Sleep quality and health in healthcare professionals fighting against COVID-19: a comparative study between high risk area (Hubei Province) and low risk area (Jiangsu Province) in China CURRENT STATUS: POSTED

Background: Novel Coronavirus Disease 2019 (COVID-19) emerged in Wuhan, Hubei Province, China in December 2019. Since then, there was an outbreak in Wuhan and the coronavirus spread quickly nationwide. Thousands of healthcare providers fought against COVID-19 in Wuhan and other areas of China. The present study aimed to investigate the levels and related factors of sleep quality of healthcare professionals fighting against COVID-19 in high risk area (Hubei Province) and low risk area (Jiangsu Province), and association between sleep quality and health. Methods: A total of 253 healthcare professionals in Hubei Province (n=119, female 72.3%, mean age=32.13±5.50, nurse 80.7%) and Jiangsu Province(n=134, female 94.0%, mean age=30.2±5.52, nurse 96.3%) were surveyed from February to March 2020. Sleep quality (Pittsburgh sleep quality index, PSQI) and health were assessed using an internet survey. Results: The global PSQI score of Hubei sample and Jiangsu sample was 9.74±5.00 and 7.79±4.64, respectively. The global PSQI score and the scores of subjective sleep quality, sleep latency, sleep duration and use of sleep medications in Hubei sample were significantly higher than that of Jiangsu sample (p<0.05). For Hubei sample, fear of infection, fatigue in Class 3 protection and worry about family were predictors of poor sleep quality (OR=5.020, 95%CI 1.761-14.306, OR=3.859, 95%CI 1.168-12.753, OR=3.576, 95%CI 1.002-12.759, respectively), while dizziness in Class 3 protection was predictor of poor sleep quality for Jiangsu sample (OR=7.063, 95%CI 2.323-21.470). Poor sleep quality was associated with reduced self-reported health after controlling for covariates for all samples(β=-0.75, p<0.01, β=-0.52, p<0.01, respectively). Conclusions: Sleep quality of healthcare professionals in Hubei was worse than that in Jiangsu. Poor sleep quality was associated to Our findings call for systematic intervention that are specially designed to professionals fighting against their sleep

There had been 81,058 people infected by the virus and 3204 people died of the virus according to the report by March 14, 2020 [5]. Word Health Organization(WHO) declared that the COVID-19 was Public Health Emergency of International Concern (PHEIC on January 30, 2020 [6]. Besides China, the coronavirus had been detected in 159 countries, areas or territories globally [7]. WHO called COVID-19 outbreak pandemic as virus spreads increasingly worldwide on March 11, 2020 [8]. With the increasing number of cases and widening geographical spread, the 2019 novel coronavirus disease  has been classified as one of the class B infectious diseases but prevented and controlled as class A infectious disease by the National Health Commission of China [9]. Due to lack of target drugs and vaccines, COVID-19 is considered to be a global threat to public health. Patients with COVID-19 in Wuhan accounted for the largest percentage among the total confirmed cases in China [1]. In order to cure patients infected by the coronavirus, Chinese government organized a panel of more than 300,000 healthcare professionals from other provinces of China to support Wuhan, Hubei Province and fought against COVID-19 since end of January, 2020 [9].
The transmission mode of COVID-19 seemed to be close person-to-person contact. The virus could be transmitted mostly by respiratory droplets [2]. Healthcare professionals confront high risk of infection because of close contact with patients [10] .They were under Tertiary biological protection with N95 masks, three pairs of gloves, shoulder cap, goggles, protective clothing, disposable surgical cap, visor, outer gown, boots and shoe covers [9]. As a result of growing number of patients diagnosed with COVID-19, healthcare professionals in Wuhan worked shift duties and underwent heavy load work and stress, which might predispose them to vulnerability to sleep disorders and health problem.
According to the report of the Centers for Disease Control and Prevention(CDC), more than half healthcare professionals who were on night shift duties slept six hours or less than per day [11]. Sleep deficiency and poor sleep quality were associated with poor performance and reduced health status of healthcare professionals [12,13]. Out of Hubei Province, there were lots of healthcare professionals working in fever clinic, emergency, surgery room and infectious hospitals. They screened suspected patients, diagnosed, cured and cared the patients with COVID-19. Based on the special occupational environment and work load, the objective of this study was to investigate 1) the sleep quality of healthcare professionals fighting against COVID-19 in high risk area (Hubei Province) and in low risk area (Jiangsu Province), and 2) the factors associated with sleep quality, and 3) the association between sleep quality and health status among healthcare professionals.

Study design
Cross-sectional study design conducted from February 29 to March 5, 2020.

Participants
Convenient sampling strategy was used. One hundred and thirty healthcare professionals working in Infectious Departments of Wuhan Maternal and Child health hospital Guanggu Branch and Jiangxia District First Hospital (located in Hubei Province) who were from Suzhou and Nanjing hospitals(located in Jiangsu Province) and one hundred and fifty healthcare professionals working in Suzhou and Nanjing hospitals were invited to complete self-administered anonymous questionnaires. Finally, 253 healthcare professionals agreed to participate and completed the questionnaires using their smartphones on internet page of Wenjuanxing.com. Questionnaires were anonymous to guarantee confidentiality. The participating rate was 90.36%.

Measures
Socio-demographic characteristics and work variables In the questionnaire, data about participants' socio-demographic characteristics and work variables were collected. Socio-demographic characteristics included age, gender, ethnicity, marital status and education. Work variables included occupation, years of working , work hours/day, number of shift work, work content and symptoms in work under Level 3 biological protection.
Sleep quality Sleep quality of the participants was assessed by Pittsburgh sleep quality index. It was a self-rating questionnaire for measuring subjective sleep quality [14]. The PSQI assessed seven sleep components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction. Seven component scores were summarized to yield a global PSQI score between 0 and 21; higher scores indicate worse sleep quality [14]. A global score ˃ 7 is generally indicating poor sleep quality in Chinese health adults [15].

Self-reported health status
Health status was assessed with one item in the WHOQOL assessment, WHOQOL-BREF. The item asked "How do you rate your health status at present?", and had five response categories that ranged from 1 (very poor ) to 5 (very good) [16].

Statistical analyses
Descriptive statistics were used to summarize participants' socio-demographic characteristics, working variables, global score of PSQI and the score of seven sleep components and health status.
Differences in the participants' characteristics, working variables, sleep quality and health status between Hubei and Jiangsu samples were evaluated with t test for the continuous variables and with χ2 test for the categorical variables. Multivariable logistic regression was used to test the dependent variable (poor sleep quality coded as 1 versus good sleep quality coded as 0). The explanatory variables with possible relationship to poor sleep quality were socio-demographic characteristics and working variables. We conducted univariable logistic regression analyses first. We then included those variables that were significantly associated with the dependent variable (p < 0.05) in the multivariable logistic regression analyses. Odds ratios and 95% confidence intervals were reported.
Multivariable linear regression was used to estimate the association between poor sleep quality and health. The analyses were conducted using the programs of SPSS version 22.0 (SPSS, Chicago, Ill, USA). Two-tailed p-values <0.05 were considered statistically significant. Hubei and Jiangsu samples. There were significantly differences in age, gender, marital status, education, occupation, working hours/day, number of shift work/week, job description and symptoms in work under Level 3 protection between Hubei and Jiangsu samples. Table 2 presents the participants' seven sleep component scores, global PSQI score, self-reported health status and self-reported factors related to sleep. The global PSQI score of Hubei sample and Jiangsu sample was 9.74±5.00 and 7.79±4.64, respectively. The global PSQI score and the score of subjective sleep quality, sleep latency, sleep duration and use of sleep medications in Hubei sample was significantly higher than that of Jiangsu sample (p<0.05), which indicated that healthcare professionals in Hubei Province had poorer sleep quality than those in Jiangsu Province. The percentage of poor sleep quality (global PSQI >7) in Hubei sample was significantly higher than that of Jiangsu sample (62.2%, 48.5%, respectively, p<0.05) . The score of self-reported health of Hubei sample was lower than that of Jiangsu sample( 3.30±0.93, 3.54±0.76, respectively, t=-2.211, p<0.05).  Table 4 presents results of linear regression of association between poor sleep quality and selfreported health among healthcare professionals in Hubei and Jiangsu samples. Both for Hubei and Jiangsu samples, after controlling for other covariates, poor sleep quality was associated with reduced self-reported health status (β=-0.75, p<0.01, β=-0.52, p<0.01, respectively).

Discussion
The study examined sleep quality and health status among healthcare professionals fighting against COVID-19 in high risk area (Hubei Province) and low risk area (Jiangsu Province). The sleep quality of healthcare professionals in Hubei Province and Jiangsu Province were both poor, and sleep quality of The scores of PSQI among healthcare professionals fight against COVID-19 in present study were higher than that of Chinese healthy adults (3.88±2.52) [15]. They were also higher than the average level of sleep quality of healthcare professionals in Hunan Province and Guangzhou Province, China [17,18]. Previous studies had demonstrated that healthcare professionals working on night shift had higher global PSQI score than those working on day shift or rotating shift [19,20]. The score of PSQI among Jiangsu sample was similar to that of healthcare professionals working on night shift in Guangzhou Province, China and Spain [18,19]. However, the score of PSQI among Hubei sample was higher than that of healthcare professionals working on night shift [19,20], which indicated that Thus, fear of infection was not a predictor of poor sleep quality in Jiangsu healthcare professionals.
Fatigue and dizziness in Class 3 protection were predictors of poor sleep quality for the Hubei and Jiangsu sample, respectively. Healthcare professionals under Class 3 protection often experienced mild anoxia, dizziness, sweating and fatigue. Previous study has showed that workers with workrelated physical fatigue were more likely to have insomnia [25]. The healthcare professionals in Hubei sample were from hospitals in Jiangsu Province. They set off to Wuhan, Hubei Province to help cure the patients with COVID-19 in late of January and beginning of February 2020. The working and living environment was unfamiliar for them. They worked on shift duties and kept hospital-dormitory routine every day. They were far from families. They could communicate with families by Wechat or telephone at off time, however, they usually hid their stress, fatigue and risk of infection before their families. On the other hand, they couldn't take care of families and they often felt worried about families, which might be related to poor sleep quality.

Limitations and strengths
The strengths of our study include a comparative study design that enable us to investigate levels and related factors of sleep quality among healthcare professionals fighting against COVID-19 in high risk area (Hubei Province) and low risk area (Jiangsu Province) in China. However, the COVID-19 outbreak in 2019 imposed limitations on present study. Healthcare professionals worked on heavy load, thus, the questionnaire had to be brief, self-administered and anonymous [26]. It encouraged healthcare professionals' participation and minimized stigma [27]. Considering the healthcare professionals fighting against COVID-19 often felt tired after work, we limited the items of questionnaire and we didn't collect the information about stress, coping strategy and social support, which may be related to sleep quality. So the association between stress, coping, social support and sleep quality was not explored. This study used convenient sampling strategy and it may have selective bias. The conclusion should be interpreted with caution.

Clinical implications
Our findings showed that sleep quality of healthcare professionals in Hubei Province and Jiangsu Province were both poor, and sleep quality of Hubei sample was worse than that of Jiangsu sample.
Poor sleep quality was significantly associated with poor self-reported health status for all samples.
These finding call for more attention paid to healthcare professionals' sleep quality. The American Academy of Nursing recommends that health care service and standard-setting organizations implement policies that promote the sleep health of nurses [28]. The findings may provide useful information for managers to develop a systematic sleep intervention program, which is specially designed for healthcare professionals fighting against an infectious disease outbreak. The intervention program would be beneficial to the improvement of sleep quality and health status of healthcare professionals. However, we understand that healthcare professionals in fighting against COVID-19 had experienced poor-quality sleep during the days caring patients with the coronavirus.
They need psychological intervention and emotional support just in time. If systematic intervention programs could be set up as contingency plans before an infectious disease outbreak, the healthcare professionals could receive training and support before or at the beginning of outbreak, then the healthcare professionals may cope more efficiently and less experienced poor-quality sleep and health status.

Conclusion
This is the first comparative study reporting levels and related factors of sleep quality and the association between sleep quality and health status among healthcare professionals fighting against COVID-19 in a high risk area (Hubei Province) and a low risk area (Jiangsu Province) in China. We found that sleep quality of healthcare professionals in high risk area was worse than that in low risk area. Poor sleep quality was significantly associated with poor self-reported health status. The findings suggested that sleep quality of healthcare professionals working in the front line is a concern when an infectious disease outbreaks, which calls for effective intervention programs. In future studies, establishing systematic sleep intervention programs for healthcare professionals fighting against infectious disease and exploring the effect of the intervention are needed.  Notes. CI confidence interval, OR odds ratio. *p < .05. **p < .01. ***p < .001