A Study on Sleeping Pattern among Undergraduate Medical Students of a Tertiary Care Teaching Hospital of Kolkata

Copyright © 2019 Phcog.Net. This is an openaccess article distributed under the terms of the Creative Commons Attribution 4.0 International license. Cite this article : Basu M, Saha SK, Majumder S, Chatterjee S, Misra R. A Study on Sleeping Pattern among Undergraduate Medical Students of a Tertiary Care Teaching Hospital of Kolkata. Int J Med Public Health. 2019;9(4):118-24. ABSTRACT Introduction: Medical students are a subgroup of the general population who are more vulnerable to poor sleep quality. Objectives: To assess the sleeping pattern and determinants among the medical undergraduate students of a Government teaching Hospital, Kolkata. Materials and Methods: An Institution-based cross-sectional study was conducted among 293 undergraduate medical students of a teaching Hospital of Kolkata from October 2017 to December 2017 using a pre-designed, pre-tested structured questionnaire, Pittsburgh Quality of Sleep Index (PSQI) score and Epworth Daytime Sleepiness Scale (EDSS). Results: About 24.91% of students had daytime sleepiness as per Epworth Daytime Sleepiness Scale (EDSS) and about 63.48% had poor sleep quality as per Pittsburgh Quality of Sleep Index (PQSI) score. There was significant correlation between Poor Sleep Quality (PSQI) score and age, year of study, hostel residence, socio-economic condition, body mass index, smoking, alcohol intake, caffeine consumption, exercise, stress and excessive use of mobile/laptop. EDS score was significantly associated with age, semester of study, residence and habit of exercise. Conclusion: To improve the sleep quality of medical students, we should provide a positive environment by establishing counselling facilities and promoting good sleep hygiene.


INTRODUCTION
Every individual of the environment requires a period of rest to enhance and empower its work ability. As per the expert panel report published in Sleep Health-The Journal of the National Sleep Foundation 2015, in younger adults (18)(19)(20)(21)(22)(23)(24)(25): Sleep range is 7-9 hr. Poor sleep quality is believed one of the most obvious public health problems and the rates of poor sleep quality are increasing in both developing and modern societies. 1 Sleep deprivation may have serious health consequences; it may be associated with decrease in the immunity, unhealthy behaviour and may lead to psychological problems and metabolic problems like diabetes mellitus, hypertension, metabolic syndrome and obesity. 2 Adequate quality of sleep is a prerequisite for optimum functioning of a student's mind and body. Concentration and attention difficulties along with poor academic performance are linked with poor sleep quality among students 3 because good sleep is needed for the best of neuro-cognitive functions, psychomotor performance, physical and mental health. 1 Sleep problems are common in the general population and approximately one-third of adults report some form of insomnia. Medical students are a subgroup of the general population who are more vulnerable to poor sleep quality. 1 Medical students are assumed to be a stressful group of students 4,5 due to their long study years, high academic load, frequent examination, fear of failure, hectic clinical duties, emotionally challenging work and the highly demanding lifestyle. 1 Several studies have reported the prevalence of sleep problems among medical students of different nationalities. Global epidemiological data about sleep problems among medical students reported a very wide range of 19% to 90%. 1 Poor sleep quality leads to Excessive Daytime Sleepiness (EDS) which affect the performance of medical students. Thus, identification of poor sleep quality among medical students is an essential step to know the load of the problem and managing it effectively which can ultimately lead to improve quality of patients' care provided by budding physicians. 1 As sleep deprivation and associated symptoms have become a widespread problem among the undergraduate medical students and as this problem has not been properly judged since long in this part of India, a study was conducted to explore the sleeping pattern and determinants among the medical undergraduate students of a teaching Hospital, Kolkata.

Type of study
Study design, study setting, study period and study population: An Institution-based observational, descriptive, study, cross-sectional in design, was conducted among undergraduate medical students of a teaching Hospital of Kolkata from October 2017 to December 2017, a duration of 3 months. Inclusion criteria: Undergraduate medical students of all semesters who were present during the data collection period and gave informed written consent to participate in the study. Exclusion criteria: Seriously ill, currently using sedative medications for any medical conditions. Study tools were a predesigned pre-tested structured self-administered Questionnaire, Pittsburg Quality of Sleep Index (PQSI) 6,7 scale and Epworth Daytime Sleepiness Scale (EDSS). 8 The questionnaire had four parts. Part I Consisted of information on the socio-demographic profile and lifestyle questions; Part II consisted of questions of Pittsbur Quality of Sleep Index (PQSI) scale; 6,7 Part III dealt with questions of Epworth Daytime Sleepiness Scale (EDSS); 8 and Part IV was measurement of Height and Weight to calculate Body Mass Index (BMI). The questionnaire was designed in consultation with three experts; 2 from community medicine and 1 from respiratory medicine department, it was pretested on fifty (50) undergraduate medical students of the same institution; then modified (issues encountered were some lifestyle questions and those were modified during pre-testing), necessary changes were done and validated by another 3 experts. Pittsburg Qual- Sample size and sampling technique: About 293 undergraduate MBBS students were selected using non-random convenience sampling technique. It was decided to collect information from all undergraduate students of this institution but is spite of repeated (three) visits, only 293 students were available during the data collection period. All gave consent for participation in the study. Thus, the response rate was cent percent.

Data Collection Technique
After getting the Institutional Ethics Committee clearance, the study population were briefed about the purpose and nature of the study; their informed consent was taken where confidentiality and anonymity were ensured in all aspects. Then, they were instructed to fill out the questionnaire completely and truthfully. Finally, their height and weight were measured following standard techniques and BMI were calculated. Collection of data were done for four (4) weeks under the supervision of authors and with the help of 12 medical students.

Statistical Analysis
Data were entered in Microsoft Office Excel 2010; analysis was done with Statistical Package for the Social Sciences (SPSS) Version 16.0 (Chicago, Illinois, USA). Descriptive results were expressed by frequency and percentages. For the association between various factors and sleeping pat-tern, Chi-square tests and 95% Confidence Intervals (CI) were calculated. P<0.05 was considered statistically significant.

Operational definition
1. Current cigarette smoker: Defined as persons who reported smoking at least 100 cigarettes in their lifetime and who, at the time of survey, smoked either every day or some days (CDC).

Alcohol consumption:
One who drinks alcohol every day during the study period. 4. Excessive Caffeine intake: Drinks per day-227 millilitres (>6 cups) serving of coffee, espresso, tea, soft drinks, hot chocolate, energy drink or 42.5 grams of chocolate. 6,7 It is a self-report questionnaire to assess the quality of sleep. There are Nineteen items with seven "component" scores, each of which has a range from '0' to '3' , '0' indicates no difficulty and '3' indicates severe difficulty. The sum of these seven component scores yields one PSQI global score with a range of '0' to '21' points, '0' indicates no difficulty and '21' indicates severe difficulty in all areas. The 7 component scores are: 1. sleep quality, 2. sleep latency, 3. sleep duration, 4. sleep efficiency, 5. sleep disturbances, 6. use of sleeping medication and 7. daytime dysfunction. Good sleep quality is defined as PQSI score ≤ 5, while scores above 5 demonstrate poor quality. 8 It is a scale to measure daytime sleepiness using a very short questionnaire, introduced in 1991 by Dr. Murray Johns of Epworth Hospital in Melbourne, Australia. There are 8 questions and scores are range from '0' to '3' for each question. 0 = would never doze 1 = slight chance of dozing 2 = moderate change of dozing 3 = high chance of dozing The higher the ESS score, the higher that person's average sleep propensity in daily life (ASP). The eight questions added together to get a single number which range from '0' to '24' . A number in the 0-10 range is considered to be normal while a number in the 11-12 is of borderline and 13-24 range indicates expert medical advice to be sought. EDS score was significantly associated with age, semester of study, residence and habit of exercise [ Table 5].

DISCUSSION
Medical students have various life constraints which cause their irregular sleep habits, evidenced by various studies around the world.
The PSQI tool used in this study is a widely used inventory for assessing sleep quality and has sufficient intrinsic reliability and validity across both medical and non-medical population groups. It is a reliable measure of sleep quality in the Indian context too.   13 Such high rates of poor sleep among medical students from different countries of globe are of great concern. This can be improved through counselling and healthy lifestyle.    19 This discrepancy might be explained by differences in sample sizes, race and study population. Moreover, in recent years there is a marked increase in the night use of social media, which increase the number of poor sleepers as opposed to older years.
In this particular study the sleep quality was almost similar in both gender, similar to Delhi 12 and China. 14 However, here our findings are not consistent with those of some other studies: in Maharashtra study by Giri et al. females had better sleep quality than males. 20 This might be due to substance abuse in males. In contrast females were more poor sleepers compared to males, which agrees with many previous studies. 10,12,[21][22][23] This may be attributed to more prevalence of psychological problems like anxiety and depression among females compared to males, This study and some other studies demonstrated that age group <=20 years had poorer sleep than higher age group. 14,16,23 This may be attributed to the fact that younger students are in the preclinical and para-clinical years, they might not adapted to high load after studying at higher secondary schools. Moreover, anxiety for passing the first professional MBBS might also play some role. Sleep scores showed a correlation with semesters, wherein sleep quality improves as students advance in academic years in this study and other studies. 10 This may be due to the fact that over time, as students become mature and accustomed to their academic schedules, they also learn how to improve their sleep habits. Students live in hostel campus in the present study had more prevalence of poor sleep quality compared to those living with their family. This result was in line with Saudi Arabia 10 and Egyptian study. 23 Medical students experience high level of stress due to academic reasons which affects adversely their sleep and this inadequate sleep cause daytime sleepiness, ultimately leading to smoking, alcohol abuse, depression, anxiety and poor interpersonal communication. In the present study, about 41% reported stress, similar to study by Giri et al. 20 Gassara et al. 11 Feng et al. 14 and Preišegolavičiūtė et al. 17 In Saudi Arabia 10 and Maharashtra study 20 anxiety was the first predictor of poor sleep quality. Egyptian study 19 20 This study documented that smokers had poor sleep compared to nonsmokers similar to the results from Maharashtra 20 and Saudi Arabia. 10 Study by Gassara, et al. 11 revealed significant association with alcohol consumption like our study. This study and many other previous studies 20 described an association of sleep with excessive caffeine intake, smoking, alcohol and long-time use of mobile phone/laptop. The present study result revealed that excessive consumption of caffeine was associated with poor sleep which agrees with the findings of Ibrahim et al. 10 and Sanchez et al. 18 However Saudi Arabia study 10 results revealed absence of statistical association between the night use of social media and sleep quality. In this study, day time sleepiness was present in 24.91% of the study population, which was higher than a study by Giri et 15 EDS was significantly higher in the study population with poor sleep quality in the present study. This result agrees with the results of a many other studies. 9,10,13,21,22 In the present study, daytime sleepiness was significantly associated with lower age group, year of study, hostel residence and exercise.

Strengths and limitations
Strengths include 1. Validated tools for measuring sleep quality. 2. Anthropometric measures were done by trained research personnel using calibrated instruments. 3. Dearth of data about sleep quality of undergraduate medical students in India including West Bengal and Kolkata. However, the results of our study should be interpreted in context of some limitations. First, instead of using random sampling technique, we considered convenience sampling method.
Second, as this study followed a cross-sectional data collection design, the temporal relationship between poor sleep quality and socio demographic and lifestyle factors cannot be determined. A longitudinal study design would be better. Third, this study was conducted from one medical college, therefore the result cannot be generalised to all medical students. A multi-centre study would be better to improve generalizability. Fourth, association of sleep quality with one very important determinant, i,e; academic performance was not assessed. Lastly, the major limitation of the study is that it is based only on subjective assessment by the study population. Incorrect information may be provided by them and they may also be unable to understand or may misinterpret the questions.

CONCLUSION
The present study revealed very high prevalence of poor sleep quality (63.48%) among undergraduate medical students as per PSQI scale. Day time sleepiness was present in 24.91% of the study population as per EDSS scale. Sleep quality was associated with lower age group, hostel residence, lower years of study, BMI, lack of exercise, stress, smoking, alcohol consumption, excessive caffeine intake, use of social media for prolong period.
To improve the sleep quality of medical students, we should provide a positive environment and greater support. This can be done by establishing counselling facilities and promoting good sleep hygiene that can serve a positive change towards their quality of life and coping with their stressful environment. Medical students also have to identify their impediments and seek for an advice from the faculty in order to find solutions for it.