The Influence of Stress in Modulating the Relationship between Coronavirus Disease-2019 Disease and Sleep Quality.

Introduction: The emotional well-being of health-care employees is critical to the quality of patient care and the efficient operation of health services. Not only has the coronavirus disease-2019 (COVID-19) virus caused significant rates of morbidity and mortality around the world but it has also caused sleep disruption, stress, and pandemic-related anxiety among health-care workers. The current study examines associations among COVID-related fear, stress, and sleep quality in health professionals.
Methods: From January to June 2021, a cross-sectional survey was done in Kerala among doctors, nurses, paramedical workers, and housekeeping employees. About 822 health-care providers from various districts took part in the study by completing a Google forms-based semi-structured, self-administered questionnaire. The data were coded, entered, and analyzed using SPSS 20.0. Descriptive statistical analysis, percentages, and ratios were employed to summarize the data.
Results: The majority of participants were between the ages of 46 and 55 (35%). Forty-four percent and 46% of respondents, respectively, were concerned about contracting COVID-19 and spreading the virus to others. COVID-19 restrictions were the primary concern of psychological distress among respondents (90%). Approximately one-fourth of the subjects reported using sleep medication, 42% took 30 min or longer to fall asleep, and 39% slept for 6 h or less. Poor sleep quality was reported to be prevalent in 62% of the population.
Conclusion: The COVID-19 pandemic has the potential to cause significant levels of fear, stress, and sleep disruption in health-care professionals. As a result, the COVID-19 pandemic represented a significant threat to their psychological health, and public health strategies should focus on improving it. Copyright:

INTRODUCTION

On January 30, 2020, the World Health Organization declared coronavirus disease-2019 (COVID-19) a public health emergency of international concern, and on March 11, 2020, it declared a pandemic. COVID-19 has been linked to about 179 million confirmed infections and 3 million fatalities worldwide as of June 24, 2021. India has 30 million confirmed cases within the same period.[1]

In comparison to most other professions, health-care workers encounter significant levels of psychological stressors, fear and anxiety, and poor sleep outcomes.[2]

Health-care workers are subject to physical and psychological fatigue and poor sleep outcomes as a result of increased workload, physical exhaustion from irregular work schedules, multiple work shifts, and the occasional need to make ethically problematic decisions, such as rationing of care. The majority of people have trouble juggling work and domestic duties.[3]

When COVID-19 is highly contagious, fear of becoming infected and infecting their friends and family is a primary source of anxiety.[4]

The link between stress and immune function may increase the danger for health-care workers who are in constant communication with COVID-19 patients for an extended amount of time. Stress can enhance a patient's vulnerability to a viral infection and delay recovery by slowing wound healing.[5]

According to Health-Care Workers research, more than half of physicians had poor sleep quality during the pandemic, which could be attributed to the contagious nature of COVID-19 and the urgency of their work.[6]

In health-care workers working in hospitals and isolation units, mass confinement can cause moral panic, fear, and anxiety. Frontline Health-care workers are medical professionals who have been exposed to or have had direct contact with confirmed or suspected coronavirus cases. They are more likely to have a heavier workload, a higher risk of infection, and mental health problems.[7]

Insomnia may result from excessive work hours and an interrupted biological rhythm during the isolation. House owners forcibly expelling them from their temporary residence, unequal treatment, violent acts in public places, and public transit all represents a danger to their lives. The social pressure connected with COVID-19 magnified Health-care workers' predicament. Insufficient government medical facilities, coupled with higher COVID-19 treatment costs in private health-care institutions, exacerbated the situation.[8]

Health-care workers' psychological problems would impair their focus, brain function, and medical decision, increasing the likelihood of medical mistakes and instances and putting patients at increased risk. It was also widely recognized that psychological pain in catastrophes can have a long-term impact on public well-being. As a result, the psychological problems of health professionals in the COVID-19 pandemic have emerged as an urgent public health issue.[910]

The Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings has produced a “Basic Psychosocial Skills Guide” for the WHO.[11]

The objective of this study was to see how stress affected the relation between COVID-19 illness and sleep quality. During a pandemic, this knowledge might be used to advise health-care staff on how to minimize poor sleep quality, stress, worry, and anxiety.

METHODS

Study design and participants

A cross-sectional study was performed using an online platform among health-care professionals, including doctors, nurses, other paramedical staff, and housekeeping staff from private and a few government hospitals across various districts of Kerala between January and June 2021.

Using Google Forms, an online semi-structured questionnaire was developed, along with a consent form.

This study's participation was entirely voluntary. A total of 925 people were chosen for the survey, with 103 opting out. Among them, there were 310 Doctors, 342 Nurses, 80 Paramedical staff, and 90 housekeeping staff. In terms of survey design, the questions were written in English and then translated to Malayalam. The survey was divided into four sections. The first segment of the poll focused on demographic features, the second on COVID-19 fear, while the third segment addressed stress and the fourth segment sleep quality of health workers.

Measures

Demographic variables

Participants' age, gender, profession, working hours, employment contract, marital status, and residence location were all questioned.

Evaluation of fear of coronavirus disease-2019

Participants were asked to assess their fear of COVID-19 on a 5-point Likert scale based on a set of questions to gauge their level of concern. Fear of becoming infected, infecting family/loved ones, insufficient personal protective equipment, and insufficient training are among them.

Evaluation of stress

In the form of statement-type questions, health-care workers, including doctors, nurses, other paramedical staff, and housekeeping staff acknowledged their distress and psychological disorders. They were questioned about their quickly increasing workloads, COVID limitations, and media coverage.

Evaluation of sleep

The polar questionnaire was used to assess participants' quality of sleep, use of prescription medication, sleep span, and sleep latency.

Statistical analysis

SPSS 20.0 version was used to code, enter, and analyze the data (IBM Corp., Armonk, NY, USA). To summarize information, descriptive statistical analysis and percentages were used.

RESULTS

Demographics of subjects

A total of 925 people were surveyed, with 822 of them completing legitimate questionnaires.

There were 822 participants in total (63% were females and 37% were males). Frontline professionals, who are directly involved in the diagnosis and management of patients with COVID19 symptoms, made up 79% of the total. Doctors accounted for 38% of the respondents, nurses for 41%, paramedics for 10%, and cleaning workers accounted for 11%. Eighty-seven percent of the participants were married. About 75% of them were permanent employees. Approximately 12% worked for <6 h, 33% for <10 h, and 55% for more than 10 h. About 78% of respondents resided in hospital-owned staff quarters, while 22% stayed with their families.

Descriptive study

The dread of COVID-19 disease among health-care employees is depicted in Table 1. In sum, 44% of the participants were afraid to go to work for fear of catching COVID-19. The concern of a shortage of workforce was cited by 53% of health workers, while the fear of viral transmission to family and others was cited by 46%. According to 35% of them, there is a dearth of adequate care for sick people.

Table 1

Fear among the health-care workers due to COVID-19 (n=822)

Items	Strongly agree, n (%)	Agree, n (%)	Neutral, n (%)	Disagree, n (%)	Strongly disagree, n (%)
1. Health workers are confident in the observance of hygiene and social distancing measures at the hospital after instituting the COVID regimen	57 (7)	49 (6)	150 (18)	480 (58)	86 (10)
2. Worried to go to work in fear of contracting COVID-19	363 (44)	167 (20)	121 (15)	139 (17)	32 (4)
3. Health workers are afraid from depleted workforce due to illness and isolation of staff	435 (53)	323 (39)	37 (5)	17 (2)	10 (4)
4. Fear of transmitting the virus to family and others	377 (46)	353 (43)	45 (5)	26 (3)	21 (3)
5. Lack of effective treatment for sick patients	288 (35)	195 (24)	320 (39)	10 (1)	9 (1)

Table 2 shows the stress levels of several types of health-care employees, such as doctors, nurses, paramedics, and housekeeping staff. Due to an ever-increasing workload, 88% of the health-care workers were stressed. Depressed or hopeless feelings were reported by 68% of the respondents. Isolation from family stressed out 79% of them. Due to the current COVID restrictions, 90% were stressed. The media had a significant impact on the mental health of about 84% of medical workers.

Table 2

Categorical response of health-care workers to stress due to pandemic

Items	Doctors, n (%)	Nurses, n (%)	Paramedics, n (%)	Housekeeping staff, n (%)	Total, n (%)
1. Feeling of depression or hopelessness	198 (64)	250 (73)	37 (46)	72 (80)	557 (68)
2. Feeling stressed up due to isolation from family	270 (87)	305 (37)	44 (44)	34 (38)	653 (79)
3. Feeling stressed up due to rapidly expanding workload	292 (94)	327 (95)	29 (36)	77 (86)	725 (88)
4. Feeling stressed up due to COVID restrictions	269 (87)	310 (91)	81 (81)	79 (88)	739 (90)
5. Feeling stressed up by the media reports	247 (80)	302 (88)	73 (91)	71 (79)	693 (84)

Doctors (n=310), nurses (n=342), paramedics (n=80), and housekeeping staff (n=90)

Table 3 shows the individuals' sleep status during the COVID-19 outbreak. In the whole sample, 62% of participants assessed their sleep quality as poor or very poor, 39% of participants slept for <6 h, the majority of participants barely used sleep medication, and 42% found it difficult to fall asleep.

Table 3

Sleep status of the participants during COVID-19 outbreak (n=822)

Components	n (%)
1. Subjective sleep quality
Very good	135 (16)
Good	178 (22)
Bad	323 (39)
Very bad	186 (23)
2. Sleep latency (min)
<15	220 (27)
15-30	252 (31)
>30 min	350 (42)
3. Sleep duration (h)
<6	320 (39)
6-8	410 (50)
>8	92 (11)
4. Use of sleep medication
None	426 (52)
<3 times in a week	200 (24)
3-6 times a week	126 (15)
Daily	70 (9)

DISCUSSION

The principal purpose of the study was to see how stress influenced fear and sleep quality during the COVID-19 pandemic. Doctors, nurses, paramedics, and cleaning employees were among those who contributed information.

The study found that stress caused by the COVID-19 pandemic was linked to illness anxiety and poor sleep among diverse groups of health-care practitioners.

Stress and symptoms of anxiety among health-care workers, are not a new occurrence, as there is ample literature on burnout among health-care workers during routine professional work.[1213]

Multiple studies have found that patient care causes significant anxiety[141516] and that social isolation and being away from family may be key causes of anxiety.[17] In our study, around 46% of health-care professionals were concerned about the virus spreading to their families and 44% of individuals stated that they were afraid to go to work after contracting COVID-19.

It is reported that fear increases anxiety and worries, which are not good for sleeping.[18] According to previous studies conducted, the pooled prevalence of stress found among the health-care workers was 65.1%.[19] In our analysis, about 90% of the health-care workers were stressed out due to the current COVID restrictions and media has also adversely affected their mental health.

A previous study revealed higher uncertainty about COVID-19 was significantly positively correlated with higher intolerance of uncertainty, which further increased perceived stress, and subsequently weakened sleep status.[20] Another study conducted by Olagunju AT et al.[21] showed that a significant proportions of participants reported sleep difficulty in several aspects, including sleep latency (81.5%), sleep duration (71.3%), sleep disturbances (75.9%), and daytime dysfunction (69.6%). Approximately, 32% of the participants reported using sleeping medication, and having difficulty with sleep quality.

In line with this study, we had results showing a majority of participants having sleep latency of more than 30 min. On assessing the sleep duration of participants, 39% had slept only for <6 h and approximately one-fourth used sleep medication. Our study reported a prevalence of poor sleep quality among 62% of health-care workers, this was similar to a study conducted in Kuwait, which demonstrated 78% suffered from bad or very bad sleep quality.[22]

Family and community members should provide adequate care, emotional support, and motivation to health-care workers, as this has been demonstrated to improve sleep outcomes and develop adaptive coping techniques.[23] Furthermore, immediate supervisors should always be available for communication and have empathy for health-care workers.[24] In addition, better community understanding about mental health is needed to minimize social stigma.[25]

Limitations

We were likely to obtain the sample group and used validated instruments to analyze fear, stress, and sleep quality as a result of the coronavirus. The study does, however, have some limitations. The study population was not chosen at random, which may limit the study's generalizability. The unavailability of the network hampered the collection of uniform data. Individual study comparability may be limited due to differences in procedure, materials used, social issues, and professional settings.

CONCLUSION

The COVID-19 pandemic is a once-in-a-lifetime threat to mental health. Health workers must be prioritized in the preventive measures of mental health issues because they are on the front lines of the current pandemic.

As the global epidemic increases demand for limited mental health-care resources, government policy should address mental health issues during outbreaks and promote effective mental well-being. Advanced diagnosis of the health-care system, as well as the execution of psychoeducation, are critical for safeguarding and ensuring the health-care functional requirement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.