Med. J. Cairo Univ., Vol. 83, No. 2, June: 179-185, 2015
www.medicaljournalofcairouniversity.net
Sleep Disorders among Female Students in Assiut University,
Upper Egypt
DALIA G. MAHRAN, M.D. and SABRA M. AHMED, M.D.
The Department of Public Health & Community Medicine, Faculty of Medicine, Assiut University
Sleep problems, especially insomnia, are a
common complaint among adults. International
studies on university students have shown prevalence rates between 4.7% and 36.2% for sleep
difficulties and 13.1% and 28.1% for insomnia.
Sleep problems are associated with lower social
and academic performance also can have a severe
impact on psychological and physical health [2] .
Nadorff, et al. reported a prevalence of 13.1 %
for insomnia symptoms among US college students
in West Virginia. Students were faced with challenging facets of their lives such as exams, work,
family, relationships and classes [3] . Sleep is normally not the focus of health-related behavior at
this age, but nevertheless the amount of requirements often leads to stress [4,5] . Thus, about 30%
of students are often sleep deprived with less sleep
than recommended with mean sleep duration of
7.02 hours per night [4] .
Sleep problems are associated with numerous
complaints in social [6] and academic performance,
such as difficulties in concentration [7] as well as
psychological and physical health [8] .
Development of these new media has been
changing culture and lifestyle of young adults including university students. Due to these cultural
changes, sleep patterns of the young adults tend
to become irregular and many of them experience
sleep deficiency [9] .
In a study in Palestine, students reported that
the mean duration of night sleep in the study sample
was 6.4±1.1 hours. Daytime naps were common
and reported in 74.5% of the study sample [10] .
In another study conducted among university
students in Germany, more than 16% of surveyed
students needed more than 30 minutes to fall asleep.
About 7.7% of the students suffered from insomnia.
179
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Sleep Disorders among Female Students in Assiut University
Short sleep duration was significantly associated
with a considerably increased rate of insomnia [11] .
Inability to sleep can lead to difficulty in sustaining attention, a slowed response time, impairments in memory and concentration, and decreased
performance [12] . Many students are unaware that
their academic difficulties may be related to their
sleep habits [13] .
There are no available studies about sleep quality and habits among Assiut University female
students, the aim of the study was to describe the
self-reported sleep characteristics and sleep problems among female students in practical faculties
of Assiut University in Egypt. Association between
these problems and their perceived health effects
was also investigated.
Material and Methods
A total of 306 female students in Assiut University in Upper Egypt were included in this study.
The sample was chosen from the practical faculties
(Faculties of Medicine, Engineering, Pharmacy
and Veterinary Medicine) to have a homogenous
sample with nearly similar type of loaded stressful
type of study. Also selection of female gender
because they are more liable to sleep disturbances
than males as shown by a German University study
that female students were more likely to fulfill
established insomnia criteria (p=0.018) [11] . Another
study conducted in Korea showed that male students
reported sleeping slightly longer than females ( p<
0.01) [9] .
A randomly selected sample from fourth year
students participated in an in-class survey and
completed questionnaires which consisted of 30
items.
The study was applied after one month of the
start of the academic year and away from the time
of exams to have data about sleep characteristics
at a nearly stable time away from stressful conditions. The study was conducted during the academic
year 2012/2013.
The questionnaire used in the present study
was divided into three sections:
1- The first section included the socio-demographic
information (age and residence during university
study).
2- The second section was about assessment of
sleep characteristics which include questions
about time of going to bed, duration of sleep,
daytime napping, time needed to fall asleep and
the occurrence of awaking during night. Additionally, receiving hypnotics, suffering from
nightmares during sleep and the general condition on awaking at morning.
3- The third section was about perception of general
health as occurrence of frequent attacks of headache and appetite and other related questions in
addition to questions about the ability to concentrate and nervousness.
The collected data was about the month prior
to the time of data collection. It took around 1015 minutes to complete the questionnaire.
Statistical analysis: Data entry and analysis
was done by using SPSS program, version 16
(Statistical Package for the Social Sciences, Windows version 16.0; SPSS Inc, Chicago [IL], US.
Frequencies were reported as percentages; comparisons between frequency-based data were performed using x 2 -test. Continuous variables were
compared using two-tailed independent-sample ttests. For all comparisons, the statistical level of
significance was set at p<0.05.
The distribution of sleep pattern by some sociodemographic variables, health-related behaviors,
perceived health status and perceived quality of
sleep was analyzed by tests for statistical significance.
Ethical consideration: The aim of the study
was explained to each participant before filling
the questionnaire. Informed consent was obtained
from those who accepted to participate in the study.
Confidentiality of the data was maintained all over
the study.
Results
This study included 306 of Assiut University
female students with a mean age (±SD) of 20.1
(±0.64) years. 37.3% of students under study were
residing with their families in Assiut City. The rest
of students were residing away from their families,
either in a private house (19.9%) or in university
hostels (42.8%).
The main sleep time was night in the majority
of students (96.4%). About 61% of students under
study slept about 6-8 hours per night, whereas only
24.2% of them slept >8 hours per night. Intermittent
sleep was present in 37.9% of them. Daytime
napping was present in about 70% of students
under study. 43.1 % of them spent a long time to
fall asleep. Only one student (0.3%) reported using
hypnotic drugs. Nightmares were present in 40.2%
of students under study (Table 1).
181
Dalia G. Mahran & Sabra M. Ahmed
Most common feelings after getting up were
tiredness (55.6%) and anxiety (23.3%). 53.3% of
students usually complain of headache after getting
up from sleep. Appetite was excellent in 23.3%
and fair in two thirds of students under study.
Blood pressure problems were present in 22.2%.
79.1% of students under study could get up early
to attend lectures. About 73% of students were
usually complaining of difficulty in concentration.
About three quarters of students under study reported good or average health (Table 2).
sleeping time (<6 hours) (p=0.002), spending long
time to fall asleep and getting up during sleep
(p<0.001) (Table 3).
Intermittent sleep was significantly associated
with residing in university hostels (p=0.025), short
Intermittent sleep was also significantly associated with presence of headache ( p=0.013), bad
appetite (p=0.001) and disturbed bowel habits (p=
0.030). Students with intermittent sleep had higher
prevalence of daytime napping, blood pressure
problems, difficulty in concentration, tiredness and
weakness during day time, feeling of nervousness
and feeling of bad health in general, than students
with continuous sleep, these differences were not
statistically significant (Table 4).
Table (1): Sleep characteristics of female students in Assiut
University, 2013.
Table (2): General perception of health by female students in
Assiut University, 2013.
Sleep characteristics
Frequency (%)
(N=306)
295 (96.4)
11 (3.6)
46 (15.0)
186 (60.8)
74 (24.2)
116 (37.9)
190 (62.1)
213 (69.6)
93 (30.4)
3 (1.4)
128 (41.9)
82 (26.8)
32 (10.4)
173 (56.6)
77 (25.2)
24 (7.8)
132 (43.1)
174 (56.9)
59 (44.7)
53 (40.2)
20 (15.1)
121 (91.7)
11 (8.3)
109 (35.6)
197 (64.4)
10 (9.1)
51 (56.0)
34 (31.1)
14 (12.9)
1
(0.3)
305 (99.7)
123 (40.2)
183 (59.8)
Perception of general health
Frequency (%)
(N=306)
Feeling at getting up:
Tiredness, laziness
Tightness, anxiety
Headache
Chest, back and neck pain
Others
170 (55.6)
71 (23.3)
19 (6.2)
15 (4.9)
31 (10.3)
Feeling of headache after getting up:
Yes
- Directly after getting up
- After sometimes
No
108 (35.3)
58 (53.7)
50 (46.3)
198 (64.7)
Appetite:
Excellent
Fair
Bad
71 (23.2)
204 (66.7)
31 (10.1)
Bowel habit:
Constipation
Diarrhea
Mixed
Normal
36 (11.1)
7 (2.3)
120 (39.2)
143 (46.7)
Presence of blood pressure problems:
Yes
- Hypotension
- Hypertension
- Do not know
No
68 (22.2)
42 (13.7)
8 (2.6)
18 (5.6)
238 (77.8)
Getting up early to attend lectures:
Yes
No
242 (79.1)
64 (20.9)
Difficulty in concentration:
Yes
No
223 (72.9)
83 (27.1)
Tiredness and weakness during daytime:
Yes
No
237 (77.5)
69 (22.5)
Do you feel that you are nervous most of the time?:
Yes
No
193 (63.1)
113 (36.9)
Perception of general health:
Excellent-Very good
Good-average-fair
Bad-Very bad
51 (16.7)
231 (75.5)
24 (7.8)
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Sleep Disorders among Female Students in Assiut University
Table (3): Relationship of sleep rhythm with students' characteristics, Assiut University, 2013.
Sleep rhythm
Students'
characteristics
pvalue
Total
Intermittent
Continuous
Residence:
Assiut city
Private house
University hostels
33 (28.4)
23 (19.8)
60 (51.6)
81 (42.6)
38 (20.0)
71 (37.4)
114 (37.3)
61 (19.9)
131 (42.8)
0.025*
The main sleep time:
Night
Daytime
112 (96.6)
4 (3.4)
183 (96.3)
7 (3.7)
295 (96.4)
11 (3.6)
0.914
Duration of sleep/night:
<6 hours
6-8 hours
>8 hours
28 (24.2)
61 (52.7)
27 (23.4)
18 (9.5)
125 (65.8)
47 (24.7)
46 (15.1)
186 (60.8)
74 (24.1)
0.002*
Daytime napping:
Yes
No
85 (73.3)
31 (26.7)
128 (67.4)
62 (32.6)
213 (69.6)
93 (30.4)
0.276
Do you spend long
time to fall asleep?
Yes
No
68 (58.6)
48 (41.4)
64 (33.7)
126 (66.3)
132 (43.1)
174 (569)
<0.001 *
76 (65.5)
40 (34.5)
33 (17.4)
157 (82.6)
109 (35.6)
197 (64.4)
<0.001 *
Getting up during sleep:
Yes
No
2 -test was used.
x
*: Significance is considered when p<0.05.
Table (4): Relationship of sleep rhythm with subjective students' problems, Assiut University, 2013.
Sleep rhythm
Subjective students'
problems
Total
pvalue
Intermittent
Continuous
Presence of nightmares:
Yes
No
51 (44.0)
65 (56.0
72 (37.9)
118 (62.1)
123 (40.2)
183 (59.8)
0.293
Presence of headache:
Yes
No
51 (44.0)
65 (56.0)
57 (30.0)
133 (70.0)
108 (35.3)
198 (64.7)
0.013
Appetite:
Excellent
Fair
Bad
26 (22.4)
69 (59.5)
21 (18.1)
45 (23.7)
135 (71.1)
10 (5.3)
71 (23.3)
204 (66.7)
31 (10.1)
0.001 *
Bowel habit:
Disturbed bowel habits
Normal
71 (61.1)
45 (38.8)
92 (48.4)
98 (51.6)
163 (53.3)
143 (46.7)
0.030*
Blood pressure problems:
Yes
No
28 (24.1)
88 (75.9)
40 (21.1)
150 (78.9)
68 (22.2)
238 (77.8)
0.529
Getting up early to attend lectures:
Yes
No
91 (78.4)
25 (21.6)
151 (79.5)
39 (20.5)
242 (79.1)
64 (20.9)
0.831
Difficulty in concentration:
Yes
No
88 (75.9)
28 (24.1)
136 (71.1)
55 (28.9)
223 (72.9)
83 (27.1)
0.359
93 (80.2)
23 (19.8)
144 (75.8)
46 (24.2)
237 (77.5)
69 (22.5)
0.373
78 (67.2)
38 (328)
115 (60.5)
75 (39.5)
193 (63.1)
113 (36.9)
0.238
18 (15.5)
85 (73.3)
13 (11.2)
33 (17.4)
148 (76.8)
11 (5.8)
51 (16.7)
231 (75.5)
24 (7.8)
0.227
Tiredness and weakness during daytime:
Yes
No
Do you feel that you are
nervous most of the time?:
Yes
No
Perception of general health:
Excellent-Very good
Good-average-fair
Bad-Very bad
2
χ -test was used.
*: Significance is considered when p<0.05.
Dalia G. Mahran & Sabra M. Ahmed
Discussion
The study included 306 female students distributed among different practical faculties of Assiut
University (Faculties of Medicine, Pharmacy, Engineering and Veterinary Medicine).
It was found that university students have reduced sleep duration among 15% (<6 hours/night),
only 24.2% of the student respondents reported
sufficient sleep (>8 hours). More than half of
students (56.6%) go to bed at midnight.
Sewelleh, et al. [10] showed that Palestinian
undergraduate students reported an average of 6.4
hours of nighttime sleep, more than half went to
bed before midnight, and 9.8% were poor sleepers.
On the other hand, among university students in
Korea 30.2% of the respondents reported having
insufficient sleep while 29.1% reported having
sufficient sleep [14] .
Also, in USA, it was found that, the average
number of sleeping hours in one study was 7.2,
which is somewhat higher than the 6.5 hours average found in another surveys but still less than the
mean of 8 hours one would expect in a normal
distribution of sleep duration [15] . In USA for
example, both sleep deprivation and poor sleep
quality are particularly prominent in young adults
and college students populations [16,17] .
In the present study, 37.9% of the participants
had intermittent sleep which is higher than that
among the German students that approximately
one quarter of the sample (25.9%) indicated frequent awakenings at night. Also 43% of the students
were suffering from taking long time to fall asleep
as what shown among the German students [11] .
In our study, daytime napping was present in
69.6% of students under study, in a Palestinian
study, daytime naps were reported by 74.5% of
respondents. In the present study, students with
intermittent sleep had higher rate of daytime napping (73.3%) compared to those with continuous
sleep (67.4%). Taking a nap during daytime and
taking sleep medications may be disruptive to
sleep. Notably compensatory sleep practices such
as daytime napping may be associated with prolonged insomnia [18] .
On the other hand, results of this study indicated
that only one student (0.3%) reported using sleep
medication. This may be due to conservative nature
of Assiut University female students and underreporting of sleep medication use.
183
The results of the present study showed that,
43.1 % of students spend a long time to fall asleep.
This is consistent with what was shown by the
studies in Palestine, USA, epidemiological studies
in Western Europe and Japan which reported a
10-48% prevalence of insomnia symptoms [19] .
The same results were reported in multiple studies
[20-22] .
In the current study, 72.9% found difficulty in
concentration because of inadequate sleep. Our
study also found that the sleep habits of many
college students are quite poor, highlighting the
need to consider sleep quality as well as quantity.
Among German students insomniacs showed
lower self-efficacy than students without sleep
problems [11] .
Kelly, et al. found that the poor academic performance associated with short sleep duration was
linked to reduced concentration ability on educational material, lower self efficiency and even
possible psychological difficulties [23] .
Prior studies addressing the impact of sleep
disturbance on students' performance and health
risks have attributed poor sleep quality to alteration
in one or more of the sleep domains [24-26] .
In our study, 79.7% and 77.5% of students
under study complained of sleepiness and tiredness
and weakness during day time respectively. Problems associated with poor sleep can result in excessive daytime sleepiness, which is severe enough
to interfere with daily activities [27] .
In the present study, students with intermittent
sleep had higher rates of blood pressure problems
(24.1%) compared to students with continuous
sleep (21.1%), a non-statistically significant difference (p=0.529). Sleep loss, seems to activate
the sympathetic nervous system, which can lead
to a rise of blood pressure and an increase in
cortisol secretion [28] .
In the present study, it was found that poor
sleep quality was associated with short sleep duration (<6 hours/night) ( p=0.002), residing in university hostels (p=0.025), spending long time to
fall asleep (p<0.001), presence of headache ( p=
0.013), bad appetite (p=0.001) and disturbed bowel
habits (p=0.030). Our findings were consistent
with a study conducted in China, which found that,
the significant association between the number of
chronic disorders, rather than the individual clinical
disorders and sleep quality, provided insights into
the association between the presence of multiple
co-morbidities and sleep disturbances [29] .
184
Sleep Disorders among Female Students in Assiut University
Conclusion:
Female students in the practical faculties in
Assiut University reported a significant poor sleep
quality with reduced sleep duration and were taking
longtime to fall asleep. They significantly had high
prevalence of suffering of bad effects like difficulty
in concentration, tiredness, headache, bad appetite,
disturbed bowel habits and tiredness and weakness
during daytime.
Raising the awareness about the importance of
good sleep quality for health and academic achievement, this can be done by multidisciplinary approach in collaboration with health services.
Acknowledgments:
We would like to acknowledge Manar Mohammad and Maha Ahmad the medical students who
helped us in data collection stage of the study.
References
1- Korea Institute for Health and Social Affairs. Health guide
Seoul. 4, 2000.
2- SCHLARB A.A. 1., KULESSA D. and GULEWITSCH
M.D.: Sleep characteristics, sleep problems, and associations of self-efficacy among German university students.
Nat. Sci. Sleep, 4: 1-7, 2012.
3- NADORFF M.R., NAZEM S. and FISKE A.: Insomnia
symptoms, nightmares and suicidal ideation in a college
student sample. Sleep, 34 (1): 93-8, 2011.
4- LUND H.G., REIDER B.D., WHITING A.B. and PRICHARD J.R.: Sleep patterns and predictors of disturbed
sleep in a large population of college students. J. Adolesc.
Health, 46 (2): 124-32, 2010.
5- STOCK C. and KRUMER A.: Psychosocial stress and
psychosomatic complaints from students: Results of a
longitudinal study. In: Sonntag U, Gruser S, Stock C,
Krumer A, editors. Health Promoting Universities, German: Weinheim und München: Juventa Verlag; 127-38,
2000.
6- SCHLEIDER K. and GÜNTERT M.: Characteristics and
conditions of the student's learning and work disruptionsan inventory, Beitr ge zur Hochschulforschung. German,
27-31: 8, 2009.
7- ENGLE-FRIEDMANN M., RIELA S. and GOLAN R.:
The effect of sleep loss on next day effort. J. Sleep Res.,
12 (2): 123-4, 2003.
8- MORIN C.M., RODRIGUE S. and IVERS H.: Role of
stress, arousal, and coping skills in primary insomnia.
Psychosom. Med., 65: 259-67, 2004.
11- SCHLARB A.A.1., KULESSA D. and GULEWITSCH
M.D.: Sleep characteristics, sleep problems, and associations of self-efficacy among German university students.
Nat. Sci. Sleep., 9; 4: 1-7, 2012.
12- MARTIN J. and ANCOLI-ISRAEL S.: Insomnia in older
adults. In: Szuba MP, Kloss JD, Dinges DF, eds. Insomnia:
Principles and Management. Cambridge UK: Cambridge
University Press., 135-52 p., 2003.
13- PILCHER J., GINTER D. and SADOWSKY B.: Sleep
quality versus sleep quantity: Relationships between sleep
and measures of health, well-being and sleepiness in
college students. Journal of Psychosomatic Research, 42:
583-96, 1997.
14- BAN D.J. and LEE T.J.: Sleep duration, subjective sleep
disturbances and associated factors among university
students in Korea. J. Korean Med. Sci., 16: 475-80, 2001.
15- American College Health Association. American college
health association national health assessment: Reference
group executive summary fall 2007. Baltimore: American
College Health Association, 2008.
16- JENSEN D.: Understanding sleep disorders in a college
student population. Journal of College Counseling, 6: 2534, 2003.
17- MARKEL H.: Lack of sleep takes its toll on student
psyches. New York Times, F6, September 2, 2003.
18- ROTH T., JAEGER S. and JIN R.: Sleep problems,
comorbid mental disorders, and role functioning in the
national comorbidity survey replication. Biol. Psychiatry,
60: 1364-71, 2006.
19- NOJOMI M., GHALHE BANDI M.F. and KAFFASHI
S.: Sleep pattern in medical students and residents. Arch.
Iran. Med., 12 (6): 542-9, 2009.
20- OHAYON M.M. and PAIVA T.: Global sleep dissatisfaction for the assessment of insomnia severity in the general
population of Portugal. Sleep. Med., 6: 435-41, 2005.
21- OHAYON M.M. and PARTINEN M.: Insomnia and global
sleep dissatisfaction in Finland. J. Sleep. Res., 11: 33946, 2002.
22- OHAYON M.M. and ZULLEY J.: Correlates of global
sleep dissatisfaction in the German population. Sleep.,
24: 780-7, 2001.
23- KELLY W.E. and KELLY K.E.: The relationship between
sleep length and grade point average among college
students. Coll. Stud. J., 35: 84-6-9, 2001.
24- LUND H.G., REIDER B.D., WHITING A.B. and PRICHARD Jr.: Sleep patterns and predictors of disturbed
sleep in a large population of college students. J. Adolesc.
Health, 46: 124-32, 2010.
9- Korea National Statistical Office. The results of the 1999
survey of time consumption. Seoul, 2000.
25- JANSON C., GISLASON T. and De BACKER W.: Prevalence of sleep disturbances among young adults in three
European countries. Sleep, 18: 589-97, 1995.
10- SWEILEH W.M., ALI I.A., SAWALHA A.F., ABU-TAHA
A.S., ZYOUD S.H. and AL-JABI S.W.: Sleep habits and
sleep problems among Palestinian students. Child. Adolesc.
Psychiatry. Ment. Health, 5 (1): 25, 2011.
26- SUEN K.P., TAM W.S. and HON K.L.: Association of
sleep hygiene-related factors and sleep quality among
university students in Hong Kong. Hong Kong Med. J.,
16: 180-5, 2010.
Dalia G. Mahran & Sabra M. Ahmed
27- TAYLOR D.J., JENNI O.G. and ACEBO C.: Sleep tendency during extended wakefulness: Insights into adolescent sleep regulation 8 and behavior. J. Sleep. Res., 14:
239-44, 2005.
28- SPIEGEL K., LEPROULT R. and VAN AUTER E.: Impact
185
of sleep debt on metabolic and endocrine function. Lancet,
354: 1435-9, 1999.
29- LUO J., ZHU G., ZHAO Q., GUO and MENG H.: Prevalence and risk factors of poor sleep quality among chinese
elderly in an urban community: Results from Shanghai
aging study, Plos. One, 8 (1): E81262, 2013.