Poor Sleep quality and health-related quality of life impact in adolescents with and without chronic immunosuppressive conditions during COVID-19 quarantine

Helito, Alberto C.; Lindoso, Livia; Sieczkowska, Sofia M.; Astley, Camilla; Queiroz, Ligia B.; Rose, Natalia; Santos, Claudia Renata P.; Bolzan, Thalis; Peralta, Rita María I.A.; Franco, Ruth R.; Cominato, Louise; Pereira, Rosa Maria R.; Tannuri, Uenis; Campos, Lucia Maria A.; Lourenço, Benito; Toma, Ricardo K.; Medeiros, Karina; Watanabe, Andréia; Grangeiro, Patricia Moreno; Farhat, Sylvia C.; Casella, Caio B.; Polanczyk, Guilherme V.; Gualano, Bruno; Silva, Clovis A.; ,

doi:10.6061/clinics/2021/e3501

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ORIGINAL ARTICLE • Clinics 76 • 2021 • https://doi.org/10.6061/clinics/2021/e3501 copy

Poor Sleep quality and health-related quality of life impact in adolescents with and without chronic immunosuppressive conditions during COVID-19 quarantine

Authorship About the non-byline-authors SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE:

To assess the possible factors that influence sleep quality in adolescents with and without chronic immunosuppressive conditions quarantined during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS:

This cross-sectional study included 305 adolescents with chronic immunocompromised conditions and 82 healthy adolescents. Online surveys were completed, which included questions on socio-demographic data and self-rated healthcare routine during COVID-19 quarantine and the following validated questionnaires: the Pittsburgh Sleep Quality Index (PSQI), Pediatric Quality of Life Inventory 4.0 (PedsQL4.0), and Pediatric Outcome Data Collection Instrument (PODCI).

RESULTS:

The median current age [14 (10-18) vs. 15 (10-18) years, p=0.847] and frequency of female sex (62% vs. 58%, p=0.571) were similar in adolescents with chronic conditions compared with healthy adolescents. The frequency of poor sleep quality was similar in both groups (38% vs. 48%, p=0.118). Logistic regression analysis, including both healthy adolescents and adolescents with chronic conditions (n=387), demonstrated that self-reported increase in screen time (odds ratio [OR] 3.0; 95% confidence interval [CI] 1.3-6.8; p=0.008) and intrafamilial violence report (OR 2.1; 95% CI 1.2-3.5; p=0.008) were independently associated with poor sleep quality in these adolescents. However, the PODCI global function score was associated with a lower OR for poor sleep quality (OR 0.97; 95% CI 0.94-0.99; p=0.001). Further logistic regression, including only adolescents with chronic conditions (n=305), demonstrated that self-reported increase in screen time (OR 3.1; 95% CI 1.4-6.8; p=0.006) and intrafamilial violence report (OR 2.0; 95% CI 1.2-3.4; p=0.011) remained independently associated with poor quality of sleep, whereas a lower PODCI global function score was associated with a lower OR for sleep quality (OR 0.96; 95% CI 0.94-0.98; p<0.001).

CONCLUSION:

Self-reported increases in screen time and intrafamilial violence report impacted sleep quality in both healthy adolescents and those with chronic conditions. Decreased health-related quality of life was observed in adolescents with poor sleep quality.

COVID-19; Sleep; Adolescent; Chronic Condition; Health-Related Quality of Life

Domains	Adolescents with preexisting chronic conditions (n=305)	Healthy Adolescents (n=82)	p
Demographic data
Current age	14 (10-18)	15 (10-18)	0.847
Female sex	189 (62)	48 (58)	0.571
PSQI score
PSQI total score (0-21)	5.16±3.34	5.87±3.49	0.092
Poor sleep quality, total score >5	116 (38)	39 (48)	0.118
Sleep latency (0-3)	1.11±1.02	1.37±1.05	0.043
Sleep duration (0-3)	0.17±0.60	0.27±0.60	0.202
Sleep efficiency (0-3)	0.52±0.94	0.68±0.92	0.155
Sleep disturbances (0-3)	1.08±0.50	1.15±0.57	0.272
Sleep medication use (0-3)	0.70±1.20	0.46±1.00	0.102
Overall sleep quality (0-3)	0.87±0.80	0.93±0.81	0.582
Day dysfunction because of sleepiness (0-3)	0.71±0.78	1.01±0.87	0.003
PedsQL score
Total scale score (0-100)	73 (21-100)	70 (41-100)	0.415
Physical health summary score (0-100)	78 (6-100)	81 (38-100)	0.385
Psychosocial health summary (0-100)	70 (13-100)	70 (25-100)	0.786
Emotional functioning (0-100)	60 (0-100)	60 (10-100)	0.411
Social functioning (0-100)	85 (10-100)	85 (20-100)	0.894
School functioning (0-100)	65 (10-100)	65 (0-100)	0.157
PODCI score
Global function score (0-100)	93 (32-100)	94 (64-100)
Upper extremity and physical functioning (0-100)	100 (46-100)	100 (75-100)	0.627
Transfer and basic mobility (0-100)	100 (5-100)	100 (50-100)	0.499
Sports and physical functioning (0-100)	88 (3-100)	88 (33-100)	0.115
Pain/comfort (0-100)	93 (8-100)	92.5 (44-100)	0.621
Happiness (0-100)	85 (5-100)	75 (0-100)	0.025

Variables	Adolescents with chronic conditions and poor sleep quality (n=116)	Adolescents with chronic conditions and good sleep quality (n=189)	p
Socio-demographic
Current age	15 (10-18)	14 (10-18)	0.369
Female sex	78 (67)	111 (59)	0.137
Caucasians	58 (50)	98 (52)	0.753
Number of households in the residence
≤3	37 (32)	63 (33)	0.795
>3	79 (68)	126 (67)	0.795
School
Level of schooling			0.546
Elementary school	65 (56)	115 (61)
Middle school	43 (37)	56 (30)
High school	5 (4)	12 (6)
Not studying	3 (3)	6 (3)
Online learning during the COVID-19 pandemic	104 (90)	156 (82)	0.098
Public school adolescents	92 (79)	129 (68)	0.036
Healthcare routine during the pandemic
Medical appointment during the pandemic			0.768
Discontinued	38 (36)	70 (39)
Decreased	41 (38)	70 (39)
Unchanged	28 (26)	41 (22)
Forgetting to take your medication			0.139
Without forgetting	64 (63)	118 (71)
1-2 days	31 (30)	45 (27)
≥3 days	7 (7)	4 (2)
General information of the COVID-19 pandemic
Reliable COVID-19 information	84 (72)	142 (75)	0.854
Compliance to “stay-home” policy	111 (96)	183 (97)	0.606
Impact of COVID-19 quarantine
Households with COVID-19	22 (19)	24 (13)	0.138
Life routine changed after the “physical distancing” policy	109 (94)	176 (93)	0.773
Housework
No housework activities	25 (22)	44 (23)	0.726
Do housework activities	91(78)	145 (77)	0.726
Sleep duration
≤8 h/day	57 (49)	48 (25)	<0.001
>8 h/day	59 (51)	141 (75)	<0.001
Sleep after midnight	85 (73)	103 (55)	0.001
Self-reported increase in screen time during the pandemic	107 (92)	157 (83)	0.023
Household worked out of home	104 (90)	160 (85)	0.214
Intrafamilial violence report during the pandemic	32 (28)	29 (15)	0.009
VAS (0-10)
Fear of underlying disease activity/complication	7.2 (0-10)	5.1 (0-10)	0.053
Fear of immunosuppression use	5.0 (0-10)	3.8 (0-10)	0.034
Fear of COVID-19	6.5 (0-10)	6.5 (0-10)	0.654
Physical activity per week	2.1 (0-10)	2.7 (0-10)	0.104
Sleep quality	6.6 (0-10)	9.6 (0-10)	<0.001
Preexisting chronic conditions
Gastrointestinal and liver conditions	59 (51)	75 (40)	0.160
Rheumatologic conditions	48 (41)	97 (51)
Kidney conditions	9 (8)	17 (9)
Previous psychiatric disorder	12 (48)	13 (52)	0.284

Domains	Adolescents with chronic conditions and poor sleep quality (n=116)	Adolescents with chronic conditions and good sleep quality (n=188)	p
PedsQL score
Total scale score (0-100)	67 (21-93)	77 (32-100)	<0.001
Physical health summary score (0-100)	72 (22-100)	81 (6-100)	<0.001
Psychosocial health summary (0-100)	63 (13-93)	73 (35-100)	<0.001
Emotional functioning (0-100)	55 (0-95)	70 (10-100)	<0.001
Social functioning (0-100)	82.5 (10-100)	90 (35-100)	0.003
School functioning (0-100)	60 (10-100)	67.5 (15-100)	<0.001
PODCI score	(n=113)	(n=177)
Global function score (0-100)	90 (40-100)	95 (32-100)	<0.001
Upper extremity and physical functioning (0-100)	100 (46-100)	100 (63-100)	0.039
Transfer and basic mobility (0-100)	100 (49-100)	100 (5-100)	0.055
Sports and physical functioning (0-100)	83 (14-100)	89 (3-100)	0.020
Pain/comfort (0-100)	78 (8-100)	100 (19-100)	<0.001
Happiness (0-100)	80 (5-100)	90 (15-100)	<0.001

Variables	r Spearman	p
PSQI total score and psychosocial health summary by PedsQL	-0.459	<0.001
PSQI total score and physical health summary score by PedsQL	-0.308	<0.001
PSQI total score and total scale score by PedsQL score	-0.413	<0.001
PSQI total score and happiness by PODCI score	-0.328	<0.001
PSQI total score and global function score by PODCI score	-0.255	<0.001
PSQI total score and increase PA per week by VAS	-0.149	0.009
PSQI total score and fear of immunosuppressive use by VAS	+0.137	0.019
PSQI total score and current age	+0.124	0.031
PSQI total score and fear of underlying disease activity or complication by VAS	+0.115	0.049

	Both adolescents with preexisting chronic conditions and healthy controls Dependent variable - poor sleep quality (n=387)
Independent variables	Odds ratio	95% CI	p
Self-reported increase in screen time during the pandemic	3.0	1.3-6.8	0.008
Intrafamilial violence report during the pandemic	2.1	1.2-3.5	0.008
PODCI global function score	0.97	0.94-0.99	0.001

	Solely adolescents with preexisting chronic conditions Dependent variable - poor sleep quality (n=305)
Independent variables	Odds ratio	95% CI	p
Self-reported increase in screen time during the pandemic	3.1	1.4-6.8	0.006
Intrafamilial violence report during the pandemic	2.0	1.2-3.4	0.011
PODCI global function score	0.96	0.94-0.98	<0.001

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E-mail: clinics@hc.fm.usp.br

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[1] *Corresponding author. E-mail: clovis.silva@hc.fm.usp.br

Age in years	_____________________________________ (use only numbers)
Gender	○ Woman
	○ Man
	○ Other gender identification
Would you like to tell us more about your gender?	_____________________________________
Sex	○ Female
	○ Male
	○ Other
	○ I’m not comfortable to answer
Describe any other	_____________________________________
Skin color	○ White ○ Black ○ Yellow
Skin color	○ Indian ○ Other
Were you attending school this year, before the new coronavirus pandemic?	○ No ○ Yes
What is your school year?	○ Fundamental school - 1st grade
	○ Fundamental school - 2nd grade
	○ Fundamental school - 3rd grade
	○ Fundamental school - 4th grade
	○ Fundamental school - 5th grade
	○ Fundamental school - 6th grade
	○ Fundamental school - 7th grade
	○ Fundamental school - 8th grade
	○ Fundamental school - 9th grade
	○ High school - 1st grade
	○ High school - 2nd grade
	○ High school - 3rd grade
	○ Incomplete university education
	○ Complete university education
	○ I am not studying
Do you study at	○ Public school ○ Private school
Have you been followed-up by our team for any disease?	○ No ○ Yes
What disease(s) or condition(s) do you treat?	_____________________________________
Do you use any routine medications?	○ No ○ Yes
Tell us what routine medications you use.	[name of medication, dose and frequency (daily, weekly or monthyl)]
Before the coronavirus pandemic, how often did you go to the hospital for appointments or treatment?	○ More than once a month
	○ Once a month
	○ Once every 2 months
	○ Once every 3 months
	○ Once every 4 months or less often
How about after the pandemic started? How often are you going to the hospital?	○ I’m not going ○ I’m going as before ○ I’m going less often
In a whole week, how often do you forget to take your medications?	○ Once a week
	○ Twice a week
	○ Three times a week
	○ Four times a week or more often
	○ I never forget
Did you take the Flu vaccine?	○ No ○ Yes
What are your sources of information about the coronavirus and social distancing?	○ Television ○ Radio
	○ Internet ○ Family members
	○ Friends ○ WhatsApp
	○ Social media such as Facebook, Instagram, Twitter, etc.
	○ Healthcare professionals such as doctors, nurses, social workers, etc.
Do you believe having enough and reliable information about the new coronavirus and COVID-19?	○ No
	○ Yes
	○ I don’t know
If not, tell us why:	_____________________________________
Write your doubts concerning the new coronavirus and COVID-19.	_____________________________________
Do you agree with the “STAY HOME” policy, made by health authorities and the government?	○ No ○ Yes
Is or was there someone in your home who was infected by the coronavirus?	○ No ○ Yes
How is quarantine being made in your home?	_____________________________________
The infected person/persons required hospital admission?	○ No ○ Yes
Where were they admitted?	_____________________________________
Was it easy to find a hospital able to admit them?	○ No ○ Yes
How did they evolve?	○ They got well
	○ They are still recovering
	○ They did not get well
Did your life routine change after physical distancing measures adopted by our country?	○ No ○ Yes

Remote school activities?	○ I don’t have remote school activities
	○ Less than 3 hours a day
	○ More than 3 hours a day
Domestic tasks?	○ I don’t do domestic tasks
	○ Less than 1 hours a day
	○ 2 or 3 hours a day
	○ more than 3 hours a day
Taking care of elders?	○ I don’t take care of the elder
	○ Less than 1 hours a day
	○ Between 1 and 2 hours a day
	○ Between 2 and 3 hours a day
	○ more than 3 hours a day
How much physical activities do you do per week in a scale from 0 to 10 (0=without any physical activity to 10=vigorous physical activity daily)?
How is your sleep?	○ Sleep more than 8 hours a day
How is your sleep?	○ Sleep less than 8 hours a day
Do you usually sleep after midnight?	○ No ○ Yes
How is your sleep in a scale from 0 to 10 (0=without difficulties to 10=severe insomnia)?
Are you experiencing trouble to sleep?	○ No ○ Yes
Use of electronic devices and screen time for accessing social media, WhatsApp, music platforms, electronic games, watching series, movies and videos.	○ Less than 3 hours a day
	○ Between 3 and 4 hours a day
	○ Between 4and 5 hours a day
	○ Between 5 and 6 hours a day
	○ More than 6 hours a day
Do you think your screen time increased after social distancing?	○ No ○ Yes
Concerning the use of alcohol during physical distancing:	○ I don’t drink alcohol
	○ I’m drinking more
	○ I’m drinking less
	○ I’m drinking the same amount
How many rooms are there in your home?	○ 1 ○ 2 ○ 3 ○ 4
	○ 5 ○ 6 ○ 7 ○ 8
	○ 9 ○ 10
How many people live in your home?	○ 1 ○ 2 ○ 3 ○ 4 ○ 5 ○ 6 ○ 7 ○ 8
How many people live in your home?	○ 9 ○ 10 ○ 11 ○ 12 ○ 13 ○ 14 ○ 15
Your family’s financial situation (money earning) after social distancing is:	○ Worse
	○ Better
	○ The same
Is anyone who lives with you going out to work?	○ No ○ Yes
Is anyone who lives with you smoking?	○ No ○ Yes
Who is the smoker?	○ Mother
	○ Father
	○ Other
Define:	_____________________________________
Where is he/she smoking?	○ Bedroom ○ Living room ○ Bathroom
Where is he/she smoking?	○ Laundry ○ Balcony ○ Street
Is there factories or industry in the two blocks near your home, during quarantine?	○ No ○ Yes
Are there gas stations in the two blocks near your home, during quarantine?	○ No ○ Yes
Concerning the fear of getting infected by the coronavirus, how are you feeling now in a scale from 0 to 10 (0=no fear to 10=with extreme fear)?
How is your fear of getting worse of your disease or condition during the coronavirus pandemic in a scale from 0 to 10 (0=no fear to 10=with extreme fear)?
How is your fear related to immunosuppressive medications use during the coronavirus pandemic in a scale from 0 to 10 (0=no fear to 10=with extreme fear)?
Did you notice any increase in conflicts or violence in your home or neighborhood after the beginning of physical distancing?	○ No ○ Yes
Would you like to talk to someone about that?	○ No ○ Yes
Describe those conflicts and violence.	_____________________________________
What do you miss the most during the distancing?	_____________________________________
What changed about your friendships?	_____________________________________
What changed about your dating/making out habits?	_____________________________________
How is your family treating you in this moment?	_____________________________________
Write freely to tell us about what you have been feeling during this period of social distancing.	_____________________________________
How did you like this questionnaire?	_____________________________________