Generalized anxiety disorder and sleep quality during COVID-19 lockdown in Egypt: a web-based cross-sectional survey

Coronavirus disease (COVID-19) was identified in China in December 2019. During any major epidemic, psychosocial disturbance occurs, which can surpass people’s capacity to handle the condition. The study aimed to estimate the prevalence of anxiety disorder and to assess sleep quality among Egyptian adults during COVID-19 lockdown. The study was cross-sectional study through an anonymous web-based survey. Majority of participants were females (80.3%), highly educated (96.8%), and with mean age of 32.9 ± 8.7 years. Nearly two-thirds were healthcare workers (65.5%). The overall prevalence of anxiety (generalized anxiety disorder score more than 9) was 42.5%. Nearly three-fourth (73.5%) of participants reported poor sleep quality (Pittsburgh Sleep Quality Index score more than 5). In the multivariate logistic regression models, being female (adjusted odds ratio = 1.75, 95% confidence interval: 1.13–2.7 for anxiety and adjusted odds ratio = 2.217, 95% confidence interval: 1.461–3.364 for poor sleep quality), younger than 35 years (adjusted odds ratio = 0.537, 95% confidence interval: 0.376–0.767 for anxiety and adjusted odds ratio = 0.578, 95% confidence interval: 0.397–0.841 for poor sleep quality), and focusing more time on COVID-19 news (adjusted odds ratio = 1.937, 95% confidence interval: 1.601–2.343 for anxiety and adjusted odds ratio = 1.494, 95% confidence interval: 1.219–1.83 for poor sleep quality) were significant predictors of anxiety and poor sleep quality. There was an increase in both anxiety and sleep disorders during COVID-19 pandemic. Young women spending more time on COVID-19 were at higher risk of developing anxiety and poor sleep quality.


Background
Coronaviruses are a group of viruses which can infect both animals and humans.It can cause respiratory infection in humans with a varying range of severity from mild to severe one [1].Coronavirus disease (COVID- 19) is a contagious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) [2].
Pandemics are a health crisis; during this crisis, people's lives are endangered, and there are substantial increases in morbidities and mortalities.Also, country resources become overloaded, with interference of public's safety.During major pandemics, psychosocial disturbance occurs, which can surpass affected people's capacity to handle the condition [3].COVID-19 pandemic had imposed extraordinary alterations in work, social, and activities network.This alteration affected sleep and psychological well-being [4].Also during *Correspondence: Eman Elfar eman.i.elfar@kasralainy.edu.eg;Elfar_eman@yahoo.com 1 Public Health and Community Medicine Department, Faculty of Medicine, Cairo University, Kasr Al Ainy St, Cairo 11956, Egypt 2 Neurology Department, Beni-Suef University, Beni Suef, Egypt lockdown, poor physical activity and poor light exposure affected individuals' mental and physical health [5].Furthermore, during confinement, people reported late wake up and poor sleep quality [6].
Globally, stress occurred due to health fears, community isolation, economic concerns, homeschooling, ambiguity about the future, and obligatory quarantine around the world [7].The search queries for insomnia increased worldwide during COVID-19 pandemic [8].
Regarding Egypt situation, first case was announced in February 2020 [9].In March 2020, the country announced a package of precautionary measurement with restriction of movement [10].Egypt had implemented a lot of efforts to face psychological problems during COVID-19 pandemic.The General Secretariat of Mental Health and Addiction Treatment (GSMHAT) with the support of WHO launched the country mental health action plan.Different stakeholders including governmental and nongovernmental working on mental health were invited to coordinate efforts, and five task force groups were formed to help and manage responses [11].During April 2020, early in the pandemic as part of the Egyptian response and efforts, GSMHAT hotline services which provided psychological support to the public reported the following complaints and symptoms from citizen's consultations: anxiety (44%), sleeplessness (15%), and depressive symptoms (22%) [11].
The psychological impact of COVID-19 pandemic on Egyptians was vast.A study performed in Egypt during the pandemic era showed high prevalence of anxiety where 30.6% reported mild to moderate and 22.9% severe to very severe, while more than one-fifth reported inadequate sleeping (< 6 h/day) [12].
The current study aimed to estimate the prevalence of anxiety disorder and to assess sleep quality among Egyptians during COVID-19 pandemic lockdown and its associated risk factors.

Study design
The study was cross-sectional study through a web-based survey.The survey was disseminated through social media platforms.This web-based electronic form was completely voluntary and anonymous.

Study population
The study participants were Egyptians living in Egypt or outside Egypt during COVID-19 pandemic.Inclusion criteria are as follows: all Egyptians above 18 years old inside or outside Egypt during the COVID-19 pandemic who accept to participate were eligible.Exclusion criteria were as follows: Egyptian below 18 years old and those who refused to participate.

Sampling technique and size
Nonrandom snowball sampling was used where each participant was asked to recruit two or three others.Prevalence of anxiety among Egyptian public aged 18-64 years from previous studies was 4.75% [13].Accordingly expected frequency was set at 5%, and confidence limits were set at 5%; this resulted in sample size estimates of 110 participants for 95% confidence level (calculated with OpenEpi, Version 3, open-source calculator).Twenty percent (20%) is added to compensate for incomplete responses.Thus, a total of 132 participants were invited to participate in the study.

Data collection tool
Participants answered the electronic form (E-form) anonymously.Data collection was done during the period from June to August 2020.All participants reported their demographic data including their sex, age, education, work, marital status, and residence.In addition, questions from two standardized Arabic questionnaires to assess their generalized anxiety disorder (GAD) [14,15] and sleep quality [16] were used.The questionnaires took about 8 min to be filled out.

GAD tool
Seven questions measure the frequency of anxiety symptoms over the past 4 weeks on a 4-point Liker scale ranging from 0 (never) to 3 (nearly every day).The total score ranged from 0 to 21.Higher scores point to more severe functional impairments as a result of anxiety.Cutoff level of more than 9 points was used to classify participants as having anxiety.

Sleep quality tool
The Arabic version of the PSQI (Pittsburgh Sleep Quality Index) scale was used to evaluate the participant's sleep quality over the past 4 weeks [16].This tool contains seven items (subjective sleep quality, sleep duration, sleep latency, habitual sleep efficiency, use of sleep medications, sleep disturbance, and daytime dysfunction), and the score for each item ranges from 0 to 3 points.Total score ranges from 0 to 21.Higher scores indicate more severe sleep disorder.Cutoff level of more than 5 was used to identify poor sleep quality.

Data management and analysis
Data was coded and entered using SPSS 21.Descriptive analysis is as follows: mean and SD for quantitative, ratio, and percentage for qualitative variables.Chi-square test was used to test for association between variables.A multivariate logistic regression model was performed to explore potential predictors for anxiety and sleep quality during COVID-19 pandemic.Adjusted odds ratio (AOR) and 95% confidence interval (95% CI) were obtained from logistic regression models (backward, stepwise method).
Pearson correlation was performed among GAD and sleep quality.P-values equal to or less than 0.05 were considered statistically significant.

Ethical consideration
All questionnaires are anonymous; hence, no identification data was required from the participants; therefore, data confidentiality and privacy were maintained all through the study.Electronic informed consent was obtained from the participants at the start of the questionnaire.The participant has the right to withdraw, by not completing the questionnaire at any point without providing any explanation.
Benefits of the study are considered as social benefits, since this research will provide insight on the proportions of anxiety and sleep disorders with possible identification of risk factors, therefore proposing recommendations for preventive interventions.This study has no more than minimal risk and was reviewed and approved by Research Ethics Committee (REC) of Faculty of Medicine, Cairo University (N-32-2020).

Results
The study was cross-sectional study among Egyptians during COVID-19 lockdown in Egypt.Data was collected through online questionnaire.Data collection was done during the period from June to August 2020.Six-hundred fifty responses were collected.Demographic characteristics of study participants are displayed in Table 1.Majority of participants were female (80.3%).Their age ranged from 18 to 71 years with mean and standard deviation of 32.9 ± 8.7 years.Nearly all of them were highly educated either university (48.5%) or post graduate (48.3%).One-third of participants were single (33.4%).Most of participants were living in urban areas (93.2%).Nearly two-thirds were healthcare workers (65.5%).More than half of them (54.9%)spent more than 1 h following COVID-19 news per day.
The prevalence of anxiety according to GAD scale was shown in Fig. 1.The overall prevalence of anxiety (GAD score more than 9) was 42.5%.Anxiety was statistically significantly higher among females (P = 0.002), participants younger than 35 years (P = 0.013), and among people spending more time focusing on COVID-19 news (P < 0.001) as shown in Table 2.
Regarding sleep quality as measured by PSQI scale, nearly three-fourth (73.5%) of participants reported poor sleep quality (PSQI score more than 5) as shown in Fig. 2. Females, participants younger than 35 years, and those who spends more time focusing on COVID-19 news reported statistically significant poorer sleep quality (P < 0.001, P = 0.007, and P = 0.005, respectively) as shown in Table 3.
Statistically significant positive correlation was found between anxiety score and sleep quality score (r = 0.562, P-value < 0.001) as shown in Fig. 3.While statistically Fig. 1 Prevalence of anxiety among study participants according to generalized anxiety disorder (GAD) scale (> 9 points) significant negative correlation was found between age and anxiety score (r = − 0.140, P-value < 0.001) (Table 5).

Discussion
During COVID-19 pandemic, a lot of countries restricted the movement to decrease the risk of infection.This led to lifestyle changes which affected mental health [17].According to the American Psychological Association survey performed in 2020, most psychologists reported increase in anxiety disorders and depressive disorders, compared to the era before COVID-19.Also, they reported the increase in trauma and stress-related disorders and sleep-wake disorders [18].In Egypt, the hot line initiated by GSMHAT reported consultations complaining of anxiety, insomnia, and depression during April 2020 [11].
The current study aimed to assess the anxiety and sleep disorders which occurred during the pandemic among Egyptians.Studying the prevalence and predictors for anxiety and sleep disorders would help future identification of at-risk population and designing proper programs to be implemented during any emerging crisis or emergency to prevent or avert public anxiety.
The current study was cross sectional among Egyptians during COVID-19 lockdown in Egypt using online questionnaire.The majority of the studied participants were females, highly educated, and majority spent time following COVID-19 news every day.Regarding anxiety and sleep quality, the current study found that the prevalence of anxiety and poor sleep quality among participants was 42.5% and 73.5%, respectively.Significant This was similar to a study performed in Egypt during COVID-19 pandemic which found that one-third of the participants had moderate to severe anxiety (33.4%), while more than two-thirds (68.4%) reported poor sleep [19].
Another Egyptian study assessed the impact of COVID-19 pandemic on Egyptians' psychology where 30.6% reported mild to moderate anxiety and 22.9% reported severe to very severe anxiety, while 23.1% reported inadequate sleeping.Also, the same study found that being female and watching or reading COVID-19 news ≥ 2 h were associated with anxiety and stress [12].The same was highlighted in a multicentric survey which reported that insomnia, anxiety, and depression were prominent during the first wave of the COVID-19 pandemic [4].In the same study, women reported to be more significantly higher in suffering anxiety, depression, and insomnia [4]; this is consistent with the current study finding.
On the contrary, a study performed in Saudi Arabia in 2020 revealed that most of respondents were normal where only 12.6% reported mild-to-moderate anxiety and nearly 1% reported moderate-to-severe anxiety.The same study showed that old age had more anxiety than younger age group [20].
Regarding following COVID-19 news, in March 2020, WHO declared some considerations for the continuous streaming of news or reports on the pandemic for the fear of making individuals more worried.WHO recommended keeping informed about COVID-19 at regular interval from trusted sources [21].Also, Kellerman et al. (2022) showed that greater daily exposure to news about COVID-19 is associated with higher worry about the pandemic [22].Most of the previous findings were highlighted and explained by the WHO news release in March 2022, where the release reported that early in COVID-19 crisis, the prevalence of anxiety and depression increased globally by 25%.The brief also mentioned risk groups like being a woman and younger in age.Factors which could explain this rise were as follows: loneliness, social isolation, loss of relatives, fear of infection, economic fears, exhaustion among healthcare workers, and gaps in mental health services [23].The brief discussed also the low budget allocated to mental health by different governments.Also, a numerous developing countries stated having shortage in mental healthcare providers [23].
There is a relation between anxiety and sleep quality.Excess anxiety can affect sleep quality, and also, insomnia could worsen anxiety [24].The current study found that there is a statistically significant positive correlation between anxiety score and sleep quality score (r = 0.562, P-value < 0.001).This was similar to the findings of Abd ElHafeez et al. (2022) which reported a positive correlation between anxiety and sleep quality score t (r = 0.51, P < 0.001) [19].

Fig. 3
Fig. 3 Correlation between generalized anxiety disorder (GAD) anxiety score and Pittsburgh Sleep Quality Index (PSQI) sleep quality score

Table 1
Demographic characteristics of study sample (N = 650)

Table 2
Distribution of anxiety by sociodemographic characteristics of study participants

Table 3
Distribution of sleep quality by sociodemographic characteristics of study participants

Table 4
Predictors of anxiety and poor sleep quality among study participants

Table 5
Correlation between anxiety score, sleep quality score, and age