Sleep issues and burnout in Irish farmers: A cross sectional survey

Rosen C.S., Kaplan A.N., Nelson D.B., La Bash H., Chard K.M., Eftekhari A., Kehle-Forbes S., Wiltsey Stirman S., Sayer N.A.

The first goal of this study was to assess longitudinal changes in burnout among psychotherapists prior to (T1) and during the COVID-19 pandemic (T2). The second objective was to assess the effects of job demands, job resources (including organizational support for evidence-based psychotherapies, or EBPs) and pandemic-related stress (T2 only) on burnout. Psychotherapists providing EBPs for posttraumatic stress disorder in U.S. Department of Veterans Affairs (VA) facilities completed surveys assessing burnout, job resources, and job demands prior to (T1; n = 346) and during (T2; n = 193) the COVID-19 pandemic. Burnout prevalence increased from 40 % at T1 to 56 % at T2 (p < .001). At T1, stronger implementation climate and implementation leadership (p < .001) and provision of only cognitive processing therapy (rather than use of prolonged exposure therapy or both treatments; p < .05) reduced burnout risk. Risk factors for burnout at T2 included T1 burnout, pandemic-related stress, less control over when and how to deliver EBPs, being female, and being a psychologist rather than social worker (p < .02). Implementation leadership did not reduce risk of burnout at T2. This study involved staff not directly involved in treating COVID-19, in a healthcare system poised to transition to telehealth delivery. Organizational support for using EBPs reduced burnout risk prior to but not during the pandemic. Pandemic related stress rather than increased work demands contributed to elevated burnout during the pandemic. A comprehensive approach to reducing burnout must address the effects of both work demands and personal stressors.

O'Shaughnessy B.R., O'Hagan A.D., Burke A., McNamara J., O'Connor S.

Due to the economic, social, and health consequences of burnout, farmer burnout is receiving increased attention in the media and in contemporary research. In this systematic review and narrative synthesis, we aim to evaluate and synthesise the current state of the international evidence for the prevalence of farmer burnout. We developed and applied a search strategy to target studies that examined the prevalence of burnout among farmers of any farming type, gender, and nationality. Combined with secondary and grey literature searching, this resulted in 811 search results. Twenty-three full texts were screened which resulted in nine eligible studies consisting of seven cross-sectional studies, one longitudinal study, and one RCT. We applied the STROBE checklist for quality appraisal, and most studies had a low risk of bias. Across North American, European and Australian studies using cutting points, the average prevalence of severe burnout in farmers was 13.72%. The prevalence rate was higher in New Zealand (25%) and Morocco (18.96%). Compared to non-farmers, farmers experienced higher overall burnout, and higher exhaustion, cynicism and professional efficacy. Gender differences indicated that women experience higher burnout than males. Associated factors included farming as primary occupation, being a dairy farmer, and work stress. Findings indicate the characteristics of farmers especially at risk of burnout which could inform the development of future research and supports to ameliorate farmer burnout. Results also highlight the limitations of the evidence for farmer burnout including the lack of standardised burnout classification methods, the potential for response-bias when examining gender issues, and the influence of socio-economic and agricultural policy in the international evidence. • In this systematic review, we present current international literature on the prevalence of farmer burnout. • Severe burnout in farmers ranged from 9.8%-13.72% depending on the measure used, cut-off points, and location • Severe burnout was significantly higher in farmers compared to non-farmer populations. • Burnout was higher in female farmers and in farmers outside Europe and North America. • Factors associated with burnout were dairy farming, work stress, workload, health and traditional (non-diversified) farming

Sørengaard T.A., Saksvik-Lehouillier I.

The aim of this study was to investigate the relations between underlying dimensions of burnout (ie exhaustion, mental distance, cognitive impairment and emotional impairment) and sleep reactivity in occupations that maintain critical societal functions during the COVID-19 pandemic. Sleep reactivity refers to the vulnerability of experiencing sleep disturbances during stressful and challenging situations, and manifests as difficulties with falling and staying asleep. Previous research has highlighted the importance investigating psychological factors that may influence or trigger vulnerability to stress induced sleep problems, including factors at work.Longitudinal self-report data was collected using an online survey administered to Norwegian workers employed in health care, education, social services, emergency services and other sectors with critical tasks during the COVID-19 pandemic at two different time points three months apart. The sample in the present study (N = 1331) consisted of 76% females and 24% males with a mean age of 44 years.The results showed that work-related exhaustion measured at baseline was the strongest symptom of burnout associated with higher sleep reactivity three months later, followed by emotional impairment. Mental distance and cognitive impairment at work were not associated with sleep reactivity, indicating that these burnout dimensions have less of an impact on sleep than exhaustion and emotional impairment.Work-related exhaustion and emotional impairment can lower the individual's tolerance to perceiving events as stressful as well as reinforce the stress response, and contribute to difficulties with initiating and/or maintaining sleep. Workers employed in occupations with critical tasks during the pandemic may be more susceptible to exhaustion, emotional strain and poorer sleep due to increased and prolonged work pressure. Organizational and individual measures that can decrease stress and increase coping should be offered to employees working in high-stress conditions.

Bui T.H., Tran T.M., Nguyen T.N., Vu T.C., Ngo X.D., Nguyen T.H., Do T.L.

Despite its popularity, Maslach Burnout Inventory-Human Service Survey (MBI-HSS)'s factorial structure has been subject to considerable debate, and its measurement invariance (MI) is seldomly examined. This cross-sectional study aims at reassessing the most popularly suggested structures of this instrument, namely the 20- and 22-item three-factor model on Vietnamese healthcare professionals. It also examines the MI of MBI-HSS across genders, occupations, and mental health conditions.Self-administered questionnaires were sent out to 1500 doctors and nurses working at 15 hospitals in big cities in Vietnam in September and October 2020, and 1162 valid questionnaires were collected. The questionnaire consists of three sets of questions covering (1) demographic information of participants; (2) MBI-HSS questionnaire; and (3) The 21-item version of the Depression-Anxiety-Stress Scale. MBI-HSS scale was validated on Vietnamese sample for the first time; therefore, we used the repeated forward-backward procedure to translate this scale into Vietnamese. To examine which model best fits the data, a series of Confirmatory Factor Analysis (CFA) was used to test the model fit of correlated three-factor model, second-order hierarchical model, and bi-factor model. The reliability of the MBI-HSS was assessed using Cronbach's α coefficients. Then, multiple-group CFA (MGCFA) was applied to determine whether the MBI-HSS has a similar structure between groups different in gender, occupation, and mental health condition.Our findings confirmed that the 22-item MBI-HSS best fit the data, and this scale measures three distinct but related aspects of burnout, including Emotional Exhaustion, Depersonalization, and Personal Accomplishment. The MI of MBI-HSS across genders and occupations was also confirmed. However, data did not fit well with group at risk for common mental health disorders. It can be concluded that the Vietnamese version of MBI-HSS is a valid measure to assess burnout level of healthcare professionals in Vietnam who are not at risk for mental health disorders.

Souto-Manning M., Melvin S.A.

Stress and well-being are known to influence the quality of teacher-student interactions, teachers' delivery of emotional and instructional support, and the social competence and executive function skills of young learners-dynamics that impact the education and development of young children. Even prior to COVID-19, 46% of teachers reported notably high levels of daily stress. Given the additional stressors associated with the pandemic, this multi-methods study explores the well-being of Latinx, Black, and multiracial early childhood teachers in New York City, where communities of Color have been particularly hard hit by COVID-19. Via an amalgamation of descriptive and interpretive approaches-a survey, time-use diaries, and qualitative interviews-this study documents early childhood teachers' experiences making sense of and negotiating the impacts of intersecting stressors on their stress, health, quality of life, and sleep amidst COVID-19. Survey findings show reduced well-being across measures among the early childhood teachers in the sample, while qualitative findings illustrate the many layers of challenges that teachers of Color faced during the pandemic. Time-use diaries show extremely high demands and long work hours associated with concerning lack of self-care and attention to mental health. Interviews elucidate how stress is layered across environmental, occupational, and racial factors. This study points to the need to attend to the well-being of Black, Latinx, and multiracial early childhood teachers in urban settings during and after COVID-19 recovery.

Pohl M., Feher G., Kapus K., Feher A., Nagy G.D., Kiss J., Fejes É., Horvath L., Tibold A.

The extensive availability of Internet has led to the recognition of problematic Internet use (so called Internet addiction, IA) mostly involving adolescents. There are limited data about the prevalence and consequences of IA in adults especially among high school teachers. Here, we present a cross-sectional prospective study focusing on the association of Internet addiction with burnout, depression, insomnia, and lower quality of life among high school teachers taking many co-variates into account. Overall, 623 males (34.3%) and 1194 females (65.7%) participated in our study. Internet addiction was detected in 5.2% (95/1817) based on the Problematic Internet Use Questionnaire. Internet addiction was associated with severe burnout (10.5 vs. 2.7%, p < 0.001), moderate (36.8 vs. 1.7%, p < 0.001), and severe (6.3 vs. 0.1%, p < 0.001) depression, insomnia (23.1 vs. 11.4%, p < 0.001), and severe sleep disturbance (severe insomnia, 27.4 vs. 3.8%, p < 0.001) and lower quality of life in all domains (p < 0.001). There was also a significant correlation of the severity of the above-mentioned parameters and the severity of IA (overall scores, p < 0.001 in all cases). In a multivariate analysis including demographic criteria, risk factors medical conditions and the above-mentioned parameters as co-variates internet addiction was significantly associated with depression (OR = 3.836, CI: 2.92–5.44, p = 0.03), and insomnia (OR: 3.932, CI: 3.6–5.69, p = 0.002). This is the first study from Hungary and is one of the first studies showing the association of IA with mental issues, burnout, and lower quality of life among adults. It underlines the clinical importance of problematic Internet use among adults.

Tangtong C., Yoosook W., Kongtip P., Woskie S.

Chengane S., Beseler C.L., Duysen E.G., Rautiainen R.H.

This study used surveillance data from 2018 and 2020 to test the stability of work-related strain symptoms (high stress, sleep deprivation, exhaustion) with demographic factors, work characteristics, and musculoskeletal symptoms among farm and ranch operators in seven midwestern states of the United States. Cross-sectional surveys were conducted among farm and ranch operators in 2018 (n = 4423) and 2020 (n = 3492). Operators were asked whether, in the past 12 months, they experienced extended work periods that resulted in high stress levels, sleep deprivation, exhaustion/fatigue, or other work-related strain symptoms. Covariates included personal and demographic factors, work characteristics, number of injuries, work-related health conditions, and exposures on the operation. Summary statistics were tabulated for explanatory and outcome variables. The classification (decision) tree approach was used to assess what variables would best separate operators with and without reported strain symptoms, based on a set of explanatory variables. Regularized regression was used to generate effect estimates between the work strain variables and explanatory variables. High stress level, sleep deprivation, and exhaustion were reported more frequently in 2018 than 2020. The classification tree reproduced the 2018 model using 2020 data with approximately 80% accuracy. The mean number of reported MSD symptoms increased slightly from 1.23 in 2018 to 1.41 in 2020. Older age, more time spent in farm work, higher gross farm income (GFI), and MSD symptoms in six body regions (ankles/feet, knees, lower back, neck, shoulders, wrists/hands) were associated with all three work strain symptoms. Musculoskeletal pain and discomfort was a strong predictor for stress, sleep deprivation, and exhaustion among farmers and ranchers. This finding indicates that reducing MSD pain and discomfort is beneficial for both physical and mental health.

Brennan M., Hennessy T., Meredith D., Dillon E.

The demands of modern farming can place substantial stress upon the farmer, adversely impacting their wellbeing. This study identifies both the prevalence of stress and assesses the demographic, farm, and social characteristics that impact the incidence of stress. We report the results of a survey of a nationally representative sample of farm enterprises in Ireland undertaken in association with the Teagasc National Farm Survey (NFS) in 2018, which saw 736 questionnaires completed by farm operators. Frequency analysis is used to report the primary sources and prevalence of stress. A probit model is developed identifying and quantifying the factors that impact the incidence of stress. There were 57% of farmers who reported experiencing stress resulting from their farm work. Key sources of stress included "poor weather", (47%), "workload" (32%) and "financial" concerns (28%). The results of the probit model establish that the effect of age on the incidence of stress is significant, positive, and non-linear, indicating as farmers get older they are more likely to experience stress but at a declining rate. Operating a sheep farm system, as opposed to any other type of farm system, reduces the probability of stress. Working off-farm also reduces the probability of stress by 0.097, other things being equal. The findings highlight variance in the levels of stress reported by farmers by age and farm system, and consequently, the need to develop targeted supports that take consideration of differences within the population of farmers and farm enterprises.

O’Sullivan R., Burns A., Leavey G., Leroi I., Burholt V., Lubben J., Holt-Lunstad J., Victor C., Lawlor B., Vilar-Compte M., Perissinotto C.M., Tully M.A., Sullivan M.P., Rosato M., Power J.M., et. al.

The COVID-19 global pandemic and subsequent public health social measures have challenged our social and economic life, with increasing concerns around potentially rising levels of social isolation and loneliness. This paper is based on cross-sectional online survey data (available in 10 languages, from 2 June to 16 November 2020) with 20,398 respondents from 101 different countries. It aims to help increase our understanding of the global risk factors that are associated with social isolation and loneliness, irrespective of culture or country, to support evidence-based policy, services and public health interventions. We found the prevalence of severe loneliness was 21% during COVID-19 with 6% retrospectively reporting severe loneliness prior to the pandemic. A fifth were defined as isolated based on their usual connections, with 13% reporting a substantial increase in isolation during COVID-19. Personal finances and mental health were overarching and consistently cross-cutting predictors of loneliness and social isolation, both before and during the pandemic. With the likelihood of future waves of COVID-19 and related restrictions, it must be a public health priority to address the root causes of loneliness and social isolation and, in particular, address the needs of specific groups such as carers or those living alone.

Hagen B.N., Sawatzky A., Harper S.L., O’Sullivan T.L., Jones-Bitton A.

Globally, farmers report high levels of occupational stress. The purpose of this study was to identify and explore factors associated with perceived stress among Canadian farmers. A sequential explanatory mixed-methods design was used. An online cross-sectional national survey of Canadian farmers (n = 1132) was conducted in 2015–2016 to collect data on mental health, demographic, lifestyle, and farming characteristics; stress was measured using the Perceived Stress Scale. A multivariable linear regression model was used to investigate the factors associated with perceived stress score. Qualitative interviews (n = 75) were conducted in 2017–2018 with farmers and agricultural sector workers in Ontario, Canada, to explore the lived experience of stress. The qualitative interview data were analyzed via thematic analysis and then used to explain and provide depth to the quantitative results. Financial stress (highest category—a lot: (B = 2.30; CI: 1.59, 3.00)), woman gender (B = 0.55; CI: 0.12, 0.99), pig farming (B = 1.07; CI: 0.45, 1.69), and perceived lack of support from family (B = 1.18; CI: 0.39, 1.98) and industry (B = 1.15; CI: 0.16–2.14) were positively associated with higher perceived stress scores, as were depression and anxiety (as part of an interaction). Resilience had a small negative association with perceived stress (B = −0.04; CI: −0.06, −0.03). Results from the qualitative analysis showed that the uncertainty around financial stress increased perceived stress. Women farmers described the unique demands and challenges they face that contributed to their overall stress. Results from this study can inform the development of mental health resources and research aimed at decreasing stress among Canadian farmers.

Mikolajczak M., Gross J.J., Roskam I.

Here, we lift the veil on an existing but long taboo phenomenon: parental burnout (PB), an exhaustion syndrome related to the parenting role. PB is caused by a perceived gap between parenting resources and demands, and has a host of serious consequences for both parents and their children.

Du Y., Baccaglini L., Johnson A., Puvvula J., Rautiainen R.H.

Agricultural work involves ergonomic and psychosocial strain, which contribute to musculoskeletal conditions. The aim of this study was to assess if specific ergonomic, psychosocial, and preventive factors are linked to musculoskeletal pain or discomfort symptoms (MSS) in farmers and ranchers. We analyzed data from the Central States Center for Agricultural Safety and Health survey that was conducted in 2018 in a seven-state region of the central United States. MSS were assessed with questions from the Standardized Nordic Questionnaire. The survey included questions on demographic, ergonomic, psychosocial and preventive factors. Farm production variables were added from the Farm Market iD database. We analyzed the data using Generalized Estimating Equations. The overall prevalence of MSS for all body sites combined was 59% among 4,354 farmers and ranchers who responded (19% response rate). After controlling for age, sex, and operator status, three factors (high stress level, sleep deprivation, and exhaustion/fatigue) showed the strongest associations with MSS in any body site, with adjusted odds ratios (OR) ranging from 4.8 to 5.6. Forceful exertions, repetitive tasks, awkward postures, frequent manual labor, and vibration were also significantly associated with MSS, with adjusted ORs ranging from 1.8 to 3.3. Recommended preventive techniques were not protective for MSS. New effective strategies are needed to reduce the high burden of musculoskeletal outcomes among farmers and agricultural workers.

Abraham C.M., Zheng K., Norful A.A., Ghaffari A., Liu J., Poghosyan L.

Poor practice environments contribute to burnout, but favorable environments containing support, resources, autonomy, and optimal relations with colleagues may prevent burnout. Compared to all nurse practitioners (NPs), 69% of these NPs provide primary care to patients, yet it is unknown whether the practice environment is associated with NP burnout. A study to examine environmental factors related to NP burnout was conducted. Overall, 396 NPs completed the survey and 25.3% were burnt-out. Higher scores on the professional visibility, NP-physician relations, NP-administration relations, independent practice and support subscales were associated with 51%, 51%, 58%, and 56% lower risk of NP burnout, respectively.

Brubaker J.R., Swan A., Beverly E.A.

Perceived stress, burnout, and poor sleep quality are high among medical students. Interventions designed to target these issues are necessary to promote the health and well-being of medical students. The purpose of this study was twofold: 1) to assess the feasibility of implementing a sunrise alarm clock intervention with medical students and 2) to evaluate the impact of the intervention on perceived stress, burnout scores, and sleep quality. We conducted a feasibility study to evaluate the efficacy of a two-week, sunrise alarm clock intervention in combination with electronic device removal at bedtime. We assessed first- and second-year medical students’ perceived stress, burnout scores, including Emotional Exhaustion, Depersonalization, and Low Sense of Personal Achievement, and sleep quality before and after the intervention. In addition, we measured smartphone addiction prior to the intervention. A total of 57 students consented to participate, of which 55 completed both the pre- and post-assessments (3.5% attrition). The mean age of the participants was 24.8 ± 1.9 years, 50.9% (n = 29) identified as women, and 68.4% (n = 39) identified as white. Pre-intervention, 42.1% (n = 24) of students met criteria for smartphone addiction and 77.2% (n = 44) met criteria for poor sleep quality. In addition, 22.8% (n = 13) of participants had high emotional exhaustion, 64.9% (n = 31) high depersonalization, and 42.1% (n = 24) low sense of personal accomplishment prior to the intervention. Following the two-week intervention, participants showed improvements in emotional exhaustion (p = 0.001, Cohen’s d = 0.353), depersonalization (p = 0.001, Cohen’s d = 0.411) low sense of personal accomplishment (p = 0.023, Cohen’s d = 0.275), perceived stress (p < .001, Cohen’s d = .334), and sleep quality (p < 0.001, Cohen’s d = 0.925). The number of participants who reported poor sleep quality decreased to 41.8% (n = 23), demonstrating a significant decline (p = 0.026). Participants also improved subjective sleep quality (p < 0.001, Cohen’s d = 1.033), sleep duration (p = 0.001, Cohen’s d = 0.431), sleep latency (p < 0.001, Cohen’s d = 0.433), and sleep efficiency (p = 0.021, Cohen’s d = 0.673). These findings suggest that the two-week sunrise alarm clock protocol with electronic device removal was effective in improving sleep quality and reducing burnout scores, and perceived stress. However, additional research comparing this intervention to a proper control group is needed to draw meaningful conclusions about the effectiveness of this intervention.

Conway K., O’Mullane M.

Abstract Aim Despite a growing awareness of the mental health challenges faced by farmers worldwide, there is a lack of understanding and recognition of the unique stressors facing women in agriculture, as well as their help-seeking behaviours, particularly in an Irish context. Using a qualitative methodology grounded in a social constructionist epistemological research approach, this paper explores the stress, anxiety, and other mental disorders impacting women in agriculture in order to help inform more effective, targeted policy interventions moving forward. Subject and methods The study used a qualitative research design grounded in a social constructionist epistemology. Twelve in-depth semi-structured interviews were conducted with female Irish farmers, aged 35 years and over, as part of this study. Topics of discussion included unique farming stressors, motivators, barriers to help-seeking, and ideas for mental health support improvements. Thematic analysis was used to identify recurring themes, which were coded and analysed using NVivo software. Results Five key themes emerged from the interviews: (1) gender-based discrimination in farming, (2) gender-related stigma, (3) gender stereotypes and roles, (4) gender-biased mental health services, and (5) gender-specific help-seeking behaviours. Women reported feeling marginalised within the agricultural sector, facing stress from deeply ingrained misogyny, and struggling with a lack of recognition for their contributions. Gender-biased mental health services and societal expectations further exacerbated their mental health challenges. While some women expressed a willingness to seek help, others cited the cultural stigma of mental health as a barrier, leading to silent suffering. Conclusion The study highlights the need for gender-specific mental health interventions and policy changes to address the unique challenges faced by women in Irish agriculture. Recommendations include promoting gender equality within the farming sector, improving access to mental health services for female farmers, and fostering support networks to encourage help-seeking behaviours. Addressing these issues will enhance the well-being of women in agriculture, contributing to their empowerment and the overall sustainability of rural farming communities.

Li X., Xu L., Sun C., Sun B.

ABSTRACTJob burnout is becoming a major threat to teachers' work. Previous studies revealed that teachers' professional identity and job burnout are negatively related. This study explored the mediating effects of career satisfaction and work engagement in the relationship between teachers' professional identity and job burnout. Investigation materials included the Chinese version of the Teachers' Professional Identity Scale, Career Satisfaction Scale, Utrecht Work Engagement Scale, and Professional Quality of Life Scale. The cross‐sectional design was conducted in this study with 3147 teachers from kindergarten, primary, and secondary schools in Zhejiang Province, China. The PROCESS macro plug‐in SPSS21.0 was used for mediating effect analysis. These results indicated that teachers' professional identity, career satisfaction, and work engagement have significant, positive correlations with each other and significant negative correlations with job burnout. Meanwhile, results showed that career satisfaction and work engagement played parallel and sequentially mediating roles in the relationship between teachers' professional identity and burnout. These findings indicate that a high level of professional identity plays an important role in strengthening career satisfaction and increasing work engagement, which may effectively help teachers reduce job burnout.

O’Connor S., O’Hagan A.D., Firnhaber J., O’Shaughnessy B.R., McNamara J., Breslin G., O’Keeffe S., Malone S.M.

Farmers around the world are at risk of depression, anxiety, and suicidal ideation yet many avoid seeking help. In Ireland, farmers’ mental health is a national concern, as farmers face barriers of masculine norms around help-seeking. This study aimed to examine the prevalence and relationship between mental health literacy and mental health help-seeking in the Irish farming community. It also aimed to identify if mental health literacy or mental health help-seeking differed depending on gender, age, education, health status and income level. We conducted a cross-sectional assessment of 351 Irish farmers’ mental health literacy and help-seeking using validated psychometric measures: the Mental Help Seeking Intention Scale (MHSIS), the Attitudes Toward Seeking Professional Psychological Help Short Form (ATSPPH-SF), and the Multicomponent Mental Health Literacy Measure (MMHL). Irish farmers’ mental health literacy and help-seeking scores were interrelated. Though low, farmers’ scores were comparable to the general population and higher than some European samples. Despite broadly favourable attitudes towards seeking professional mental health help, Irish farmers perceived significant barriers to accessing care and exhibited stoic health attitudes. Farmers with less education and men were particularly at risk. Irish farmers’ stoic attitudes may be a response to their perceived lack of services. Interventions providing mental health literacy education and improving access to existing mental health services are particularly important for this population of farmers.

Shin S., Ryoo J.

Abstract Objective This cross-sectional study aimed to determine the mediating role of burnout in the relationship between work-related boredom and insomnia among Korean workers. Methods Data from 30,992 wage workers in the sixth Korean Working Conditions Survey were analyzed. The odds ratio (OR) and 95% confidence interval (CI) for insomnia according to work-related boredom were estimated using a survey-weighted logistic regression model. A mediation analysis was performed with burnout as the mediator. Results The survey-weighted logistic regression model revealed that work-related boredom was significantly associated with an increased risk of insomnia. In the mediation model, both the total and direct association of work-related boredom on insomnia were statistically significant. Moreover, the indirect association, mediated by burnout, was also significant, accounting for 23.38% of the total association. Conclusions Our findings burnout may play a mediating role between work-related boredom and insomnia.