In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Sleep and Awakening Quali y du ing COVID-19 Con inemen :
Complexi y and Rele ance o Heal h and Beha io
Te esa Pai a 1,2,3,*, Cá ia Reis 1,2,4,5 , Amélia Feliciano 1,3,6, Hugo Canas-Simião1,3,7 , Ma ia Augus a Machado 8,
Tânia Gaspa 1,2,3,9, Gina Tomé2,10, Cá ia B anquinho 2,10, Ma ia Raquel Sil a 3,11 , Lúcia Rami o 2,12,
Susana Gaspa 2,13 , Ca la Ben es 4,14,15, F ancisco Sampaio 11,16 , La a Pinho 3,17 , Conceição Pe ei a 18,
Alexand a Ca ei o 19, Susana Mo ei a 20, Isabel Luzei o 21,22,23 , Joana Pimen el 1,24, Gab iela Videi a 15,
Júlio Fonseca 25, Ana Be na da 26, Joana Vaz Cas o 1,3 , So ia Rebocho 1, Ka ie Almondes 27, Helena Canhão3
and Ma ga ida Gaspa Ma os 2,10


Ci a ion: Pai a, T.; Reis, C.; Feliciano,
A.; Canas-Simião, H.; Machado, M.A.;
Gaspa , T.; Tomé, G.; B anquinho, C.;
Sil a, M.R.; Rami o, L.; e al. Sleep and
Awakening Quali y du ing COVID-19
Con inemen : Complexi y and
Rele ance o Heal h and Beha io .
In . J. En i on. Res. Public Heal h 2021,
18, 3506. h ps://doi.o g/10.3390/
ije ph18073506
Academic Edi o : Giuseppe Ba ba o
Recei ed: 12 Feb ua y 2021
Accep ed: 16 Ma ch 2021
Published: 28 Ma ch 2021
Publishe ’s No e: MDPI s ays neu al
wi h ega d o ju isdic ional claims in
published maps and ins i u ional a il-
ia ions.
Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Sleep Medicine Cen e —CENC, 1070-068 Lisbon, Po ugal; [email p o ec ed] (C.R.);
[email p o ec ed] (A.F.); [email p o ec ed] (H.C.-S.); ania.gaspa [email p o ec ed] (T.G.);
[email p o ec ed] (J.P.); [email p o ec ed] (J.V.C.); [email p o ec ed] (S.R.)
2Ins i u o de Saúde Ambien al (ISAMB), Faculdade de Medicina, Uni e sidade de Lisboa,
1649-026 Lisbon, Po ugal; [email p o ec ed] (G.T.); [email p o ec ed] (C.B.);
[email p o ec ed] (L.R.); [email p o ec ed] (S.G.); ma [email p o ec ed] (M.G.M.)
3Comp ehensi e Heal h Resea ch Cen e (CHRC), No a Medical School, Uni e sidade No a de Lisboa,
1169-056 Lisbon, Po ugal; [email p o ec ed] (M.R.S.); [email p o ec ed] (L.P.);
[email p o ec ed] (H.C.)
4Faculdade de Medicina de Lisboa, Ins i u o de Medicina Molecula João Lobo An unes (IMM),
1649-028 Lisbon, Po ugal; [email p o ec ed]
5Ca ólica Resea ch Cen e o Psychological Family and Social Wellbeing (CRC-W), Ca holic Uni e si y,
1649-023 Lisbon, Po ugal
6Clínica Lusíadas de Almada/Pa que das Nações-Lisboa 2810-500, 1990-095 Almada, Po ugal
7Psychia y and Men al Heal h Depa men —Cen o Hospi ala de Lisboa Ociden al (CHLO),
1349-019 Lisbon, Po ugal
8Depa amen o de Medicina, Se iço de Pneumologia, Cen o Hospi ala Pó oa de Va zim/Vila do Conde,
4490-421 Pó oa do Va zim, Po ugal; [email p o ec ed]
9Cen o Lusíada de In es igação em Se iço Social e In e enção Social (CLISSIS), Uni e sidade Lusíada,
1349-001 Lisboa, Po ugal
10 Facul y Human Kyne ics, Uni e sidade de Lisboa, 1495-751 Lisboa, Po ugal
11 Facul y o Heal h Sciences/Highe School o Heal h, Uni e si y Fe nando Pessoa/Fundação Fe nando
Pessoa, 4200-150 Po o, Po ugal; [email p o ec ed]
12 Escola Secundá ia Poe a Al Be o, 7520-902 Sines, Po ugal
13 Escola Supe io de Saúde A lân ica, Uni e sidade A lân ica, 2730-036 Ba ca ena, Po ugal
14 Depa men o Neu ology, CHULN—Cen o Hospi ala Uni e si á io Lisboa No e,
1649-028 Lisbon, Po ugal
15 Neu ology and Den al Medicine, Hospi al da Luz, 1500-065 Lisbon, Po ugal; [email p o ec ed]
16 Inno a ion & De elopmen in Nu sing esea ch g oup, CINTESIS—Cen e o Heal h Technology and
Se ices Resea ch, 4200-450 Po o, Po ugal
17 Nu sing Depa men , Escola Supe io de En e magem S. João de Deus (ESESJD), Uni e si y É o a,
7000-811 É o a, Po ugal
18 Ins i u o de Sono e Medicina Den á ia (ISMD), 9000-098 Funchal, Po ugal;
[email p o ec ed]
19 Unidade do Sono, Hospi al do Di ino Espí i o San o de Pon a Delgada, 9500-370 Pon a Delgada, Po ugal;
alexand aca ei [email p o ec ed]
20 Pneumologia, Hospi al dos Lusíadas, 1500-458 Lisbon, Po ugal; [email p o ec ed]
21 Cen o Medicina Sono e Se iço Neu ologia e Neu o isiologia, Hospi al CUF Coimb a,
3000-600 Coimb a, Po ugal; [email p o ec ed]
22 Se iço Neu ologia e Neu o isiologia, Hospi al CUF Coimb a, 3000-600 Coimb a, Po ugal
23 Escola Supe io de Tecnologia da Saúde de Coimb a, 3046-854 Coimb a, Po ugal
24 Pneumologia, Hospi al de Vila F anca de Xi a, 2600-009 Vila F anca de Xi a, Po ugal
25 O isclinic—Cen o In eg ado de Medicina Den á ia de Coimb a, 3030 Coimb a, Po ugal;
[email p o ec ed]
26 Linde Saúde—Homeca e, Linde Saúde, 1800-217 Lisbon, Po ugal; ana.be na [email p o ec ed]
27 UFRN—AMBSONO Sleep Clinic, Depa men Psychology, Fede al Uni e si y Rio G ande do No e,
Na al 59030-180, B azil; [email p o ec ed]
In . J. En i on. Res. Public Heal h 2021,18, 3506. h ps://doi.o g/10.3390/ije ph18073506 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 3506 2 o 17
*Co espondence: e [email p o ec ed]
Abs ac :
Objec i e: The aim o his s udy was o e alua e sleep and awakening quali y (SQ and AQ)
du ing COVID-19 in a la ge and di e si ied popula ion in o de o iden i y signi ican associa ions
and isks in e ms o demog aphy, heal h and heal h- ela ed beha io s, sleep a iables, men al
heal h, and a i udes. Me hods/Resul s:Online su eys we e used o da a collec ion, ecei ed
om 5479 indi iduals om he gene al popula ion, sleep diso de pa ien s, and COVID-in ol ed
(medical doc o s (MDs) and nu ses) and COVID-a ec ed p o essionals ( eache s, psychologis s,
and den is s). SQ and AQ we e wo se in adul s, emales, and high-educa ion subjec s. Feeling
wo se, ha ing economic p oblems, dep ession, anxie y, i i abili y, and a high Calami y Expe ience
Check Lis (CECL) sco e du ing COVID we e signi ican ly associa ed wi h poo SQ and AQ. Sho e
sleep du a ion, inc eased la ency, poo nu i ion, low physical ac i i y, inc eased mobile and social
ne wo k use, mo e nega i e and less posi i e a i udes and beha io s we e associa ed wi h poo
AQ. Conclusions: The SQ logis ic eg ession showed gende , mo bidi ies, CECL, and awakenings
as ele an , whe eas, o AQ, ele an a iables u he included age and physical ac i i y. Aiming
o ha e a high s ess compliance, each indi idual should sleep well, ha e impo an con ol o
hei mood, p ac ice posi i e beha io s while dismissing nega i e beha io s and a i udes, p ac ice
exe cise, ha e adequa e nu i ion, and bewa e o echnologies and dependences.
Keywo ds:
heal h; COVID-19; sleep/awakening quali y; Calami y Expe ience Check Lis ; mood;
a i udes; heal h- ela ed beha io s; dependences; heal h p o essionals; sleep pa ien s
1. In oduc ion
Sleep is c i ical o men al physical heal h and o su i al. Sleep becomes pa icu-
la ly ele an when acing s essing si ua ions such as hose aced du ing he COVID-19
pandemic [1,2].
Sleep quali y (SQ) is conside ed a basic sleep a iable impac ing he indi idual’s
daily wellbeing. I may be conside ed a subjec i e e alua ion i em o sleep sa is ac ion
o may be objec i ely quan i ied by polysomnog aphy and ac ig aphy. The subjec i e
dimension is quan i iable by se e al ins umen s, among which he Pi sbu g Sleep Quali y
Index (PSQI) eme ges as he in e na ional s anda d [
3
]. Ne e heless, he Jenkins Sleep
Scale [
4
], he Medical Ou comes S udy-Sleep Scale (MOS-SS) [
5
], he Insomnia Se e i y
Scale [
6
], he Visual Analogue [
7
], o he Like Scale a e also alid ins umen s ha assess
subjec i e SQ.
The Sel Ra ing Ques ionnai e o Sleep Quali y e alua es SQ, AQ, and soma ic com-
plain s in 20 ques ions wi h ou le els pe ques ion, which al oge he p o ide a single
sco e [
8
]. This scale has been used in se e al polysomnog aphic s udies, bu he co ela ions
wi h objec i e sleep pa ame e s a e mode a e, and no dis inc ion exis s be ween sleep and
awakening quali y [9].
The objec i e sleep con inui y a iables (sleep la ency, numbe o awakenings
<5 min
,
wake a e sleep onse (WASO), and sleep e iciency) a e good indica o s o SQ 10]. The Na-
ional Sleep Founda ion add esses exac alue anges associa ed wi h good o poo SQ,
wi h some o hem being used o all ages, while o he s a y acco ding o age [10].
Du ing he COVID-19 pandemic, SQ was pa icula ly a ec ed. A s udy in ol ing
G eece, Swi ze land, Aus ia, Ge many, F ance, and B azil epo ed wo se SQ in 31.3% o
pa icipan s, and 15% o hem cha ac e ized hei sleep as bad [
11
]. Poo SQ p e alence
a ied be ween 18.4% in China [
12
] and much highe numbe s in I aly, 55.3% [
13
] and
57.1% [
14
]. Howe e , 75.2% o Chinese adul s in home isola ion o mo e han 77 days
a ed hei SQ as e y good [
15
]. This migh sugges ha some cul u al and/o egional
di e ences migh also a ec subjec i e SQ [16,17].
The ac o s associa ed wi h poo sleep quali y a e anxie y, s ess, o dep ession [
10
,
11
,
13
–
24
],
ma ked changes in sleep/wake hy hm [
10
,
18
,
25
], insomnia [
18
], no exe cising [
19
,
23
],
In . J. En i on. Res. Public Heal h 2021,18, 3506 3 o 17
inc eased use o mul imedia such as ele ision (TV) iewing and high pe sonal compu e
(PC) use [
23
], nega i e a i ude owa d COVID-19 con ol measu es [
26
], highe educa ion
le el [
19
,
26
], amily bu den [
24
], low social capi al [
13
,
19
], educed lexibili y [
27
], nega i e
mood and “shielding” om he i us [
24
,
28
], COVID-19- ela ed wo ies, o dec eased
esilience [29].
P o ec i e ac o s a e high social capi al [
13
], social suppo , s aying busy, and using
ee ime in elaxing ac i i ies [
30
]. Fu he mo e, SQ media es he ela ionship be ween
physical ac i i y and quali y o li e (QoL) [12].
The mo e a ec ed g oups we e heal hca e wo ke s, mos ly hose wo king in on line
se ices [
7
,
14
,
24
,
31
–
33
], young people [
11
], olde age [
7
], emales [
10
,
11
,
18
,
19
], males
pe o ming highly demanding jobs [
34
], people su e ing om dea h in he amily [
20
],
o hose li ing in places wi h high COVID-19 p e alence [14].
Despi e he p edominan ly nega i e impac upon SQ, some da a sugges ha he lock-
down e ec is bimodal since his ac o imp o es in a subse o indi iduals [
35
,
36
]. This
occu ed in subse s o adul s [
12
], pa icula ly insomniacs. Mo ning awakening is a c i ical
unc ional pe iod due o he associa ion wi h sleep ine ia, sleep es o a ion, inc eased blood
p essu e and co isol ci cadian hy hms, inc eased isk o mo ning headaches [
37
], awaken-
ing epilepsies, ca dio- o ce eb o ascula acu e diso de s, and sleep-awakening symp oms.
Poo quali y o awakening is o en associa ed wi h excessi e day ime sleepiness [
38
], in-
somnia symp oms, sleep/wake phase delay synd ome [
39
], sleep dep i a ion/insu icien
sleep, and non es o a i e sleep [
40
]. In spi e o being a key ac o o indi iduals’ daily
wellbeing, he quali y o mo ning awakening is no cu en ly in es iga ed in popula ion
su eys.
The aim o his s udy was o cha ac e ize he impac o he COVID-19 pandemic
on sleep and awakening quali ies o a la ge, di e si ied popula ion. A u he objec i e
was o iden i y signi ican associa ions and isks in e ms o demog aphy, heal h, o he
sleep a iables, con inemen mood, a i udes, beha io s, mood scales (dep ession, anxie y,
i i abili y, and wo ies), economic p oblems, and heal h- ela ed/ isk beha io s (physical
ac i i y, mul imedia use, nu i ion, oxic habi s, and addic ions, i.e., habi s, p ac ices,
ac i i ies, o pe sonal a ibu es ha ei he enhance o pu a isk he o e all heal h).
2. Ma e ials and Me hods
The Su ey Legend
®
pla o m was used. Su eys we e anonymous, o adul s
(
>18 yea s
), allowing da a analysis and s a is ical use. The i s page included pu pose,
au ho s, e hical e e ence, con ac pe son, and suppo ing en i ies. I was online du ing he
i s COVID-19 wa e, om Ap il o Augus 2020. Al hough he su eys we e adap ed o
each main subg oup, hey all had a co e and common s uc u e used in his s udy.
The o e all p ojec was app o ed by CENC’s E hical Commi ee 1/2020. The e was
no unding, public o p i a e, and no con lic o in e es s.
Online su eys we e used, and 5479 indi iduals we e included and dis ibu ed as ol-
lows: he gene al popula ion (GP) (N= 972; age = 49.2
±
13.5; 77.1% emales); sleep diso de
pa ien s (SDPs) (N= 1261; age = 57.8
±
14.2; 42.2% emales); p o essionals COVID-in ol ed:
medical doc o s and nu ses (N= 2794; age = 44.8
±
13.4; 72.7% emales); p o essionals
COVID-a ec ed: eache s, psychologis s, and den is s (N= 452;
age = 45.0 ±8.9;
88.1%
emales). Age and gende di e ences o he subg oups a e conside ed an impo an issue,
since hey achie e popula ion di e si y. The s udy includes da a ob ained in he Po uguese
mainland and islands (Madei a and Azo es).
Su eys add essed he ollowing opics: demog aphics, heal h s a us; con inemen
mood, a i udes, and beha io s; Calami y Expe ience Check Lis (CECL); sleep; physical
ac i i y (PA); mul imedia use; nu i ion; oxic habi s and addic ions.
Demog aphics, in addi ion o con en ional in o ma ion, included he numbe o
people li ing oge he du ing he pandemic.
Heal h s a us included yes/no ques ions o he ollowing opics: being heal hy (sub-
jec i e) o su e ing om sleep, psychia ic, neu ologic, ca dio ascula , espi a o y, alle -
In . J. En i on. Res. Public Heal h 2021,18, 3506 4 o 17
gies, gas oin es inal, heuma ologic, endoc inologic/me abolic, au oimmune, o hopedic,
cance , enal, de ma ologic, hema ologic, gynecologic, u ologic, ea /nose/ h oa (ENT),
o oph halmologic diso de s, ch onic pain, a igue, and dizziness.
The mo bidi ies index (MI) is he sum o all e e ed mo bidi ies a baseline wi h
espec o COVID-19 in e ms o wo sening (mo bidi ies wo sening index (MWI)) and
imp o emen (mo bidi ies imp o emen index (MII)).
Con inemen a i udes and beha io s we e e alua ed by yes/no answe s. The a e age
and numbe o bo h posi i e and nega i e a i udes and beha io s we e compu ed pe
subjec and used in his s udy. Posi i e a i udes we e he ollowing: el OK; had less
s ess; made impo an disco e ies. Nega i e a i udes we e he ollowing: ed up o i ed;
canno s and i ; loneliness; missing amily o iends; el in imp isonmen /claus ophobia:
had wo ies and ea s; had unexpec ed con lic s; canno s and companion; canno s and
child en; canno s and elde ly; ed up wi h he child en’s ele-school. Posi i e beha io s
we e he ollowing: idying up; new ype o wo k: phone iends; decided li e changes;
w o e a book, a icles, o memo ies; lea ned new abili ies; ga dening/ag icul u e; in en ed
unny o spi i ual hings; wo ked; walking/gym/spo s; eading/music/s udying; domes-
ic wo k. Nega i e beha io s we e he ollowing: de eloped new addic ions; ge bo ed;
mou ned all ime; slep as much as possible.
Calami y mood da a we e ob ained using 1–10 VASs ( isual analogue scales). The Calami y
Expe ience Check Lis (CECL) was compu ed by a e aging, o each subjec , he scales o
dep ession, anxie y, i i abili y, and wo ies (Tomée al. in publica ion). The eason o
such a selec ion is ela ed o he ac ha hese symp oms, in clinical p ac ice, a e qui e
equen ly associa ed wi h sleep complain s.
Sleep da a included he ollowing da a ela i e o weekdays and weekends du ing
COVID-19: sleep schedules, subjec i e sleep du a ion in hou s, sleep la ency in minu es,
numbe o awakenings, and sleep quali y (SQ) and awakening quali y (AQ) ob ained using
a 1–10 VAS.
Physical ac i i y was quan i ied in e ms o in ensi y (null, mild, mode a e, and in-
ense) and equency (hou s/week).
Sc een ime ( ele ision, social ne wo ks, mobile phone, and gaming use) was quan i-
ied in hou s/day.
Nu i ion included daily meals, and sco es o he ecommended in ake equencies
we e calcula ed [41] (Appendix A).
Toxic habi s—Smoking and alcoholic consump ion we e ca ego ized as yes/no,
and daily ciga e es and glasses o bee , wine, ape i i e wine, and b andy we e assessed,
espec i ely. D ug use was quan i ied as no, occasionally, some imes, o egula ly
S a is ics—Quali a i e a iables we e desc ibed by absolu e and ela i e equencies,
while quan i a i e a iables we e calcula ed as he mean o median depending on da a
dis ibu ion. No mali y was es ed by he Kolmogo o –Smi no es . Mos con inuous
a iables had a no mal dis ibu ion excep o CECL, ge up ime o weekdays and
weekends, and ciga e es pe /day. The 25 h pe cen ile (P25) alues o SQ and AQ we e
calcula ed o he p e-COVID-19 pe iod, and he a iables we e dicho omized as P25 o
below (poo quali y) and >P25 (good quali y). The e ec o he a iables o in e es was
e alua ed acco ding o he a iables in ques ion using a pai ed - es o compa e SQ and AQ
be o e ( ou inely occu ing p io o he pandemic) and du ing COVID-19, chi-squa e es s
(quali a i e answe s/ equency ables), and ANOVA (unidi ec ional analysis o a iance)
wi h pos hoc Bon e oni es s. A logis ic eg ession model was pe o med o SQ and AQ
wi h age, sex, CECL, numbe o mo bidi ies, sleep la ency, sleep awakenings on weekdays
du ing COVID-19, and physical ac i i y in ensi y as co a ia es. All es s we e pe o med
using SPSS® 25. S a is ical signi icance was se a 0.05.
In . J. En i on. Res. Public Heal h 2021,18, 3506 5 o 17
3. Resul s
3.1. SQ and AQ be o e and du ing COVID-19
Da a om SQ and AQ be o e and du ing COVID-19 we e compa ed; hey a e shown
in Table 1.
Table 1. Da a om sleep quali y (SQ) and awakening quali y (AQ) be o e and du ing COVID-19.
Va iable Value SQ P e COVID SQCOVID AQ P e COVID AQ COVID
Numbe Valid 4230 4232 4227 4223
Missing 1249 1247 1252 1256
Median 7 6 7 6
Minimum 1 1 1 1
Maximum 10 10 10 10
Pe cen iles 25 5 4 5 4
50 7 6 7 6
75 8 7 8 7
90 9 8 9 8
The educ ion in SQ and AQ du ing COVID-19 was signi ican : = 32,456, n= 4222,
p< 0.001 and = 25.06, n= 4213, p< 0.001, espec i ely. Be o e COVID-19, 21.9% had
poo SQ; his numbe inc eased o 36.3% du ing COVID-19; he alues o AQ we e 22.8%
be o e and 34.6% du ing he COVID-19 pe iod. Howe e , compa ing be o e and du ing
COVID-19 pe iods, 4.2% and 4.8% o he indi iduals imp o ed hei SQ and AQ, and 44.6%
and 48.8% changed nei he o hem.
3.2. SQ and AQ du ing COVID-19
3.2.1. Demog aphic Da a
Di e ences conside ing demog aphic da a a e shown in Table 2. SQ and AQ we e
wo se o adul s (30–64 yea s), emales, and subjec s wi h highe educa ion. Di e ences
conce ning ci il s a us we e only signi ican o AQ, which we e be e o ma ied people
(χ2= 19.767; p= 0.001).
3.2.2. Mood and P oblems
The di e ences be ween he wo g oups (poo and good SQ and AQ) we e signi ican
o mood and economic p oblems.
Du ing he 2020 con inemen , lowe alues ( eeling wo se) we e signi ican o bo h
poo SQ and poo AQ; in e ms o he economic p oblems, dep ession, anxie y, i i abili y,
and he CECL, hese we e inc eased (i.e., mo e p oblems/mo e dep essed, e c.) o poo
SQ and AQ (Table 3).
Table 2. Associa ions o sleep and awakening quali y wi h demog aphic da a.
Age G oups Young Adul s Elde ly To al (%) p-Value
Sleep
Quali y P25
Poo 166
(3.0)
1544
(28.3)
269
(4.9) 1979 (36.3) <0.001
Good
317
(5.8)
2516
(46.1)
645
(11.8) 3478 (63.7)
Awakening
Quali y P25
Poo 165
(3.0)
1499
(27.5)
224
(4.1) 1888 (34.6) <0.001
Good
318
(5.8)
2561
(47.0)
690
(12.6) 3569 (65.4)
To al (%) 483
(8.8)
4060
(74.4)
914
(16.8)
5457
(100.0)

In . J. En i on. Res. Public Heal h 2021,18, 3506 6 o 17
Table 2. Con .
Age G oups Young Adul s Elde ly To al (%) p-Value
Gende Male Female To al
(%) p-Value
Sleep
Quali y P25
Poo 505
(9.2)
1482
(27.1)
1987
(36.3)
<0.001
Good
1264
(23.1)
2228
(40.6)
3492
(63.7)
Awakening
Quali y P25
Poo 486
(8.9)
1408
(25.7)
1894
(34.6)
<0.001
Good 1283(23.4)
2302
(42.0)
3585
(65.4)
To al (%) 1769
(32.3)
3710
(67.7)
5479
(100.0)
Educa ion Low High To al
(%) p-Value
Sleep
Quali y P25
Poo 268
(4.9)
1719
(31.4)
1987
(36.3)
<0.001
Good
624
(11.4)
2868
(52.3)
3492
(63.7)
Awakening
Quali y P25
Poo 232
(4.2)
1662
(30.4)
1894(34.6)
<0.001
Good
660
(12.1)
2925
(53.3)
3585
(65.4)
To al (%) 892
(16.3)
4587
(83.7)
5479
(100.0)
Ci il s a us Ma ied Single Widow Di o ced Union To al (%) p-Value
Sleep
Quali y P25
Poo 1016
(18.6) 458 (8.4) 50
(0.9) 206 (3.8) 255 (4.6) 1987 (36.3) 0.316
Good
1876
(34.2)
790
(14.4)
85
(1.6) 315 (5.7) 422 (7.8) 3492 (63.7)
Awakening
Quali y P25
Poo 928
(17.0) 472 (8.6) 41
(0.7) 196 (3.6) 255 (4.7) 1894 (34.6) <0.001
Good
1964
(35.8)
776
(14.2)
94
(1.7) 325 (5.9) 422 (7.7) 3585 (65.4)
To al (%) 2892
(52.8)
1248
(22.8)
135
(2.5) 521 (9.5) 677
(12.4)
5479
(100.0)
People a
heHousehold 1 2 3 4 5 ≥6 To al (%) p-Value
Sleep
Quali y P25
Poo 324 (6.3) 645
(12.5)
436 (8.5) 385 (7.5) 108 (2.1) 76 (1.5) 1974 (38.3) 0.029
Good
439 (8.5) 1173
(22.8)
685 (13.3) 605
(11.7) 167 (3.2) 113 (2.2) 3182 (61.7)
Awakening
Quali y P25
Poo 322 (6.2) 631
(12.2)
408 (6.9) 358 (6.9) 255 (4.7) 65 (1.3) 1886 (36.6) 0.018
Good
441 (13.5) 1187
(23.0)
632 (12.3) 632
(12.3) 422 (7.7) 124 (2.4) 3270 (63.4)
To al (%) 763 (14.8) 1818
(35.3)
1121 (21.7) 990
(19.2) 275 (12.4) 189
(3.7.0) 5156 (100%)
Pea son’s chi-squa e es o all g oup compa isons; alues a e gi en as he equency (pe cen age); P25- ep esen s he 25 h pe cen ile o he
sco e dis ibu ion; young-≤29 yea s; adul s-30–64 yea s; elde ly- ≥65yea s.
In . J. En i on. Res. Public Heal h 2021,18, 3506 7 o 17
Table 3. Di e ences in sleep and awakening quali y ela i e o eelings and mood du ing COVID-19.
Sleep Quali y P25 NMean SE Minimum Maximum Z p-Value
How a e you li ing du ing con inemen Poo 1168 6.31 6.21 1 10
33.025
<0.001
Good 3774 6.66 6.60 1 10
How a e you economic p oblems? Poo 1186 3.38 3.25 1 10
51.831
<0.001
Good 3790 2.87 2.80 1 10
How is you dep ession? Poo 1190 4.17 4.03 1 10
42.987
<0.001
Good 3819 3.65 3.58 1 10
How is you anxie y? Poo 1190 5.13 4.99 1 10 42.71 <0.001
Good 3804 4.58 4.50 1 10
How is you i i abili y? Poo 1186 4.95 4.81 1 10
18.996
<0.001
Good 3817 4.58 4.50 1 10
How a e you wo ies s. unce ain y? Poo 1185 6.37 6.23 1 10
25.407
<0.001
Good 3788 5.96 5.88 1 10
Calami y Expe ience Check Lis Poo 1197 5.11 5.00 1 10
47.941
<0.001
Good 3847 4.64 4.58 0.75 10
Awakening Quali y P25 NMean SE Minimum Maximum Z p-Value
How a e you li ing du ing con inemen ? Poo 1845 6.03 1.784 1 10
290.166
<0.001
Good 3097 6.91 1.741 1 10
How a e you economic p oblems? Poo 1878 3.33 2.237 1 10
74.496
<0.001
Good 3098 2.79 2.06 1 10
How is you dep ession? Poo 1879 4.58 2.353 1 10
364.663
<0.001
Good 3130 3.3 2.266 1 10
How is you anxie y? Poo 1883 5.6 2.39 1 10
408.062
<0.001
Good 3111 4.17 2.439 1 10
How is you i i abili y? Poo 1879 5.51 2.42 1 10
359.52
<0.001
Good 3124 4.16 2.443 1 10
How a e you wo ies s. unce ain y? Poo 1878 6.74 2.236 1 10
254.552
<0.001
Good 3095 5.64 2.457 1 10
Calami y Expe ience Check Lis Poo 1892 5.57 1.92 1 10
530.367
<0.001
Good 3152 4.26 1.98 0.75 10
P25— ep esen s he 25 h pe cen ile o he sco e dis ibu ion; SE—s anda d e o ; Z-sco es indica e he di e ences be ween he g oups.
3.2.3. Sleep
Fewe di e ences we e obse ed in sleep a iables o he compa isons be ween poo
and good SQ and AQ (Table 4).
Fo SQ, only he ge up ime on weekdays (la e o poo SQ) and he highe alues
o sleep la ency and awakenings, bo h on weekdays and weekends, we e signi ican ly
di e en .
Fo AQ, di e ences conce ned mos ly weekdays in ela ion o ea lie ge up ime,
sho e sleep du a ion, and longe sleep la ency.
3.2.4. Heal h-Rela ed and Risks Beha io s
Heal h- ela ed beha io s (HRBs) a e p esen ed in Table 5. Fo SQ da a, hese esul s
we e ambiguous since pa icipan s wi h poo SQ a e mo e ecommended and less non-
ecommended ood, smoked less, and had lowe le els o TV and game dependence.
Howe e , o AQ, he da a a e qui e clea , i.e., pa icipan s wi h poo AQ p ac iced less
PA, while hey a e ewe meals and less ecommended ood and mo e non- ecommended
ood, wi h a poo yes/no p opo ion; hey had highe use o social ne wo ks and mobile
phones, as well as a highe dependence o social ne wo ks, bu hey consumed ewe
alcoholic d inks.
3.2.5. A i udes and Beha io s
The associa ions be ween a i udes and SQ/AQ a e de ailed in Table 6.
In . J. En i on. Res. Public Heal h 2021,18, 3506 8 o 17
Poo SQ was associa ed wi h nega i e a i udes and beha io s, while AQ was signi i-
can ly lowe in e ms o nega i e a i udes and highe in e ms o nega i e beha io s and
posi i e a i udes and beha io s, as well as in nega i e beha io s, which was unexpec ed.
Table 4. Di e ences in sleep a iables o he compa isons be ween poo and good SQ and AQ du ing COVID.
Sleep Quali y P25 NMean SE Minimum Maximum Z p-Value
Ge up ime weekdays (hou s) Poo 1007 8.05 1.535 3.75 19.25
15.825
<0.001
Good 3449 7.85 1.428 3.00 19.00
Ge up ime weekends (hou s) Poo 1012 9.00 1.511 5.00 15.00 3.732 0.053
Good 3461 8.90 1.506 3.25 19.00
Time in o bed weekdays (hou s) Poo 980 0.00 1.548 18.00 8.00 2.863 0.091
Good 3342 23.51 1.516 18.00 15.00
Time in o bed weekends (hou s) Poo 986 0.35 1.659 18.00 11.50 3.716 0.054
Good 3330 0.24 1.603 18.00 12.00
Sleep du a ion weekdays (hou s) Poo 980 6.69 1.615 00.25 16.00 0.042 0.838
Good 3302 6.68 1.641 00.13 16.00
Sleep du a ion weekends (hou s) Poo 975 7.41 1.849 00.34 16.00 0.881 0.348
Good 3295 7.48 1.973 00.13 19.00
Sleep la ency weekdays (min) Poo 928 34.16 35.017 0 300 3.937 0.047
Good 3153 31.68 32.972 0 240
Sleep la ency weekends (min) Poo 927 34.06 35.841 0 300 5.6 0.018
Good 3140 31.04 33.693 0 302
Nigh awakenings weekdays (numbe ) Poo 802 3.00 3.128 1 30 7.158 0.007
Good 2524 2.72 2.451 0.5 30
Nigh awakenings weekends (numbe ) Poo 760 2.59 2.260 1 30 9.994 0.002
Good 2420 2.34 1.689 0.1 30
Awakening Quali y P25 NMean SE Minimum Maximum Z p-Value
Ge up ime weekdays (hou s) Poo 1589 7.83 1.47 3.00 19.25 4.799 0.029
Good 2867 7.93 1.45 3.00 17.00
Ge up ime weekends (hou s) Poo 1592 8.93 1.51 4.00 19.00 0.069 0.794
Good 2881 8.92 1.51 3.25 18.00
Time in o bed weekdays (hou s) Poo 1545 23.51 1.51 18.00 09.50 0.426 0.514
Good 2777 23.54 1.53 18.00 15.00
Time in o bed weekends (hou s) Poo 1551 0.28 1.65 18.00 12.00 0.141 0.708
Good 2765 0.26 1.60 18.00 12.00
Sleep du a ion weekdays (hou s) Poo 1540 6.57 1.58 0.29 16.00
12.005
0.001
Good 2742 6.75 1.66 0.13 16.00
Sleep du a ion weekends (hou s) Poo 1539 7.40 1.87 0.29 16.00 2.85 0.091
Good 2731 7.50 1.99 0.13 19.00
Sleep la ency weekdays (min) Poo 1478 33.82 34.90 0.00 300.00 5.165 0.023
Good 2603 31.35 32.59 0.00 240.00
Sleep la ency weekends (min) Poo 1475 33.09 34.97 0.00 300.00 3.68 0.055
Good 2592 30.95 33.76 0.00 302.00
Nigh awakenings weekdays (numbe ) Poo 1228 2.85 2.70 1.00 30.00 0.989 0.32
Good 2098 2.75 2.59 0.50 30.00
Nigh awakenings weekends (numbe ) Poo 1163 2.43 1.81 0.10 30.00 0.414 0.52
Good 2017 2.39 1.86 0.50 30.00
P25— ep esen s he 25 h pe cen ile o he sample dis ibu ion; SE—s anda d e o ; hou s a e gi en in decimal alues o local ime and in
24 h o ma ; Z-sco es indica e he di e ences be ween he g oups.
3.2.6. Heal h P io o and du ing COVID-19
A small numbe o subjec s (n= 122) we e COVID-19-in ec ed, o which 30 we e
asymp oma ic, wi h poo SQ and AQ in eigh and se en esponden s, espec i ely; 81 had
mild symp oms, wi h poo SQ and AQ in 46 and 37 esponden s, espec i ely; se en had
pneumonia, wi h poo SQ and AQ in ou and ou esponden s, espec i ely; ou we e
hospi alized, none o which had poo SQ o AQ. Fo SQ, he chi-squa e alue was 17.561
(p< 0.002) and, o AQ, he chi-squa e alue was 8.921 (p= 0.063).
In . J. En i on. Res. Public Heal h 2021,18, 3506 9 o 17
The s a is ical links be ween SQ/AQ and body mass index (BMI)/heal h a e p esen ed
in Table 7.
Table 5. Di e ences in sleep quali y and awakening quali y ela i e o heal h- ela ed and isk beha io s.
SLEEP Quali y P25 N Mean SE Minimum Maximum Z p-Value
Physical ac i i y du ing COVID (hou s) Poo 905 2.66 4.027 0 48 0.518 0.472
Good
2229
2.77 3.828 0 60
Meals/day du ing COVID Poo
1162
3.81 0.901 1 5 1.556 0.212
Good
2942
3.85 0.906 1 5
Food Recommended Poo
1161
1.3167
0.14009
1 2 2.144 0.143
Good
2940
1.31
0.13375
1 2
Food Recommended YES Poo
1147
5.37 2.324 0 14 4.551 0.033
Good
2917
5.26 2.211 1 14
Food Recommended NO Poo
1154
11.45 2.452 1 17 4.133 0.042
Good
2932
11.63 2.324 1 17
Food Recommended YES/NO p opo ion Poo
1146
0.5421
0.39774
0 4.67 2.144 0.143
Good
2915
0.5158
0.36136
0.06 4.67
Alcohol du ing COVID Poo 755
9.1836
26.8108
0 563.5 0.052 0.819
Good
1866
9.3843
17.0966
0 139.5
Numbe ciga e es/mon h du ing COVID Poo 172 11.23 8.907 0 60 4.597 0.032
Good 376 12.94 8.563 0 40
TV/Day du ing COVID (hou s) Poo
1055
3.199
2.4342
0.1 20 3.044 0.081
Good
2687
3.044
2.4365
0.1 20
Social Ne wo ks du ing COVID (hou s) Poo 927 2.541
2.4236
0.1 20 2.539 0.111
Good
2347
2.398
2.2852
0 20
Mobile use/Day du ing COVID (hou s) Poo
1008
2.649
2.8126
0 20 1.485 0.223
Good
2624
2.532
2.5031
0.1 20
Games/Day du ing COVID (hou s) Poo 227 1.825
1.4432
0.1 14 0.526 0.469
Good 672 1.925
1.9114
0.1 20
TV dependence Poo
1097
3.19 1.962 1 10 6.236 0.013
Good
2812
3.38 2.122 1 10
Social Ne wo ks dependence Poo
1098
3.55 2.312 1 10 2.659 0.103
Good
2817
3.68 2.4 1 10
Games dependence Poo
1090
1.59 1.392 1 10 4.063 0.044
Good
2813
1.7 1.579 1 10
Alcohol dependence Poo
1094
1.45 1.171 1 10 0.308 0.579
Good
2811
1.47 1.159 1 10
AWAKENING Quali y P25 N Mean SE Minimum Maximum Z p-Value
Physical ac i i y du ing COVID (hou s) Poo
1302
2.46 3.848 0 48 11.8 <0.001
Good
1832
2.94 3.903 0 60
Meals/day du ing COVID Poo
1835
3.8 0.937 1 5 4.635 0.031
Good
2269
3.87 0.877 1 5
Food Recommended Poo
1831
1.2997
0.13788
1 2
26.741
<0.001
Good
2270
1.3217
0.13294
1 2
Food Recommended (YES) Poo
1810
5.09 2.266 0 14
26.402
<0.001
Good
2254
5.45 2.213 1 14
Food Recommended (NO) Poo
1824
11.74 2.437 1 17
14.696
<0.001
Good
2262
11.45 2.292 1 17
Food Recommended YES/NO p opo ion Poo
1808
0.4987
0.37094
0 4.67
14.171
<0.001
Good
2253
0.5429
0.372 0.06 4.67
Alcohol consump ion du ing COVID Poo
1159
7.8347
22.94508
0 563.5
11.188
<0.001
Good
1462 10.5091 17.99032
0 139.5
Numbe ciga e es/mon h du ing COVID Poo 277 12.92 8.736 0 40 1.983 0.16
Good 271 11.88 8.648 0 60
TV/Day du ing COVID (hou s) Poo
1645
3.009
2.4141
0.1 20 3.094 0.079
Good
2097
3.15
2.4527
0.1 20
Social Ne wo ks du ing COVID (hou s) Poo
1504
2.565
2.4988
0 20 8.266 0.004
Good
1770
2.331
2.1628
0.1 20
Mobile use/Day du ing COVID (hou s) Poo
1624
2.761
2.7572
0 20
17.003
<0.001
Good
2008
2.405 2.441 0.1 20
Games/Day du ing COVID (hou s) Poo 389 1.919
1.9467
0.1 20 0.08 0.777
Good 510 1.885
1.6897
0.1 20
TV dependence Poo
1731
3.3 2.058 1 10 0,689 0.407
Good
2178
3.35 2.097 1 10
Social Ne wo ks dependence Poo
1736
3.84 2.407 1 10
21.279
<0.001
Good
2179
3.49 2.34 1 10
Games dependence Poo
1731
1.69 1.606 1 10 0.916 0.339
Good
2172
1.65 1.466 1 10
Alcohol dependence Poo
1733
1.48 1.206 1 10 0.509 0.476
Good
2172
1.46 1.126 1 10
P25— ep esen s he 25 h pe cen ile o he sample dis ibu ion; SE—s anda d e o ; hou s a e gi en in decimal alues o local ime and in
24 h o ma ; Z-sco es indica e he di e ences be ween he g oups.
In . J. En i on. Res. Public Heal h 2021,18, 3506 16 o 17
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