A descriptive, cross-sectional design was used to collect data for this study in Bahrain. Self-administered, structured questionnaires were delivered via instant chat groups and social media advertisements between September and December 2019. Medical students (years 1–6) enrolled at the College of Medicine and Medical Sciences (CMMS), Arabian Gulf University, were recruited. Ethical approval was obtained from the Research and Ethics Committee, CMMS, Arabian Gulf University. Electronic consent or e-signatures were obtained from the participants who were informed that their participation was voluntary and that they could withdraw from the study at any time.
Convenience sampling was applied, and a poll or questionnaire was mailed to a student mass from year 1 to 6(CMMS).
General population control
Published data estimates suggest that approximately 10% of all medical students are at risk of EDs and 50% experience poor sleep quality and high stress levels. Thus, to measure this proportion using a 5% margin of error, it was estimated that a minimum of 500 survey responses would be required. Based on an anticipated 50% response rate, the survey was distributed to 1100 participants. Convenience sampling was used to select the sample. It was estimated that the minimum sample size required (i.e., 384 participants with a 95% CI) would have a real value within a 5% (type I error [α]) level and 20% (type II error [β]) level of the observations made. The formula for sample size n was as follows: n N*X/(X + N – 1), where X Zα/22*p*(1-p)/MOE2. Zα/2 denoted the critical value of normal distribution at α/2 (e.g., at a 95% CI level, α was 0.050, with a critical value of 1.96); MOE was the margin of error; p was the sample proportion, and N was the population size.
The research was performed in compliance with the World Medical Association’s Declaration of Helsinki, and approval for the research to be conducted was received from the faculty.
An anonymous questionnaire comprising open- and closed-ended questions was administered electronically. The electronic survey included questions on the participants’ demographic characteristics, including their age, sex, educational level, residence setting (urban or rural), and their parents’ level of educational attainment. The tools used to evaluate sleep problems, eating problems, and stress were the Pittsburg Sleep Quality Index (PSQI), the 26-Item Eating Attitudes Test (EAT-26), and the 10-Item Perceived Stress Scale (PSS-10), respectively.
Pittsburg Sleep Quality Index
The PSQI, a self-rated questionnaire, assesses sleep quality over a one-month interval. Responses to 19 individual items are used to generate seven “component” scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. The sum of the scores of these seven components yields one global score.23
26-Item Eating Attitudes Test
The 26-Item Eating Attitudes Test (EAT-26) is used to identify ED risk based on attitudes, feelings, and behaviors related to eating. Twenty-six items assess general eating behaviors, and five additional questions evaluate risky behaviors. This measure can be used for adolescents, adults, and special at-risk samples, such as athletes. The scale contains three subscales: dieting, bulimia, and food preoccupation/oral control.24
10-Item Perceived Stress Scale
The 10-Item Perceived Stress Scale (PSS-10) is the most widely used psychological instrument for measuring perceptions of stress. It is a measure of the degree to which situations in an individual’s life is appraised as stressful. The items are designed to assess the extent to which respondents gauge their lives to be unpredictable, uncontrollable, and overloaded. The scale also includes a number of direct queries about current levels of stress. There are no cut-off scores because the PSS-10 is not a diagnostic tool; the respondents’ PSS-10 scores merely reflect stress severity. Individual PSS-10 scores range from 0–40, with higher values denoting greater perceptions of stress. Low stress is denoted by a score of 0–13; moderate stress is indicated by a score of 14–26, and high levels of perceived stress are signified by a score of 27–40.25 The survey takes 30–40 minutes to complete.
Before the start of the current research, a pilot study was conducted on 10–15 students to test the clarity, practicality, and reliability of the instruments used. The instruments were administered to and answered by the participants online. Suitable incentives such as educational materials were proposed to encourage student participation in the study.
The data were analyzed using Stata® (version 17.0), along with descriptive frequency analysis. Mean ± standard deviation was used to measure the continuous variables, and frequency counts and percentages were utilized to evaluate the categorical variables. Bivariate and multivariate analyses were employed to identify factors associated with the outcomes of interest (EDs, sleep disturbances, and stress). Odds ratios (ORs) with 95% CIs were computed to reflect the level of association and statistical significance. The level of statistical significance was set at 0.050.