The sleep quality can be assessed subjectively and objectively. In the study, 76.5% (n= 153) of the participants described their sleep quality as 'very good and 'fairly good sleep'. In a study done by Lemma et al. (2012), among university students, the subjective sleep quality was reported as very good by 33.4% and fairly good by 54.3% of students, which is more than reported in our study. [15]. In another study, 67.7% of medical students have reported their subjective sleep quality as very good and fairly good [16]. In a study conducted on female medical students, 80.76% have reported their subjective sleep quality as very good and fairly good [8]. In our study, 71.5% (n=30) of participants from the Faculty of Medicine reported very good and fairly good sleep quality, which is higher than similar studies. 58% of subjects reported that they take less than 30 minutes on the bed to fall asleep. Mean sleep latency was 2.22 (SD = 1.453), indicating that these subjects usually take less than 60 minutes to fall asleep. In the study conducted by Lemma et al. (2012), 52.4% of subjects have taken less than 30 minutes to fall asleep. [15] Another study by Supartini et al. observed these phenomena in 76.6% of students indicating a higher sleep latency [17]. 57.2% medical students in this study reported sleep latency as less than 30 minutes. In the study conducted by Almojali mentioned as 74.5% of medical students reported their sleep latency to be less than 30 minutes, sleep latency was lower in the sample of medical students in the current study. [16]
The mean of total hours on bed was 6.853 (SD= 1.513) and the mean of total hours slept was 6.259 (SD= 1.457), indicating the actual sleep duration was less than seven hours. 63% (n= 126) of students had a sleep duration of less than seven hours per night and actual sleep was ranged from 2.45hours to 9.42hours. This finding is important as this indicates that the undergraduates are getting a sleep duration less than the recommended sleep, about 7-8 hours. [18] In the study conducted by Lemma et al. (2012), 62.4% of the students had an actual sleep duration of less than 7 hours [15] while in the other study by Williams (2016), 76% of participants reported sleep duration less than 7 hours. According to Williams et al., the mean sleep duration was 6.64± 1.40 which was more than the index study population [19]. The participants' sleep duration in our study was less than seven hours, which is compatible with the studies conducted by Williams and Lemma. The mean sleep duration reported by medical students was 6.197 (SD= 1.800) in our study and 64.3% of them reported sleep duration less than seven hours. (Figure 1) In the study conducted by Almojali et al. (2017), 73.4% of medical students reported a sleep duration less than seven hours which was replicated in our study. (mean = 5.8h, SD= 1.3h) [16]. This further describes students taken less amount of sleep rather than they should be taken.
67.5% (n= 135) of undergraduates experienced sleep disturbances once or twice a week which was statically significant (p = 0.312) with a mean of 1.29 (SD = 0.579). Lemma et al. (2012), in their study, reported that 67.4% of students experienced sleep disturbances once or twice a week, which was the same as our study.[15] The current study found that 71.4% of medical students have experienced sleep disturbances at least once or twice a week. In the study by Lohitashwa et al. (2015) among medical students, sleep disturbances were experienced by 34.16% participants at least once a week. [8] It explains that participants from the medical Faculty of this study have experienced sleep disturbances more than the same population from other countries.
The mean of daytime dysfunction is 2.38 (SD = 1.542), indicating that most participants (63%, n= 126) experienced daytime dysfunction as a big problem more than once per week. 53.84% of medical students have experienced daytime dysfunction at least once a week, according to Lohitashwa et al. (2015), while 49.7% of University students have experienced daytime dysfunction in the study conducted by Lemma et al. (2012). [8,14]
The mean global PSQI score of the study population in our study was 7.99 (SD = 3.721), indicating poor sleep quality. In the study, 82.5% (n= 165) of all students had poor sleep quality. Out of the faculties, 95% (n= 38) of the participants from the Faculty of law experienced poor sleep quality. Among medical undergraduates, 78.6% (n= 33) had poor sleep quality, while 85% (n= 34) of the participants from the Management faculty reported poor sleep quality. (Figure 2) The study done by Lemma et al. (2012) observed poor sleep quality in 55.8% of (mean =6.23, SD =2.89) University students [15]. Williams et al. classified 42.4% of participants as poor sleepers. (mean= 5.50, SD= 2.46, range 0 - 18) [19]. Therefore, 82.5% of participants reporting poor sleep quality in our study sample is high compared to the other studies. In studies conducted among medical undergraduates by Lohitashwa et al. (2015) and Almojali et al. (2017), 57.89% and 76% (mean =7.1, SD = 3.84) experienced poor sleep quality, respectively. [8,16] In our study, 78.6% of medical undergraduates and 83.8% of undergraduates from the Science faculty reported poor sleep quality.
There was a significant difference between the subjective and objective measures of sleep quality in our study. 76.5% (n= 153) of students reported that their sleep was very good and fairly good subjectively. Interestingly 9% (n= 18) of them were on sleep medications less than once a week or once or twice a week. In the objective component, depending on the global PSQI score, 82.5% (n= 165) of all the students had poor sleep quality, and 63.0% (n= 126) students had daytime dysfunction more than once or twice, three or more times in a week. The difference between subjective and objective sleep quality components may be due to a lack of understanding about symptoms of sleep issues.
Stress levels among undergraduates were rated as mild (14%), moderate (16%), severe (12.5%) and extremely severe (10.5%). (Figure 3) In a study done in Sri Lanka among undergraduate nursing students, the stress score was 18.91± 10.017 indicating that the stress scores of university students were less. In a study done by Rathnayake and Ekanayake found that there were correlations between depression, anxiety, and stress among subjects. (Depression and stress (0.785**), anxiety and stress (0.763**)) [20] Stress among undergraduates was 12.4 (SD= 8.0), and it comprised of mild (15.7%), moderate (11.6%), severe (5.1%) and extremely severe (1.5%) levels. [15] In a study done using Kessler Psychological Distress Scale (K10) among medical students, stress was reported as mild, moderate and severe by 23.2%, 13.3% and 16.7% of students, respectively. [16] The stress level of medical undergraduates in the current study was mild (16.7%), moderate (9.5%), severe (19%) and extremely severe (16.7%), giving an overall high stress level of the study participants. A study among female undergraduates in Indonesia revealed that 72.7% of undergraduates in Health Sciences and 73.30% in Science Technology had moderate to severe degrees of stress. [21] Therefore, the stress levels of our study participants are higher than in similar studies indicating that the selected population is more stressed.
The means of individual scores of coping strategies in this study were higher than 5, indicating that the University students commonly used those coping strategies. The individual scores for self-distraction was 5.11 (SD= 1.711), active coping 5.10 (SD= 1.681), positive reframing 5.01(SD= 1.716), planning 5.18 (SD= 1.643) and acceptance 5.07 (SD= 1.737). Similar results were observed by Średniawa (2019) et al. with planning 2.06 (SD= 0.68), acceptance 1.87(SD= 0.64), active coping 2.13 (SD= 0.62), positive reframing 1.57 (SD= 0.76) and self-distraction 1.68 (SD= 0.68) being the coping strategies commonly used by the participants.[22] A previous study on coping strategies among female medical students revealed higher means indicating that 46.3% of students have some stress. They used coping strategies such as self-distraction 6.1 (SD= 1.4), religious coping 6.3 (SD= 1.6), emotional support 6.0 (SD= 1.4), instrumental support 5.9 (SD= 1.4), and planning 6.2 (SD= 1.3) commonly which is similar to the findings of our study. [23]
The students in the present study, coping strategies reported as "have been doing it a lot" were self-distraction (23%), active coping (20%), positive reframing (20.5%), planning (24.5%), acceptance (21.5%), religion (20%) and instrumental support (16%). Similar results were observed in a study done by Shakthivel et al. (2017,) indicating that most first-year female medical students in India used religion and self-blaming as coping strategies while boys used humor. 19.4% of them used self-distraction and instrumental support, and 21.5% used positive reframing. Planning was used by 15.1%, while 30.1% used religion. [24]
Strong correlations (r > 0.5) with sleep quality were seen with stress score and DASS total score. The PSQI scores correlated positively with the total DASS score (r=0.526**, p= 0.000) in a statistically significant manner. The correlation was stronger for the total score than for the stress score (r= 0.474, p=0.000). In a study conducted among undergraduate students in Southern Thailand, PSQI score highly correlated with depression (r=0.34; p < 0.001), anxiety (r=0.35; p < 0.001) and stress scores (r=0.38; p < 0.001). [19](17) A previous study done among German students observed a strong positive correlation between sleep quality and chronic stress. ( r= 0.416**, p < 0.001)[10](10) In our study, there is a statistically positive correlation between global PSQI and stress. (r= 0.474**, p= 0.000)
In our study, 57.6% poor sleepers reported stressed. (Figure 4) The percentage of poor sleepers who were extremely stressed was 12% (n= 20). A similar study done among female students yielded that 41.8% of poor sleepers were stressed. [19] Another study described that 84% of students with poor sleep as stressed to a moderate to a severe degree. Students with poor sleep were reported as having higher 4.7 times stress levels than students with good sleep quality. [21] These findings describe that there was a positive correlation between sleep quality and stress level.
The stress score highly correlated with coping. In our study, the positive correlations between stress and coping strategies indicated that undergraduates commonly use both adaptive and maladaptive coping strategies. The correlations with higher coefficients were self-blame (r= 0.585**, p= 0.000), denial (r= 0.423**, p= 0.000), emotional support (r= 0.420**, p= 0.000), venting (r= 0.379**, p= 0.000) and planning (r = 0.455**, p= 0.000). In a previous research done using Perceived Stress Scale and brief COPE scale, significant correlations were observed between self distraction, (r=0.225, p <0.0001), denial (r=0.232, p <0.0001), behavioral disengagement (r= 0.355, p<0.0001), venting (r=0.258, p <0.0001) and self-blame (r= 0.258, p <0.0001) which was similar our study. [24] There were significant associations between perceived stress and coping strategies by using Perceived Stress Scale and brief COPE scale. Students who felt stressed used venting (r= 5.0, p = 0.001), denial (r= 4.5, p = 0.032), self-blame (r= 5.0, p < 0.001), and disengagement (r= 4.4, p = 0.004) more than the students who were not stressed (r= 4.5, 4.1, 4.3, and 3.9, respectively). Students who were not stressed used emotional support (r= 5.9, p = 0.032) more than stressed students (r= 5.6). The study findings are similar to the studies done in other countries and had similar statistical correlation with stress and coping. Out study found that correlations between coping strategies and stress were statistically significant and similar with findings of studies done elsewhere.
This study revealed a statistically significant correlation between sleep quality and its components with subcategories of brief COPE scale even when stress was not considered. Positive correlations were seen with emotional support and sleep disturbances (r= 0.237**, p= 0.001), PSQI score (r= 0.242**, p= 0.001) and quality of sleep (r= 0.207**, p= 0.003). Self-blame correlated with daytime dysfunction (r= 0.217**, p= 0.002) and PSQI score (r= 0.228**, p= 0.001).
The findings of this study were limited by the lack of laboratory measures on sleep health. The Depression Anxiety Stress Scale (DASS) was used to reduce bias when stress interfered with depression and anxiety. The individual's behavior during stressful events varies for everyone. Therefore, we were unable to calculate the total coping score and compare it with others. The stressful events are also different from individual to individual. In future studies, we recommend using laboratory measures to explore the relationship between sleep quality, stress and coping.