Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study

Sowmini Padmanabh Kamath; Prasanna Mithra; Padmanabh Kamath; Bhaskaran Unnikrishnan

doi:10.12688/f1000research.141274.2

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Research Article

Revised

Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study

[version 2; peer review: 2 approved]

Previously titled: Insomnia in teachers with the resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study

Sowmini Padmanabh Kamath ¹, Prasanna Mithra², Padmanabh Kamath³, Bhaskaran Unnikrishnan²

PUBLISHED 05 Sep 2024

Author details Author details

¹ Department of Pediatrics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576 104, India
² Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576 104, India
³ Department of Cardiology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576 104, India

Sowmini Padmanabh Kamath
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Prasanna Mithra
Roles: Formal Analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Padmanabh Kamath
Roles: Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Bhaskaran Unnikrishnan
Roles: Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Background: The coronavirus (COVID-19) pandemic has affected people's economies, lifestyles, and physical, emotional, and sleep health. This research aimed to estimate the prevalence of insomnia and symptoms of stress, anxiety, and depression among teachers with the resumption of in-person instruction at schools following a hiatus after COVID-19 lockdowns in India. We also studied the association of teachers' insomnia with psychological symptoms and demographic variables.

Methods: We conducted a cross-sectional survey between October –November 2021 after schools had reopened during the COVID-19 pandemic. Data was collected using standard questionnaires online among schoolteachers. We explored the association of insomnia with teachers' symptoms of stress, anxiety, depression, sex, school boards, and age groups.

Results: Of 124 schoolteachers surveyed, the prevalence of insomnia was 37.9% (subthreshold in 25% and clinical in 12.9%). The prevalence of stress, depression, and anxiety was 20.2%, 30.6%, and 45.2%, respectively. There was a significant association (p<0.001) of insomnia with symptoms of anxiety, stress, and depression in univariate analysis. On multivariate analysis, we found that those feeling stressed had a 6.4 times higher risk of insomnia (95% CI: 1.5-28.3, p - 0.01). There was no association of insomnia with age, sex, school educational boards, and type of institution.

Conclusions: Over one-third (37.9%) of teachers reported having trouble sleeping when they returned to the school's typical face-to-face instruction modalities through COVID-19 times, and insomnia was more prevalent in those with stress.

Keywords

Anxiety, COVID-19, Cross sectional studies, Humans, Pandemics, Depression, Insomnia, Schools

Corresponding author: Sowmini Padmanabh Kamath

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Kamath SP et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Kamath SP, Mithra P, Kamath P and Unnikrishnan B. Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study [version 2; peer review: 2 approved]. F1000Research 2024, 12:1217 (https://doi.org/10.12688/f1000research.141274.2) First published: 26 Sep 2023, 12:1217 (https://doi.org/10.12688/f1000research.141274.1) Latest published: 05 Sep 2024, 12:1217 (https://doi.org/10.12688/f1000research.141274.2)

Revised Amendments from Version 1

Based on the comments and suggestions from the reviewers, we revised and modified the title, abstract, introduction, methodology, results, and discussion sections. We included the psychometric properties of the questionnaire tools - ISI and short DASS 21(English version). We restructured the discussion section to provide a more comprehensive analysis of the findings. References were added and updated in the manuscript.

See the authors' detailed response to the review by Ravichandra Karkal
See the authors' detailed response to the review by Sreejayan Kongasseri

Introduction

Insomnia is the most frequent sleep disorder encountered among the public. Disturbances in sleep following significant stressful situations, including natural disasters, have been reported previously.¹ The COVID-19 pandemic has caused crises globally, causing significant changes in the lifestyle of people.

The pandemic has resulted in anxiety, stress, worries about one's health and family, job insecurities, economic instabilities, financial crises, and challenges in managing work and family duties. In addition, people had to follow COVID-appropriate behavior resulting in lesser social contacts and interactions. Uncertainties and increasing unprecedented changes occurred worldwide, and people began encountering impairment in sleep and altered circadian rhythms. Hurley refers to the sleep disturbances related to the pandemic as “coronasomnia or covidsomnia”.²

The teaching profession is stressful, and teachers have reported symptoms of stress,³^–⁵ burnout, anxiety, and depression⁵ along with sleep problems⁶ even during pre-covid times. With the onset of the COVID-19 pandemic, there was a significant shift from conventional pedagogy teaching to e-learning methodology. Teachers had to adapt to the online teaching mode abruptly and balance their duties to their families during the pandemic crises. Most teachers were unfamiliar with e-learning and worried about delivering quality teaching, especially for children from lower socioeconomic status and remote villages who still needed internet access.⁷^–¹⁰

The effect of the COVID-19 pandemic on psychological symptoms in various populations,¹¹^,¹² including teachers, has been studied previously,¹³^,¹⁴ along with disturbances in sleep in the general public have been documented during the COVID-19 lockdowns.¹⁵^,¹⁶ Adapting to e-learning increased stress for the schoolteachers and affected their sleep.¹⁷ More than half of the teachers in the USA during COVID-19 have reported insomnia.¹⁸

A survey in the United Kingdom during the COVID-19 pandemic revealed an increase in sleeplessness from pre-pandemic values of 15.7% to 24.7%.¹⁹ Another study showed changes in sleep schedules and quality/quantity of sleep at nighttime.²⁰ There is a link between insomnia severity with signs of despair, anxiety, and poor sleep hygiene.²¹ Female sex is usually predisposed to insomnia.¹⁶^,¹⁹ On the contrary, an Indian survey among the public did not show statistically significant differences with sex.¹⁵ Further, having a Type D personality,²² and factors such as having young children, perceived financial difficulties, and the presence of symptoms of COVID-19 were predictive of sleep loss in yet another study.¹⁹

As the pandemic continued, The Ministry of Education, India,²³ initiated the reopening of schools and educational institutions from the online teaching mode to in-person instructive classes in a gradational manner following the second COVID-19 wave in India. There was fear of a resurgence of infection and additional responsibility to maintain implemented COVID-appropriate behaviors at schools and manage the children once schools reopened. So reverting to regular face-to-face teaching in schools would be challenging for the teachers and students, especially when there was an impending third wave.

Following a hiatus of school closure during the pandemic, in the context of face-to-face teaching mode when schools reopened, the teachers' psychological symptoms were high in a Spanish study.²⁴ Similarly, our study reported a high prevalence of psychological symptoms among schoolteachers after schools reopened for regular face-to-face instruction.²⁵ The data for the current research was also gathered concurrently from the same group of teachers as part of a more extensive study. We used the English version of the Insomnia Severity Index (ISI) questionnaire²⁶ to assess insomnia levels. The ISI questionnaire is valid and reliable for usage in the Indian population.²⁷

Despite the volume of evidence on psychological symptoms and insomnia in various populations,²⁸^,²⁹ limited literature is available on teachers' insomnia levels during the pandemic. Additionally, this research focused on instructors and looked at a specific time during the COVID-19 outbreak when Indian schools were moving from a complete lockdown to a gradual resumption of in-person activities.

Therefore, this study's primary goal is to assess teacher's insomnia and its association with their psychological states and demographic variables at a crucial juncture during the COVID-19 crisis, especially in the scenario when schools and educational institutes were reopening after a hiatus to contain the spread of COVID-19 from March 2020 to October 2021.

Methods

Study design and participants

We conducted a cross-sectional study involving teachers in a few chosen schools in the Dakshina Kannada district, situated in a state in southern India. The study duration was two months (November to December 2021). All teachers who agreed to participate in the study were incorporated. We excluded teachers who expressed poor internet connectivity access and those who could not enroll owing to ongoing medical conditions that could affect sleep. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement³⁰ is adhered to in this study and a completed checklist is provided in the Reporting guidelines.³¹ Figure 1 depicts the study flow as per the STROBE criteria.

Figure 1. Study flow diagram.

Sample size

The sample size calculation is based on teachers' anxiety levels estimated to be 49.4 %,²⁴ similar to insomnia prevalence of 52 % in another study.¹⁸ Considering an 80% power, a 95% confidence level, a 10% relative precision, and a 20% non-response rate, we determined the sample size to be 115. Our study on the teachers levels of depression anxiety and stress was reported earlier²⁵ (https://doi.org/10.12688/f1000research.110720.2) with the same data collection procedures as the current study.

Ethical considerations

The conduct of the study adhered to the 1964 Declaration of Helsinki and its later amendments, as well as other relevant ethical standards. The institutional ethics committee of Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India authorized the study (approval number: IEC KMC MLR -06/2020/184). We got permission from the Block Education Officer (BEO). Further, we obtained permission from the school administration in charge and the principals of the selected schools. The participant information sheet (as in Extended Data)³¹ provided the purpose of the study. We collected informed consent (as in Extended Data)³¹ and permission to publish from the teachers.

Data collection

The Block Education Officer's (BEO) office furnished us with a school list of our district. There were an equal number of private and public schools in the sample. We listed the schools in increasing order of teacher count. Then, we chose schools by lottery until we obtained the necessary sample size. The BEO and the concerned school administration consented once we outlined the specifics of the study. We prepared the questionnaire using the online data collection tool Google Forms. Through WhatsApp and school email, we shared the questionnaire link, the participant information sheet having study details, the Block Education Officers letter of authorization, and the IEC certificate with the head teacher or principal of the selected school. At the investigator's request, the principal sent the link to each school's WhatsApp group for teachers to answer the questionnaire link. We gathered informed consent through the questionnaire link. After responding to the question in hand, teachers had to scroll down to the following ones because it was necessary to answer all the questions in the link. The participants could respond to the questionnaires in less than ten minutes.

Tools

We gathered data through a questionnaire using Google Forms. The questionnaire (provided as Extended Data)³¹ consisted of Section 1 for demographic details; Section 2 comprised the insomnia severity index (ISI) scales for insomnia; and Section 3-featured Depression, anxiety, and stress scales (DASS-21) to measure stress and anxiety and depression levels. Two weeks after returning to their jobs at the school, we ensured the questionnaires were accessible to the teachers.

A) Insomnia Severity Index (ISI)

The Insomnia severity index (ISI) is a seven-item screening tool for insomnia.²⁶^,³² The questionnaire evaluates the severity of recent two-week bouts of insomnia by Likert scale. The seven items' scores were added (total score ranges from 0-28), and we classified insomnia into the following four groups: Moderately severe clinical insomnia (score of 15-21); Severe clinical insomnia (score of 22–28); Subthreshold insomnia (score of 8-14), and No clinically relevant insomnia (scores of 0-7).

We procured permission to use the ISI questionnaire (English version) from the author through Mapi Research Trust (https://eprovide.mapi-trust.org/instruments/insomnia-severity-index). In a population-based sample, the ISI’s internal consistency was outstanding (Cronbach α-0.90),³³ and reliable across community and clinical samples.³⁴ A study on the Indian population also exhibited excellent test-retest reliability, validity, and internal consistency.²⁷

B) Depression, anxiety, and stress (DASS 21) scale

The English short version of the DASS 21 questionnaire³⁵ (https://eprovide.mapi-trust.org/instruments/depression-anxiety-stress-scales), is a self-report questionnaire that is designed to identify the psychological conditions of stress, depression, and anxiety (seven items in each domain, twenty-one statements). The replies show how much each respondent found the statement true over the previous week. Based on the cut-off scores, we categorized the severity of the symptoms into five groups: No symptoms; Minor symptoms; Moderate symptoms; Severe symptoms, and Extremely severe symptoms.³⁵

For the DASS 21 subscales, Cronbach’s alpha values were 0.91 for stress, 0.87 for anxiety, and 0.94 for depression in an earlier study.³⁶ In the Indian context,³⁷^,³⁸ the three-factor model of 21-item DASS questionnaire has been used to assess psychological symptoms and the English version were found to be suitable for use in Indians.³⁹^,⁴⁰

Additionally, we divided the symptoms into categories based on their presence or absence, such as “insomnia absent and insomnia present,” “depression absent and depression present,” “anxiety absent and anxiety present,” and “stress absent and stress present.” We compared the presence/absence of insomnia with sex, age groups, school boards, type of school, and presence/absence of psychological symptoms.

Study groups and definitions

Schools run or assisted by the government are categorized as public schools. The Council for the Indian Secondary Certificate Examination (CISCE), a private board of school education in India, administers the Indian Certificate of Secondary Education (ICSE). The Government of India supervises the Central Board of Secondary Education (CBSE), a national-level board of education in India for both public and private schools. Karnataka State Board manages the State Education Examination Board. To compare the levels of stress, depression, and anxiety among teachers, we divided school education boards into (CBSE+ICSE) against state boards and school institution types into public versus private schools.

Data analysis

IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. analyzed the information gathered. We used the appropriate tables and figures to express the results as proportions. To compare the groups, we used Chi-square tests. We used Logistic regression analysis to calculate the odds ratio of the variables contributing to teachers' insomnia risk. A p-value of less than 0.05 was used to denote statistical significance.

Results

Of 180 teachers contacted, 124(68.89%)³¹ completed the survey. Of 124 teachers, 108(87.1%) were females, and nearly 30% of teachers were aged less than 40 years. About 112 (90.3 %) were teaching at private institutions, while 70 (56.5%) and 54 (43.5%) were teaching in the central boards (CBSE+ICSE) and state boards of education, respectively (Table 1). The full raw data can be found under Underlying data.³¹

Table 1. Basic demographic characteristics of school teachers.

Variables	N (%)
Age groups
<40 years	37 (29.8)
≥40 years	87 (70.2)
Sex
Female	108 (87.1)
Male	16 (12.9)
School board
State board	54 (43.5)
CBSE+ICSE	70 (56.5)
Institution
Government aided institutes	12 (9.7)
Private institution	112 (90.3)

The prevalence of insomnia was 37.9% (subthreshold in 25% and clinical in 12.9%). The prevalence of stress, depression, and anxiety was 20.2%, 30.6%, and 45.2%, respectively (Table 2).

Table 2. Prevalence’s of insomnia and psychological symptoms (depression, anxiety and stress) in school teachers.

Symptomatology	Presence of symptoms N (%)	Absence of symptoms N (%)
Insomnia	47 (37.90)	77 (62.10)
Depression	38 (30.6)	86 (69.4)
Anxiety	56 (45.2)	68 (54.8)
Stress	25 (20.2)	99 (79.8)

The frequency of teacher’s responses towards the ISI questionnaires is depicted in Table 3. Depressive symptoms were present in 38 (30.6%), with severity varying from mild (12.9%) to moderate (9.7%) to severe (5.6%) to extremely severe (2.4%). Anxiety was expressed by 56(45.2%), with severity being mild in 17.7%, moderate in 16.9%, severe in 3.2%, and extremely severe in 7.3%. Stress symptoms were seen in 25(20.2%), with variations being mild (12.1%), moderate (3.2%), severe (3.2%), and extremely severe (1.6%).

Table 3. Frequency of the teacher’s responses towards the ISI questionnaire.

Sl no	Variables	n (%)
1a.	Difficulty falling asleep
	None	57 (46)
	Mild	35 (28.2)
	Moderate	27 (21.8)
	Severe	4 (3.2)
	Very severe	1 (0.8)
1b.	Difficulty staying asleep
	None	66 (53.2)
	Mild	33 (26.6)
	Moderate	21 (16.9)
	Severe	3 (2.4)
	Very severe	1 (0.8)
1c.	Problems waking up too early
	None	47 (37.9)
	Mild	45 (36.3)
	Moderate	23 (18.5)
	Severe	7 (5.6)
	Very severe	2 (1.6)
2	How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
	Very satisfied	24 (19.4)
	Satisfied	49 (39.5)
	Neutral	34 (27.4)
	Dissatisfied	17 (13.7)
	Very dissatisfied	-
3	To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?
	Not at all interfering	53 (42.7)
	A little	44 (35.5)
	Somewhat	16 (12.9)
	Much	10 (8.1)
	Very much interfering	1 (0.8)
4.	How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
	Not at all noticeable	61 (49.2)
	A little	43 (34.7)
	Somewhat	15 (12.1)
	Much	3 (2.4)
	Very much noticeable	2 (1.6)
5.	How WORRIED/DISTRESSED are you about your current sleep problem?
	Not at all	59 (47.6)
	A little	46 (37.1)
	Somewhat	9 (7.3)
	Much	8 (6.5)
	Very much	2 (1.6)

On univariate analysis, using Chi-square tests, we found a significant association of insomnia with symptoms of stress, depression and anxiety (p<0.001 for all). On multivariate analysis using logistic regression, we found that only stress was an independent factor for insomnia (95% CI:1.5-28.3, p=0.01). Those teachers who were stressed had 6.4-fold higher odds of insomnia than those who were not stressed. The presence of anxiety or depressive symptoms, sex, school educational boards, and type of institution were neither independently nor jointly associated with insomnia (Table 4).

Table 4. Logistic regression showing the association of demographic and psychological factors with insomnia among school teachers.

Characteristics		Insomnia (n=47) n (%)	Unadjusted OR (95% CI)	Adjusted OR (95% CI)	“p”
Age groups (years)	<40 (n=37)	18 (48.7)	1.9 (0.87-4.1)	2.5 (0.9-6.3)	0.05
Age groups (years)	≥40 (n=87)	29 (33.3)	1	1	0.05
Sex	Male (n=16)	9 (56.3)	2.4 (0.8-6.9)	1.67 (0.46-6.1)	0.44
Sex	Female (n=108)	38 (35.2)	1	1	0.44
Depression	Present (n=38)	27 (71.1)	8.1 (3.4-19.2)	2.6 (0.79-8.60)	0.12
Depression	Absent (n=86)	20 (23.3)	1	1	0.12
Anxiety	Present (n=56)	33 (58.9)	5.5 (2.5-12.2)	1.5 (0.54-4.4)	0.42
Anxiety	Absent (n=68)	14 (20.6)	1	1	0.42
Stress	Present (n=25)	21 (84.0)	14.7 (4.6-47.0)	6.4 (1.5-28.3)	0.01*
Stress	Absent ( n=99)	26 (26.3)	1	1	0.01*

* OR-Odds ratio from binary logistic regression, “p” of <0.05 was considered as statistically significant.

Discussion

Symptoms of insomnia

We observed that 37.9% of teachers expressed the presence of insomnia (subthreshold - 25% and clinical - 12.9%) at the time of resuming face-to-face classes at school amid the COVID-19 pandemic.

As per the United Kingdom's “Education Support” charity's annual teacher well-being survey findings, 52% of teachers have experienced trouble sleeping during the pandemic, up from 37% who claimed they battled with sleep in the preceding two years.¹⁸ The increased prevalence in the United Kingdom was most likely because the study data were collected during the peak of the COVID-19 pandemic when people were alarmed about the COVID-19 crisis, had economic concerns, and had societal constraints. The current study insomnia rates were comparable with insomnia (36.9%) in unvaccinated teachers in Bangladesh and was higher than levels noted in vaccinated teachers (25.2%).⁴¹ A review study has documented that the COVID -19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia,⁴² and it was not possible to know if the prevalence had increased in our study.

During the pandemic, moderate and severe clinical insomnia was present in 13.32% and 1.85% of the Indian adult population, respectively¹⁵ this was comparable to the moderate clinical insomnia rates in our study. The general population in another Indian study reported poor sleep quality in higher numbers (57.2%),⁴³ with quality of sleep significantly associated with self-reported mental health status (by Pittsburgh Sleep Quality Index questionnaire). The pooled prevalence rates were lower (18%,29.7% and 32.3 %)⁴⁴^–⁴⁶ and similar (36.7%) ²⁸ in the previous studies on the general public.

Previous studies on insomnia levels in healthcare care workers showed varied results with some either similar (35-38.9%)⁴⁵^–⁵⁰ lower (18.9%, 31%, and 34%)⁴⁴^,⁵¹^,⁵²or higher (44.1% and 47.9%)⁵³^,⁵⁴ than that shown in our study. The subthreshold insomnia levels in the current study were like the levels found in HCW in Saudi.⁵⁵

In contrast to the insomnia levels in our study, the higher pooled prevalence rate of insomnia symptoms of 48%, ⁵⁶ 57%,⁴⁴ and 74.8%,⁴⁵ were reported among COVID-19 patients. Across various other populations, the prevalence of insomnia was 20.05% in public China,¹⁶ 31.3%,⁵⁷ and 43.6 %⁵⁸ in university students and 23.2 %⁵⁹ in adolescents and young adults in China.

There were variations in the insomnia prevalences in previous studies across a spectrum of populations in different countries,⁴³^–⁴⁵^,⁵³^,⁵⁴^,⁵⁶^,⁵⁸ with data collection done during other times of the COVID-19 pandemic, with some conducted at its peak times when many unprecedented and uncertain changes were occurring in people’s daily lives. We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-19 appropriate behaviors along with effective vaccination drive by the Indian Government might have contributed to the lesser prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection’s unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

Symptoms of depression, anxiety and stress

We found that 20.2%, 30.6%, and 45.2% of teachers had expressed psychological symptoms of stress, depression, and anxiety, respectively. Previous studies on teachers had documented higher stress levels (46.60% and 50.6%),²⁴^,⁶⁰ lower (39.90% & 23.20%),⁶⁰ and higher (49.5% & 32.2%)²⁴ anxiety and depression levels, respectively, as compared to our study. Symptoms of stress, depression, and anxiety were present in teachers at rates of 30 %, 19%, and 17%, respectively, in a systematic review and meta-analysis.¹³ A similar systematic analysis among teachers found anxiety in 10% to 49.4%, stress in 12.6% to 50.6%, and depression in 15.9% to 28.9%.¹⁴ In another review, teacher’s rates of stress, anxiety, and depression ranged from 8.3% to 87.1%, 38% to 41.2%, and 4% to 77%, respectively.⁵

The prevalence of depression anxiety and stress levels in our study was higher than rates reported among HCW by Thu Pham et al. (19.2%,24.7%, & 13.9%, respectively),⁶¹ and Le Thi Ngoc et al. (18%,11.5%, & 7.7% respectively).⁶² Chen et al.⁶³ and Pappa et al.⁵⁰ documented lower pooled prevalences of 18.29%⁶³ & 22.8%⁵⁰ for depression and 16.63%⁶³ & 23.2%⁵⁰ for anxiety, respectively. Sharma et al. reported a lower pooled prevalence of 20.1% and 25% for depression and anxiety, along with higher stress levels of 36%.⁵¹ On the contrary, Kakemam et al.⁶⁴ and Abdullah et al.⁶⁵ in HCW reported higher levels of depression (42.65%⁶⁴ & 41.9%⁶⁵), and stress (40.3%⁶⁴ & 58.04%⁶⁵), respectively, and nearly similar anxiety status (42.9%)⁶⁴^,⁶⁵ as in our study.

Earlier studies among the general population had stress (29.6%,¹¹ 36.5%,⁶⁶ & 37.54%⁶⁷), depression (28%,⁶⁶ 33.7%,¹¹ & 34.31%⁶⁷), and anxiety (26.9%,⁶⁶ 31.9%,¹¹ & 38.12%⁶⁷), which were higher, nearly similar, and lower, respectively, than that seen in our teachers. Teacher’s stress levels were lower than those of COVID-19 patients (28%,⁶⁸ 36%,⁶⁹ & 46.6%⁷⁰). Symptoms of depression among COVID-19 patients were 21%,⁶⁹ 31%,⁶⁸ and 54.29%,⁷⁰ which were lower, similar, and higher, respectively, than levels in our teachers. Anxiety in COVID-19 patients was 22%,⁶⁹ 42%,⁶⁸ and 97.2%,⁷⁰ which was lower, similar, and higher, respectively, than the levels found among our teachers. The discrepancies in the prevalences in various research may result from several variables, including sample size disparities, participant demographics, measurement tool usage, and cultural considerations and changes in the settings under study.

It is well-known that females make up most teachers in many schools. Likewise, our selected schools have female teachers, contributing to 87.1% of participation. Higher psychological symptoms in teachers have been reported earlier,²⁴^,⁷¹ and in the current study, we found a significant association between symptoms of anxiety and sex.²⁵ However, we did not find an association between insomnia and sex in the present study, although women expressed higher insomnia in previous studies.⁵²^,⁵⁹^,⁷²^,⁷³

Association of insomnia with psychological symptoms

We found a significant association between insomnia and symptoms of stress, depression, and anxiety with univariate analysis. However, on logistic regression analysis, we observed a significant independent relationship between stress and sleeplessness (p-value < 0.001). At the same time, there was no discernible correlation between anxiety, sadness, sex, education school boards, or type of educational institution; this could probably be due to unknown confounding factors that could influence the relationship between insomnia and these variables. Association of insomnia symptoms with depression,⁴⁴^,⁴⁸^,⁵⁹^,⁷³^,⁷⁴ anxiety,¹⁵^,⁴⁴^,⁴⁸^,⁵⁹^,⁷³^,⁷⁴ and stress in various populations were present in earlier research.⁷³^–⁷⁵ Multiple other factors in different people, such as older age, being an HCP, education level, and living in a city or near the epicenter¹⁵^,¹⁶^,⁴⁸^,⁵²^,⁵⁹^,⁷³ were significantly associated with insomnia.

Stress activates the hypothalamic-pituitary-adrenal (HPA) axis and triggers the cortisol release, promoting insomnia.⁷⁶ Conversely, lack of sleep can cause neuroendocrine dysregulation because of maladaptive alterations in the HPA axis. As a result, stress and sleeplessness may worsen one another and produce a vicious cycle that affects mental health over the long run.⁷⁷ Shorter sleep duration and increased cortisol levels are linked to higher day-to-day stress levels.⁷⁸ Additionally, research has shown that individuals with anxiety and depression had HPA axis hyperactivity. Stress activates the HPA axis, inducing insomnia, which can further disrupt HPA functioning and raise the risk of anxiety and depressive symptoms. Thus, stress, sleeplessness, and emotional disorders are physiologically linked to activation of the HPA axis.⁷⁹ This valid contention adds credibility to the idea that insomnia acts as a mediator in the connection between emotional problems and perceived stress.⁸⁰

Teachers with type D (distressed) personalities had higher stress levels, significant insomnia, and depression.²² A known risk factor for the emergence of depression is insomnia. Depression is known to increase a person’s negative attitude about their work and responsibilities, which in turn negatively affects the manner and effectiveness of their work. In addition, rapidly evolving norms regarding infection control procedures and adopting COVID-19-appropriate behaviors in schools will cause teachers to feel uneasy and oblivious. The risk of resurgence of infection and the fear of spreading the illness to family members can affect emotional and sleep health. Thus, psychological, physiological, emotional, and social variables contribute to the multidimensional nature of stress.

The study had a few limitations. The sample size was relatively small, which could impact the generalizability of the results. Additionally, there was an underrepresentation of male teachers, which may have skewed the findings toward a female perspective. Lastly, there is a possibility of bias in the responses to the questionnaire, which could have influenced the results. Further, though there was a significant association between insomnia and psychological symptoms, it is unclear if insomnia causes psychological symptoms or vice versa because the study was cross-sectional. We did not establish the causality of insomnia and psychological symptoms. We speculated it to be a blend of adopting COVID-appropriate behaviors at school, worry of being infected, and school reopening after a halt.

The study's strengths included using a standard questionnaire to measure teachers' levels of insomnia prevalence (by ISI) and manifestations of stress, anxiety, and depression (by DASS 21). In addition, this study is the first one in the Indian context to assess insomnia and psychological symptoms in teachers who joined back to work at school after a hiatus.

Insomnia will impact the performance of teachers by affecting concentration, memory, and decision-making abilities. Strategic interventions such as cognitive behavioral therapy, mindfulness practices,⁸¹ and various sleep hygiene techniques will improve sleep quality and reduce stress, anxiety, and depressive symptoms in the long run.

It will be prudent if a longitudinal study is conducted in the future to establish the causality of insomnia and psychological symptoms and explore the effectiveness of different interventions to reduce insomnia among teachers.

Conclusions

To conclude, we reported insomnia in 37.9 % of teachers after resuming face-to-face classes in schools during the COVID-19 pandemic. Symptoms of stress, depression, and anxiety were present in 20.2%, 30.6%, and 45.2% of teachers, respectively. An independent risk factor for insomnia was the presence of psychological stress. Identifying sleeplessness and psychological issues in teachers and addressing them as early as possible is essential for an effective teaching atmosphere at school and overall well-being.

Data availability

Underlying data

Open Scientific Framework: Insomnia in teachers with the resumption of in-person instruction at schools amidst the COVID-19 pandemic–a cross-sectional study. 2023. https://osf.io/b4c3u.³¹

This dataset contains the following underlying data:

• Excel Data file
• Data code Key

Extended data

Open Scientific Framework: Insomnia in teachers with the resumption of in-person instruction at schools amidst the COVID-19 pandemic–a cross-sectional study. 2023. https://osf.io/b4c3u.³¹

This dataset contains the following underlying extended data:

• Parent information sheet
• Informed consent form
• Study Questionnaire

Reporting guidelines

Open Scientific Framework: STROBE checklist for Insomnia in teachers with the resumption of in-person instruction at schools amidst the COVID-19 pandemic–a cross-sectional study. 2023. https://osf.io/b4c3u

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgments

We thank the school teachers who participated in the study.

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Prasanna Mithra
Roles: Formal Analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Padmanabh Kamath
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Bhaskaran Unnikrishnan
Roles: Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

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No competing interests were disclosed.

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Kamath SP, Mithra P, Kamath P and Unnikrishnan B. Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study [version 2; peer review: 2 approved]. F1000Research 2024, 12:1217 (https://doi.org/10.12688/f1000research.141274.2)

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Sreejayan Kongasseri, Psychiatrist, Northern Health, Melbourne, Australia

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Ravichandra Karkal, Department of Psychiatry, Yenepoya Medical College Hospital, Mangaluru, Karnataka, India

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The following modifications are required for the manuscript.

The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep and mental health of many people, including teachers who had to adapt to online teaching and then resume in-person instruction at schools. This study aimed to estimate the prevalence of insomnia and its association with stress, anxiety, and depression among teachers in India after schools reopened following a hiatus due to the pandemic.

The introduction is too lengthy and contains some irrelevant information. For example, the paragraph on the effects of insomnia on health could be omitted or moved to the discussion section, as it is not directly related to the research question.

Replace Ref no. 5 with following as the current reference is from teachers from special education school and may not be applicable to all teachers in regular schools. Agyapong, B., Obuobi-Donkor, G., Burback, L., & Wei, Y. (2022). Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. International Journal of Environmental Research and Public Health, 19. (Ref. 1).

In methodology: The details of the tools (ISI and DASS 21) can be made concise and psychometric properties can be highlighted rather than describing the tool in great details.

In results section- "The presence of anxiety or depressive symptoms, sex, school educational boards, or the type of institution did not significantly correlate with insomnia in teachers."-- Use the term “association” instead of “correlation” to describe the relationship between insomnia and psychological symptoms, as this is more appropriate for categorical variables.

Table 4 title - Logistic regression
Table 4- Use "p" instead of "p value"

Those teachers who were stressed out had a 6.4 times higher incidence of insomnia (odds ratio).- Replace incidence with odds. Those teachers who were stressed out had a 6.4 times higher odds of reporting insomnia.

Last paragraph of results can be replaced with following- On univariate analysis using Chi-square tests, we found a significant association of insomnia with symptoms of stress, depression, and anxiety (p < 0.001 for all). On multivariate analysis using logistic regression, we found that only stress was an independent factor for insomnia (95% CI: 1.5-28.3, P = 0.01). Those teachers who were stressed had a 6.4-fold higher odds of insomnia than those who were not stressed. The presence of anxiety or depressive symptoms, sex, school educational boards, and type of institution were neither independently nor jointly associated with insomnia.

In discussion 6th paragraph- Avoid using “by” to introduce the statistical test, as this can be ambiguous and misleading. Instead, use “using” or “with” to indicate the method of analysis.

In discussion section focus on the comparison of the prevalence and severity of insomnia and psychological symptoms among teachers with other populations, such as health care workers, general public, and COVID-19 patients. The authors could use more specific terms to describe the differences, such as higher, lower, similar, or comparable.

Discuss the possible mechanisms and explanations for the association between insomnia and stress, as well as the lack of association between insomnia and other variables, such as anxiety, depression, sex, school boards, and type of institution. The authors could provide (wherever feasible)more evidence and reasoning to support their hypotheses, such as biological, psychological, or social factors that could mediate or moderate the relationship between insomnia and stress.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

1. Agyapong B, Obuobi-Donkor G, Burback L, Wei Y: Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review.Int J Environ Res Public Health. 2022; 19 (17). PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Mood disorders, Social media addiction, Insomnia

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Author Response 05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

05 Sep 2024

Author Response

The following modifications are required for the manuscript.

1. The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep ... Continue reading The following modifications are required for the manuscript.

1. The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep and mental health of many people, including teachers who had to adapt to online teaching and then resume in-person instruction at schools. This study aimed to estimate the prevalence of insomnia and its association with stress, anxiety, and depression among teachers in India after schools reopened following a hiatus due to the pandemic.
Author Response: As suggested, changes have been made in the background section of the abstract.

2. The introduction is too lengthy and contains some irrelevant information. For example, the paragraph on the effects of insomnia on health could be omitted or moved to the discussion section, as it is not directly related to the research question.
Author Response: As suggested, the changes have been made. The paragraph on the effects of insomnia on health has been omitted in the introduction section.

3. Replace Ref no. 5 with following as the current reference is from teachers from special education school and may not be applicable to all teachers in regular schools. Agyapong, B., Obuobi-Donkor, G., Burback, L., & Wei, Y. (2022). Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. International Journal of Environmental Research and Public Health, 19. (Ref. 1).
Author Response: The reference 5 has been updated as suggested
Agyapong B, Obuobi-Donkor G, Burback L, Wei Y. Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. Int J Environ Res Public Health. 2022 Aug 27;19(17):10706. https://doi.org/10.3390/ijerph191710706

4. In methodology: The details of the tools (ISI and DASS 21) can be made concise and psychometric properties can be highlighted rather than describing the tool in great details.
Author Response: The details of the tools have been concised, and psychometric properties are highlighted with relevant references.

5.In results section- "The presence of anxiety or depressive symptoms, sex, school educational boards, or the type of institution did not significantly correlate with insomnia in teachers."-- Use the term “association” instead of “correlation” to describe the relationship between insomnia and psychological symptoms, as this is more appropriate for categorical variables.
Author Response: As suggested, the term association is used instead of correlation

6. Table 4 title - Logistic regression
Table 4- Use "p" instead of "p value"
Author Response: The necessary changes are done in Table 4.

7. Those teachers who were stressed out had a 6.4 times higher incidence of insomnia (odds ratio).- Replace incidence with odds. Those teachers who were stressed out had a 6.4 times higher odds of reporting insomnia.
Author Response: The word incidence has been replaced by the word odds - Those teachers who were stressed had 6.4 times higher odds of reporting insomnia.

8. Last paragraph of results can be replaced with following- On univariate analysis using Chi-square tests, we found a significant association of insomnia with symptoms of stress, depression, and anxiety (p < 0.001 for all). On multivariate analysis using logistic regression, we found that only stress was an independent factor for insomnia (95% CI: 1.5-28.3, P = 0.01). Those teachers who were stressed had a 6.4-fold higher odds of insomnia than those who were not stressed. The presence of anxiety or depressive symptoms, sex, school educational boards, and type of institution were neither independently nor jointly associated with insomnia.
Author Response: As suggested, last paragraph of results has been reframed.

9. In discussion 6th paragraph- Avoid using “by” to introduce the statistical test, as this can be ambiguous and misleading. Instead, use “using” or “with” to indicate the method of analysis.
Author Response: Appropriate suggested word has been used to indicate the method of analysis

10. In discussion section focus on the comparison of the prevalence and severity of insomnia and psychological symptoms among teachers with other populations, such as health care workers, general public, and COVID-19 patients. The authors could use more specific terms to describe the differences, such as higher, lower, similar, or comparable.
Author Response: The prevalence of insomnia and psychological symptoms among teachers with other populations such as health care workers, the general public, and COVID-19 patients have been discussed with specific terms such as higher, lower, similar, and comparable to describe differences. Relevant references added

11. Discuss the possible mechanisms and explanations for the association between insomnia and stress, as well as the lack of association between insomnia and other variables, such as anxiety, depression, sex, school boards, and type of institution. The authors could provide (wherever feasible)more evidence and reasoning to support their hypotheses, such as biological, psychological, or social factors that could mediate or moderate the relationship between insomnia and stress.
Author Response: The explanation has been described in the last few paragraphs (before the limitations section) of the discussion, with relevant references added
The following modifications are required for the manuscript.

1. The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep and mental health of many people, including teachers who had to adapt to online teaching and then resume in-person instruction at schools. This study aimed to estimate the prevalence of insomnia and its association with stress, anxiety, and depression among teachers in India after schools reopened following a hiatus due to the pandemic.
Author Response: As suggested, changes have been made in the background section of the abstract.

2. The introduction is too lengthy and contains some irrelevant information. For example, the paragraph on the effects of insomnia on health could be omitted or moved to the discussion section, as it is not directly related to the research question.
Author Response: As suggested, the changes have been made. The paragraph on the effects of insomnia on health has been omitted in the introduction section.

3. Replace Ref no. 5 with following as the current reference is from teachers from special education school and may not be applicable to all teachers in regular schools. Agyapong, B., Obuobi-Donkor, G., Burback, L., & Wei, Y. (2022). Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. International Journal of Environmental Research and Public Health, 19. (Ref. 1).
Author Response: The reference 5 has been updated as suggested
Agyapong B, Obuobi-Donkor G, Burback L, Wei Y. Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. Int J Environ Res Public Health. 2022 Aug 27;19(17):10706. https://doi.org/10.3390/ijerph191710706

4. In methodology: The details of the tools (ISI and DASS 21) can be made concise and psychometric properties can be highlighted rather than describing the tool in great details.
Author Response: The details of the tools have been concised, and psychometric properties are highlighted with relevant references.

5.In results section- "The presence of anxiety or depressive symptoms, sex, school educational boards, or the type of institution did not significantly correlate with insomnia in teachers."-- Use the term “association” instead of “correlation” to describe the relationship between insomnia and psychological symptoms, as this is more appropriate for categorical variables.
Author Response: As suggested, the term association is used instead of correlation

6. Table 4 title - Logistic regression
Table 4- Use "p" instead of "p value"
Author Response: The necessary changes are done in Table 4.

7. Those teachers who were stressed out had a 6.4 times higher incidence of insomnia (odds ratio).- Replace incidence with odds. Those teachers who were stressed out had a 6.4 times higher odds of reporting insomnia.
Author Response: The word incidence has been replaced by the word odds - Those teachers who were stressed had 6.4 times higher odds of reporting insomnia.

8. Last paragraph of results can be replaced with following- On univariate analysis using Chi-square tests, we found a significant association of insomnia with symptoms of stress, depression, and anxiety (p < 0.001 for all). On multivariate analysis using logistic regression, we found that only stress was an independent factor for insomnia (95% CI: 1.5-28.3, P = 0.01). Those teachers who were stressed had a 6.4-fold higher odds of insomnia than those who were not stressed. The presence of anxiety or depressive symptoms, sex, school educational boards, and type of institution were neither independently nor jointly associated with insomnia.
Author Response: As suggested, last paragraph of results has been reframed.

9. In discussion 6th paragraph- Avoid using “by” to introduce the statistical test, as this can be ambiguous and misleading. Instead, use “using” or “with” to indicate the method of analysis.
Author Response: Appropriate suggested word has been used to indicate the method of analysis

10. In discussion section focus on the comparison of the prevalence and severity of insomnia and psychological symptoms among teachers with other populations, such as health care workers, general public, and COVID-19 patients. The authors could use more specific terms to describe the differences, such as higher, lower, similar, or comparable.
Author Response: The prevalence of insomnia and psychological symptoms among teachers with other populations such as health care workers, the general public, and COVID-19 patients have been discussed with specific terms such as higher, lower, similar, and comparable to describe differences. Relevant references added

11. Discuss the possible mechanisms and explanations for the association between insomnia and stress, as well as the lack of association between insomnia and other variables, such as anxiety, depression, sex, school boards, and type of institution. The authors could provide (wherever feasible)more evidence and reasoning to support their hypotheses, such as biological, psychological, or social factors that could mediate or moderate the relationship between insomnia and stress.
Author Response: The explanation has been described in the last few paragraphs (before the limitations section) of the discussion, with relevant references added
Competing Interests: Nil Close
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COMMENTS ON THIS REPORT

Author Response 05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

05 Sep 2024

Author Response

The following modifications are required for the manuscript.

1. The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep ... Continue reading The following modifications are required for the manuscript.

1. The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep and mental health of many people, including teachers who had to adapt to online teaching and then resume in-person instruction at schools. This study aimed to estimate the prevalence of insomnia and its association with stress, anxiety, and depression among teachers in India after schools reopened following a hiatus due to the pandemic.
Author Response: As suggested, changes have been made in the background section of the abstract.

2. The introduction is too lengthy and contains some irrelevant information. For example, the paragraph on the effects of insomnia on health could be omitted or moved to the discussion section, as it is not directly related to the research question.
Author Response: As suggested, the changes have been made. The paragraph on the effects of insomnia on health has been omitted in the introduction section.

3. Replace Ref no. 5 with following as the current reference is from teachers from special education school and may not be applicable to all teachers in regular schools. Agyapong, B., Obuobi-Donkor, G., Burback, L., & Wei, Y. (2022). Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. International Journal of Environmental Research and Public Health, 19. (Ref. 1).
Author Response: The reference 5 has been updated as suggested
Agyapong B, Obuobi-Donkor G, Burback L, Wei Y. Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. Int J Environ Res Public Health. 2022 Aug 27;19(17):10706. https://doi.org/10.3390/ijerph191710706

4. In methodology: The details of the tools (ISI and DASS 21) can be made concise and psychometric properties can be highlighted rather than describing the tool in great details.
Author Response: The details of the tools have been concised, and psychometric properties are highlighted with relevant references.

5.In results section- "The presence of anxiety or depressive symptoms, sex, school educational boards, or the type of institution did not significantly correlate with insomnia in teachers."-- Use the term “association” instead of “correlation” to describe the relationship between insomnia and psychological symptoms, as this is more appropriate for categorical variables.
Author Response: As suggested, the term association is used instead of correlation

6. Table 4 title - Logistic regression
Table 4- Use "p" instead of "p value"
Author Response: The necessary changes are done in Table 4.

7. Those teachers who were stressed out had a 6.4 times higher incidence of insomnia (odds ratio).- Replace incidence with odds. Those teachers who were stressed out had a 6.4 times higher odds of reporting insomnia.
Author Response: The word incidence has been replaced by the word odds - Those teachers who were stressed had 6.4 times higher odds of reporting insomnia.

8. Last paragraph of results can be replaced with following- On univariate analysis using Chi-square tests, we found a significant association of insomnia with symptoms of stress, depression, and anxiety (p < 0.001 for all). On multivariate analysis using logistic regression, we found that only stress was an independent factor for insomnia (95% CI: 1.5-28.3, P = 0.01). Those teachers who were stressed had a 6.4-fold higher odds of insomnia than those who were not stressed. The presence of anxiety or depressive symptoms, sex, school educational boards, and type of institution were neither independently nor jointly associated with insomnia.
Author Response: As suggested, last paragraph of results has been reframed.

9. In discussion 6th paragraph- Avoid using “by” to introduce the statistical test, as this can be ambiguous and misleading. Instead, use “using” or “with” to indicate the method of analysis.
Author Response: Appropriate suggested word has been used to indicate the method of analysis

10. In discussion section focus on the comparison of the prevalence and severity of insomnia and psychological symptoms among teachers with other populations, such as health care workers, general public, and COVID-19 patients. The authors could use more specific terms to describe the differences, such as higher, lower, similar, or comparable.
Author Response: The prevalence of insomnia and psychological symptoms among teachers with other populations such as health care workers, the general public, and COVID-19 patients have been discussed with specific terms such as higher, lower, similar, and comparable to describe differences. Relevant references added

11. Discuss the possible mechanisms and explanations for the association between insomnia and stress, as well as the lack of association between insomnia and other variables, such as anxiety, depression, sex, school boards, and type of institution. The authors could provide (wherever feasible)more evidence and reasoning to support their hypotheses, such as biological, psychological, or social factors that could mediate or moderate the relationship between insomnia and stress.
Author Response: The explanation has been described in the last few paragraphs (before the limitations section) of the discussion, with relevant references added
The following modifications are required for the manuscript.

1. The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep and mental health of many people, including teachers who had to adapt to online teaching and then resume in-person instruction at schools. This study aimed to estimate the prevalence of insomnia and its association with stress, anxiety, and depression among teachers in India after schools reopened following a hiatus due to the pandemic.
Author Response: As suggested, changes have been made in the background section of the abstract.

2. The introduction is too lengthy and contains some irrelevant information. For example, the paragraph on the effects of insomnia on health could be omitted or moved to the discussion section, as it is not directly related to the research question.
Author Response: As suggested, the changes have been made. The paragraph on the effects of insomnia on health has been omitted in the introduction section.

3. Replace Ref no. 5 with following as the current reference is from teachers from special education school and may not be applicable to all teachers in regular schools. Agyapong, B., Obuobi-Donkor, G., Burback, L., & Wei, Y. (2022). Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. International Journal of Environmental Research and Public Health, 19. (Ref. 1).
Author Response: The reference 5 has been updated as suggested
Agyapong B, Obuobi-Donkor G, Burback L, Wei Y. Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. Int J Environ Res Public Health. 2022 Aug 27;19(17):10706. https://doi.org/10.3390/ijerph191710706

4. In methodology: The details of the tools (ISI and DASS 21) can be made concise and psychometric properties can be highlighted rather than describing the tool in great details.
Author Response: The details of the tools have been concised, and psychometric properties are highlighted with relevant references.

5.In results section- "The presence of anxiety or depressive symptoms, sex, school educational boards, or the type of institution did not significantly correlate with insomnia in teachers."-- Use the term “association” instead of “correlation” to describe the relationship between insomnia and psychological symptoms, as this is more appropriate for categorical variables.
Author Response: As suggested, the term association is used instead of correlation

6. Table 4 title - Logistic regression
Table 4- Use "p" instead of "p value"
Author Response: The necessary changes are done in Table 4.

7. Those teachers who were stressed out had a 6.4 times higher incidence of insomnia (odds ratio).- Replace incidence with odds. Those teachers who were stressed out had a 6.4 times higher odds of reporting insomnia.
Author Response: The word incidence has been replaced by the word odds - Those teachers who were stressed had 6.4 times higher odds of reporting insomnia.

8. Last paragraph of results can be replaced with following- On univariate analysis using Chi-square tests, we found a significant association of insomnia with symptoms of stress, depression, and anxiety (p < 0.001 for all). On multivariate analysis using logistic regression, we found that only stress was an independent factor for insomnia (95% CI: 1.5-28.3, P = 0.01). Those teachers who were stressed had a 6.4-fold higher odds of insomnia than those who were not stressed. The presence of anxiety or depressive symptoms, sex, school educational boards, and type of institution were neither independently nor jointly associated with insomnia.
Author Response: As suggested, last paragraph of results has been reframed.

9. In discussion 6th paragraph- Avoid using “by” to introduce the statistical test, as this can be ambiguous and misleading. Instead, use “using” or “with” to indicate the method of analysis.
Author Response: Appropriate suggested word has been used to indicate the method of analysis

10. In discussion section focus on the comparison of the prevalence and severity of insomnia and psychological symptoms among teachers with other populations, such as health care workers, general public, and COVID-19 patients. The authors could use more specific terms to describe the differences, such as higher, lower, similar, or comparable.
Author Response: The prevalence of insomnia and psychological symptoms among teachers with other populations such as health care workers, the general public, and COVID-19 patients have been discussed with specific terms such as higher, lower, similar, and comparable to describe differences. Relevant references added

11. Discuss the possible mechanisms and explanations for the association between insomnia and stress, as well as the lack of association between insomnia and other variables, such as anxiety, depression, sex, school boards, and type of institution. The authors could provide (wherever feasible)more evidence and reasoning to support their hypotheses, such as biological, psychological, or social factors that could mediate or moderate the relationship between insomnia and stress.
Author Response: The explanation has been described in the last few paragraphs (before the limitations section) of the discussion, with relevant references added
Competing Interests: Nil Close
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Views

Reviewer Report 20 Dec 2023

Sreejayan Kongasseri, Psychiatrist, Northern Health, Melbourne, Australia

Approved with Reservations

https://doi.org/10.5256/f1000research.154704.r226960

This is a well conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are well presented.

Here are few suggestions:

This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.
Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here
“ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.

“ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.

In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access they would not have known about the study.
Some more points to include in discussion ( not covered)
More women than men
Lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.

“Lastly, there is a possibility of bias in the responses to the questionnaire” this statement is not clear. Needs some elaboration.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Psychiatry, mental health, addictions

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

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Author Response 05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

05 Sep 2024

Author Response

This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However ... Continue reading This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here

A. We have changed the title as follows: Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study.

“ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.

A. We have changed the sentence as follows:We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) at the time of resuming face-to-face classes at school amid the COVID-19 pandemic

“ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.

A. As suggested, the sentence has been placed in the subsequent paragraphs- Similarly, a review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” and it was not possible to know if the prevalence had increased in our study.

In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access they would not have known about the study.

A. About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the WhatsApp group, those teachers with the above conditions expressed dissent.

The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further on the same because of feasibility issues.

We have now clarified that 16 teachers did opt out of the study since they mentioned they have poor internet connectivity issues since they resided in remote rural areas and came to work at school in the city.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion (not covered)

More women than men
A. It is well known that females make up most teachers in a large number of schools. Likewise, our selected schools were populated with female teachers. Thus, our study also had more participation from female teachers (87.1%). We did not find an association between insomnia and sex in the present study; however, women expressed higher insomnia in previous studies. ⁴⁰^, ⁴³^– ⁴⁵

There is a lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
A. Earlier studies ^{15,16,35,37-42} had insomnia prevalence ranging between 13.32 % and 57.2 % across various populations in various countries, with data collection done during the peak COVID-19 pandemic times when a lot of unprecedented and uncertain changes were occurring in people's daily lives.

We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-appropriate behaviors along with effective vaccination drive by the Indian government must have contributed to the lesser prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection's unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

“Lastly, there is a possibility of bias in the responses to the questionnaire.” This statement is not clear. Needs some elaboration
A. We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here

A. We have changed the title as follows: Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study.

“ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.

A. We have changed the sentence as follows:We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) at the time of resuming face-to-face classes at school amid the COVID-19 pandemic

“ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.

A. As suggested, the sentence has been placed in the subsequent paragraphs- Similarly, a review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” and it was not possible to know if the prevalence had increased in our study.

In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access they would not have known about the study.

A. About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the WhatsApp group, those teachers with the above conditions expressed dissent.

The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further on the same because of feasibility issues.

We have now clarified that 16 teachers did opt out of the study since they mentioned they have poor internet connectivity issues since they resided in remote rural areas and came to work at school in the city.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion (not covered)

More women than men
A. It is well known that females make up most teachers in a large number of schools. Likewise, our selected schools were populated with female teachers. Thus, our study also had more participation from female teachers (87.1%). We did not find an association between insomnia and sex in the present study; however, women expressed higher insomnia in previous studies. ⁴⁰^, ⁴³^– ⁴⁵

There is a lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
A. Earlier studies ^{15,16,35,37-42} had insomnia prevalence ranging between 13.32 % and 57.2 % across various populations in various countries, with data collection done during the peak COVID-19 pandemic times when a lot of unprecedented and uncertain changes were occurring in people's daily lives.

We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-appropriate behaviors along with effective vaccination drive by the Indian government must have contributed to the lesser prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection's unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

“Lastly, there is a possibility of bias in the responses to the questionnaire.” This statement is not clear. Needs some elaboration
A. We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
Competing Interests: nil Close
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Author Response 05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

05 Sep 2024

Author Response

This is a well-conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are ... Continue reading This is a well-conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are well presented.

Here are a few suggestions:

1. This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.
Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here.
Author Response: We have changed the title as follows: “Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study”.

2. “ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.
Author Response: We have changed the sentence as follows: we observed that 37.9% of teachers expressed the presence of insomnia (subthrhold-25% and clinical -12.9%) at the time of resuming face -to face classes at school amid the COVID -19 pandemic.

3. “ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.
Author Response: As suggested, the sentence has been placed in the subsequent paragraphs-
A review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia,⁴²and it was not possible to know if the prevalence had increased in our study. The reference number has been updated.

4. In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access, they would not have known about the study.

Author Response: About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the What’s app group, those teachers with the above conditions expressed dissent. About 16 teachers could open the questionnaire link; however, due to internet issues and technical glitches, they could not either complete or submit the questionnaire and, therefore, decided to opt out of the study.
The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further into this because of feasibility issues.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion ( not covered)
5. More women than men
Author Response: It is well-known that females make up most teachers in many schools. Likewise, our selected schools have female teachers, contributing to 87.1% of participation. Higher psychological symptoms in teachers have been reported earlier, ^24,71, and in the current study, we found a significant association between symptoms of anxiety and sex.²⁵However, we did not find an association between insomnia and sex in the present study, although women expressed higher insomnia in previous studies.^52, ^59,72,73

6. Lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
Author Response: There were variations in the insomnia prevalences in previous studies across a spectrum of populations ^{43,44,45,53,54,56,58} in different countries, with data collection done during other times of the COVID-19 pandemic, with some conducted at its peak times when many unprecedented and uncertain changes were occurring in people's daily lives. We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-19 appropriate behaviors along with an effective vaccination drive by the Indian government might have contributed to the lower prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection’s unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

7. “Lastly, there is a possibility of bias in the responses to the questionnaire” this statement is not clear. Needs some elaboration.
Author Response: We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
This is a well-conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are well presented.

Here are a few suggestions:

1. This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.
Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here.
Author Response: We have changed the title as follows: “Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study”.

2. “ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.
Author Response: We have changed the sentence as follows: we observed that 37.9% of teachers expressed the presence of insomnia (subthrhold-25% and clinical -12.9%) at the time of resuming face -to face classes at school amid the COVID -19 pandemic.

3. “ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.
Author Response: As suggested, the sentence has been placed in the subsequent paragraphs-
A review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia,⁴²and it was not possible to know if the prevalence had increased in our study. The reference number has been updated.

4. In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access, they would not have known about the study.

Author Response: About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the What’s app group, those teachers with the above conditions expressed dissent. About 16 teachers could open the questionnaire link; however, due to internet issues and technical glitches, they could not either complete or submit the questionnaire and, therefore, decided to opt out of the study.
The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further into this because of feasibility issues.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion ( not covered)
5. More women than men
Author Response: It is well-known that females make up most teachers in many schools. Likewise, our selected schools have female teachers, contributing to 87.1% of participation. Higher psychological symptoms in teachers have been reported earlier, ^24,71, and in the current study, we found a significant association between symptoms of anxiety and sex.²⁵However, we did not find an association between insomnia and sex in the present study, although women expressed higher insomnia in previous studies.^52, ^59,72,73

6. Lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
Author Response: There were variations in the insomnia prevalences in previous studies across a spectrum of populations ^{43,44,45,53,54,56,58} in different countries, with data collection done during other times of the COVID-19 pandemic, with some conducted at its peak times when many unprecedented and uncertain changes were occurring in people's daily lives. We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-19 appropriate behaviors along with an effective vaccination drive by the Indian government might have contributed to the lower prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection’s unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

7. “Lastly, there is a possibility of bias in the responses to the questionnaire” this statement is not clear. Needs some elaboration.
Author Response: We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
Competing Interests: No competing interests were disclosed. Close
Report a concern
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Author Response 05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

05 Sep 2024

Author Response

This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However ... Continue reading This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here

A. We have changed the title as follows: Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study.

“ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.

A. We have changed the sentence as follows:We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) at the time of resuming face-to-face classes at school amid the COVID-19 pandemic

“ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.

A. As suggested, the sentence has been placed in the subsequent paragraphs- Similarly, a review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” and it was not possible to know if the prevalence had increased in our study.

In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access they would not have known about the study.

A. About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the WhatsApp group, those teachers with the above conditions expressed dissent.

The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further on the same because of feasibility issues.

We have now clarified that 16 teachers did opt out of the study since they mentioned they have poor internet connectivity issues since they resided in remote rural areas and came to work at school in the city.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion (not covered)

More women than men
A. It is well known that females make up most teachers in a large number of schools. Likewise, our selected schools were populated with female teachers. Thus, our study also had more participation from female teachers (87.1%). We did not find an association between insomnia and sex in the present study; however, women expressed higher insomnia in previous studies. ⁴⁰^, ⁴³^– ⁴⁵

There is a lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
A. Earlier studies ^{15,16,35,37-42} had insomnia prevalence ranging between 13.32 % and 57.2 % across various populations in various countries, with data collection done during the peak COVID-19 pandemic times when a lot of unprecedented and uncertain changes were occurring in people's daily lives.

We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-appropriate behaviors along with effective vaccination drive by the Indian government must have contributed to the lesser prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection's unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

“Lastly, there is a possibility of bias in the responses to the questionnaire.” This statement is not clear. Needs some elaboration
A. We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here

A. We have changed the title as follows: Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study.

“ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.

A. We have changed the sentence as follows:We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) at the time of resuming face-to-face classes at school amid the COVID-19 pandemic

“ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.

A. As suggested, the sentence has been placed in the subsequent paragraphs- Similarly, a review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” and it was not possible to know if the prevalence had increased in our study.

In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access they would not have known about the study.

A. About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the WhatsApp group, those teachers with the above conditions expressed dissent.

The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further on the same because of feasibility issues.

We have now clarified that 16 teachers did opt out of the study since they mentioned they have poor internet connectivity issues since they resided in remote rural areas and came to work at school in the city.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion (not covered)

More women than men
A. It is well known that females make up most teachers in a large number of schools. Likewise, our selected schools were populated with female teachers. Thus, our study also had more participation from female teachers (87.1%). We did not find an association between insomnia and sex in the present study; however, women expressed higher insomnia in previous studies. ⁴⁰^, ⁴³^– ⁴⁵

There is a lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
A. Earlier studies ^{15,16,35,37-42} had insomnia prevalence ranging between 13.32 % and 57.2 % across various populations in various countries, with data collection done during the peak COVID-19 pandemic times when a lot of unprecedented and uncertain changes were occurring in people's daily lives.

We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-appropriate behaviors along with effective vaccination drive by the Indian government must have contributed to the lesser prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection's unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

“Lastly, there is a possibility of bias in the responses to the questionnaire.” This statement is not clear. Needs some elaboration
A. We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
Competing Interests: nil Close
Report a concern
Author Response 05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

05 Sep 2024

Author Response

This is a well-conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are ... Continue reading This is a well-conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are well presented.

Here are a few suggestions:

1. This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.
Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here.
Author Response: We have changed the title as follows: “Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study”.

2. “ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.
Author Response: We have changed the sentence as follows: we observed that 37.9% of teachers expressed the presence of insomnia (subthrhold-25% and clinical -12.9%) at the time of resuming face -to face classes at school amid the COVID -19 pandemic.

3. “ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.
Author Response: As suggested, the sentence has been placed in the subsequent paragraphs-
A review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia,⁴²and it was not possible to know if the prevalence had increased in our study. The reference number has been updated.

4. In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access, they would not have known about the study.

Author Response: About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the What’s app group, those teachers with the above conditions expressed dissent. About 16 teachers could open the questionnaire link; however, due to internet issues and technical glitches, they could not either complete or submit the questionnaire and, therefore, decided to opt out of the study.
The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further into this because of feasibility issues.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion ( not covered)
5. More women than men
Author Response: It is well-known that females make up most teachers in many schools. Likewise, our selected schools have female teachers, contributing to 87.1% of participation. Higher psychological symptoms in teachers have been reported earlier, ^24,71, and in the current study, we found a significant association between symptoms of anxiety and sex.²⁵However, we did not find an association between insomnia and sex in the present study, although women expressed higher insomnia in previous studies.^52, ^59,72,73

6. Lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
Author Response: There were variations in the insomnia prevalences in previous studies across a spectrum of populations ^{43,44,45,53,54,56,58} in different countries, with data collection done during other times of the COVID-19 pandemic, with some conducted at its peak times when many unprecedented and uncertain changes were occurring in people's daily lives. We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-19 appropriate behaviors along with an effective vaccination drive by the Indian government might have contributed to the lower prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection’s unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

7. “Lastly, there is a possibility of bias in the responses to the questionnaire” this statement is not clear. Needs some elaboration.
Author Response: We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
This is a well-conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are well presented.

Here are a few suggestions:

1. This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.
Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here.
Author Response: We have changed the title as follows: “Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study”.

2. “ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.
Author Response: We have changed the sentence as follows: we observed that 37.9% of teachers expressed the presence of insomnia (subthrhold-25% and clinical -12.9%) at the time of resuming face -to face classes at school amid the COVID -19 pandemic.

3. “ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.
Author Response: As suggested, the sentence has been placed in the subsequent paragraphs-
A review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia,⁴²and it was not possible to know if the prevalence had increased in our study. The reference number has been updated.

4. In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access, they would not have known about the study.

Author Response: About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the What’s app group, those teachers with the above conditions expressed dissent. About 16 teachers could open the questionnaire link; however, due to internet issues and technical glitches, they could not either complete or submit the questionnaire and, therefore, decided to opt out of the study.
The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further into this because of feasibility issues.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion ( not covered)
5. More women than men
Author Response: It is well-known that females make up most teachers in many schools. Likewise, our selected schools have female teachers, contributing to 87.1% of participation. Higher psychological symptoms in teachers have been reported earlier, ^24,71, and in the current study, we found a significant association between symptoms of anxiety and sex.²⁵However, we did not find an association between insomnia and sex in the present study, although women expressed higher insomnia in previous studies.^52, ^59,72,73

6. Lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
Author Response: There were variations in the insomnia prevalences in previous studies across a spectrum of populations ^{43,44,45,53,54,56,58} in different countries, with data collection done during other times of the COVID-19 pandemic, with some conducted at its peak times when many unprecedented and uncertain changes were occurring in people's daily lives. We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-19 appropriate behaviors along with an effective vaccination drive by the Indian government might have contributed to the lower prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection’s unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

7. “Lastly, there is a possibility of bias in the responses to the questionnaire” this statement is not clear. Needs some elaboration.
Author Response: We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2 PUBLISHED 26 Sep 2023

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Version 1 26 Sep 23	read	read

Sreejayan Kongasseri, Northern Health, Melbourne, Australia
Ravichandra Karkal, Yenepoya Medical College Hospital, Mangaluru, India

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25 Sep 2024 | for Version 2

Sreejayan Kongasseri, Psychiatrist, Northern Health, Melbourne, Australia

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Approved

No further comments to make
The authors have responded appropriately

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No competing interests were disclosed.

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Psychiatry, mental health, addictions

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19 Views

04 Jan 2024 | for Version 1

Ravichandra Karkal, Department of Psychiatry, Yenepoya Medical College Hospital, Mangaluru, Karnataka, India

19 Views Cite this report Responses(1)

Approved

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Mood disorders, Social media addiction, Insomnia

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Author Response

05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

The following modifications are required for the manuscript.

1. The background section of abstract is lengthy and can be summarised as follows- The COVID-19 pandemic has affected the sleep and mental health of many people, including teachers who had to adapt to online teaching and then resume in-person instruction at schools. This study aimed to estimate the prevalence of insomnia and its association with stress, anxiety, and depression among teachers in India after schools reopened following a hiatus due to the pandemic.
Author Response: As suggested, changes have been made in the background section of the abstract.

2. The introduction is too lengthy and contains some irrelevant information. For example, the paragraph on the effects of insomnia on health could be omitted or moved to the discussion section, as it is not directly related to the research question.
Author Response: As suggested, the changes have been made. The paragraph on the effects of insomnia on health has been omitted in the introduction section.

3. Replace Ref no. 5 with following as the current reference is from teachers from special education school and may not be applicable to all teachers in regular schools. Agyapong, B., Obuobi-Donkor, G., Burback, L., & Wei, Y. (2022). Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. International Journal of Environmental Research and Public Health, 19. (Ref. 1).
Author Response: The reference 5 has been updated as suggested
Agyapong B, Obuobi-Donkor G, Burback L, Wei Y. Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review. Int J Environ Res Public Health. 2022 Aug 27;19(17):10706. https://doi.org/10.3390/ijerph191710706

4. In methodology: The details of the tools (ISI and DASS 21) can be made concise and psychometric properties can be highlighted rather than describing the tool in great details.
Author Response: The details of the tools have been concised, and psychometric properties are highlighted with relevant references.

5.In results section- "The presence of anxiety or depressive symptoms, sex, school educational boards, or the type of institution did not significantly correlate with insomnia in teachers."-- Use the term “association” instead of “correlation” to describe the relationship between insomnia and psychological symptoms, as this is more appropriate for categorical variables.
Author Response: As suggested, the term association is used instead of correlation

6. Table 4 title - Logistic regression
Table 4- Use "p" instead of "p value"
Author Response: The necessary changes are done in Table 4.

7. Those teachers who were stressed out had a 6.4 times higher incidence of insomnia (odds ratio).- Replace incidence with odds. Those teachers who were stressed out had a 6.4 times higher odds of reporting insomnia.
Author Response: The word incidence has been replaced by the word odds - Those teachers who were stressed had 6.4 times higher odds of reporting insomnia.

8. Last paragraph of results can be replaced with following- On univariate analysis using Chi-square tests, we found a significant association of insomnia with symptoms of stress, depression, and anxiety (p < 0.001 for all). On multivariate analysis using logistic regression, we found that only stress was an independent factor for insomnia (95% CI: 1.5-28.3, P = 0.01). Those teachers who were stressed had a 6.4-fold higher odds of insomnia than those who were not stressed. The presence of anxiety or depressive symptoms, sex, school educational boards, and type of institution were neither independently nor jointly associated with insomnia.
Author Response: As suggested, last paragraph of results has been reframed.

9. In discussion 6th paragraph- Avoid using “by” to introduce the statistical test, as this can be ambiguous and misleading. Instead, use “using” or “with” to indicate the method of analysis.
Author Response: Appropriate suggested word has been used to indicate the method of analysis

10. In discussion section focus on the comparison of the prevalence and severity of insomnia and psychological symptoms among teachers with other populations, such as health care workers, general public, and COVID-19 patients. The authors could use more specific terms to describe the differences, such as higher, lower, similar, or comparable.
Author Response: The prevalence of insomnia and psychological symptoms among teachers with other populations such as health care workers, the general public, and COVID-19 patients have been discussed with specific terms such as higher, lower, similar, and comparable to describe differences. Relevant references added

11. Discuss the possible mechanisms and explanations for the association between insomnia and stress, as well as the lack of association between insomnia and other variables, such as anxiety, depression, sex, school boards, and type of institution. The authors could provide (wherever feasible)more evidence and reasoning to support their hypotheses, such as biological, psychological, or social factors that could mediate or moderate the relationship between insomnia and stress.
Author Response: The explanation has been described in the last few paragraphs (before the limitations section) of the discussion, with relevant references added

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20 Dec 2023 | for Version 1

Sreejayan Kongasseri, Psychiatrist, Northern Health, Melbourne, Australia

33 Views Cite this report Responses(2)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Psychiatry, mental health, addictions

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Author Response

05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here

A. We have changed the title as follows: Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study.

“ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.

A. We have changed the sentence as follows:We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) at the time of resuming face-to-face classes at school amid the COVID-19 pandemic

“ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.

A. As suggested, the sentence has been placed in the subsequent paragraphs- Similarly, a review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” and it was not possible to know if the prevalence had increased in our study.

In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access they would not have known about the study.

A. About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the WhatsApp group, those teachers with the above conditions expressed dissent.

The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further on the same because of feasibility issues.

We have now clarified that 16 teachers did opt out of the study since they mentioned they have poor internet connectivity issues since they resided in remote rural areas and came to work at school in the city.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion (not covered)

More women than men
A. It is well known that females make up most teachers in a large number of schools. Likewise, our selected schools were populated with female teachers. Thus, our study also had more participation from female teachers (87.1%). We did not find an association between insomnia and sex in the present study; however, women expressed higher insomnia in previous studies. ⁴⁰^, ⁴³^– ⁴⁵

There is a lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
A. Earlier studies ^{15,16,35,37-42} had insomnia prevalence ranging between 13.32 % and 57.2 % across various populations in various countries, with data collection done during the peak COVID-19 pandemic times when a lot of unprecedented and uncertain changes were occurring in people's daily lives.

We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-appropriate behaviors along with effective vaccination drive by the Indian government must have contributed to the lesser prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection's unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

“Lastly, there is a possibility of bias in the responses to the questionnaire.” This statement is not clear. Needs some elaboration
A. We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.

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Competing Interests

nil

Author Response

05 Sep 2024

Sowmini Padmanabh Kamath, Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

This is a well-conducted study with a strong methodology. Authors have used standardised scales and have explained the sampling method elaborately. Appropriate statistical methods have been used and results are well presented.

Here are a few suggestions:

1. This is a cross sectional study which means that the prevalence of insomnia has been estimated at a certain point of time ( when the in person teaching resumed). However authors have used words in ways as if the in person teaching was causal to the insomnia and stress.
Title “ Insomnia in teachers with the resumption of in-person” suggests causality. “ at the time of” will be more appropriate here.
Author Response: We have changed the title as follows: “Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study”.

2. “ We observed that 37.9 % of teachers expressed the presence of insomnia (subthreshold - 25 % and clinical -12.9 %) after resuming face-to-face classes at school amid the COVID-19 pandemic” instead of after “ at the time of”.
Author Response: We have changed the sentence as follows: we observed that 37.9% of teachers expressed the presence of insomnia (subthrhold-25% and clinical -12.9%) at the time of resuming face -to face classes at school amid the COVID -19 pandemic.

3. “ Similarly, a review study documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia.34” this sentence can come later with a statement that it was not possible to know if the prevalence had increased.
Author Response: As suggested, the sentence has been placed in the subsequent paragraphs-
A review study has documented that the COVID-19 pandemic is linked with a significant increase in subthreshold insomnia but not with moderate or severe symptoms of insomnia,⁴²and it was not possible to know if the prevalence had increased in our study. The reference number has been updated.

4. In the flow diagram the reasons for exclusions could have been mentioned. Medical condition has been reported as reason for exclusion. It is difficult to imagine a condition with which a teacher can attend work but get excluded from the study. If the authors excluded them due to conditions that caused insomnia then it would be clearer if those excluded conditions were mentioned. Were prior psychiatric conditions excluded? “16 teachers did not have internet facility” is not clear. The survey was sent electronically. If they did not have internet access, they would not have known about the study.

Author Response: About 56 teachers were excluded from the study. A total of 40 teachers did not consent to the study because of unwillingness in 28 and medical conditions that affect sleep in 12 {diabetes in 7, heart disease in 3, and asthma in 2}. Once the principal sent the questionnaire link to the What’s app group, those teachers with the above conditions expressed dissent. About 16 teachers could open the questionnaire link; however, due to internet issues and technical glitches, they could not either complete or submit the questionnaire and, therefore, decided to opt out of the study.
The subjects approached did not mention any presence of prior psychiatric conditions, probably due to fear of social stigma. We could not probe further into this because of feasibility issues.
The explanation is done in the flow diagram and enclosed.

Some more points to include in the discussion ( not covered)
5. More women than men
Author Response: It is well-known that females make up most teachers in many schools. Likewise, our selected schools have female teachers, contributing to 87.1% of participation. Higher psychological symptoms in teachers have been reported earlier, ^24,71, and in the current study, we found a significant association between symptoms of anxiety and sex.²⁵However, we did not find an association between insomnia and sex in the present study, although women expressed higher insomnia in previous studies.^52, ^59,72,73

6. Lower prevalence in this study when compared to existing literature. Even though India had a high mortality rate during COVID.
Author Response: There were variations in the insomnia prevalences in previous studies across a spectrum of populations ^{43,44,45,53,54,56,58} in different countries, with data collection done during other times of the COVID-19 pandemic, with some conducted at its peak times when many unprecedented and uncertain changes were occurring in people's daily lives. We conducted our study after a prolonged hiatus of lockdown. In addition, improved knowledge and treatment facilities for COVID-19 infection and adapting to COVID-19 appropriate behaviors along with an effective vaccination drive by the Indian government might have contributed to the lower prevalence compared to a few earlier studies. The reopening of schools after a hiatus, the difficulties in implementing and adopting new routines, and the possibility of an infection’s unpredictable reappearance were the combined reasons for insomnia and the psychological symptoms, which we could not prove to be causal.

7. “Lastly, there is a possibility of bias in the responses to the questionnaire” this statement is not clear. Needs some elaboration.
Author Response: We have removed the sentence since both questionnaire scales have demonstrated reliability and validity in populations.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Study design and participants

Figure 1. Study flow diagram.

Sample size

Ethical considerations

Data collection

Tools

Study groups and definitions

Data analysis

Results

Table 1. Basic demographic characteristics of school teachers.

Table 2. Prevalence’s of insomnia and psychological symptoms (depression, anxiety and stress) in school teachers.

Table 3. Frequency of the teacher’s responses towards the ISI questionnaire.

Table 4. Logistic regression showing the association of demographic and psychological factors with insomnia among school teachers.

Discussion

Symptoms of insomnia

Symptoms of depression, anxiety and stress

Association of insomnia with psychological symptoms

Conclusions

Data availability

Underlying data

Extended data

Reporting guidelines

Acknowledgments

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