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Original research
Anxiety and depressive symptoms are associated with poor sleep health during a period of COVID-19-induced nationwide lockdown: a cross-sectional analysis of adults in Jordan
  1. Yazan A Al-Ajlouni1,
  2. Su Hyun Park2,
  3. Jude Alawa3,
  4. Ghaith Shamaileh4,
  5. Aziz Bawab5,
  6. Wafaa M El-Sadr2,6,
  7. Dustin T Duncan2
  1. 1Department of Primary Care and Public Health, Cambridge University, Cambridge, UK
  2. 2Department of Epidemiology, Columbia University Mailman School of Public Health, New York City, New York, USA
  3. 3Institute of Public Health, University of Cambridge, Cambridge, UK
  4. 4Department of Cell and Molecular Biology, Tulane University School of Science and Engineering, New Orleans, Louisiana, USA
  5. 5Presbyterian Hospital, New York City, New York, USA
  6. 6ICAP at Columbia University, New York City, New York, USA
  1. Correspondence to Yazan A Al-Ajlouni; yal_ajlo{at}


Background Jordan, a Middle Eastern country, declared a state of national emergency due to COVID-19 and a strict nationwide lockdown on 17 March 2020, banning all travel and movement around the country, potentially impacting mental health. This study sought to investigate the association between mental health (eg, anxiety and depressive symptoms) and sleep health among a sample of Jordanians living through a state of COVID-19-induced nationwide lockdown.

Methods Using Facebook, participants (n=1240) in Jordan in March 2020 were recruited and direct to a web-based survey measuring anxiety (items from General Anxiety Disorder 7-item (GAD-7) scale instrument), depressive symptoms (items from Center for Epidemiologic Studies Depression Scale), sleep health (items from the Pittsburgh Sleep Quality Index) and sociodemographic. A modified Poisson regression model with robust error variance. Adjusted prevalence ratios (aPRs) and 95% CIs were estimated to examine how anxiety and depressive symptoms may affect different dimensions of sleep health: (1) poor sleep quality, (2) short sleep duration, (3) encountering sleep problems.

Results The majority of participants reported having experienced mild (33.8%), moderate (12.9%) or severe (6.3%) levels of anxiety during lockdown, and nearly half of respondents reported depressive symptoms during lockdown. Similarly, over 60% of participants reported having experienced at least one sleep problem in the last week, and nearly half reported having had short sleep duration. Importantly, anxiety was associated with poor sleep health outcomes. For example, corresponding to the dose–response relationship between anxiety and sleep health outcomes, those reporting severe anxiety were the most likely to experience poor sleep quality (aPR =8.95; 95% CI=6.12 to 13.08), short sleep duration (aPR =2.23; 95% CI=1.91 to 2.61) and at least one problem sleep problem (aPR=1.73; 95% CI=1.54 to 1.95). Moreover, depressive symptoms were also associated with poor sleep health outcomes. As compared with scoring in the first quartile, scoring fourth quartile was associated with poor sleep quality (aPR=11.82; 95% CI=6.64 to 21.04), short sleep duration (aPR=1.87; 95% CI=1.58 to 2.22), and experiencing at least one sleep problem (aPR=1.90; 95% CI=1.66 to 2.18).

Conclusions Increased levels of anxiety and depressive symptoms can negatively influence sleep health among a sample of Jordanian adults living in a state of COVID-19-induced nationwide lockdown.

  • mental health
  • infectious diseases
  • sleep medicine
  • public health

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  • Contributors YAA-A contributed to the design of this research work. GS was involved in data collection for this project. YAA-A and SHP was involved in data analysis and interpretation. YAA-A, SHP, JA, AB and DTD were involved in drafting the article. WME-S and DTD provided critical revision of the article. YAA-A, SHP, JA, GS, AB, WME-S and DTD approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval All protocols and procedures were approved by the University of Jordan Hospital Institutional Review Board prior to data collection.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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