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. 2024 Mar 16;41:102685. doi: 10.1016/j.pmedr.2024.102685

Factors associated with insomnia and fatigue symptoms during the outbreak of Oct.7th war on Gaza: A study from Jordan

Omar Salem Gammoh a,⁎, Abdelrahim Alqudah b, Bardiah Alotaibi c
PMCID: PMC10957494  PMID: 38524272

Highlights

  • •

    Jordanians and Palestinians are integrated communities.

  • •

    The ongoing Gaza war has detrimental psychological impacts on Jordanians.

  • •

    We examined the risk factors for severe insomnia and fatigue.

  • •

    Age, sex, smoking, and self-medication with anti-histamines were all risk factors.

  • •

    Prompt care is required to address this public health challenge.

Keywords: Gaza War, Palestine, Insomnia, Fatigue, Risk factors

Abstract

Objective

The Jordanian and the Palestinian communities are tightly related, hence, the current war on Gaza also has social and psychological impacts on Jordanians. Therefore, this study aims to identify the factors associated with severe insomnia and fatigue symptoms in a cohort of Jordanians during the Gaza War outbreak.

Methods

This is a cross-sectional web-based questionnaire study. The Insomnia Severity Index-Arabic version (ISI-A), and the Brief Fatigue Inventory-Arabic (BFI-A) were employed, binary logistic and linear regression analyses was performed to identify predictors to severe insomnia and fatigue respectively. Data were collected between December 2023 and January 2024.

Results

Data were analyzed from 477 participants, of which 315 (66 %) were females, 107 (22.4 %) reported having a family relative or a friend residing in Gaza, 365 (76.5 %) reported not using any sleep aid, 78 (16.4 %) reported using homeopathy herbal remedies for sleep, and only 52 (10.9 %) reported using over-the-counter sedating antihistamines. Severe insomnia was significantly associated with participants “younger than 30 years old” (OR = 1.81, 95 %CI = 1.22–2.66, p = 0.003), participants “using over-the-counter sedating antihistamines” (OR = 2.78, 95 % CI = 1.27–6.06, p = 0.01). Severe fatigue was significantly associated with “females” (B = 5.87, t = 2.78, p = 0.006), and “smokers” (B = 5.09, t = 2.52, p = 0.01). On the other hand, “not using sleep aids” demonstrated significantly lower odds for severe insomnia (OR = 0.41, 95 % CI = 0.24–0.68, p = 0.001), and fatigue (B = -10.84, t = -4.81, p < 0.001).

Conclusions

Addressing modifiable risk factors such as smoking and sleep self-medications is essential to improve insomnia and fatigue symptoms.

1. Introduction

Insomnia, a leading sleep disturbance, is featured by difficulty in sleep initiation and maintenance (Schutte-Rodin et al., 2008). Globally, a recent worldwide study estimated insomnia prevalence between 2.3 % and 25.5 % in the general population (Zhang et al., 2019). Insomnia is associated with daytime distress, impaired function, and decreased productivity (Sateia et al., 2017). Different insomnia management strategies are employed including pharmacotherapy, and sleep hygiene approaches that help to control the symptoms and improve the quality of life (Qaseem et al., 2016)

Fatigue is characterized by tiredness, and lack of energy accompanied by physical, cognitive, and emotional distress (Mariman et al., 2013, Mota and Pimenta, 2006). Fatigue is regarded as common with high prevalence reaching up to 45 % in the community (Guessous et al., 2006).

The relationship between insomnia and fatigue is well-established, indeed, fatigue is considered the most prevailing and persistent daytime symptom of insomnia during daytime (Theorell-Haglöw et al., 2006). Also, both insomnia and fatigue share a common ground of stress and psychological disturbances (Alqahtani et al., 2022).

According to the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5), continuous exposure to shocking, horrific, and upsetting scenes leads to profound mental distress (Greinacher et al., 2019). Since the commencement of the war in Gaza on Oct.7th until drafting these lines, all the world has been exposed to horrific videos and pictures of children and women massacres, fathers carrying the remaining bodies of their children, and whole building blocks collapsing on their inhabitants.

The Jordanian and the Palestinian communities are tightly related and integrated, for example, numerous Jordanian families reside in Palestine and vice versa (Qabaha and Hamamra, 2021, Sa’di and Abu-Lughod, 2007). In other words, the war on Gaza has direct social and psychological impacts on Jordanians.

Despite the ongoing brutal war, factors associated with insomnia and fatigue have not been examined yet among Jordanians. Unraveling these risk factors helps in setting strategies to mitigate the detrimental consequences of insomnia and fatigue and provides insights for improving the community’s physical, mental, and social well-being.

Therefore, the current research aimed to identify the factors associated with severe insomnia and fatigue outcomes in a cohort of Jordanians during the ongoing war in Gaza.

2. Methodology

2.1. Study design and recruitment

This is a cross-sectional cohort study recruiting a cohort of Jordanians using a convenient sampling method using social media networks such as what’s up and Facebook. The web-based study was approved by Yarmouk University IRB committee (692/2023). All the participants read and agreed to be enrolled in the study by choosing the option “I agree to participate” right after the informed consent form provided by the corresponding author. All participants were asked to verify their nationality, only Jordanians were included in the study. The study instrument was uploaded on a Google form, and the link was distributed on different social media platforms in Jordan. The period of data collection was between 29/12/2023 and 10/01/2024, a time frame that falls within the ongoing war on Gaza. The sample size was informed based on confidence level of 95 %, confidence interval of 5 % and an estimated population size of 10 million. This resulted the need to recruit 384 participants.

2.2. Study instrument

A well-designed questionnaire was developed to achieve the study objectives as mentioned below.

2.3. Covariates

The demographics and related information were recorded. The sex, age, marital status, number of family members, highest educational level, smoking status, the relation of the participant to the medical field, employment status, previous diagnosis with chronic diseases, having relatives or friends in Gaza, the frequency of daily social media platforms checks related to Gaza war news were recorded. To explore what type of self-medication sleep aid is used by the study sample, participants were given the freedom to choose one or more options between “homeopathy herbal remedies”, “over-the-counter antihistamines”, or “had never used any sleep aid” for the past two weeks.

2.4. Outcome measures

2.4.1. Insomnia

Insomnia severity was screened using the Arabic version of the Insomnia Severity Index (ISI-A). The scale consists of seven questions that assess sleeping disturbances for the past week, each question is rated on a scale from 0 to 4 yielding a score range from zero to twenty-eight. A cut-off score of above 14 is indicative of severe insomnia symptoms, the Arabic scale is reliable (Cronbach alpha = 0.81) (Morin, 1993, Suleiman and Yates, 2011).

2.4.2. Fatigue

The second outcome variable, fatigue, was assessed using the Brief Fatigue Inventory- Arabic version (BFI-A) (Suleiman et al., 2019). The scale which is composed of nine items provides insights about the severity of fatigue and its interference with daily functioning, the scale demonstrated to be reliable (Cronbach alpha = 0.93) (Mendoza et al., 1999).

2.5. Data analysis

The demographical data of the study sample was described as frequencies and percentages. The study identifies two outcome variables “severe insomnia” and “severe fatigue” symptoms. Insomnia was treated as a categorical outcome variable: “severe” and “non-severe”. To determine what covariates are associated with severe insomnia, a preliminary univariate logistic regression was performed, followed by a multivariable logistic regression for the potentially confounding factors showing p < 0.1. Fatigue, on the other hand, was treated as a scale variable, with an increasing score reflecting higher fatigue severity. To determine what covariates were associated with severe fatigue, a preliminary univariate linear regression analysis was performed, followed by a multivariable linear regression for the potentially confounding factors showing p < 0.1. The Confidence intervals were set at 95 % and significance was set at p < 0.05. Data were analyzed using SPSS version 21.

3. Results

3.1. Sample features

Data were analyzed from 477 participants, of which 315 (66 %) were females, 304 (63.7 %) were below 30 years old, 395 (82.6 %) hold bachelor degree, 289 (60.6 %) were non-smokers, 398 (83.6 %) were free from any chronic disease, 107 (22.4 %) reported having a family relative or a friend residing in Gaza, 242 (50.7 %) reported checking their social media platforms more than 6 times daily for news updates. In regards to the sleep aid used by the study sample for the past two weeks, 365 (76.5 %) reported not using any sleep aid, 78 (16.4 %) reported using homeopathy herbal preparations for sleep such as anise, fennel, and only 52 (10.9 %) reported using over-the-counter sedating antihistamines. Table 1.

Table 1.

Descriptive statistics of the study sample (n = 477) from Jordan during (December 2023-January 2024) showing the demographics and clinical information as frequencies and percentages.

Factor Category n (%)
Sex Male 162 (34)
Female 315 (66)
Age Below 30 years 304 (63.7)
31 years and above 173 (36.3)
Family members Less than 5 235 (49.3)
5 and more 242 (50.7)
Highest Education Bachelors 395 (82.6)
Graduate studies 82 (17.2)
Employment status Unemployed 311 (65.2)
Employed 166 (34.8)
Medical field No 245 (51.4)
Yes 232 (48.6)
Smoking status Non-smoker 289 (60.6)
Smoker 188 (39.4)
Diagnosed with chronic diseases? No 398 (83.6)
Yes 78 (16.4)
Do you have friends or relatives in Gaza? No 370 (77.6)
Yes 107 (22.4)
How many times a day you check social media platforms? Five times a day or less 235 (49.3)
Six times and more daily 242 (50.7)
I use herbal homeopathy preparations for sleep 78 (16.4)
I use over-the-counter antihistamines for sleep 52 (10.9)
I do not use any sleep aids 365 (76.5)
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3.2. Correlates of insomnia

Insomnia severity was determined based on a score > 14 according to the ISI-A scale. To identify the determinants of severe insomnia, an initial univariate logistic regression analysis was carried out to identify potential confounders. Next, potential confounders showing p < 0.1 were included in the subsequent multivariable regression. The multivariable model initially included: age, marital status, employment status, medical field, use of homeopathy herbal preparations, using over-the-counter sedating antihistamines, and not using sleep aids. The final model was adjusted for age, using over-the-counter sedating antihistamines, I do not use any sleep aids. The model revealed that severe insomnia was significantly associated with participants “younger than 30 years old” (OR = 1.81, 95 %CI = 1.22–2.66, p = 0.003), participants “using over-the-counter sedating antihistamines” (OR = 2.78, 95 %CI = 1.27–6.06, p = 0.01). On the other hand, participants who reported “not using sleep aids” demonstrated significantly lower odds for severe insomnia (OR = 0.41, 95 % CI = 0.24–0.68, p = 0.001). Table 2.

Table 2.

Univariate logistic regression analysis to investigate the associations between the covariates and severe insomnia (dependent variable) in the study sample from Jordan during (December 2023-January 2024).

Factor OR 95 % CI p-value
Female gender 1.35 0.93–1.99 0.12
Younger than 30 years old 1.68 1.16–4.32 0.006*
Married 0.61 0.42–0.90 0.01*
Five or more family members 1.16 0.81–1.66 0.42
Graduate studies 0.76 0.47–1.24 0.27
Employed 0.72 0.49–1.05 0.08
Medical field 1.36 0.95–1.95 0.09
Smoking 1.06 0.74–1.53 0.74
Diagnosed with chronic diseases 1.30 0.80–2.11 0.29
Having friends or relatives in Gaza 1.38 0.90–2.13 0.14
Six times or more reviews of social media platforms daily 1.32 0.92–1.90 0.12
I use herbal homeopathy preparations for sleep 2.31 1.40–3.82 0.001*
I use over-the-counter antihistamines for sleep 4.93 2.47–9.85 <0.001*
I do not use any sleep aids 0.31 0.19–0.48 <0.001*
Multivariable logistic regression analysis final model for the significant factors associated with severe insomnia (dependent variable) in the study sample from Jordan during (December 2023-January 2024)
Factor OR 95 % CI p-value
Younger than 30 years old 1.81 1.22–2.66 0.003*
I use over-the-counter antihistamines for sleep 2.78 1.27–6.06 0.01*
I do not use any sleep aids 0.41 0.24–0.68 0.001*
Severe insomnia was assessed using the ISI-A using a cut-off score above 14. OR: Odds ratio, CI: confidence interval, *p < 0.05. R2: 0.10
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3.3. Correlates of fatigue

Fatigue was assessed using the BFI-A scale, with a higher score indicating higher fatigue severity. To identify the potential predictors for severe fatigue, an initial univariate linear regression model was pursued, factors showing p < 0.1 were then included in a multivariable model. This model for fatigue as the “dependent variable” firstly included: “gender”, “age”, “medical field”, “smoking”, and “Having friends or relatives in Gaza”, I use herbal homeopathy preparations for sleep, using over-the-counter sedating antihistamines”, and “not using sleep aids”. The model was finally adjusted for “female”, “age above 31’, “smoking”, “Having friends or relatives in Gaza”, and “not using sleep aids”. The model revealed that severe fatigue was significantly associated with “females” (B = 5.87, t = 2.78, p = 0.006), and “smokers” (B = 5.09, t = 2.52, p = 0.01). Conversely, the multivariable regression analysis revealed that less fatigue severity was associated with participants “aged above 31 years” (B = -6.73, t = -3.46, p = 0.001) and who “did not use sleep aids” (B = -10.84, t = -4.81, p < 0.001). Table 3A and 3B.

Table 3.

Univariate linear regression analysis to investigate the associations between the covariates and fatigue severity (dependent variable) in the study sample from Jordan during (December 2023-January 2024).

Factor B t p 95 % CI
Female gender 5.75 2.72 0.007* 1.60–9.91
Age above 31 years −6.94 −3.42 0.001* −10.92- −2.95
Married −4.82 −2.31 0.02* −8.92- −0.72
Five or more family members 1.31 0.65 0.51 −2.64–−5.23
Graduate studies 1.46 0.35 0.58 −3.79–6.72
Employed 0.86 0.41 0.68 −3.29–5.02
Medical field 4.83 2.41 0.01* 0.89–8.71
Smoking 3.48 1.69 0.09* −0.56–7.52
Diagnosed with chronic diseases −1.20 −0.44 0.66 −6.56–4.15
Having friends or relatives in Gaza 10.39 4.38 <0.001* 4.04–14.62
Six times or more reviews of social media platforms daily 2.11 1.05 0.30 −1.84–6.07
I use herbal homeopathy preparations for sleep 9.33 3.47 <0.001* 4.04–14.62
I use over-the-counter antihistamines for sleep 13.94 4.40 <0.001* 7.71–20.17
I do not use any sleep aids −12.12 −5.24 <0.001* −16.67–7.58
Multivariable linear regression analysis final model for the significant factors associated with fatigue severity (dependent variable) in the study sample from Jordan during (December 2023-January 2024)
Factor B t p 95 % CI
Female gender 5.87 2.78 0.006* 1.72–10.04
Age above 31 years −6.73 −3.46 0.001* −10.55–2.92
Smoking 5.09 2.52 0.01* 1.13–9.06
Having friends or relatives in Gaza 9.91 4.36 <0.001* 5.44–14.38
I do not use any sleep aids −10.84 −4.81 <0.001* −15.27- −6.42
Fatigue was assessed using the BFI-Arabic version, where a higher score indicates higher fatigue. CI: confidence interval, *p < 0.05. R2 = 0.13
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4. Discussion

The present study aimed to identify the correlates of insomnia and fatigue in a cohort of Jordanians witnessing the war in Gaza.

According to our results, the severity of insomnia was associated with young age (below 30 years old) and using the OTC sleep aids. On the other hand, lower insomnia severity was significantly associated with not using any sleep aid.

The study of insomnia and its risk factors is still emerging in developing countries such as Jordan. This study revealed that severe insomnia was associated with young age. This finding is challenged by previous studies confirming that insomnia severity increases with aging. Several factors contribute to poor sleep quality, for example the presence of chronic illnesses such as cardiovascular diseases, cancer, in addition, the use of chronic medications could predispose patients to side effects of insomnia. These factors could also interact with environmental stressors thus exacerbating the overall sleep quality (Al Maqbali et al., 2022, BaHammam and Pandi-Perumal, 2010).

The findings of this study can be explained by the fact that younger adults could spend more time on social media to follow war news (Bhat et al., 2018), in addition, it can be hypothesized that younger adults lack resilience and coping mechanisms to alleviate insomnia (Palagini et al., 2018).

Although the management of insomnia depends on pharmacotherapy in primary care settings where family practitioners prescribe sedatives and hypnotics, (Miller et al., 2017), however, the present study focused on the self-medication findings of our study the tendency of the participants to use homeopathy remedies (16.4 %), followed by OTC antihistamines (10.9 %), this can be due to the perception that these options are non-addictive and more accessible and safe options, this pattern is seen in similar studies where natural products and OTC medications were demanded more than prescriptions for sedatives (Miller et al., 2017, Pallesen et al., 2001).

The findings of this study demonstrated that the use of OTC antihistamines was associated with poor sleep outcomes. This can be explained in part by the fact that OTC antihistamines fail to control insomnia symptoms, this explanation is supported by previous studies showing that the efficacy of antihistamines in insomnia is still controversial and requires high-quality evidence (Culpepper and Wingertzahn, 2015, Vande Griend and Anderson, 2012). Another explanation could be that participants experiencing higher insomnia were using the OTC antihistamines to control their insomnia symptoms.

The findings of this study revealed the preference for not using sleep-aid medications as the vast majority of the respondents are not currently on any sleep aid. Effective insomnia management strategies involve non-medicated approaches such as sleep hygiene and others (Everitt et al., 2014). This non-pharmacological approach proved to be effective, this could explain in part that in our study “not using sleep aids” was associated with better insomnia outcomes.

Our findings revealed that higher fatigue severity was associated with females, smoking, and having relatives or friends in Gaza. On the other hand, lower fatigue severity was evident in participants with older age and who were not using any sleep aid.

Previous studies confirmed that females report higher fatigue compared to males. This could be explained by the multiple tasks women are performing such as household responsibilities (Fieo et al., 2014). Also, findings of the current study showed that fatigue decreases with age, this has been confirmed in previous literature (Lerdal et al., 2005) and could be explained by the highly stressful and demanding life experienced by younger individuals (Lerdal et al., 2005). Moreover, in the present study, “not using any sleep aid” was related to better fatigue outcomes. This is consistent with the finding that insomnia outcomes are better without the use of sleep aids. Fatigue and insomnia are closely related symptoms and could lead to a vicious cycle (Alqahtani et al., 2022, Theorell-Haglöw et al., 2006). Although the majority of the participants did not use sleep aids, however, exploring the non-pharmacological approach (if any) is an attractive objective to pursue in future studies.

5. Limitations

The present study represents the first attempt to highlight the importance of insomnia and fatigue symptoms among Jordanians as a result of the destructive war on their relatives in Gaza. This brutal war with unacceptable support from some countries impacted the whole world and perhaps had a negative impact on mental health globally. Jordanians, being the closest geographically, socially, and culturally are expected to me the most affected by this horrific war.

Although the research idea, the prompt implementation, and the validated scales are all strengths, however, the cross-sectional design did not allow for investigating insomnia and fatigue at different time points, also, the design allowed to investigate associations but not causal relationships. Also, the study did not involve the diagnosis of insomnia and fatigue by specialized healthcare providers, however, the validated and reliable scales are considered acceptable tools in such community-based screening studies (Gammoh et al., 2023, Gerber et al., 2016, Léger et al., 2012).

6. Conclusion

In conclusion, insomnia and fatigue are tightly related and understudied disorders in Jordan. Age and gender are considered important risk factors for severe insomnia and fatigue. While using OTC sleep aids was associated with higher insomnia severity, however, not using any sleep aids was associated with significantly lower insomnia and fatigue severity. National-wide targeted campaigns are required to raise awareness about the risk factors and the proper management of stress-induced disorders including insomnia and fatigue in Jordan during and after the war.

CRediT authorship contribution statement

Omar Salem Gammoh: Investigation, Formal analysis, Conceptualization. Abdelrahim Alqudah: Conceptualization. Bardiah Alotaibi: Resources, Funding acquisition.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

“Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2024R73), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia’’. Also, the corresponding author would like to thank Nour, Yasmina, Suzi, and Sama.

Data availability

Data will be made available on request.

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Data Availability Statement

Data will be made available on request.

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