Sleep quality among undergraduate medical students in Rwanda: A comparative study

doi:10.21203/rs.3.rs-2010523/v1

Download PDF

Research Article

Sleep quality among undergraduate medical students in Rwanda: A comparative study

https://doi.org/10.21203/rs.3.rs-2010523/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

Good sleep quality is critical to health and wellbeing. However, due to a hectic modern world, sleep is ignored thus poor sleep quality remains one of the endemics affecting medical students than the general population. Regrettably, little has been studied about this alarming issue in Rwanda. Therefore, this study determined the sleep quality of undergraduate medical students in Rwanda and explored existing differences in sleep quality across all classes.

Methods

This cross-sectional study was conducted among 290 undergraduate medical students who were randomly recruited countrywide from 1st November 2021 to 1st March 2022.The questionnaire was self-administered with 2 sections: socio-demographic characteristics and Pittsburgh Sleep Quality Index (PSQI). Chisquare test was used to compare components of sleep quality while ANOVA was used to test the difference across all classes.

Results

Of the 290 respondents,167 (58%) and 123(42%) were male and female respectively. Subjective sleep quality of 102(85%) in fourth year was reported fairly good to very good. Falling asleep took the majority in this class 30 minutes or less, 106(88.4%). Sleeping duration was 5–6 hours per night in most las year students, 44(75.9%). The use of medication to fall asleep was mostly observed among first year students ,3(11%). The habitual sleep efficiency was below 65% in the majority from last year 53(91.4%). There was mild to moderate sleep disturbances reported in most fourth-year students ,106(88.3%) while 38(86.7%) third year students reported daytime dysfunctions. The overall PSQI was > 5 among 231(80%) indicating poor sleep quality and it was particularly poorer among final year students, 50(86.2%) had PSQI > 5.The subjective sleep quality, sleep duration, habitual sleep efficiency, and daytime dysfunction were significant across classes ((F = 3.347, p-value = 0.001), (F = 2.196, p-value = 0.007), (F = 10.2, p-value = < 0.001), (F = 3.604, p-value = 0.007)) respectively.

Conclusions

The prevalence of poor sleep quality among medical students in Rwanda is high. The issue is even worse among final year medical students who presented poorest sleep quality. Two sleep components including habitual sleep efficiency and sleep duration were the poorest. Intervention methods like sleep education, behavioral changes, and relaxation techniques are recommended to address contributing factors and eventually maximize their academic purposes.

Medical Students

poor sleep quality

good sleep quality

Rwanda

Sleep quality is defined as one’s satisfaction of the sleep experience, integrating aspects of sleep initiation, sleep maintenance, sleep quantity and refreshment upon awakening (1). Though the modern world ignores sleep, sleep is considered a basic human need occupying a third of human life (2, 3). Between 7 and 9 hours of sleep is recommended for adults (4, 5) and 9.5 hours for teenagers (6). The deviation from this range is regarded as disruption of sleep wake cycle (7).

For medical students, good sleep quality is essential to have optimum cognitive function, memory and decision making to excel and master their learning needs(6). Even so, medical students are more vulnerable to poor sleep, perhaps due to the long duration and high intensity of study (8). Worldwide, compared to non-medical students, medical students are more prone to poor sleep (9–11). In Nepal, the prevalence of poor sleep quality among medical students was 44.2% compared to non-medical students 30.3% (2). More other global reviews reported that sleep disturbances affect 41% of participating students in Iran,70% in Hong Kong and 90% in China (2). In Sub-Saharan Africa countries like Ethiopia, poor sleep among medical students is at 62%(12). Poor sleep quality among Nigerian Medical students was also reported to be 32.5%(13). Factors leading to poor sleep quality among medical students were studied and most medical students are over stressed because of intensive learning period with limited break time as compared to non-medical students(12). Their daily schedule is full of academic lectures, hospital activities and painful emotional events such as dealing with patients who are suffering or dying (14). Participating in internship also leads to sleep deprivation and thus disrupt their sleep habits(9). High stress levels and subclinical depression have been also identified as risk factors for poor sleep quality (9).

Though medical students may not consider sleep as top priority due to their academic requirements, and minimize sleeping time to have extra hours for studying (15),sleep deprivation in medical career leads to sleepiness during daytime, which may contribute to medical errors, road traffic accidents and decrease in academic performance (14).More studies demonstrated that poor sleep quality cause psychiatric disorders (8, 5, 4), physical problems (8, 7), impairment in job performance (7), decreased work efficiency (7) and learning disability (16, 17).It is known that joining a university is a big leap for students as they will encounter a lot of challenges like new schedule, unfamiliar environment, social obligation, and academic demands, thus cut down their sleep to adapt to heavy workloads (6). Regrettably, research on sleep quality among medical students in Rwanda remain less researched, however, this area of research is an important indicator of quality of life and biopsychosocial wellbeing (18). This study aimed to determine the sleep quality of undergraduate medical students in Rwanda and explore the differences in sleep quality across all classes. This study is a baseline to identify sleep quality issues of medical students in Rwanda and help concerned parties to plan management plans. A study like this has been considered an essential step elsewhere for identifying the magnitude of the problem and managing it (11). Sleep disorders among medical students need attention as they negatively impact quality of life, cognitive performance, and more associated health problems.

Study design

This was a cross sectional study conducted from 1st November 2021 to 1st March 2022 among undergraduate medical students pursuing Bachelor of Medicine and bachelor Surgery in Rwanda.

Study population and settings

Rwanda is a sub-Sahara African country located in the East Africa with the surface of 26,338 km². The country is divided into four provinces (East, West, South and North) plus Kigali city which is the capital city. Medical school in Rwanda started from former national University of Rwanda, which is currently in the University of Rwanda, College of Medicine and Health Sciences, School of Medicine, and Pharmacy. It is biggest medical school so far with both undergraduate and post graduate studies. Medical school at the University of Rwanda is a five-year program while it is six-year program in the private university both awarding the Bachelor of Medicine and Bachelor of surgery (MBBS). This medical school has three campuses including: REMERA campus located in Kigali city, HUYE campus located in southern province and GAKO campus located in the Eastern province. Though it remains the only public university, the university of Rwanda is not the only university with medical school. During the study period, Rwanda had two other private universities with medical schools. They were Adventist University of central Africa (AUCA) based in Kigali city and the University of Global Health Equity (UGHE) based in Northern Province. Both universities awards MBBS.

Sample size and sampling technique

A list of registered medical students in 2021–2022 was obtained from the Deans of school of Medicine at each university. The total number of students was 1062, with 960 from UR, 66 from UGHE and 36 from AUCA. The sample size was calculated using Yamane approach \(\mathbf{n}\mathbf{Y}=\frac{\text{N}}{1+\text{N}{\text{e}}^{2}}\)Where “N” stands for population size, and “e” for Alpha level (e = 0.05) at the confidence interval of 95%. \({n}{Y}=\frac{1062}{1+1062(0.0{5)}^{2}}=\)290(19). Disproportionate stratified sampling was used and as a result, 254 participants were enrolled from UR, 30 from UGHE and 6 from AUCA.

Data collection and measurements

Data was collected from 1st November 2021 to 1st March 2022 by trained data collectors. All medical students registered in one of the three universities were included. As done with similar studies, medical students with chronic disease were not included(20). The study employed a self-administered questionnaire made of two sections: Sociodemographic characteristics and Pittsburgh Sleep Quality Index (PSQI). Sociodemographic characteristics asked 12 variables including: gender, age, university, class, scholarship, clinical rotations, accommodation, living with roommate, smoking, class attendance, studying in teams, and self-reported academic score. PSQI assessed participants’ sleep quality as done in similar studies (21). PSQI is a tool that demonstrated a high internal consistency (α = 0.81) with predictive validity cut-off point of a PSQI score > 5 showing 89.6% sensitivity and 86.5% specificity for identifying poor sleep quality (21). In the context of the current study, this tool demonstrated a satisfactory internal consistency (Cronbach’s Alpha, α = 0.87). The PSQI has 19 items grouped into seven components: (a) subjective sleep quality, (b) sleep latency, (c) sleep duration, (d) habitual sleep efficiency, (e) sleep disturbances, (f) use of sleeping medications, and (g) sleep dysfunction. Each component scores from 0 to 3, while total PSQI score ranges from 0 to 21, with higher scores suggesting poorer sleep quality.

Data analysis

Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 25.0. Descriptive statistics were computed, and results presented in frequency and percentages. The Chisquare test was computed to compare seven components of sleep quality across all classes while ANOVA was used to compare seven components of sleep quality with global PSQI score. The statistical significance was considered if p-value was < 0.05 .

Ethical consideration

This study complies with the ethical standards of the national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The ethical clearance was requested and approved by the Institutional Review Board of College of Medicine and Health Sciences (IRB/CMHS) at the University of Rwanda under a reference number CMHS/IRB/284/2021.Participants voluntarily consented to participate. The study participants provided their informed consents after adequate information about the study and their potential benefits have been provided by the researchers using online system. Data collection was performed after providing consent form to participate. Confidentiality was ensured.

Socio-demographic characteristics of medical students

The study involved 290 medical students aged 17–35 with average of 24. Male were 169 (58.3%) and 121(41.7%) were female. A total of 253 (87.2%) were from university of Rwanda,31(10.7%) from the University of Global health equity (UGHE) and 6 (2.1%) from the Adventist University of Central Africa (AUCA). More participants were in 4th year, 120 (41.4%), while 58 (20%) were in 5th year, 44 (15.2%) were in 3rd year, 41(14.5%) were in 2nd year were, and 26 (9%) were in 1st year. 259 (89.3%) had scholarship but 31 (10.7%) had no scholarship. 156 (53.8%) were in clinical rotations/clinical clerkship. More than half were accommodated in campus 170 (58.6%), while 67(23.1%) were in renting houses and 53 (18.3%) were staying in their family. Majority had a roommate 202 (69.7%) or family member 63 (21.7%) but 25 (8.62%) reported that they were living alone. The study found only 2 medical students (0.7%) who reported to be smokers. Majority reported that they attend class regularly 264 (91%) while 26 (9%) were attending class irregularly. The self-reported academic grade of most medical students was 71–80%, 154 (53.10%) followed by 61–70%,77(26.6%), then above 80%, 38 (13.1%) and 50–60%, 21(7.2%). 36 (12.4%) reported that they always study in team, while 210 (72.4%) reported that it is sometimes, 37(12.8%) reported that it is only when assigned to a group work and 7(2.4%) said never. (Table 1)

Table 1

Socio-demographic characteristics of medical students
Variables	Frequency	Percent
Gender
Male	169	58.3
Female	121	41.7
Age
≤ 19	20	6.9
20–24	205	70.7
25–30	58	20
31–35	7	2.4
University
University of Rwanda (UR)	253	87.24
University of Global Health Equity (UGHE)	31	10.7
Adventist University of Central Africa (AUCA)	6	2.1
Academic level of study
1st Year	26	9
2nd Year	42	14.5
3rd Year	44	15.2
4th Year	120	41.4
5th Year	58	20
Scholarship
Yes	259	89.3
No	31	10.7
Clinical rotation
Yes	156	53.8
No	134	46.2
Accommodation
Campus	170	58.6
Rent house/room	67	23.1
Home	53	18.3
Living partner
Living alone	25	8.6
Living with family	63	21.7
Living with roommate	202	69.7
Smoking
Yes	288	99.3
No	2	0.7
Class attendance
Regular attendance	264	91
Irregular attendance	26	9
Studying in team
Sometimes	210	72.4
All the time	36	12.4
Only during group assignment	37	12.8
Never	7	2.4
Grade
50–60	21	7.24
61–70	77	26.55
71–80	154	53.10
> 80	38	13.10

Distribution of participants by Sleep Quality Components and Classes

Of the 290,66 (23%) and 167 (57%) respectively reported their subjective sleep quality as very good and fairly good. Nearly half, 135 (47%) reported falling asleep in less than 15 minutes. Majority slept 5–6 hours per night ,202 (70%). The habitual sleep efficiency was less than 65% among 197 (68%). Mild and moderate sleep disturbances was observed in 152 (52%) and 73 (25%) respectively. The use of sleeping medications was reported by 19 (6.5%). The Daytime sleep dysfunctions were observed among 211 (73%). Globally, poor sleep quality was observed among 231 (80%). Subjective sleep quality was very good and fairly good among second year students, 20 (20.8%) and 27(64.8%) respectively. However, 20 (34.5%) in fifth year reported their subjective sleep quality as fairly bad. Second year students were taking more minutes to fall asleep. A total of 6 (14.3%) and 1(11.1%) took 31–60 minutes and more than 60 minutes respectively. Contrary, 59 (49.2%) students in fourth year took ≥ 15 minutes to fall asleep. Fifth year medical students were sleeping 5–6 hours per night ,44 (75.9%) while 6 (23.1%) in first year were sleeping 6–7 hours. The habitual sleep efficiency of 21(50%) and 1(2.4%) second year students was ≥ 85% and 75–84% respectively. However, 53 (91.4%) in fifth year it was less than 65%. Sleep disturbances was more prevalent among fourth year students, a total of 73(60.8%) and 33(27.5%) had mild and moderate sleep disturbances respectively. However, the use of sleeping medications was more prevalent among first year students, 3(11.5%) while sleep dysfunctions were more prevalent among third year students 40 (90.9%). Poor sleep quality was more prevalent among fifth year and first year students, 21(80%) and 50 (86.2%) respectively. The chi-square test revealed that subjective sleep quality, sleep duration, habitual sleep efficiency, and daytime dysfunction were significant across classes ((x² = 34.170, p-value = 0.001), (x² = 22.512, p-value = 0.032), (x² = 46.579, p-value = < 0.001), (x² = 33.348, p-value = 0.001)) respectively. (Table 2).

Table 2

Distribution of respondents by Sleep Quality Components and Classes
Sleep Quality Component	Year I	Year II	Year III	Year IV	Year V	Pearson Quisquare	p-value
	n (%)	n (%)	n (%)	n (%)	n (%)	X²
Subjective Sleep Quality
Very good	1 (3.8)	10(23.8)	6(13.6)	33(27.5)	14(24.1)	34.170	< .001***
Fairly good	16 (61.5)	27(64.3)	31(70.5)	69(57.5)	24(41.4)
Fairly bad	7 (26.9)	5(11.9)	4(9.1)	15(12.5)	20(34.5)
Very bad	2 (7.7)	0(0)	3(6.8)	3(2.5)	0(0)
Sleep Latency (Minutes)
≤ 15 minutes	12(8.9)	20(47.6)	16(36.4)	59(49.2)	28(48.3)	10.470	0.575
16–30 minutes	12(46.2)	15(35.7)	22(50)	47(39.2)	23(39.7)
31–60 minutes	0(0)	6(14.3)	6(13.6)	10(8.3)	5(8.6)
> 60 minutes	2(22.2)	1(11.1)	0(0)	4(3.3)	2(3.4)
Sleep Duration (Hours)
> 7 hours	0(0)	2(4.9)	0	8(6.7)	0(0)	22.512	0.032*
6–7 hours	6(23.1)	9(22)	3(6.8)	13(10.8)	8(13.8)
5–6 hours	13(50)	27(65.9)	33(75)	85(70.8)	44(75.9)
< 5 hours	7(26.9)	3(7.3)	8(18.2)	14(11.7)	6(10.3)
Habitual Sleep Efficiency
≥ 85%	12(46.2)	21(50)	22(50)	28(23.3)	5(8.6)	46.579	< 0.001***
75–84%	1(3.8)	1(2.4)	0(0)	0(0)	0(0)
65–74%	0(0)	0(0)	0(0)	3(2.5)	0(0)
< 65%	13(50)	20(47.6)	22(50)	89(74.2)	53(91.4)
Sleep Disturbances
None	5(19.2)	5(11.9)	6(13.6)	14(11.7)	15(25.9)	16.845	0.032*
Mild	9(34.6)	27(64.3)	21(47.7)	73(60.8)	22(37.9)
Moderate	12(46.2)	10(23.8)	17(38.6)	33(27.5)	21(36.2)
Severe	0(0)	0(0)	0(0)	0(0)	0(0)
Sleeping Medication
None	23(88.5)	40(95.2)	42(95.5)	110(91.7)	56(96.6)	9.456	0.664
Mild	1(3.8)	2(4.8)	2(4.5)	6(5)	2(3.4)
Moderate	1(3.8)	0(0)	0(0)	3(2.5)	0(0)
Severe	1(3.8)	0(0)	0(0)	1(0.8)	0(0)
Daytime Dysfunction
None	7(26.9)	6(14.3)	4(9.1)	43(35.8)	19(32.8)	33.348	< 0.001**
Mild	7(26.9)	26(61.9)	23(52.3)	50(41.7)	23(39.7)
Moderate	7(26.9)	9(21.4)	15(34.1)	24(20)	12(20.7)
Severe	5(19.2)	1(2.4)	2(4.5)	3(2.5)	4(6.9)
Total PSQI Global Score							0.504
PSQI > 5	21(80.8)	30(71.1)	35(79.5)	95(79.2)	50(86.2)
PSQI < 5	5(19.2)	12(28.6)	9(20.5)	25(20.8)	8(13.8)
PSQI: Pittsburgh Sleep Quality Index, X²: Pearson Chi-square value : Statistical significance at p < 0.05; : Statistical significance level at p < 0.01, **: statistical significance at p < 0.001

Comparison of mean score of sleep Quality components by class

The mean score of subjective sleep Quality was 1.01 (SD = 0.71). The mean score of sleep latency was 0.68 (SD = 0.76). Mean score for sleep duration was 1.92 (SD = 0.63). Habitual Sleep efficiency mean score was 2.06 (SD = 1.3). Mean score of Sleep disturbances was 1.16(SD = 0.67). The mean score on use of sleeping medications was 0.09 (SD = 0.39). The mean score for daytime dysfunction was 1.06 (SD = 0.84). The total Mean PSQI Score was 7.73 (SD = 2.83) indicating poor sleep quality. The use of Sleeping medication had the lowest mean score ,0.09(SD = 039) indicating least problems while habitual sleep efficiency 2.06(SD = 1.38) had the highest mean score, indicating more problems. Fifth year had a higher Global PSQI mean score (8.44, SD = 2.77) suggesting a more poorer sleep quality compared to other classes, while lower global PSQI mean score was observed in second year (6.64, SD = 2.63) indicating less poor sleep quality compared to others (Table 3)

Table 3

Comparison of mean score of sleep Quality components by class
Class	Mean Std.D	Comp I	Comp II	Comp III	Comp IV	Comp V	Comp VI	Comp VII	PSQI
Year I	Mean	1.38	0.69	2.03	1.53	1.26	0.23	1.38	8.15
	Std.D	0.69	0.83	0.72	1.50	0.77	0.71	1.09	3.31
Year II	Mean	0.88	0.71	1.75	1.45	1.11	0.47	1.11	6.64
	Std.D	0.59	0.80	0.66	1.50	0.59	0.21	0.67	2.63
Year III	Mean	1.09	0.77	2.11	1.5	1.25	0.045	1.34	8.00
	Std.D	0.70	0.67	0.49	1.5	0.68	0.21	0.71	3.03
Year IV	Mean	0.9	0.65	1.87	2.27	1.15	0.125	0.89	7.60
	Std.D	0.70	0.77	0.69	1.2	0.60	0.45	0.80	2.65
Year V	Mean	1.10	0.67	1.96	2.74	1.10	.034	1.01	8.44
	Std.D	0.76	0.78	0.49	0.84	0.78	0.18	0.90	2.77
Total mean	Mean	1.01	0.68	1.92	2.06	1.16	0.09	1.06	7.73
	Std.D	0.71	0.76	0.63	1.3	0.67	0.39	0.84	2.83
Std. D: Standard deviation, Comp I: Subjective sleep quality, Comp II: Sleep latency, Comp III: Sleep duration, Comp IV: Habitual Sleep Efficiency, Comp V: Sleep disturbances, Comp VI: Use of sleeping medications, Comp VII: Daytime dysfunction

Table 4

ANOVA
Sleep component	Mean Square	F value	p-value
Subjective sleep quality	1.649	3.347	0.011
Sleep latency	0.116	1.95	0.941
Sleep duration	0.896	2.196	0.0070
Habitual sleep efficiency	17.211	10.200	< 0.001
Sleep disturbances	0.229	0.504	0.733
Sleeping medication	0.250	1.640	0.164
Daytime dysfunction	2.466	3.604	0.007
PSQI	0.135	0.827	0.509

Upon completion of analysis of variance (ANOVA), Tukey post-hoc tests were used to determine which classes presented significant difference among seven sleep quality components. The ANOVA revealed a significant difference in subjective sleep quality between class I vs class II(p-value = 0.004) and between class I and class IV(p-value = 0.002), sleep duration between class I and Class IV(p-value = 0.032), and between class III and IV(p-value = 0.032), habitual sleep efficiency between class V and all other classes, daytime dysfunction between class III and Class IV(p-value:0.002) (Table 4).

Table 5

P values of mean score of sleep quality components and PSQI between classes
Class	Comp I	Comp II	Comp III	Comp IV	Comp V	Comp VI	Comp VII	PSQI
Class I vs Class II	0.004*	0.909	0.074	0.791	0.372	0.061	0.199	0.355
Class I vs Class III	0.092	0.674	0.009	0.905	0.908	0.056	0.831	0.903
Class I vs Class IV	0.002*	0.839	0.032*	0.009	0.447	0.212	0.006	0.855
Class I vs Class V	0.91	0.913	0.239	< 0.001***	0.298	0.034	0.061	0.569
Class II vs Class III	0.167	0.726	0.009	0.865	0.368	0.980	0.215	0.352
Class II vs Class IV	0.880	0.686	0.296	< 0.001***	0.745	0.249	0.126	0.286
Class II vs Class V	0.119	0.789	0.103	< 0.001***	0.909	0.888	0.544	0.072
Class III vs Class IV	0.124	0.401	0.032*	< 0.001*	0.440	0.249	0.002*	0.958
Class III vs Class V	0.929	0.516	0.239	< 0.001***	0.277	0.888	0.051	0.410
Class IV vs Class V	0.071	0.909	0.368	0.026*	0.611	0.148	0.343	0.276
Comp I: Subjective sleep quality, Comp II: Sleep latency, Comp III: Sleep duration, Comp IV: Habitual Sleep Efficiency, Comp V: Sleep disturbances, Comp VI: Use of sleeping medications, Comp VII: Daytime dysfunction

This study determined sleep quality of undergraduate medical students in Rwanda using Pittsburgh Sleep Quality Index (PSQI) and explored differences of seven components of sleep quality across classes. Primarily, this study revealed a high prevalence of poor sleep quality, 231 (80%) medical students had PSQI score greater than 5 and overall PSQI score was 7.73 (SD = 2.83). These findings are like studies conducted in Malysia and Saudi Arabia that found a high prevalence of poor sleep quality among medical students (6, 22). However, the rate from the current study is high compared to studies conducted in the region like Ethiopia and Nigeria, (23–25). The result from current study is a wake-up call to address contributing factors of poor sleep quality among medical students in Rwanda so that improved academic and clinical performance can be expected from them. Poor sleep quality observed in the current study may be explained by stress level facing medical students as it has been found in a study assessing stress level among medical students in Rwanda(20).

Though poor sleep was prevalent all medical students, poorest sleep quality was reported among last year students compared to others, 50 (86.2%). This contrasts with a study from North India where first year students reported poorer sleep quality as opposed to final year students(26). Last year medical students in Rwanda have earlier reported to face financial hardship as there is no allowance allocated for clinical rotations which dominates their last year, thus increased their stress level(20). Stress among medical students has been found related to poor sleep quality at King Abdulaziz University (27). Measures are needed to address this alarming issue because if sleep quality of medical students remains poor it can jeopardize the life of patients they follow up with during their clinical rotations. However, because of their excessive academic burden, they may sacrifice their sleeping hours with studying, thus health education is recommended

The sleeping hours recommended by literature recommends is 7 hours or more of per night for younger adults (18–45 years)(28). However, on average, medical students in the current slept 5.5 hours per night. These results agree with similar studies conducted among medical students, 24% in United Kingdom,30% in Korea and 49% in Taiwan also slept less than recommended hours per night (2). Sleep deprivation leads to sleepiness during daytime and contributes to medical errors, road traffic accidents and decrease in academic performance among medical students (14). More medical students in the current study reported sleeping difficulties, 135 (46.5 %) weretaking 15 minutes or less to fall asleep. In contrast, a higher number of medical students at the international Islamic University in Malaysia was reported take 15 minutes or less to fall asleep 302 (66%) (6). The predictors of sleep difficulties among Mexican medical students have been found as symptoms of stress, anger, worry, cognitive hyperarousal, and hypervigilance(29).Measures to address possible factors leading to fewer hours of sleep among medical students in Rwanda are needed.

Sleep disturbances ranging from mild to moderate were reported among 225 (77.5%) medical students in the current study. These results are in line with a global review on sleep disturbances than found 76.8% of medical students assumed to have sleep disturbances(29). Similarly, a study conducted in Italian university revealed that 63% medical students had symptoms of sleep disturbances (9). The issue of sleep disturbances are the possible markers of current and future psychiatric problems among medical students (29).Sleep disturbances among medical students not only put them at risk of psychiatric problems but also affects their cognitive skills, emotional intelligence, and academic performances(30). In addition to sleep disturbances, the current study revealed that daytime dysfunctions were among 211 (73%) medical students. These results are higher compared to a study conducted in Jordan that found a prevalence of 50 %(31). Daytim sleep dysfunctions cause medical errors and decrease academic performance (14).Thus, some measures to address daytime sleep dysfunction among medical students in Rwanda that to lessen medical errors and improve academic performance among medical students. Regular counselling and education to improve paramount to improve their behaviors and lifestyle.

Interestingly, the use of sleeping medications was comparatively low in the current study, it was among 9 (6.5%). In comparison with seven components of PSQI, this component was the best in the current study with the lowest PSQI mean score (0.09) indicating less problems. These results correlate with a study conducted at Kathmandu medical college which found that the use of sleeping medications was at 6%(32).In Ethiopia, the use of sleeping medication was at 8.7%(33), which is high compared to the current stud. Subjective sleep quality of 66 (23%) and 167 (57%) medical students in the current study was reported as very good and fairly good respectively. These results are related to findings from King Khalid university in Saudi Arabia where majority reported their subjective sleep quality as very good and fairly good(34).The habitual sleep efficiency was less than 65% in the majority from current study, 197 (68%). In Malaysia, 347(76.1%) of medical students reported their habitual sleep efficiency above 85%(35). These results from current study indicate a serious problem of habitual sleep efficiency. Habitual sleep efficiency was even the poorest sleep component in the current study with PSQI mean score of 2.06. in contrast, Iranian study found that habitual sleep efficiency was the best sleep components(36).

From seven components of PSQI, four including: subjective sleep quality, sleep duration, habitual sleep efficiency, sleep disturbances and daytime dysfunction were significantly different across all classes. These results are in line with previous studies done in India and Brazil which also found these components significantly different among various phases of medical course(26)(37). Subjective sleep quality was significantly different with F-value = 3.347 and p-value = 0.001). The significant difference observed was between class I vs class II(p-value = 0.004) and between class I and class IV(p-value = 0.002). More medical students (20 (34.5%) in last year presented fairly bad subjective sleep quality compared to other classes, with a p-value of 0.022. These findings are in contrast with a study conducted in North India which reported that first year medical students had worse subjective sleep quality compared to other classes(26).Sleep duration was also significant across classes, (F = 2.196, p-value = 0.007) and significant difference was between class I and Class IV(p-value = 0.032). The current study observed that first year medical students had less hours of sleep compared to others, 7 (26.9%) were sleeping less than 5 hours. The component of habitual sleep efficiency was also significant and more students with less habitual sleep efficiency were from fifth year ,53 (91.4%). The observed significant difference was between final year and all other classes. The component of sleep disturbances was also significant across classes with F-value = 10.2 and p-value = < 0. 001.More sleep disturbances were observed among second year students, 32 (76.2%). The observed significantly difference was between class II and Class III, p-value = 0.038. Daytime dysfunctions were significant with F-value = 3.604 and p-value = 0.007). More problems were observed among third year medical students, 41 (90.9%) and the significant difference was observed between class III and Class IV(p-value:0.002). These results are also close to a study in Brazil that reported greater daytime dysfunctions among first- and second-year medical students for a program of six years(37). In Ethiopia, second and third-year students had high odds of poor sleep quality compared to others(24).Though, factors linked to modern technologies like use of social media or more time spend on screens are globally known as main factors leading to poor sleep quality among medical students (38, 39), we recommend a study about socio-demographic characteristics contributing to poor sleep quality among medical students in Rwanda.

Strengths and limitations

This study was the first study of its kind conducted to best knowledge of authors. It was conducted countrywide, and this gives a strength to the study as it presents a general picture on sleep quality of medical students in Rwanda. Secondly, this study used a validated tool used in other similar studies to assess sleep quality. However, we experienced some limitations: First, during this study, education sector was recovering from delays caused by COVID-19, thus medical students had both online and virtual classes which could affect their sleep Quality. Secondly, this study did not assess factors possible to contribute to poor sleep quality among medical students in Rwanda and thus future research is recommended to assess more factors leading to poor sleep quality among medical students in Rwanda.

The prevalence of poor sleep quality among medical students in Rwanda is high and poorer sleep quality is among final year students. The habitual sleep efficiency was found worse compared to other sleep components and mild to severe daytime dysfunctions affect a great number of medical students. Interventions methods like sleep education, behavioural changes and relaxation techniques are recommended to address contributing factors aiming to maximize academic purposes. Further studies on psychological, and environmental factors that contribute to poor sleep quality among medical students are recommended as this study is descriptive, there is a need of prospective study to determine the cause effect relationship of risk factors of poor sleeps quality

PSQI: Pittsburgh Sleep Quality Index

UR: University of Rwanda

UGHE: University of global health equity

AUCA: Adventist university of central Africa

IRB/CMHS: Institutional Review Board of College of Medicine, and Health Sciences

Ethics approval and consent to participate

The Ethical Clearance was requested and approved by the Institutional Review Board of College of Medicine, and Health Sciences (IRB/CMHS) at the University of Rwanda under a reference number CMHS/IRB/284/2021. Consent was obtained from the participants and all methods were conducted respecting regulations and principles of the Helsinki Declaration.

Consent for publication

Not applicable

Availability of data and materials

All relevant data were included in the manuscript. However, data may be shared upon reasonable request is provided to the corresponding author.

Competing interests

The authors declare no conflicts of interests.

Funding

Authors of the current study assert that they received no financial support for the research, authorship and/or publication of this study.

Authors’ contribution

All authors approved and reviewed the final draft of the manuscript. AN and EM conceived the manuscript. AN drafted the manuscript and made substantial contributions to the study design, analysis, and interpretation of data. EB and JN revised the article critically for important intellectual content. EN, JH and RM contributed to the data acquisition and took part in revising the manuscript. AN EM and RN were the study guarantors. RN played a supervisory role and provided final approval of the version to publish.

Acknowledgements

The authors gratefully acknowledge the consent and participation of the participants.

Abdul Rehman Arshad;Mohammed Hamza Khan;Fahad Hasan;SeharKhautija Khan;Farhat Ijaz and RanaKhurram Aftab. Qualityof Sleep and Sleep Disorders among Medical Students at A Private Medical College in Lahore, Pakistan. Adv Biores. 2021 Jan;12(1):1–8.
Paudel K, Adhikari TB, Khanal P, Bhatta R, Paudel R, Bhusal S, et al. Sleep quality and its correlates among undergraduate medical students in Nepal: A cross-sectional study. PLOS Global Public Health. 2022 Feb 18;2(2):e0000012.
Alqudah M, Balousha SAM, Balusha AAK, Al-U’datt DG, Saadeh R, Alrabadi N, et al. Daytime Sleepiness among Medical Colleges’ Students in Jordan: Impact on Academic Performance. Sleep Disord. 2022 Mar 10;2022:1–7.
Al-Khani AM, Sarhandi MI, Zaghloul MS, Ewid M, Saquib N. A cross-sectional survey on sleep quality, mental health, and academic performance among medical students in Saudi Arabia. BMC Res Notes [Internet]. 2019;12(1):1–5. Available from: https://doi.org/10.1186/s13104-019-4713-2
Vedaa Ø, Erevik EK, Hysing M, Hayley AC, Sivertsen B. Insomnia, sleep duration and academic performance: a national survey of Norwegian college and university students. Sleep Med X. 2019;1:100005.
Farah Natashah Mohd A, Manh A, Hanapiah MH. Poor Sleep Quality among Medical Students in International Islamic University Malaysia (IIUM) and Its Association with Mental Health and other Factors. Vol. 19. 2020.
Alghannami A, Alrashed A, Alshehri R, Alotaibi S, Alharbi M, Mukaddem A, et al. The sleep pattern of medical students: examining the impact of excessive Internet use. International Journal of Medicine in Developing Countries. 2021;1225–31.
Alfadeel MA, Alfadeel MA, Alqahtani N, Alhudaib M, Almudhee S, Aljarbou R, et al. MEDICAL STUDENTS OF ALMAAREFA COLLEGES IN. 2019;06(02):3377–91.
Belingheri M, Pellegrini A, Facchetti R, de Vito G, Cesana G, Riva MA. Self-reported prevalence of sleep disorders among medical and nursing students. Occup Med (Chic Ill). 2020;70(2):127–30.
Javaid R, Ul Momina A, Sarwar MZ, Naqi SA. Quality of sleep and academic performance among medical university students. Journal of the College of Physicians and Surgeons Pakistan. 2020 Aug 1;30(8):844–8.
SK J, NK I, AN F, FA B, RA A, YM M, et al. Sleep Quality among Medical Students at King Abdulaziz University: A Cross-sectional Study. J Community Med Health Educ. 2017;07(05).
Wondie T, Molla A, Mulat H, Damene W, Bekele M, Madoro D, et al. Magnitude and correlates of sleep quality among undergraduate medical students in Ethiopia: cross –sectional study. Sleep Sci Pract. 2021 Dec;5(1).
James B, Omoaregba J, Igberase O. Prevalence and correlates of poor sleep quality among medical students at a Nigerian university. Annals of Nigerian Medicine. 2011;5(1):1.
Alhazzani N, Masudi E, Algarni A. The Relationship between Sleep Patterns and Academic Performance among Medical Students at King Saud Bin Abdulaziz University for Health Sciences. Egypt J Hosp Med. 2018;70(7):1131–4.
Almojali AI, Almalki SA, Alothman AS, Masuadi EM, Alaqeel MK. The prevalence and association of stress with sleep quality among medical students. J Epidemiol Glob Health. 2017;7(3):169–74.
Siraj HH, Salam A, Roslan R, Hasan NA, Jin TH, Othman MN. Sleep pattern and academic performance of undergraduate medical students at universiti Kebangsaan Malaysia. J Appl Pharm Sci. 2014;4(12):052–5.
Abdulghani HM, Alrowais NA, Bin-Saad NS, Al-Subaie NM, Haji AMA, Alhaqwi AI. Sleep disorder among medical students: Relationship to their academic performance. Med Teach. 2012;34(SUPPL. 1).
James B, Omoaregba J, Igberase O. Prevalence and correlates of poor sleep quality among medical students at a Nigerian university. Annals of Nigerian Medicine. 2011;5(1):1.
Naing NN. Determination of sample size. Malaysian Journal of Medical Sciences. 2003;10(2):84–6.
Kubwimana L, Mutatsineza G, Tesi L, Wong R. Assessing the Stress Level among Medical Students in Rwanda. Open J Psychiatr. 2022;12(02):174–87.
Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. PSQI.pdf. Oakland Psychiatric Associate.
Al-Khani AM, Sarhandi MI, Zaghloul MS, Ewid M, Saquib N. A cross-sectional survey on sleep quality, mental health, and academic performance among medical students in Saudi Arabia. BMC Res Notes. 2019 Oct 21;12(1).
James B, Omoaregba J, Igberase O. Prevalence and correlates of poor sleep quality among medical students at a Nigerian university. Annals of Nigerian Medicine. 2011;5(1):1.
Lemma S, Gelaye B, Berhane Y, Worku A, Williams MA. Sleep quality and its psychological correlates among university students in Ethiopia: A cross-sectional study. BMC Psychiatry. 2012 Dec 28;12.
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(4):380–2.
Gupta S, Bhardwaj A, Nadda A, Gill A, Mittal A, Gupta S. A comparative study of sleep quality in different phases of the medical course: A study from Haryana (North India). J Family Med Prim Care. 2020;9(4):2006.
Safhi M, Alafif R, Alamoudi N, Alamoudi M, Alghamdi W, Albishri S, et al. The association of stress with sleep quality among medical students at King Abdulaziz University. J Family Med Prim Care. 2020;9(3):1662.
Al-Khani AM, Sarhandi MI, Zaghloul MS, Ewid M, Saquib N. A cross-sectional survey on sleep quality, mental health, and academic performance among medical students in Saudi Arabia. BMC Res Notes. 2019 Oct 21;12(1).
Azad MC, Fraser K, Rumana N, Abdullah AF, Shahana N, Hanly PJ, et al. Sleep disturbances among medical students: A global perspective. Vol. 11, Journal of Clinical Sleep Medicine. American Academy of Sleep Medicine; 2015. p. 69–74.
Javaid R, Ul Momina A, Sarwar MZ, Naqi SA. Quality of sleep and academic performance among medical university students. Journal of the College of Physicians and Surgeons Pakistan. 2020 Aug 1;30(8):844–8.
Alqudah M, Balousha SAM, Balusha AAK, Al-U’dat DG, Saadeh R, Alrabadi N, et al. Daytime Sleepiness among Medical Colleges’ Students in Jordan: Impact on Academic Performance. Sleep Disord. 2022 Mar 10;2022:1–7.
Shrestha D, Rajbhandari P. Sleep Quality among medical students of a tertiary care hospital:A descriptive cross-sectional study. Journal of the Nepal Medical Association. 2018 Jan 1;56(212):719–23.
Lemma S, Gelaye B, Berhane Y, Worku A, Williams MA. Sleep quality and its psychological correlates among university students in Ethiopia: A cross-sectional study. BMC Psychiatry. 2012 Dec 28;12.
Siddiqui AF, Al-Musa H, Al-Amri H, Al-Qahtani A, Al-Shahrani M, Al-Qahtani M. Sleep patterns and predictors of poor sleep quality among medical students in King Khalid university, Saudi Arabia. Malaysian Journal of Medical Sciences. 2016 Nov 1;23(6):94–102.
Farah Natashah Mohd A, Manh A, Hanapiah MH. Poor Sleep Quality among Medical Students in International Islamic University Malaysia (IIUM) and Its Association with Mental Health and other Factors. Vol. 19. 2020.
Mohammadbeigi A, Absari R, Valizadeh F, Saadati M, Sharifimoghadam S, Ahmadi A, et al. Sleep Quality in Medical Students; the Impact of Over-Use of Mobile Cell-Phone and Social Networks ARTICLE INFORMATION ABSTRACT [Internet]. Vol. 16, JRHS Journal of Research in Health Sciences Res Health Sci. 2016. Available from: www.umsha.ac.ir/jrhs
Corrêa C de C, de Oliveira FK, Pizzamiglio DS, Ortolan EVP, Weber SAT. Qualidade de sono em estudantes de medicina: Comparação das diferentes fases do curso. Jornal Brasileiro de Pneumologia. 2017 Jul 1;43(4):285–9.
Tahir MJ, Malik NI, Ullah I, Khan HR, Perveen S, Ramalho R, et al. Internet addiction and sleep quality among medical students during the COVID-19 pandemic: A multinational cross-sectional survey. PLoS One. 2021 Nov 1;16(11 November).
Mohammadbeigi A, Absari R, Valizadeh F, Saadati M, Sharifimoghadam S, Ahmadi A, et al. Sleep Quality in Medical Students; the Impact of Over-Use of Mobile Cell-Phone and Social Networks ARTICLE INFORMATION ABSTRACT [Internet]. Vol. 16, JRHS Journal of Research in Health Sciences Res Health Sci. 2016. Available from: www.umsha.ac.ir/jrhs

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Sleep quality among undergraduate medical students in Rwanda: A comparative study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Study design

Study population and settings

Sample size and sampling technique

Data collection and measurements

Data analysis

Ethical consideration

Results

Socio-demographic characteristics of medical students

Distribution of participants by Sleep Quality Components and Classes

Comparison of mean score of sleep Quality components by class

Discussion

Strengths and limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1