|Ahead of print
|Daytime sleepiness and sleep quality among undergraduate medical students in Dammam, Saudi Arabia
Mubashir Zafar1, Eltigani O M Omer1, Mohamed Elfatih1, Khalid Ansari2, Abdul Kareem1, Ali fawaz1, Reem Fares1, Wadha Saad1
1 Department of Public Health, College of Public Health, Imamm Abdul Rehman Bin Faisal University, Dammam, KSA
2 Department of Respiratory Care, College of Applied Medical Sciences, Imamm Abdul Rehman Bin Faisal University, Dammam, KSA
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|Date of Submission||01-Jun-2020|
|Date of Decision||24-Jun-2020|
|Date of Acceptance||19-Jul-2020|
|Date of Web Publication||18-Aug-2020|
Introduction: Daytime sleepiness and poor sleep quality are common among medical students. The objective of the study is to determine the prevalence of daytime sleepiness and sleep quality and the associated risk factors among medical students in medical college of Dammam, Saudi Arabia. Materials and Methods: It was a cross-sectional study and 149 medical students were selected through stratified random sampling techniques. The Pittsburgh Sleep Quality Index was used to assess the sleep pattern and Epworth Sleepiness Scale was used to measure daytime sleepiness. Association of sleep quality and daytime sleepiness with its risk factors were determined through regression analysis. Results: Students suffering from severe disorder of sleep quality and daytime sleepiness were 30.9% and 34.9%, respectively. In the multivariate analysis after the adjustment of covariates, males (odd ratio [OR]: 1.43, confidence interval [CI]: 1.16–1.95) (P = 0.035) and students who smoke cigarettes (OR: 1.62, CI: 1.18–2.11) (P = 0.045) were at higher risk of having severe daytime sleepiness. First academic year students were more than five times (OR: 5.34, CI: 1.30–12.58) (P = 0.042) and students who had low academic score (grade point average) were more than three times (OR: 3.13, CI: 1.28–4.87) (P = 0.035) likely associated with severe sleep quality disorder. Conclusion: The majority of students had suffered from poor sleep quality and daytime sleepiness. Male gender, smoking, academic score, and academic years were the major predictors for poor sleep quality and daytime sleepiness. There is a need for awareness and counseling among students to reduce the sleep disorder burden.
Keywords: Disorder, medical, narcolepsy, sleep, students
|How to cite this URL:|
Zafar M, Omer EO, Elfatih M, Ansari K, Kareem A, fawaz A, Fares R, Saad W. Daytime sleepiness and sleep quality among undergraduate medical students in Dammam, Saudi Arabia. Indian J Med Spec [Epub ahead of print] [cited 2020 Nov 25]. Available from: http://www.ijms.in/preprintarticle.asp?id=292390
| Introduction|| |
Normal sleep is essential for good health and good quality of life.,, The duration of sleep varies between different species and only 8 h is needed for a human being. Good sleep is important for learning, critical thinking, and working., A study showed that high school students commonly faced disturbances of sleep due to their high burden of studies. According to research, sleep is classified into three categories: monophasic (6 h duration every 24 h), biphasic (two times every 24 h), and polyphasic (many times sleep per day).
Graduate students have suffered sleep disorders due to a complex study schedule. A previous study's results found that 50% of students were experiencing daytime sleep episodes due to insufficient sleep at night, which leads to poor academic performance and increased risk of accidents.
Medical students suffered more from sleep disorders due to a higher burden of studies compared to other science students. Long working hours were one of the most important factors, which caused sleep disorders among medical students. Sleep disorders affected the mental and physical health of medical students, which leads to a reduction in their working abilities.
Sleep disorders among medical undergraduates not only leads to physical and psychological morbidities but also affects learning, memory, and cognition of students. A study was conducted in a Nigerian university, which showed that 32.5% of medical students were sleep deprived. Similarly, a study was conducted in a medical college of Pakistan, which showed that a poor sleep habit was common among medical students and was associated with affected lifestyle.
Globally, medical students are more susceptible to sleep disturbance and problems. In a previous study done in China, the results found that most of the students had poor quality of sleep. Another study reported that the majority of medical students had experienced daytime sleepiness in a class and male students were more affected. In a study conducted in India, the results found that 30.6% reported daytime sleepiness.
A previous study's result found that only 47% of medical students had refreshing sleep at night compared to law students, and insomnia problems were more common in medical students.
When medical students move from 1st year to final year, there is an increased burden of study. Students are involved in clinical working from 3rd year and have a different working time schedule, which leads to more sleep disorders. Sleep disorders' outcomes include decreased morale, reduced motivation, depression, and anxiety, which, in turn, affects their academic performance. There are very few studies conducted available in Saudi Arabia to determine the sleep quality and daytime sleepiness among medical students. There are more than 100 medical colleges working in the country and more than 20,000 students studying in these medical colleges. The results of this study will help in the revision of the curriculum of medical programs and increase the awareness among the medical students regarding sleep problems. The objective of this study is to determine the prevalence of daytime sleepiness and sleep quality among medical students at Dammam College of Medicine, Saudi Arabia.
| Materials and Methods|| |
Study design, study site, sampling technique, and sample size
This was a cross-sectional study, conducted at Dammam Medical College. It is a public sector medical college and each year 150 students were enrolled. The sample size was calculated by the WHO sample size calculator by keeping the proportion of poor sleep quality 11% from the previous study and using 95% confidence interval (CI) and 5% margin of error. The total sample size of the study was 149 subjects. Stratified random sampling technique was used. From the total 5 years of medical education, 30 students were selected from each year of education.
Inclusion criteria, exclusion criteria, and study variables
Participants included were undergraduate students of medical college and those who are willing to giving consent to participate in the study. Participants were excluded those who have any chronic mental disorder.
Study varibales were age, gender, academic year, sleep hours, Narcolepsy by Epworth Sleepiness Scale (ESS), Sleep Habits by Pittsburgh Sleep Quality Index (PSQI), Sleep Habits during Exams, Sleep Habits and Extracurricular Activities, Stress and Sleep Habits, Sleep and Physical Activity, Satisfaction with Sleep Habits.
Data collection tool
Sleep quality and daytime sleepiness were measured through a semi-structured questionnaire which was based on objective of the study. It consisted of two sections which were sociodemographic characteristic and sleep disorder of participants. A self-administered proforma was used for collection of data. The proforma contains standard sleep scales, i.e., ESS and PSQI., Subjects were given instruction prior to data collection.
Permission was taken from participants and they were informed about the purpose of the study. Written consent was also taken before beginning to ask the questions from them.
The data were analyzed using SPSS version 22 (IBM Software, Chicago, USA). The data from the questionnaire were encoded into database by data encoder. Questionnaire forms and database were checked for completeness daily. The data were entered twice and then cleaned for any missing variables. All the data were supervised by the principal investigator on regular basis. Quantitative variables such as mean age and standard deviation were calculated. Categorical variables such as gender, years of education, and father's occupation were described using frequencies and percentages. Association between poor sleep quality and associated risk factors was determined by regression (multinomial) analysis. Independent variables which appeared with P < 0.05 were included in the multivariate analysis. Daytime sleepiness was classified into four categories: normal, mild, moderate, and severe. Multinomial regression analysis was done to determine the association of daytime sleepiness (normal is reference category and mild, moderate, and severe are risk category with the sociodemographic characteristics.
The study was approved by the Imam Abdul Rahman Bin Faisal University Ethical Committee. The approval code is IRB-UGS-2019-179. Verbal and written informed consent after explanation about the study was obtained from the study participants. Counseling was done after the interview providing basic information regarding the prevention of sleep disorder.
Sleep quality (difficulty in falling asleep [sleep latency]): It is also determined by validated PSQI* scale. 0–10 = normal (reference), 10–15 = mild, 15–20 = moderate, and >20 = severe.
Daytime sleepiness: Daytime sleepiness is determined by validated scale ESS** (0–7 = normal (reference category), 8–9 = mild, 10–15 = moderate, and 16–24 = severe daytime).
*PSQI: Pittsburgh Sleep Quality Index to assess the sleep quality.
**ESS: Epworth Sleepiness Scale to measure daytime sleepiness.
| Results|| |
The mean age of study participants was 21.33 ± 1.59 years. Most of the study participants (65.8%) were female and 16.8% of students had smoking habit [Table 1].
According to ESS, 34.9% of the study participants suffered severe daytime sleepiness and only 13.4% suffered moderate daytime sleepiness [Table 2].
|Table 2: Prevalence of daytime sleepiness among study participants (n=149)|
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According to the PSQI scale, 30.9% of the study participants were severely impaired in quality of sleep and 20.1% had mildly impaired quality of sleep [Table 3].
After the adjustment of covariates, male gender (odd ratio [OR]: 1.07 [CI 0.33–3.45] [P = 0.901]) and those students who had smoking habits (OR: 1.62 [CI: 1.18–2.11] [P = 0.045]) were significantly associated with daytime sleepiness [Table 4].
|Table 4: Association of daytime sleepiness with risk factors among study participants (n=149)|
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First academic year (age group: 17–20 years) was more than five times (OR: 5.34 [CI: 1.30–12.58] [P = 0.042]) more likely to be associated with severe impairment of quality of sleep. Those students who had lower academic scores were more than three times (OR: 3.13 [CI: 1.28–4.87] [P = 0.035]) more likely to be associated with severe impairment of quality of sleep [Table 5].
|Table 5: Association of sleep quality with risk factors among study participants (n=149)|
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Fifth academic year students were suffering more in severe daytime sleepiness and poor quality of sleep compared to other academic year of students [Figure 1] and [Figure 2].
| Discussion|| |
Our study found that poor sleep quality was of a high prevalence rate among study participants. It was above the prevalence estimate (32%–57%) reported by other studies using the same instrumentation (PSQI questionnaire). Moreover, daytime sleepiness was more common in the male gender. With 34.9% of study participants having severe daytime sleepiness, this result was coinciding with a previous study's results, which was conducted in Karachi, the prevalence rate of daytime sleepiness ranging from 20% to 35%.,,,,
Our study showed that severe poor quality of sleep narcolepsy prevalence is 30.9%. It was higher compared to another study which was conducted on medical students. This can be attributed to differences in the study design and the ethnic, cultural, and geographical variability between the studied populations. Evaluating causes of poor quality of sleep requires a holistic approach and confirmation with objective tests. Our study result showed that the prevalence rate of overall poor sleep quality was 69.8%. Like poor sleep quality, sleep disturbances were dominant in males. This was higher than the prevalence rate in a previous study. Examinations are an integral part of any study; medical examinations are far more difficult relatively. Professional examinations are stressful psychologically as well as physically. Our study result showed that about 42% of students have severe daytime sleepiness when their father's occupation is a business. This result is far less than the previous study which showed around 60%.
Stress is a major factor in the prevalence of sleep problems. This study showed that 105 (70.9%) students had observed poor sleep quality overall. Consistent with the previous study, poor sleep quality had affected poor mental activity, which leads to depression and anxiety. Our study showed that 1st year academic year students were five times more likely to experience severe poor quality of sleep (OR: 5.34). This correlates with the previous studies which also showed that sleep quality improves following increased academic year.
Our study showed that those students who had a low academic score (grade point average [GPA]) were three times (OR: 3.34) more likely to be associated with severe poor quality of sleep; this correlates with international studies showing that low GPA students had poor quality of sleep., This result's rate showed that low-grade students were more prone to depression compared to good-grade students, which leads to poor quality of sleep.
These findings should be interpreted considering some study limitations. First, it was a cross-sectional study, which did not determine the causality. Second, information bias is present because of the survey based on subjective measures of sleep quality. This high prevalence rate can be due to poor awareness among students. There is a need to make aware students about the importance of sleep. Good sleep benefits students as it improves their mental status as well as social and academic performance. Workshops and seminars relating to sleep disorders improves the academic performance of students and reduces the chronic disorders in professional life. By doing so, students will be able to stand out among other medical institutes and score better in professional examinations.
| Conclusion|| |
Medical students have a high prevalence of poor sleep quality and daytime sleepiness, the main factors being a higher burden of studies and irregular working hours. There is a need to revise the policies, and counseling services should be provided at the college level to improve the mental health of students.
Compliance with ethical standard
Research involving human participants
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The research involved human participants, research was approved by the ethical review committee from hospital, and confidentiality of the data has been maintained.
Written inform consent was obtained from each participant.
Consent for publication
Informed written consent was received for publication of the manuscript and figure.
We thank all the staff of medical college who helped make this research possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gregory JM, Xie X, Mengel SA. SLEEP (sleep loss effects on everyday performance) model. Aviat Space Environ Med 2004;75:A125-33.
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193-213.
Bassetti CL, Randerath W, Vignatelli L, Ferini-Strambi L, Brill AK, Bonsignore MR, et al
. EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur Respir J 2020 Apr 1;55(4).
Ezquiaga AD, Vas CP, Neito GP, Blanco SA, Schweimer M, Roca L, et al
. Sleep quality evaluation in medical students. J Neurol Sci 2015;357:435.
Harrison Y, Horne JA. The impact of sleep deprivation on decision making: a review. J Exp Psychol Appl 2000;6:236-49.
Mednick S, Nakayama K, Stickgold R. Sleep-dependent learning: a nap is as good as a night. Nat Neurosci 2003;6:697-8.
Brown F, Buboltz W, Soper B. Prevalence of delayed sleep phase syndrome in university students. Coll Stud J 2001;35:472-6.
Mirghani HO, Ahmed MA, Elbadawi AS. Daytime sleepiness and chronic sleep deprivation effects on academic performance among the Sudanese medical students. J Taibah Univer Med Sci 2015;10:467-70.
Mirghani HO, Mohammed OS, Almurtadha YM, Ahmed MS. Good sleep quality is associated with better academic performance among Sudanese medical students. BMC Res Notes 2015;8:706.
Buysse DJ, Barzansky B, Dinges D, Hogan E, Hunt CE, Owens J, et al
. Sleep, fatigue, and medical training: Setting an agenda for optimal learning and patient care. Sleep 2003;26:218-25.
Mume CO, Olawale KO, Osundina AF. Excessive daytime sleepiness, nocturnal sleep duration and psychopathology among Nigerian university students. South Afr J Psychiatry 2011;17:108-11.
Sahraian A, Javadopur A, Shiraz E. Sleep disruption and its correlation to psychological distress among medical students. Med J 2010;11:12-7.
James BO, Omoaregba JO, Igberase OO. Prevalence and correlates of poor sleep quality among medical students at a Nigerian university. Ann Niger Med 2011;5:1-5.
Khan UA, Pasha SN, Khokhar SK, Rizvi AA. Sleep habits and their consequences: A survey. Rawal Med J 2004;29:3-7
Azad MC, Fraser K, Rumana N, Abdullah AF, Shahana N, Hanly PJ, et al
. Sleep disturbances among medical students: A global perspective. J Clin Sleep Med 2015;11:69-74.
Allen GA, José T, Helena AM. Sleep-Wake Patterns and Academic Performance in University Students. Paper Presented at the European Conference on Educational Research. University of Lisbon; 2002. Available from: http://www.leeds.ac.uk/educol/documents/00002200.html
. [Last accessed on April 2020].
American Academy of Sleep Medicine. International Classification of Sleep Disorders, Revised: Diagnostic and Coding Manual. Chicago, Illinois: American Academy of Sleep Medicine; 2001. Available from: http://www.esst.org/ads/ICSD.pdf
. [Last accessed on April 2020].
Lumley S, Ward P, Roberts L, Mann JP. Self-reported extracurricular activity, academic success, and quality of life in UK medical students. Int J Med Educ 2015;6:111-7.
Kim EJ, Dimsdale JE. The effect of psychosocial stress on sleep: a review of polysomnographic evidence. Behav Sleep Med 2007;5:256-78.
Hartescu I, Morgan K, Stevinson CD. Increased physical activity improves sleep and mood outcomes in inactive people with insomnia: a randomized controlled trial. J Sleep Res 2015;24:526-34.
Giri P, Baviskar M, Phalke D. Study of sleep habits and sleep problems among medical students of Pravara institute of medical sciences Loni, Western Maharashtra, India. Ann Med Health Sci Res 2013;3:51-4.
] [Full text]
Surani AA, Zahid S, Surani A, Ali S, Mubeen M, Khan RH. Sleep quality among medical students of Karachi, Pakistan. J Pak Med Assoc 2015;65:380-2.
Abdulghani HM, Alrowais NA, Bin-Saad NS, Al-Subaie NM, Haji AM, Alhaqwi AI. Sleep disorder among medical students: relationship to their academic performance. Med Teach 2012;34 Suppl 1:S37-41.
Ghoreishi A, Aghajani AH. Sleep quality in Zanjan university medical students. Tehran Univer Med J 2008;66:61-7.
Moo-Estrella J, Pérez-Benítez H, Solís-Rodríguez F, Arankowsky-Sandoval G. Evaluation of depressive symptoms and sleep alterations in college students. Arch Med Res 2005;36:393-8.
Nojomi M, Ghalhe Bandi MF, Kaffashi S. Sleep pattern in medical students and residents. Arch Iran Med 2009;12:542-9.
Department of Public Health, College of Public Health, Imamm Abdul Rehman Bin Faisal University, Dammam
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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