Associations between Sleep Hygiene and Mental Complaints in a French Healthcare Worker Population during the COVID-19 Crisis: A Cross-Sectional Analysis to Personalize Sleep Health Interventions

Round 1

Reviewer 1 Report

The topic sounds interesting and the paper is well organized. The paper provides clarity, novelty, and contribution to the area of research and it demands a great level of in-depth understanding of the subject and a well-structured arrangement of discussions and arguments. There is one point about the discussion section need to provide information about research gaps and future perspectives. There are some point need further explain, For example, about the rationales for this study. There is one point about the discussion section need to provide information about research gaps and future perspectives.

The topic sounds interesting and the paper is well organized. The paper provides clarity, novelty, and contribution to the area of research and it demands a great level of in-depth understanding of the subject and a well-structured arrangement of discussions and arguments. There is one point about the discussion section need to provide information about research gaps and future perspectives. There are some point need further explain, For example, about the rationales for this study. There is one point about the discussion section need to provide information about research gaps and future perspectives.

Author Response

We acknowledge the reviewer's suggestion to provide further explanation regarding the rationales for conducting this study. We recognize that additional clarity regarding the specific motivations for investigating sleep hygiene and mental complaints in this population may enhance the manuscript's comprehensibility. We have added the following section: 

Page 1: Assessing sleep hygiene in this population could enable us to propose specific prevention campaigns, improve the overall health of this population and ultimately improve the quality of care. 

We appreciate the reviewer's suggestion to include information about research gaps and future perspectives in the discussion section. We have expanded the discussion section to highlight specific areas where further research is needed.

Page 5-6: Our study contributes to the growing body of literature highlighting the significant associations between sleep hygiene and mental health outcomes among healthcare workers, particularly during the COVID-19 crisis. However, several research gaps remain to be addressed. Future studies should focus on elucidating the underlying mechanisms linking sleep hygiene to mental health outcomes in this population, exploring the effectiveness of interventions targeting sleep hygiene, and investigating the long-term implications of poor sleep health, including its impact on occupational performance and patient care. Longitudinal studies are warranted to establish the temporal relationships between sleep hygiene, mental health, and occupational outcomes among healthcare professionals.

Reviewer 2 Report

1. Moderately extensive English grammatical errors were detected and need to be addressed.

2. The authors need to address the fact that most hospital workers work rotational or other forms of shift work. Are the shifts in line with circadian theory in terms of rotational direction and days off for recovery etc.. Research shows that when someone works shifts for some years sleep duration decreases possibly at the expense of stages 1 and 2 (becomes more efficient) and typically shift workers sleep about 6 hours or less. This has not been factored into the paper anywhere. In addition, many papers have shown that new interns in hospitals are subjected to ridiculously long hours of continuous work resulting in sleep, mental health and medical error issues (ironic given health facilities are supposed to care for people). Although this is changing there are still many "old school" supervisors who follow this "blooding" procedure with new interns a practice that should be stopped, but also needs to be accounted for in the research presented here.

3. It is not clear how much of the variance in sleep issues is due to covid-19 as the study was done during the pandemic. Comparisons with other research conducted in similar populations pre-pandemic are useful to try to determine if the pandemic worsened sleep. However, the best would comparison would be the same population re-sampled in the next year or two?

4. The study probably has generalisability to workers from other industries that work shifts and this has not been mentioned.

5. It is suggested that the authors take into account the shift work issues throughout the paper. The fact that covid-19 was present cannot be separated from these issues as there is no pre or post comparisons. Is the problem shift work or covid or both?

There are too many small issues of English expression and grammar to list here. The paper requires a very careful edit by someone for these specific issues.

Author Response

Moderately extensive English grammatical errors were detected and need to be addressed.

Thank you for bringing this to our attention. We have conducted a thorough proofreading and editing of the manuscript to correct any English grammatical errors.

The authors need to address the fact that most hospital workers work rotational or other forms of shift work. Are the shifts in line with circadian theory in terms of rotational direction and days off for recovery etc.. Research shows that when someone works shifts for some years sleep duration decreases possibly at the expense of stages 1 and 2 (becomes more efficient) and typically shift workers sleep about 6 hours or less. This has not been factored into the paper anywhere. In addition, many papers have shown that new interns in hospitals are subjected to ridiculously long hours of continuous work resulting in sleep, mental health and medical error issues (ironic given health facilities are supposed to care for people). Although this is changing there are still many "old school" supervisors who follow this "blooding" procedure with new interns a practice that should be stopped, but also needs to be accounted for in the research presented here.

We appreciate the reviewer's insightful comments regarding the prevalence of shift work among hospital workers and its potential impact on sleep patterns and mental health. To address these concerns, we will expand the discussion section to include a thorough examination of the effects of shift work on sleep duration, sleep architecture, and mental health outcomes. Additionally, we will discuss the historical practice of long hours for new interns and its implications for sleep, mental health, and medical errors within the healthcare setting.

Page 5-6: "While we acknowledge the influence of shift work on sleep patterns and mental health outcomes among hospital workers, the historical practice of long hours for new interns, although gradually changing, remains a concern due to its potential adverse effects on sleep, mental health, and medical errors. Future longitudinal studies may provide further insights into the complex interplay between shift work, the COVID-19 crisis, and their combined effects on sleep and mental health, explore the underlying mechanisms linking sleep hygiene to mental health outcomes in this population, and study the effectiveness of interventions targeting sleep hygiene, and investigating the long-term implications of poor sleep health, including its impact on occupational performance and patient care. "

It is not clear how much of the variance in sleep issues is due to COVID-19 as the study was done during the pandemic. Comparisons with other research conducted in similar populations pre-pandemic are useful to try to determine if the pandemic worsened sleep. However, the best comparison would be the same population re-sampled in the next year or two?

Thank you for highlighting this important consideration. We agree that it is essential to evaluate the impact of the COVID-19 pandemic on sleep issues among healthcare workers. In the revised manuscript, we have discussed the limitations of our study in assessing the specific contributions of COVID-19 to sleep disturbances and mental health outcomes. Additionally, we have explored potential comparisons with pre-pandemic research to better understand any changes in sleep patterns over time. We have also suggested the possibility of conducting future longitudinal studies to assess the long-term effects of the pandemic on sleep and mental health among the same population.

Page 5-6: "Fourth, it is essential to acknowledge the limitations of our study in assessing the specific contributions of the COVID-19 pandemic to sleep issues among healthcare workers. While our research was conducted during the pandemic, we recognize the need for comparisons with pre-pandemic studies to better understand any changes in sleep patterns over time. Future longitudinal studies may provide valuable insights into the long-term effects of the pandemic on sleep and mental health among the same population."

The study probably has generalizability to workers from other industries that work shifts and this has not been mentioned.

Thank you for pointing out the potential generalizability of our findings to workers in other industries who also engage in shift work. In the revised manuscript, we will discuss the relevance of our study findings beyond the healthcare sector and highlight the implications for workers in other industries with similar shift work schedules.

Page 6: "In addition to its implications for healthcare professionals, our study findings may have broader relevance to workers in other industries that also engage in shift work. The challenges associated with shift work, such as disrupted sleep patterns and increased risk of mental health issues, are not unique to the healthcare sector. Therefore, our findings may offer valuable insights for developing interventions to address sleep hygiene and mental health in various occupational settings."

It is suggested that the authors take into account the shift work issues throughout the paper. The fact that COVID-19 was present cannot be separated from these issues as there are no pre or post comparisons. Is the problem shift work or COVID or both?

We appreciate this important suggestion. In the revised manuscript, we have integrated discussions about the synergic interaction between shift work and pandemic.

Page 6: "The COVID-19 pandemic has undoubtedly exacerbated existing challenges associated with shift work, such as disrupted sleep patterns and increased stress levels. However, disentangling the specific contributions of shift work and the pandemic to sleep issues and mental health outcomes remains a complex task. Future research endeavors should aim to elucidate these relationships and develop targeted interventions to support the well-being of shift workers, particularly in light of ongoing public health crises."

Reviewer 3 Report

Dear authors,

Thank you for the opportunity to review the results of your research.

The strengths of your research are the unconditional relevance of the study, a large sample size, which indicates its representativeness, the use of multivariate methods of statistical processing, which allows us to draw a conclusion about the reliability of the results obtained, and the availability of practical recommendations based on the results of the study.

Given the overall positive impression of the work, there are a number of recommendations that will make the article more meaningful for readers:

The introduction analyzes the problem, but the authors conduct a rather meager review of the literature despite the fact that the impact of the pandemic on medical workers is a very relevant topic on which many publications can be found. This is also indicated by the total volume of literature sources – 18 pieces. The introduction should be expanded, as well as the discussion of the results, with a more in-depth analysis of the work of other authors. The goal of the work is not clearly defined; there is no research hypothesis.

Materials and methods are not well described. Information is not provided on the validity and reliability of the questionnaires used, and how their results compare with the results of objective methods (for example, regarding sleep disorders and depression). There is insufficient information provided regarding the choice of specific questionnaires; what dictated it? To what extent do similar studies use the same questionnaires or do the authors use different methods for the purpose of novelty of the results obtained?

A description of the results in only three paragraphs is not enough; it is necessary to expand the description of the analysis procedure itself (its stages) and the results obtained, there are more of them than described in three paragraphs.

The discussion of the results is also expanded (see comment above).

Expand the conclusion of the article closer to the results of the work.

With respect for your work and best wishes, reviewer.

Author Response

The introduction analyzes the problem, but the authors conduct a rather meager review of the literature despite the fact that the impact of the pandemic on medical workers is a very relevant topic on which many publications can be found. This is also indicated by the total volume of literature sources – 18 pieces. The introduction should be expanded, as well as the discussion of the results, with a more in-depth analysis of the work of other authors. The goal of the work is not clearly defined; there is no research hypothesis.

We appreciate the reviewer's feedback and acknowledge the importance of providing a comprehensive review of the literature, especially regarding the impact of the pandemic on medical workers' sleep hygiene and mental health. We will revise the introduction to include a more in-depth analysis of relevant literature to better contextualize the study and its objectives. Additionally, we will ensure that the research hypothesis is clearly defined to provide a focused direction for the study.

Page 2: "Assessing sleep hygiene in this population could enable us to propose specific prevention campaigns, improve the overall health of this population and ultimately improve the quality of care. Thus, our study was aimed to determine the prevalence of poor sleep hygiene and mental complaints and their associations in a French hospital worker population.  By identifying factors associated with poor sleep hygiene and mental health outcomes, we can develop personalized interventions to promote sleep health and improve the overall well-being of healthcare workers."

Materials and methods are not well described. Information is not provided on the validity and reliability of the questionnaires used, and how their results compare with the results of objective methods (for example, regarding sleep disorders and depression). There is insufficient information provided regarding the choice of specific questionnaires; what dictated it? To what extent do similar studies use the same questionnaires or do the authors use different methods for the purpose of novelty of the results obtained?

We have provided the missing elements in the methods section

Page 3: "[...] based on the methodology proposed by the Munich ChronoType Questionnaire (MCTQ) (7)

[...] according to the guidelines of the National Sleep Foundation (9). 

[...] according to previous studies (8,10).

This scale has shown great reliability and validity in a previous meta-analysis (12).

This scale has shown great reliability and validity in a previous meta-analysis (14)."

A description of the results in only three paragraphs is not enough; it is necessary to expand the description of the analysis procedure itself (its stages) and the results obtained, there are more of them than described in three paragraphs.

We are sorry this presentation isn't suitable for the reviewer. We have added a few elements but the majority of the results are already available in the tables and figures and we do not wish to be redundant as requested by the reviewer.

The discussion of the results is also expanded (see comment above).

Page 5-6: "Fourth, it is essential to acknowledge the limitations of our study in assessing the specific contributions of the COVID-19 pandemic to sleep issues among healthcare workers. While our research was conducted during the pandemic, we recognize the need for comparisons with pre-pandemic studies to better understand any changes in sleep patterns over time. Future longitudinal studies may provide valuable insights into the long-term effects of the pandemic on sleep and mental health among the same population. Our study contributes to the growing body of literature highlighting the significant associations between sleep hygiene and mental health outcomes among healthcare workers, particularly during the COVID-19 crisis. The COVID-19 pandemic has undoubtedly exacerbated existing challenges associated with shift work, such as disrupted sleep patterns and increased stress levels. However, disentangling the specific contributions of shift work and the pandemic to sleep issues and mental health outcomes remains a complex task. Future research endeavors should aim to elucidate these relationships and develop targeted interventions to support the well-being of shift workers, particularly in light of ongoing public health crises. In addition to its implications for healthcare professionals, our study findings may have broader relevance to workers in other industries that also engage in shift work. The challenges associated with shift work, such as disrupted sleep patterns and increased risk of mental health issues, are not unique to the healthcare sector. Therefore, our findings may offer valuable insights for developing interventions to address sleep hygiene and mental health in various occupational settings. However, several research gaps remain to be addressed. While we acknowledge the influence of shift work on sleep patterns and mental health outcomes among hospital workers, the historical practice of long hours for new interns, although gradually changing, remains a concern due to its potential adverse effects on sleep, mental health, and medical errors. Future longitudinal studies may provide further insights into the complex interplay between shift work, the COVID-19 crisis, and their combined effects on sleep and mental health, explore the underlying mechanisms linking sleep hygiene to mental health outcomes in this population, and study the effectiveness of interventions targeting sleep hygiene, and investigating the long-term implications of poor sleep health, including its impact on occupational performance and patient care. Longitudinal studies are warranted to establish the temporal relationships between sleep hygiene, mental health, and occupational outcomes among healthcare professionals."

Reviewer 4 Report

I reviewed your paper with great interest. I think the issue of Covid-19 crisis and sleep health is an important topic. As a result of the peer review, I found several issues that need to be considered.

1) SWD
This paper deals with issues related to sleep health of health care workers. Shift Work Disorder (SWD) is common among healthcare workers who engage in shift work. In this study, 32.9% were engaged in shift work and 13.3% were engaged in night work. The impact of SWD on sleep health also should be considered in the discussion.

2) hypnotics
It has been reported that nurses engaged in shift work have a higher rate of use of sleeping medications (hypnotics) than the general population. Sleeping medication status was not mentioned in this study.
If a survey regarding sleeping medication status was not conducted, it should be included in limitation.

3) Alcohol and tobacco
Alcohol consumption and cigarette smoking are two lifestyle habits that negatively affect insomnia.
If a survey on alcohol consumption and smoking was not conducted, it should be included in the limitation.

Author Response

This paper deals with issues related to sleep health of health care workers. Shift Work Disorder (SWD) is common among healthcare workers who engage in shift work. In this study, 32.9% were engaged in shift work and 13.3% were engaged in night work. The impact of SWD on sleep health also should be considered in the discussion.

We added the following elements in the discussion:

Page 6: "Our study contributes to the growing body of literature highlighting the significant associations between sleep hygiene and mental health outcomes among healthcare workers, particularly during the COVID-19 crisis. The COVID-19 pandemic has undoubtedly exacerbated existing challenges associated with shift work, such as disrupted sleep patterns and increased stress levels. However, disentangling the specific contributions of shift work and the pandemic to sleep issues and mental health outcomes remains a complex task. Future research endeavors should aim to elucidate these relationships and develop targeted interventions to support the well-being of shift workers, particularly in light of ongoing public health crises. In addition to its implications for healthcare professionals, our study findings may have broader relevance to workers in other industries that also engage in shift work. "

It has been reported that nurses engaged in shift work have a higher rate of use of sleeping medications (hypnotics) than the general population. Sleeping medication status was not mentioned in this study.
If a survey regarding sleeping medication status was not conducted, it should be included in limitation. Alcohol consumption and cigarette smoking are two lifestyle habits that negatively affect insomnia.
If a survey on alcohol consumption and smoking was not conducted, it should be included in the limitation.

We thank the reviewer for his/her comment. We added the following statement in the limitations:

Page 5: "Also, data is missing regarding usual consumption including tobacco, alcohol, and hypnotic drugs intake, which may have influenced sleep and mental health. 

Round 2

Reviewer 2 Report

minor editing only

minor editing only 

Author Response

We thank the reviewer for pointing out some corrections, which we have integrated into the new version of the manuscript

Author Response File: Author Response.docx