The coronavirus disease (COVID-19) pandemic and news of daily increasing cases inside Nepal and worldwide is adding to the fear that leads to anger, anxiety, frustration, and stress, emotions that directly affect sleep quality. This study aimed to assess sleep disturbances during the COVID-19 pandemic in a Nepalese population.
This cross-sectional study recruited 206 Nepali residents who completed anonymous self-administered questionnaires. The Insomnia Severity Index (ISI) questionnaire was used to measure sleep disturbances before and after the COVID-19 pandemic. The gathered data were analyzed using descriptive statistics and inferential statistics using SPSS version 20 statistical software.
There was a significant variation in sleep disturbances among Nepalese residents before versus after the COVID-19 pandemic (
Our study findings suggest that people are suffering tremendously with sleep disturbances and calls for further research and active measures to help increase sleep quality during the COVID-19 pandemic.
Sleep (or at least a physiological period of quiescence) is a highly conserved behavior that occurs in animals ranging from fruit flies to humans [
Sleep quality and disturbances have strong correlations with indices such as occupational activities, physical and psychological well-being, and even death [
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 [
During the pandemic and lockdown period, reduced physical activity and disrupted routines became the main threats to sleep patterns [
Many studies have assessed the impact of COVID-19 on sleep disorders [
Sleep disturbances, including insomnia, can be precipitated by stressful events [
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.
This observational, cross-sectional study aimed to assess sleep disturbances during the COVID-19 pandemic in a Nepalese population. On March 11, 2020, the WHO characterized COVID-19 as a pandemic; soon thereafter (on March 24, 2020), the Nepalese government announced a nationwide total lockdown. The survey was performed from April 20 to May 2, 2020, in Nepal. A non-probability convenience sampling technique was used to select 206 Nepalese residents. The sample size was determined using the Cochran formula [
Nepalese residents aged 18 years or older who would read and write Nepalese or English were included in this study. Those who refused to provide study consent, had a chronic disease condition, were infected with COVID-19 or any respiratory disease, or had a history of alcohol consumption or smoking were excluded from the study. Among the 220 recruited Nepalese residents, 14 were excluded from the study (five were infected with COVID-19; six were unable to respond to the second set of questionnaires, that is, sleep conditions during the pandemic; and three refused to provide consent to participate). As it was not feasible to conduct a community-based national sampling survey due to lockdown in Nepal, an online survey was provided. Questionnaires were prepared in a Google form and sent via email, Facebook, and Viber messenger. The participants received a link to access the survey, which took approximately 20 minutes to complete. Subjects completed an anonymous web-based online survey after reading the written consent form and explicitly agreed to participate in the survey. This study underwent proper approval process from Internal Review Board of Annapurna Neurological Institute and Allied Sciences.
The self-structured questionnaire was developed based on a literature review and the Insomnia Severity Index (ISI). The questionnaire was adopted to gather socio-demographic variables and identify the prevalence and severity of sleep disturbances in the form of insomnia. A similar questionnaire was provided twice to the same subjects to measure the disturbances of sleep before versus during the COVID-19 pandemic. The first set of questionnaires reported on the sleep condition before the COVID-19 pandemic and lockdown started, while the second set of questionnaires captured the sleep condition after the COVID-19 pandemic was declared and the lockdown started in Nepal. The participants rated the ISI depending on their own experience regarding sleep before (March 16) and during (March 24) the lockdown.
The ISI is a brief self-reporting instrument that measures the patient’s perception of his or her insomnia. The ISI targets the subjective symptoms and consequences of insomnia, as well as the degree of concerns or distress caused by those difficulties. Its content corresponds to the diagnostic criteria for insomnia [
The subjects’ responses were collected using the Google form. The gathered data were analyzed using descriptive statistics and inferential statistics using SPSS version 20 statistical software (IBM Corp., Armonk, NY, USA). A descriptive analysis of frequency, percentage distribution, mean, and standard deviation were used to describe the socio-demographic variables, whereas in inferential analysis, a paired t-test was used to assess the quality of sleep before and during the COVID-19 pandemic among Nepalese residents, and the chi-square test was used to assess the association between sleep disturbance and selected variables. The Karl-Pearson correlation coefficient was used to determine the relationship between socio-demographic variables and sleep disturbances during the COVID-19 pandemic. The statistical significance level was set at
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 (
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 (
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.
The study showed that sleep disturbances during the COVID-19 pandemic had a poor negative correlation with age (
The COVID-19 pandemic in 2020 is a paradigm of a new emerging zoonotic disaster [
Insomnia is highly prevalent and associated with COVID-19 pandemic–related psychological reactions and poor sleep hygiene [
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 [
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 [
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 [
Another study reported that sleep disturbances have a significant positive relationship with female sex and a negative correlation with age [
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 [
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.
The authors have no potential conflicts of interest to disclose.
Conceptualization: Avinash Chandra. Data Curation: Avinash Chandra. Formal analysis: Ayush Chandra. Investigation: Ayush Chandra. Methodology: Nabina Sharma. Project administration: Ayush Chandra. Resources: Avinash Chandra. Software: Nabina Sharma. Supervision: Avinash Chandra. Validation: Ayush Chandra. Visualization: Ayush Chandra. Writing—original draft: Pooja Prakash. Writing—review & editing: Ayush Chandra, Avinash Chandra.
None.
We acknowledge the cooperation and support of all participants for the time and effort they devoted to the study.
Socio-demographic variables of Nepali residents who completed self-administered questionnaires
Variables | Value (n=206) |
---|---|
Sex | |
Female | 96 (46.6) |
Male | 110 (53.4) |
Age (yr) | 29.5±9.8 |
16–30 yrs | 142 (68.9) |
31–45 yrs | 48 (23.3) |
46–60 yrs | 12 (5.8) |
>60 yrs | 4 (1.9) |
Data are presented as n (%) or mean±standard deviation
Comparison of prevalence of insomnia between before and during COVID-19 pandemic among Nepali residents based on ISI (n=206)
Components of insomnia problem | Before COVID-19 pandemic |
During COVID-19 pandemic |
|||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
None | Mild | Moderate | Severe | Very severe | None | Mild | Moderate | Severe | Very severe | ||
Difficulty falling asleep | 107 (51.9) | 53 (25.7) | 36 (17.5) | 10 (4.9) | - | 97 (47.1) | 44 (21.4) | 36 (17.5) | 24 (11.7) | 5 (2.4) | |
Difficulty staying asleep | 107 (51.9) | 60 (29.1) | 31 (15.0) | 6 (2.9) | 2 (1.0) | 94 (45.6) | 61 (29.6) | 36 (17.5) | 11 (5.3) | 4 (1.9) | |
Awakening problem | 86 (41.7) | 56 (27.2) | 42 (20.4) | 15 (7.3) | 7 (3.4) | 87 (42.2) | 41 (19.9) | 42 (20.4) | 26 (12.6) | 10 (4.9) | |
Satisfaction with current sleep pattern | 43 (20.9) | 95 (46.1) | 56 (27.2) | 9 (4.4) | 3 (1.5) | 38 (18.4) | 78 (37.9) | 49 (23.8) | 33 (16.0) | 8 (3.9) | |
Impairment of quality of life | 89 (43.2) | 70 (34.0) | 37 (18.0) | 6 (2.9) | 4 (1.9) | 82 (39.8) | 62 (30.1) | 41 (19.9) | 16 (7.8) | 5 (2.4) | |
Worried about current sleep problem | 104 (50.5) | 64 (31.1) | 29 (14.1) | 9 (4.4) | - | 83 (40.3) | 59 (28.6) | 30 (14.6) | 26 (12.6) | 8 (3.9) | |
Interfere with daily functioning | 75 (36.4) | 64 (31.1) | 48 (23.3) | 14 (6.8) | 5 (2.4) | 66 (32.0) | 64 (31.1) | 43 (20.9) | 24 (11.7) | 9 (4.4) | |
Result of ISI evaluation | |||||||||||
Absent insomnia | 130 (63.1) | 109 (52.9) | |||||||||
Subthreshold insomnia | 68 (33.0) | 61 (29.6) | |||||||||
Moderate clinical insomnia | 6 (2.9) | 34 (16.5) | |||||||||
Severe clinical insomnia | 2 (1.0) | 2 (1.0) |
Data are presented as n (%). ISI, Insomnia Severity Index; COVID-19, coronavirus disease
Sleep disturbances before and during COVID-19 pandemic (n=206)
Components of insomnia problem | ISI score |
95% confidence interval of the difference | “t” value | ||
---|---|---|---|---|---|
Before COVID-19 | During COVID-19 | ||||
Difficulty falling asleep | 0.75±0.91 | 1.01±1.16 | 0.44–0.72 | 2.74 |
0.007 |
Difficulty staying asleep | 0.72±0.89 | 0.88±1.01 | 0.33–0.0001 | 1.98 |
0.049 |
Awakening problem | 1.03±1.12 | 1.18±1.24 | 0.36–0.70 | 1.33 | 0.184 |
Satisfaction with current sleep pattern | 1.19±0.87 | 1.49±1.20 | 0.49–0.104 | 3.03 |
0.003 |
Impairment of quality of life | 0.86±0.94 | 1.03±1.06 | 0.34–0.01 | 1.86 | 0.065 |
Worried about current sleep problem | 0.72±0.87 | 1.11±1.18 | 0.59–0.18 | 3.74 |
<0.001 |
Interfere with daily functioning | 1.08±1.04 | 1.25±1.15 | 0.39–0.037 | 1.63 | 0.105 |
Total score of ISI | 6.35±4.65 | 8.01±6.01 | 0.65–0.65 | 3.23 |
<0.001 |
Data are presented as mean±standard deviation.
significant at
ISI, Insomnia Severity Index; COVID-19, coronavirus disease
Association of age and ISI score during COVID-19 pandemic (n=206)
Components of sleep disturbances | Insomnia severity |
Chi-square test (χ2) | |||||
---|---|---|---|---|---|---|---|
None (0) | Mild (1) | Moderately (2) | Severe (3) | Very severe (4) | |||
Difficulty falling asleep | 1.56 | 0.82 | |||||
<45 | 90 | 41 | 32 | 22 | 4 | ||
≥45 | 7 | 3 | 4 | 2 | 1 | ||
Difficulty staying asleep | 3.72 | 0.45 | |||||
<45 | 83 | 58 | 33 | 11 | 4 | ||
≥45 | 11 | 3 | 3 | 0 | 0 | ||
Awakening problem | 9.23 | 0.56 | |||||
<45 | 76 | 41 | 40 | 22 | 10 | ||
≥45 | 11 | 0 | 2 | 4 | 0 | ||
Satisfaction with current sleep pattern | 0.69 | 0.95 | |||||
<45 | 35 | 72 | 44 | 31 | 7 | ||
≥45 | 3 | 6 | 5 | 2 | 1 | ||
Noticeable impairment of quality of life | 5.70 | 0.22 | |||||
<45 | 75 | 60 | 36 | 13 | 5 | ||
≥45 | 7 | 2 | 5 | 3 | 0 | ||
Worried about current sleep problem | 6.60 | 0.16 | |||||
<45 | 78 | 56 | 25 | 22 | 8 | ||
≥45 | 5 | 3 | 5 | 4 | 0 | ||
Interfere with daily functioning | 10.74 |
0.03 | |||||
<45 | 60 | 63 | 35 | 22 | 9 | ||
≥45 | 6 | 1 | 8 | 2 | 0 | ||
Total score of ISI | 19.91 |
0.008 | |||||
<45 | 11 | 85 | 54 | 31 | 2 | ||
≥45 | 2 | 5 | 7 | 3 | 0 |
significant at
ISI, Insomnia Severity Index; COVID-19, coronavirus disease
Association of sex and ISI score during COVID-19 pandemic (n=206)
Components of sleep disturbances | Insomnia severity |
Chi-square test (χ2) | |||||
---|---|---|---|---|---|---|---|
None (0) | Mild (1) | Moderately (2) | Severe (3) | Very severe (4) | |||
Difficulty falling asleep | 6.69 | 0.15 | |||||
Male | 59 | 24 | 15 | 9 | 3 | ||
Female | 38 | 20 | 21 | 15 | 2 | ||
Difficulty staying asleep | 8.51 | 0.80 | |||||
Male | 59 | 31 | 15 | 3 | 2 | ||
Female | 35 | 30 | 21 | 8 | 2 | ||
Awakening problem | 10.31 |
0.04 | |||||
Male | 54 | 23 | 21 | 7 | 5 | ||
Female | 33 | 18 | 21 | 19 | 5 | ||
Satisfaction with current sleep pattern | 7.16 | 0.13 | |||||
Male | 19 | 47 | 25 | 18 | 1 | ||
Female | 19 | 31 | 24 | 15 | 7 | ||
Noticeable impairment of quality of life | 3.44 | 0.49 | |||||
Male | 50 | 31 | 19 | 8 | 2 | ||
Female | 32 | 31 | 22 | 8 | 3 | ||
Worried about current sleep problem | 15.27 |
0.01 | |||||
Male | 49 | 36 | 17 | 7 | 1 | ||
Female | 34 | 23 | 13 | 19 | 7 | ||
Interfere with daily functioning | 11.08 |
0.03 | |||||
Male | 36 | 43 | 20 | 8 | 3 | ||
Female | 30 | 21 | 23 | 16 | 6 | ||
Total score of ISI | 33.86 | 0.07 | |||||
Male | 11 | 57 | 27 | 15 | 0 | ||
Female | 8 | 33 | 34 | 19 | 2 |
significant at
ISI, Insomnia Severity Index; COVID-19, coronavirus disease
Correlation of age, sex with sleep disturbances during COVID-19 pandemic (n=206)
Components of insomnia problem | Age |
Sex (female) |
||
---|---|---|---|---|
r-value | r-value | |||
Difficulty falling asleep | -0.04 | 0.58 | 0.15 |
0.03 |
Difficulty staying asleep | -0.05 | 0.47 | 0.19 |
0.01 |
Awakening problem | -0.10 | 0.15 | 0.19 |
0.01 |
Satisfaction with current sleep pattern | -0.09 | 0.19 | 0.08 | 0.25 |
Noticeable impairment of quality of life | -0.09 | 0.18 | 0.11 | 0.11 |
Worried about current sleep problem | -0.001 | 0.99 | 0.23 |
<0.01 |
Interfere with daily functioning | -0.01 | 0.89 | 0.16 |
<0.01 |
Total score of ISI | ||||
Before COVID-19 pandemic | -0.08 | 0.25 | 0.59 | 0.03 |
During COVID-19 pandemic | -0.07 | 0.36 | 0.199 |
<0.01 |
r-value: Karl-pearson’s Coefficient correlation.
significant at
significant at p≤0.001.
ISI, Insomnia Severity Index; COVID-19, coronavirus disease