Abstract
The outbreak of novel coronavirus pneumonia in Wuhan, Hubei Province, in 2019 and its rapid spread across the country caused severe public panic in China. The purpose of this study was to investigate the mental health problems of children’s chaperones at the emergency clinic during the coronavirus disease 2019 (COVID-19) outbreak and to analyze the related influencing factors. A total of 260 chaperones for children in the emergency department participated in this cross-sectional study through the questionnaire constellation platform. The survey period was from February to June 2021. Information collected included demographic data and mental health scales. The Self-Assessment Scale for Anxiety, the Self-Rating Scale for Depression, and the Pittsburgh Sleep Quality Index assessed anxiety, depression, and sleep quality, respectively. Logistic regression was used to analyze influential factors associated with mental health problems. The prevalence of depression, anxiety, and sleep disorders among family members accompanying children attending the emergency room was 41.54%, 20.00%, and 93.08%, respectively, with 21.54% of family members suffering from moderate sleep disorders. Univariate analysis showed that being in Wuhan or not during the city closure (X2 = 8.61, P < .01) was strongly associated with the occurrence of depression; female (X2 = 4.87, P = .03), working or not (X2 = 6.39, P = .01) and fear of going to the hospital (X2 = 7.80, P = .01) were key factors for the occurrence of anxiety symptoms; Knowledge of transmission routes and prevention of COVID-19 (X2 = 12.56, P = .03) was a key factor for sleep disorders; logistic stepwise regression analysis showed that fear of going to the hospital was a risk factor for anxiety symptoms (odds ratio = 2.51, P < .01, 95% confidence interval = 1.30–4.85). Our findings suggest that mental health problems were prevalent among family members accompanying children attending the emergency department during the COVID-19 outbreak, with a high prevalence of sleep disturbances in particular. Relevant factors included presence or absence in Wuhan during the outbreak closure, gender, work or absence, and fear of hospital visits. There is a need to focus on the mental health distress of the chaperones for children in the emergency department, and to provide timely intervention and diversion.
Keywords: anxiety, chaperones for children in the emergency department, COVID-19, depression, sleep disorders
1. Introduction
Coronavirus disease 2019 (COVID-19) is a human-to-human infectious disease caused by a novel coronavirus called severe acute respiratory syndrome coronavirus 2 that can cause a complex set of symptoms, primarily involving the respiratory tract, but in many cases also affecting multiple organs, leading to life-threatening illness and even death. Compared to other categories of coronaviruses, such as severe acute respiratory syndrome and Middle East respiratory syndrome coronaviruses, COVID-19 has emerged as the disease with the highest mortality rate.[1] On January 30, 2020, the World Health Organization Committee on Emergencies designated COVID-19 as a global health emergency. To date, 347 million people have been infected and 5.57 million have died worldwide.[2]
Due to its high risk of transmission, COVID-19 has rapidly spread throughout the country, causing great public concern and panic.[3–5] As a result, COVID-19 not only threatens people’s physical health but also severely afflicts their psychological health. An online survey showed that 31.3% and 36.4% of the general Chinese population experienced symptoms of depression and anxiety, respectively, during the COVID-19 outbreak, and that these mental health problems are likely to develop into long-term mental health problems.[6,7]
The COVID-19 virus is rapidly mutating and highly contagious, which has led to a shift in the management model of medical institutions, and thus the general public may experience psychological distress when they come to the hospital. The emergency department is a key treatment unit for acute and critical illnesses, and patients attending the emergency department often have an acute onset and poor prognosis, which causes most patients’ accompanying family members to show negative emotions such as anxiety, anxiety, and fear. Most of the children in the pediatric emergency department are young and have difficulty expressing their discomfort, which makes them uncooperative and noisy. More importantly, during the COVID-19 outbreak, the family members accompanying the children are extremely prone to negative experiences in the face of the changing management model of the medical institution, as well as the fear that the children will suffer from the disease and have a poor prognosis, leading to negative emotions such as depression and anxiety. This leads to the growth of negative emotions such as depression and anxiety.
In this study, we investigated the probability and risk factors for depression, anxiety, and sleep disturbances in chaperones for children in the emergency department during the COVID-19 outbreak, in order to provide appropriate management strategies and targeted intervention strategies to maintain the physical and mental health of the children’s families.
2. Method
2.1. Participants
The protocol of the study was approved by the ethics committee of Wuhan Children’s Hospital. Prior to taking part in the trial, every participant signed an informed consent form. From February to June 2021, chaperones for children in the emergency department’s detention ward were chosen to participate in the survey. Inclusion criteria were primary caregiver of the child in the emergency admission ward; possession of a cell phone smart terminal and ability to use it; clear consciousness and ability to express their thoughts and wishes correctly; and signing the informed consent form and voluntarily joining this research project. Exclusion criteria were severe cognitive dysfunction and communication impairment; and those who had participated in other similar studies.
2.2. Study design and questionnaire survey
A cross-sectional study was used in this study. The questionnaire used in the study was designed by epidemiologists and collected online through the Questionnaire Constellation platform (https://www.wjx.cn/). To ensure that participants did not duplicate questionnaires, the same IP address could only be submitted once. The questionnaires were conducted by professionally trained physicians to strictly control the quality of the questionnaires. Structured questionnaires were used to collect personal data, the survey was anonymous, and the information in the questionnaire ensured confidentiality. Between February and June 2021, 265 questionnaires were distributed, and 260 valid questionnaires were eventually returned. Missing basic information (demographics) in the recovered questionnaires was added by contacting the individuals who filled out the questionnaires or based on the hospital medical record system.
2.3. Measurement tools
Self-Assessment Scale for Anxiety (SAS), Self-Rating Scale for Depression (SDS), and Pittsburgh Sleep Quality Index (PSQI) were used to screen for anxiety, depression, and sleep quality, respectively.
The SAS was developed by W.K. Zung in 1971.[8] There are 20 items, each of which is scored 1 to 4, for a total of 80 points. The total score is obtained by adding the individual scores of the 20 items; the standard score is obtained by multiplying the total score by the integer part after 1.25. SAS ≥ 50 identifies as anxiety symptoms.[9,10]
The SDS was developed by W.K. Zung in 1965.[11–13] The SDS is composed of 20 question entries that respond to 4 specific symptoms of psychotic, somatic disorders, psychomotor disorders, and depressive psychological disorders. The score of the 20 entries is the total score, and the standard score is equal to the total score multiplied by the integer part of 1.25, the smaller the score the better. SDS ≥ 53 was considered depressive symptoms.[14,15]
The PSQI was developed by Buysse et al in 1989 for the overall assessment of sleep status over time.[16,17] The PSQI consists of 19 self-rated and 5 other rated items, of which 18 are scored items with 7 dimensions and a total score of 0 to 21, with higher scores indicating poorer sleep quality. In this study, a score of ≥7 was considered a positive sleep disorder population.
2.4. Statistical analysis
ANOVA and chi-square tests were used to compare continuous and categorical variables, respectively. All demographic and clinical data were normally distributed among the investigators and expressed by descriptive statistics (n, %). Demographic information and clinical variables were tested by the chi-square test. The prevalence of depression, anxiety, and sleep disorders was described by percentages. Anxiety-related factors were analyzed using dichotomous logistic stepwise regression. All analyses were performed using SPSS software (Version 21, SPSS Inc., Chicago, IL). All tests were 2-tailed, and statistical significance was defined as P < .05.
3. Results
A total of 260 family members accompanying children attending the emergency department participated in this cross-sectional survey. Table 1 shows that the anxiety, depression, and sleep scores of the family members accompanying children in the emergency department were 43.10 ± 7.54, 49.49 ± 10.64, and 9.78 ± 2.18, respectively. The prevalence of anxiety (SAS ≥ 50) and depression (SDS ≥ 53) in the families of 260 children was 20.00% and 41.54%, respectively. The percentage of accompanying family members of children with PSQI ≥ 7 was 93.08%, of which 21.54% were accompanied by moderate sleep disorders, suggesting that sleep disorders were present in the accompanying family members of >90% of children attending the emergency department during the COVID-19 outbreak.
Table 1.
Incidence of depression, anxiety, and sleep disorder symptoms (N = 260).
| Number of cases | SDS incidence (%) | χ 2 | P | SAS incidence (%) | χ 2 | P | PSQI incidence (%) | χ 2 | P | |
|---|---|---|---|---|---|---|---|---|---|---|
| Gender | 0.47 | .83 | 4.87 | .03 | 2.03 | .15 | ||||
| Man | 110 (42.31) | 44 (40.00) | 15 (13.64) | 100 (90.91) | ||||||
| Women | 150 (57.70) | 62 (41.33) | 37 (24.67) | 142 (94.67) | ||||||
| Age (yr) | 1.31 | .52 | 0.26 | .88 | 0.17 | .92 | ||||
| ≤30 | 110 (42.31) | 44 (40.00) | 23 (20.81) | 120 (92.73) | ||||||
| 30~40 | 118 (45.38) | 46 (39.00) | 22 (18.64) | 111 (94.07) | ||||||
| >40 | 32 (12.31) | 16 (50.00) | 7 (21.88) | 30 (93.75) | ||||||
| Occupation and medical related or not | 1.31 | .25 | 0.44 | .74 | 1.11 | .61 | ||||
| Yes | 15 (5.77) | 4 (26.67) | 2 (13.33) | 15 (100.00) | ||||||
| Not | 245 (94.23) | 102 (41.63) | 50 (20.41) | 228 (93.06) | ||||||
| Education | 0.88 | .35 | 2.83 | .10 | 0.46 | .50 | ||||
| College and below | 143 (55.00) | 62 (43.63) | 34 (23.78) | 135 (94.41) | ||||||
| Bachelor’s degree or above | 117 (45.00) | 44 (27.61) | 18 (15.38) | 108 (90.32) | ||||||
| Number of children | 0.30 | .58 | 0.60 | .44 | 2.34 | .13 | ||||
| 1 | 167 (64.23) | 66 (39.52) | 31 (18.56) | 159 (95.21) | ||||||
| ≥2 | 93 (35.77) | 40 (43.01) | 21 (22.58) | 84 (90.32) | ||||||
| Work or not | 0.29 | .59 | 6.39 | .01 | 0.08 | .78 | ||||
| Yes | 191 (73.46) | 76 (39.79) | 31 (16.23) | 179 (93.72) | ||||||
| Not | 69 (26.54) | 30 (43.48) | 21 (30.43) | 64 (92.75) | ||||||
| Only child or not | 0.12 | .91 | 2.94 | .09 | 0.03 | .87 | ||||
| Yes | 102 (39.23) | 42 (41.18) | 15 (14.71) | 95 (93.14) | ||||||
| Not | 158 (60.77) | 64 (40.51) | 37 (23.42) | 148 (93.37) | ||||||
| Whether an only child or not | 8.61 | .00 | 3.65 | .06 | 1.61 | .21 | ||||
| Yes | 174 (66.92) | 60 (34.50) | 29 (16.67) | 165 (94.83) | ||||||
| Not | 86 (33.08) | 46 (53.49) | 23 (26.74) | 78 (90.70) | ||||||
| Whether with families during the COVID-19 outbreak or not | 0.20 | .89 | 0.01 | .92 | 0.57 | .44 | ||||
| Yes | 229 | 93 (40.61) | 46 (20.09) | 215 (93.90) | ||||||
| Not | 31 | 13 (41.94) | 6 (19.35) | 28 (90.32) | ||||||
| With family recently or not | 2.66 | .10 | 0.00 | 1.00 | 1.35 | .22 | ||||
| Yes | 235 | 92 (39.15) | 47 (20.00) | 221 (94.04) | ||||||
| Not | 25 | 4 (16.00) | 5 (20.00) | 22 (88.00) | ||||||
| Family member infected with COVID-19 or not | 0.05 | .82 | 0.03 | 1.00 | 0.32 | .46 | ||||
| Yes | 9 (3.46) | 4 (21.05) | 2 (10.53) | 8 (88.89) | ||||||
| Not | 251 (96.54) | 102 (40.64) | 50 (19.92) | 235 (93.63) | ||||||
| Elderly people living together or not | 0.30 | .58 | 1.36 | .24 | 0.23 | .63 | ||||
| Yes | 167 (64.23) | 66 (39.52) | 37 (22.16) | 157 (94.01) | ||||||
| Not | 93 (35.77) | 40 (43.01) | 15 (16.13) | 86 (92.47) | ||||||
| Knowledge of the COVID-19 or not | 1.97 | .31 | 0.06 | 1.00 | 12.56 | .02 | ||||
| Yes | 256 (98.46) | 103 (40.23) | 51 (19.92) | 241 (94.14) | ||||||
| Not | 4 (1.54) | 3 (75.00) | 1 (25.00) | 2 (50.00) | ||||||
| Worry about going to the hospital or not | 3.09 | .08 | 7.80 | .01 | 0.84 | .36 | ||||
| Yes | 135 (51.92) | 62 (45.93) | 36 (26.67) | 128 (94.81) | ||||||
| Not | 125 (48.08) | 44 (35.20) | 16 (12.80) | 115 (92.00) | ||||||
| Number of family members caring for the child | 0.98 | .32 | 0.52 | .47 | 0.01 | .92 | ||||
| 1 | 89 (34.23) | 40 (44.94) | 20 (22.47) | 83 (93.26) | ||||||
| ≥2 | 171 (65.77) | 66 (38.60) | 32 (18.71) | 160 (93.57) | ||||||
| Average household income (RMB/mo) | 1.73 | .19 | 0.10 | .75 | 0.84 | .36 | ||||
| ≤8000 | 110 (42.31) | 50 (45.45) | 23 (20.91) | 101 (91.82) | ||||||
| >8000 | 150 (57.69) | 56 (37.33) | 29 (19.33) | 142 (94.67) |
COVID-19 = coronavirus disease 2019, PSQI = Pittsburgh Sleep Quality Index, SAS = Self-Assessment Scale for Anxiety, SDS = Self-Rating Scale for Depression.
Second, Table 1 also shows that staying in Wuhan during the COVID-19 outbreak (X2 = 8.61, P = .003) was a significant factor for depressive symptoms; being female (X2 = 4.87, P = .03), working (X2 = 6.39, P = .01), and fear of going to the hospital (X2 = 7.80, P = .01) were key factors for anxiety symptoms. Knowledge of COVID-19 transmission routes and prevention and control (X2 = 12.56, P = .03) was a key factor for sleep disturbance.
Next, with anxiety symptoms as the dependent variable (assigned values: no anxiety symptoms = 1, with anxiety symptoms = 2) and variables with statistical differences in Table 1 as independent variables, the results of the dichotomous logistic stepwise regression analysis showed that fear of going to the hospital (odds ratio = 2.51, P = .006, 95% confidence interval = 1.298–4.85) was associated with anxiety in the chaperones for children in the emergency department (Table 2).
Table 2.
Dichotomous logistic stepwise regression analysis of factors influencing anxiety symptoms.
| Independent variable | B | SE | Wals χ2 | P | OR (95% CI) |
|---|---|---|---|---|---|
| Gender (“man” as reference) | 0.60 | 0.36 | 2.76 | .09 | 1.81 (0.90–3.64) |
| Work or not (“Not” as reference) | -0.63 | 0.35 | 3.26 | .07 | 0.53 (0.27–1.06) |
| Worry about going to the hospital or not (“Not” as reference) | 0.92 | 0.34 | 7.47 | <.01 | 2.51 (1.29–4.85) |
| Constant | -3.72 | 0.72 | 26.93 | <.01 | 0.02 |
Bold value: significance.
CI = confidence interval, OR = odds ratio, SE = standard error.
4. Discussion
To our knowledge, this is the first investigation of the prevalence and factors associated with depression, anxiety, and sleep quality among family members accompanying children seen in the emergency department during the COVID-19 outbreak. We found that depression, anxiety, and sleep disturbances were prevalent among family members accompanying children seen in the emergency department during the COVID-19 outbreak. In addition, several demographic and clinical variables were also considered as risk factors for psychological distress among chaperone family members of children attending the emergency department, such as being female, staying in Wuhan during the outbreak closure, and visiting the hospital.
The results of this study showed that family members accompanying children attending the emergency department during the COVID-19 outbreak had varying degrees of psychological distress problems, including anxiety and depression, with sleep disturbances being the most prominent. Cénat et al found[18–20] that the prevalence of sleep disturbances in the general population during COVID-19 was 23.87%. The higher prevalence of sleep disorders in the families of the children in this study may be related to family concerns about the children’s disease and to the fact that the transmission of COVID-19 has not been fully controlled. The epidemic has caused significant stress. The relationship between stress and sleep has been reported in the literature to be reciprocal.[21,22] As COVID-19 is extremely contagious, the families of children with the disease are more stressed during the visit for fear of being infected, thus remaining tense, excited, and alert. Secondly, the condition of the child in the emergency room may deteriorate rapidly at any time, and the family members often experience uneasiness and anxiety during the consultation, especially the mother of the child.[23] Because anxiety and restlessness and other adverse emotions can adversely affect sleep,[24–27] which in turn can lead to sleep disorders.[28,29] In addition, the noisy environment of the emergency holding ward and concerns can easily lead to reduced psychological flexibility of the family members. As a result, the incidence of sleep disorders in the child’s family will be higher. As anxiety, depression, and sleep disorders interact, the psychological burden caused by insomnia in the child’s family members tends to blame insomnia for their bad moods during the day such as irritability, anxiety, and depression, thus weakening their psychological tolerance and regulation.
Wuhan was the most severely affected area in China. After the outbreak, Wuhan was on lockdown for close to 3 months. To prevent infection, most Wuhan residents had to stay at home and isolated from society. As a result, most Wuhan residents may not only suffer from the epidemic, but also from isolation and stress.[18] This study found that being blockaded in Wuhan during the COVID-19 outbreak was a significant factor in the depressive symptoms of the families of the affected children. The prevalence of depressive symptoms among family members accompanying children attending the emergency department was higher than in previous studies[15] and the prevalence of depression was higher among family members of children who were not in Wuhan during the COVID-19 outbreak, which may be due to the fact that family members who were not in Wuhan may have serious concerns about the unknown status of the child’s illness, thus increasing the prevalence of depressive symptoms.
To our knowledge, current studies on psychological status and insomnia during COVID-19 outbreaks have focused on medical personnel and adult patients, with less attention paid to chaperones for children in the emergency department. However, attention to the psychological state of the child’s family has important clinical and prognostic implications. Families of children with chronic poor psychological status are more likely to experience stress, fatigue, and mental health problems, which lead to a reduced quality of life and a high risk of neurological disorders that may have many negative effects on the child’s development.
5. Limitations
This study has several limitations. First, it was a cross-sectional study that could not explore the causal relationship between psychological state and other variables. Second, the sample size was relatively small. And, there was a lack of investigation into the prevalence of depression, anxiety, and insomnia in the chaperones for children in the emergency department before the outbreak of COVID-19, so there was no suitable control to match. Third, the questionnaire was self-designed and there was no standardized questionnaire to investigate social and psychological factors; fourth, the data in this paper were obtained from the families of the children and could not be extended to other populations at this time.
6. Policy recommendations
To gain a comprehensive understanding of the mental health status of the primary caregivers of children in the emergency setting, so that targeted psychological intervention strategies can be developed to maintain the physical and mental health of the community. In this study, we found that families of children in emergency care had different levels of mental health problems in the new coronary pneumonia epidemic, with sleep problems being more serious. It is recommended that in future clinical work, the psychological safety of families of children in emergency care should be enhanced through a simplified access environment and easily accessible health information. This study provides data on the current psychological status of families of children in emergency care under epidemic conditions and provides a reference for future targeted solutions that will help to further optimize emergency childcare visits.
7. Conclusion
In conclusion, during the COVID-19 outbreak, the incidence of depression, anxiety, and sleep disturbances among family members accompanying children seen in the emergency room was much higher than usual. We should pay attention not only to patients but also to the group of children’s family members. We should guide the chaperones for children in the emergency department to improve their psychological stress reduction and self-adjustment ability and carry out targeted psychological intervention therapy when necessary to reduce psychological stress and improve poor mental health.
Author contributions
Conceptualization: Zaihua Wang.
Data curation: Li Wang, Jun Yang, Pei Wang.
Formal analysis: Jili Zeng.
Resources: Jun Yang.
Writing – original draft: Hanlan Jiang.
Writing – review & editing: Zaihua Wang.
Abbreviations:
- COVID-19
- coronavirus disease 2019
- PSQI
- Pittsburgh Sleep Quality Index
- SAS
- Self-Assessment Scale for Anxiety
- SDS
- Self-Rating Scale for Depression
HJ and JZ contributed equally to this work.
This study was supported by Hubei Provincial Health and Health Commission Project (Project No. WJ2021F020).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Jiang H, Zeng J, Wang L, Yang J, Wang P, Wang Z. Prevalence, risk factors, and clinical correlates of anxiety, depression, and sleep disorders in chaperones for children in the emergency department in China during COVID-19. Medicine 2023;102:10(e32828).
Contributor Information
Hanlan Jiang, Email: jianghanlan@zgwhfe.com.
Jili Zeng, Email: zeng_jili712@163.com.
Li Wang, Email: wangzaihua@zgwhfe.com.
Jun Yang, Email: yangjun1@zgwhfe.com.
Pei Wang, Email: wangzaihua@zgwhfe.com.
References
- [1].Zu ZY, Jiang MD, Xu PP, et al. Coronavirus disease 2019 (COVID-19): a perspective from China. Radiology. 2020;296:E15–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].Peeling RW, Heymann DL, Teo YY, et al. Diagnostics for COVID-19: moving from pandemic response to control. Lancet. 2022;399:757–68. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Abbas J. The impact of coronavirus (SARS-CoV2) epidemic on individuals mental health: the protective measures of pakistan in managing and sustaining transmissible disease. Psychiatr Danub. 2020;32:472–7. [DOI] [PubMed] [Google Scholar]
- [4].Zeidabadi S, Abbas J, Mangolian Shahrbabaki P, et al. The effect of foot reflexology on the quality of sexual life in hemodialysis patients: a randomized controlled clinical trial. Sex Disabil. 2022;40:567–81. [Google Scholar]
- [5].Wang C, Horby PW, Hayden FG, et al. A novel coronavirus outbreak of global health concern. Lancet. 2020;395:470–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17:1729. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Zhou Y, Draghici A, Abbas J, et al. Social media efficacy in crisis management: effectiveness of non-pharmaceutical interventions to manage COVID-19 challenges. Front Psychiatry. 2022;12:626134. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12:371–9. [DOI] [PubMed] [Google Scholar]
- [9].Roberts NJ, McAloney-Kocaman K, Lippiett K, et al. Levels of resilience, anxiety and depression in nurses working in respiratory clinical areas during the COVID pandemic. Respir Med. 2021;176:106219. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10].Jiakui C, Abbas J, Najam H, et al. Green technological innovation, green finance, and financial development and their role in green total factor productivity: empirical insights from China. J Clean Prod. 2023;382:135131. [Google Scholar]
- [11].Cansel N, Tetik BK, Demir GH, et al. Assessment of psychological responses and related factors of discharged patients who have been hospitalized with COVID-19. Psychiatr Danub. 2021;33:611–9. [DOI] [PubMed] [Google Scholar]
- [12].Aqeel M, Rehna T, Shuja KH, et al. Comparison of students’ mental wellbeing, anxiety, depression, and quality of life during COVID-19’s full and partial (smart) lockdowns: a follow-up study at a 5-month interval. Front Psychiatry. 2022;13:835585. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [13].Abbas J, Aman J, Nurunnabi M, et al. The impact of social media on learning behavior for sustainable education: Evidence of students from selected universities in Pakistan. Sustainability. 2019;11:1683. [Google Scholar]
- [14].Zung WW. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63–70. [DOI] [PubMed] [Google Scholar]
- [15].Dunstan DA, Scott N, Todd AK. Screening for anxiety and depression: reassessing the utility of the Zung scales. BMC Psychiatry. 2017;17:329. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Farzadfar F, Naghavi M, Sepanlou SG, et al. Health system performance in Iran: a systematic analysis for the global burden of disease study 2019. Lancet. 2022;399:1625–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [17].Buysse DJ, Reynolds CR, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213. [DOI] [PubMed] [Google Scholar]
- [18].Zhuang D, Abbas J, Al-Sulaiti K, et al. Land-use and food security in energy transition: role of food supply. Front Sustai Food Syst. 2022;6:510. [Google Scholar]
- [19].Cénat JM, Blais-Rochette C, Kokou-Kpolou CK, et al. Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: a systematic review and meta-analysis. Psychiatry Res. 2021;295:113599. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [20].Strygin KN. Sleep and stress. Ross Fiziol Zh Im I M Sechenova. 2011;97:422–32. [PubMed] [Google Scholar]
- [21].Schmidt CA, Cromwell EA, Hill E, et al. The prevalence of onchocerciasis in Africa and Yemen, 2000–2018: a geospatial analysis. BMC Med. 2022;20:1–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [22].Li X, Wu X. Psychological characteristics of parents in a paediatric outpatient during the SARS-CoV-2 epidemic. Psychol Health Med. 2021;26:114–8. [DOI] [PubMed] [Google Scholar]
- [23].Thun E, Sivertsen B, Knapstad M, et al. Unravelling the prospective associations between mixed anxiety-depression and insomnia during the course of cognitive behavioral therapy. Psychosom Med. 2019;81:333–40. [DOI] [PubMed] [Google Scholar]
- [24].Galimberti A, Cena H, Campone L, et al. Rethinking urban and food policies to improve citizens safety after COVID-19 pandemic. Front Nutr. 2020;7:569542. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [25].Fu W, Wang C, Zou L, et al. Psychological health, sleep quality, and coping styles to stress facing the COVID-19 in Wuhan, China. Transl Psychiatry. 2020;10:225. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [26].Yu S, Abbas J, Draghici A, et al. Social media application as a new paradigm for business communication: the role of COVID-19 knowledge, social distancing, and preventive attitudes. Front Psychol. 2022;13:903082. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [27].Hayes SC, Luoma JB, Bond FW, et al. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1–25. [DOI] [PubMed] [Google Scholar]
- [28].Gebara MA, Siripong N, Dinapoli EA, et al. Effect of insomnia treatments on depression: a systematic review and meta-analysis. Depress Anxiety. 2018;35:717–31. [DOI] [PubMed] [Google Scholar]
- [29].Horton R. Offline: 2019-nCoV—“a desperate plea.”. Lancet. 2020;395:400. [DOI] [PMC free article] [PubMed] [Google Scholar]