6% awakened too early.

Around 11.7% of our Nepalese participants reported that poor sleep quality interfered with their daily living functions during the lockdown period. Previous studies reported that the prevalence of worsened sleep quality, difficulty falling asleep, and early awakening problems were 38.3%, 29.8%, and 29.1%, respectively [34]. This study reported a significant difference in sleep quality before and during the COVID-19 pandemic with regard to difficulty falling asleep, difficulty staying asleep, satisfaction with current sleep, and worry about sleep problems. These findings are inconsistent with those of a previous study conducted in Italy that focused on perceived sleep quality and psycho-emotional well-being. The study’s results showed that the 24% prevalence of insomnia before the COVID-19 pandemic significantly increased to 40% during the pandemic; likewise, the 15% of subjects who reported difficulty falling asleep increased to 42%, the 19.5% of subjects who reported difficulty staying asleep increased to 33.7%, and the 24.4% of subjects who reported early morning awakening problems increased to 38.7% [36].

A survey of COVID lockdown impact of disrupted sleep patterns in India reported that 67% of respondents who worked from home had altered sleep schedules, 50% believed that their sleep pattern had become disrupted, and 81% felt their sleep schedule would improve after the lockdown. Only 25% of the respondents had a post-midnight bedtime before versus 35% after the lockdown, while 25% of the subjects used to get less than 6 hours of sleep before the lockdown versus 36% after the lockdown [33].

There was a statistically significant decrease in sleep disturbances before versus during the COVID-19 pandemic among Nepalese residents. The present study demonstrated that 29.6% of subjects had subthreshold, 16.5% had moderate, and 1% had severe clinical insomnia during the COVID-19 pandemic. An earlier study in India reported that the prevalence of insomnia was 60.5% (31.8% with subthreshold, 23.2% with moderate, and 5.5% with severe) during the COVID-19 outbreak [37]. A similar study in China reported a 37% increase in the rate of clinical insomnia before versus during the COVID-19 pandemic [38].

Another study reported that sleep disturbances have a significant positive relationship with female sex and a negative correlation with age [39]. The age factor was significantly associated with sleep quality during the COVID-19 pandemic as well as satisfaction with sleep patterns and interference with daily functioning. A study conducted in Greece revealed that women’s insomnia scores were significantly higher than men’s scores and younger age was associated with greater sleep difficulties [40]. In the present study, female participants reported facing more problems with waking early, falling asleep, and staying asleep than male participants. Women were more distressed about their current sleeping problems. Women seem to be more vulnerable to stress-related disorders, such as post-traumatic stress disorder and anxiety [41].

The current study showed that the prevalence of insomnia was higher among female participants, while subjects younger than 45 years old more commonly had clinically severe insomnia. A cross-sectional study in China demonstrated that the combination of anxiety and stress reduces the positive effects of social capital on sleep quality [42]. Another study of the influence of coronavirus disease on sleep quality in China demonstrated that participants with a Wuhan exposure history generally showed longer sleep latency (χ²=9.77, p<0.05), which confirmed that subjective sleep quality, delayed sleep onset, sleep fragmentation, and sleep duration all regulated the effect of Wuhan exposure history on post-traumatic stress disorder. The study findings suggested that sleep quality levels decreased and post-traumatic stress symptoms increased with time [43]. A previous study aimed to assess the mental health burden of the Chinese public during the outbreak and stated that 18.2% of the public had poor sleep quality, while healthcare workers (23.6%) were more likely to have poor sleep quality and reported the highest rate of poor sleep quality (p<0.001) [44]. Our study findings also indicated that sleep pattern changes were evident after the country went into complete lockdown.

Thus, our study pointed out the fact that stress in the form of the COVID-19 pandemic and lockdown significantly affects the quality of life of Nepalese citizens. Nepal is an economically lower nation; the lockdown has played a greater role in joblessness and lower income, resulting in various health issues that most prominently manifest as sleep pattern changes. Our findings may provide support for the implementation of measures to improve sleep quality and reduce the impact of the COVID-19 pandemic on sleep quality among Nepalese residents. We recognize some limitations of this study, including its small size of 206 participants and the self-reported questionnaire, the use of which was necessary due to the lack of direct contact with people during the lockdown. Further studies should assess other factors contributing to insomnia.

In conclusion, our study revealed a high prevalence of poor sleep among Nepalese residents. The ISI is an eye-opener for the mostly ignored fact of sleep patterns. It showed that sleep disturbances significantly increased before versus during the COVID-19 pandemic among Nepalese residents. Public awareness should be increased through proper health education about the importance of good sleep quality for maintaining one’s mental health and reducing the prevalence of insomnia during the COVID-19 pandemic and lockdown.

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