Advertisement

Sleep quality and associated factors among undergraduate medical students during Covid-19 confinement

Open AccessPublished:March 11, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101004

      Abstract

      Problem considered

      Medical students are vulnerable to poor sleep quality which may lead to attention difficulties and poor academic performance. Good quality sleep is needed for optimal neurocognitive and psychomotor functions as well as physical and mental health. This study aimed to assess the prevalence of poor sleep quality among undergraduate medical students during home confinement at the time of Covid-19 pandemic and analyze the relationship between sleep quality and relevant socio-demographic and psychological variables.

      Methods

      A cross-sectional study was conducted among 284 undergraduate medical students of a teaching hospital of Bhubaneswar from October–November 2020. Using a semi-structured questionnaire, relevant information was collected. Sleep quality of the students was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire and mental health status of the students using Depression, Anxiety, and Stress Scale - 21 (DASS-21).

      Results

      The prevalence of poor sleep quality among undergraduate medical students was 45%. Multivariate logistic regression revealed that students doing exercise for <3 days/week (AOR: 1.81, 95% CI: 1.01–3.23), spending ≥8 h screen time/day (AOR: 2.02, 95%: 1.12–3.66), having anxiety symptoms (AOR: 3.61, 95% CI: 1.72–7.57), and those who were not satisfied with own self (AOR: 2.69, 95% CI: 1.35–5.38) were more likely to report poor sleep quality.

      Conclusion

      Poor sleep quality was prevalent among undergraduate medical students during their home confinement at the time of Covid-19 pandemic. Sleep educational programs, anxiety management, and lifestyle modifications can be recommended to improve sleep quality among medical students.

      Keywords

      1. Introduction

      World Health Organization (WHO) has declared corona virus disease (Covid-19) as an international emergency on 30th January 2020 and a pandemic on 11th March.
      • Statement on the second meeting of the International Health Regulations
      ,
      • Cucinotta D.
      • Vanelli M.
      WHO declares COVID-19 a pandemic.
      In response to the outbreak, the Indian government issued social distancing measures including restriction of social gatherings, closure of educational and religious institutions, and limitation of population movement. The current Covid-19 pandemic is causing psychological distress such as depression, anxiety, stress, fear, and sleep problems among the general population.
      • Xiong J.
      • Lipsitz O.
      • Nasri F.
      • Lui L.M.W.
      • Gill H.
      • Phan L.
      During Covid-19 home confinement, a greater proportion of individuals experienced psychosocial and emotional disorders with a tendency towards an unhealthy lifestyle.
      • Ammar A.
      • Trabelsi K.
      • Brach M.
      • et al.
      Effects of home confinement on mental health and lifestyle behaviours during the COVID-19 outbreak: insights from the ECLB-COVID19 multicentre study.
      Medical students are a subgroup of the general population who are vulnerable to poor sleep quality which may be due to greater academic pressure, longer study hours, frequent examinations, anxiety associated with their studies and results, irregular work schedule, and lifestyle choices.
      • Azad M.C.
      • Fraser K.
      • Rumana N.
      • et al.
      Sleep disturbances among medical students: a global perspective.
      ,
      • Preisegolaviciute E.
      • Leskauskas D.
      • Adomaitiene V.
      Associations of quality of sleep with lifestyle factors and profile of studies among Lithuanian students.
      Moreover, there is a high prevalence of poor sleep quality among medical students who had been in home confinement during Covid-19 pandemic.
      • Saguem B.N.
      • Nakhli J.
      • Romdhane I.
      • Nasr S.B.
      Predictors of Sleep Quality in Medical Students during COVID-19 Confinement.
      Students have faced numerous challenges during this pandemic, such as adjustment to modified teaching-learning format, loss of social connectedness, and lifestyle changes. This might negatively impact their sleep quality
      • Altena E.
      • Baglioni C.
      • Espie C.A.
      • et al.
      Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy.
      and the levels of depression, anxiety, and stress may be increased.
      • Cao W.
      • Fang Z.
      • Hou G.
      • et al.
      The psychological impact of the COVID-19 epidemic on college students in China.
      ,
      • Wang C.
      • Pan R.
      • Wan X.
      • et al.
      Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in China.
      Worldwide, it has been reported that the prevalence of poor sleep quality varies with a wide range from 19% to 90% among medical students.
      • Azad M.C.
      • Fraser K.
      • Rumana N.
      • et al.
      Sleep disturbances among medical students: a global perspective.
      Poor sleep quality may lead to attention difficulties and poor academic performance as good quality sleep is needed for optimal neurocognitive and psychomotor functions as well as physical and mental health.
      • Azad M.C.
      • Fraser K.
      • Rumana N.
      • et al.
      Sleep disturbances among medical students: a global perspective.
      ,
      • Giri P.
      • Baviskar M.
      • Phalke D.
      Study of sleep habits and sleep problems among medical students of pravara Institute of medical sciences loni, Western Maharashtra, India.
      Poor sleep quality is associated with several factors including psychological factors, physical activity, screen time, lifestyle factors, life satisfaction, chronic diseases.
      • Lemma S.
      • Gelaye B.
      • Berhane Y.
      • Worku A.
      • Williams M.A.
      Sleep quality and its psychological correlates among university students in Ethiopia: a cross-sectional study.
      • Hsu M.F.
      • Lee K.Y.
      • Lin T.C.
      • Liu W Te
      • Ho S.C.
      Subjective sleep quality and association with depression syndrome, chronic diseases and health-related physical fitness in the middle-aged and elderly.
      • Ma C.
      • Zhou L.
      • Xu W.
      • Ma S.
      • Wang Y.
      Associations of physical activity and screen time with suboptimal health status and sleep quality among Chinese college freshmen: a cross-sectional study.
      This is a first-of-its-kind study in India to assess the prevalence of poor sleep quality among undergraduate medical students during home confinement at the time of Covid-19 pandemic and analyze the relationship between sleep quality and relevant socio-demographic and psychological variables. Understanding these factors may help in developing strategies to promote sleep quality and thereby raising the quality of life of medical students.

      2. Materials and methods

      This online cross-sectional survey was carried out during October–November 2020 among the undergraduate medical students studying at Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar. This study was approved by the Institutional Ethics Committee of Kalinga Institute of Medical Sciences (Ref. No: KIIT/KIMS/IEC/365/2020) and registered with Clinical Trial Registry-India (CTRI registration No: CTRI/2020/08/027492). Informed consent was obtained from all participants of this study.
      A sample size of 267 was estimated assuming a prevalence of 50% poor sleep quality among undergraduate medical students, a confidence level of 95%, and an allowable error of 6%. All the first and second-year MBBS students studying in KIMS were considered for the study. They were contacted over phone/e-mail, informed about the study procedure and provided the protocol, information sheet, and consent form through e-mail. They were clarified about their doubts and assured about the privacy and confidentiality of their data. Students suffering from Covid-19 or any acute severe illness, and those having any of their family members infected/died with Covid-19 were excluded from the study. A google form was created using a semi-structured questionnaire and sent to the eligible study participants through e-mail after obtaining their informed consent. Overall, 293 students were approached and 284 responded by sending back the filled questionnaire.
      Information on demographic characteristics, lifestyle behaviors such as days of exercise (at least 30 min a day) per week, screen time (time spent on electronic devices including smartphones, laptops, tablets, TV, videogames) per day, frequency of fast food (pizza, burger, muffin, noodle, rolls, chips, etc.) consumption per week, frequency of soft drink (nonalcoholic sweetened carbonated beverages like soda, Pepsico, coca-cola, sprite, etc.) consumption per week was collected. Students were also asked about their satisfaction with themselves, family life, college life, and the place where they live. Sleep quality of the respondents was assessed using the Pittsburgh Sleep Quality Index (PSQI), which is a self-administered questionnaire that assesses sleep quality in the past month.
      • Buysse D.J.
      • Reynolds C.F.
      • Monk T.H.
      • et al.
      The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.
      It consists of 19 items grouped into 7 components: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction. Each component score ranges from 0 to 3, and the total score ranges from 0 to 21 points. The lower the score, the better the quality of sleep. Students having a total PSQI score >5 were considered as having poor sleep quality in this study. Cronbach’ α for this tool was 0.718 in this study.
      DASS-21 questionnaire was used to assess the mental health status of the students.
      • Lovibond S.H.
      • Lovibond P.F.
      Manual for the Depression Anxiety & Stress Scales.
      It consists of 21 items categorized into 3 sub-scales namely depression, anxiety, and stress each containing 7 items. The responses for each item are based on a 4-point Likert scale (0 - did not apply to me at all; 1- applied to me to some degree, or some of the time; 2 - applied to me to a considerable degree or a good part of time; 3 - applied to me very much or most of the time). The scores for the relevant items were added, scores for depression, anxiety, and stress were calculated and categorized into absence or presence of these distress symptoms.
      All statistical analyses were performed by SPSS version 21.0 software. Categorical variables were expressed as frequencies and percentages whereas continuous variables were presented as means ± standard deviations. The continuous variables across subgroups of categorical variables were compared using Student's t-test and the relationship between categorical variables was analyzed using Pearson's chi-square test. Variables with p value < 0.1 in bivariate analyses were included in the final multivariate logistic regression model to control the effect of confounding variables. Finally, the variables that have significant (p value < 0.05) associations with sleep quality were considered as potential risk factors of sleep quality. Adjusted Odds Ratio and 95% confidence intervals were also estimated after controlling for other confounders. Multicollinearity among the independent variables was not present in our data.

      3. Results

      3.1 Characteristics of the study sample

      In total, 284 completed questionnaires from undergraduate university student participants were considered for final analysis. The age of the students ranged from 18 to 23 years, and the mean age was 20.6 (SD = 1.1) years. Almost half of the participants (48.9%) were aged below 20 years and a majority of the students were females (59.5%). Moreover, more than half of the students (58.8%) were overweight/obese. With regard to lifestyle behavior, more than two-thirds of students (66.9%) were doing exercise for ≥3 days (at least 30 min every day) in a week. Also, nearly two-thirds of students (65.5%) were spending ≥8 h per day with electronic devices such as smartphones, laptops, tablets, TV, video games. Almost one-quarter of the participants (23.6%) were consuming fast food ≥3 times in a week and nearly 18% were consuming soft drink > once in a week. The mean global PSQI score was 5.8 points overall (SD = 3.3), 5.7 points in males (SD = 3.2), and 5.9 points in females (SD = 3.4). There was no statistically significant difference in the PSQI score between males and females (p = 0.462). The total PSQI score decreased with increased age, from 6.1 points (SD = 3.4) in students aged ≤20 years to 5.6 points (SD = 3.2) in students aged >20 years (p = 0.167). In addition, the overall prevalence of poor sleep quality was 45%. Bivariate analyses showed that variables like exercise, screen time, and soft drink consumption were significantly associated with poor sleep quality among the students. The results in detail are presented in Table 1.
      Table 1Sociodemographic and lifestyle characteristics of the respondents (n = 284).
      TotalGood sleeperPoor sleeperp-value
      n (%)n (%)n (%)
      Age group (year)
       ≤ 20139 (48.9)75 (54.0)64 (46.0)0.747
       >20145 (51.1)81 (55.9)64 (44.1)
      Gender
       Female169 (59.5)89 (52.7)80 (47.3)0.352
       Male115 (40.5)67 (58.3)48 (41.7)
      Body mass index
       Underweight21 (7.4)09 (42.9)12 (57.1)0.483
       Normal96 (33.8)55 (57.3)41 (42.7)
       Overweight/Obese167 (58.8)92 (55.1)75 (44.9)
      Exercise per week
       <3 days94 (33.1)42 (44.7)52 (55.3)0.015
       ≥3 days190 (66.9)114 (60.0)76 (40.0)
      Screen time per day
       <8 h98 (34.5)65 (66.3)33 (33.7)0.005
       ≥8 h186 (65.5)91 (48.9)95 (51.1)
      Fast food consumption per week
       <3 times217 (76.4)121 (55.8)96 (44.2)0.613
       ≥3 times67 (23.6)35 (52.2)32 (47.8)
      Soft drink consumption per week
       Nil/Once234 (82.4)135 (57.7)99 (42.3)0.043
       More than once50 (17.6)21 (42.0)29 (58.0)

      3.2 Components of sleep quality

      The average bedtime of the participants was 7.5 ± 1.3 h, and the average sleep duration was 6.8 ± 1.2 h. The average sleep efficiency of the participants was 91%. Although 85% and 73% of students complained of sleep disturbance and daytime dysfunction respectively, only 15% of the students used sleep medication. No statistically significant differences were observed between younger (≤20 years) and older (>20 years) students on all components of sleep quality except habitual sleep efficiency. More female students had sleep disturbance and daytime dysfunction than their male counterparts whereas more male students were using sleep medications. Non-significant differences between males and females were observed on other components of sleep quality. The results are presented in Table 2.
      Table 2Gender and age specific scores of sleep quality components among the respondents (n = 284).
      Sleep qualityTotalGenderAge group (years)
      ComponentsMaleFemalep-value20> 20p-value
      Subjective sleep quality (Mean ± SD)0.93 ± 0.680.93 ± 0.670.93 ± 0.680.9560.99 ± 0.690.88 ± 0.660.146
      Sleep latency, n (%)
       ≤15min72 (25.4)26 (36.1)46 (63.9)0.27235 (48.6)37 (51.4)0.646
       16–30 min91 (32.0)43 (47.3)48 (52.7)48 (52.7)43 (47.3)
       >30 min121 (42.6)46 (38.0)75 (62.0)56 (46.3)65 (53.7)
       Sleep duration (Mean ± SD) 0.0116.78 ± 1.226.73 ± 1.116.81 ± 1.290.5886.59 ± 1.256.96 ± 1.17
      Sleep duration, n (%)
       >7 h90 (31.7)34 (37.8)56 (62.2)0.57236 (40.0)54 (60.0)0.065
       6–7 h160 (56.3)69 (43.1)91 (56.9)82 (51.3)78 (48.8)
       <6 h34 (12.0)12 (35.3)22 (64.7)21 (61.8)13 (38.2)
      Habitual sleep efficiency, n (%)
       >85%223 (7.5)94 (42.2)129 (57.8)0.16498 (43.9)125 (56.1)0.005
       75–84%32 (11.3)14 (43.8)18 (56.3)22 (68.8)10 (31.3)
       <75%29 (10.2)07 (24.1)22 (75.9)19 (65.5)10 (34.5)
      Any sleep disturbance, n (%)
       No42 (14.8)23 (54.8)19 (45.2)0.04119 (45.2)23 (54.8)0.603
       Yes242 (85.2)92 (38.0)150 (62.0)120 (49.6)122 (50.4)
      Use of sleep medication, n (%)
       No242 (85.2)92 (38.0)150 (62.0)0.041122 (50.4)120 (49.6)0.234
       Yes42 (14.8)23 (54.8)19 (45.2)17 (40.5)25 (59.5)
      Daytime dysfunction, n (%)
       No76 (26.840 (52.6)36 (47.4)0.01237 (48.7)39 (51.3)0.958
       Yes208 (73.2)75 (36.1)133 (63.9)102 (49.0)106 (51.0)
      SD: Standard deviation.

      3.3 Health status and life satisfaction

      In most of the participants, comorbidities like hypertension, diabetes, asthma, depression, anxiety, and stress were absent. More than half of the students were satisfied with their self and college life, whereas nearly two-thirds were satisfied with family life and the living place. Poor sleepers were those who had depression, anxiety, stress, and dissatisfaction with themselves. Results in detail are shown in Table 3.
      Table 3Health disorder and satisfaction with life among the respondents (n = 284).
      TotalGood sleeperPoor sleeperp-value
      n (%)n (%)n (%)
      Comorbidity
       Absent255 (89.8)139 (54.5)116 (45.5)0.673
       Present29 (10.2)17 (58.6)12 (41.4)
      Depression
       Absent194 (68.3)131 (67.5)63 (32.5)0.000
       Present90 (31.7)25 (27.8)65 (72.2)
      Anxiety
       Absent204 (71.8)138 (67.6)66 (32.4)0.000
       Present80 (28.2)18 (22.5)62 (77.5)
      Stress
       Absent252 (88.7)151 (59.9)101 (40.1)0.000
       Present32 (11.3)05 (15.6)27 (84.4)
      Satisfied with family life
       No96 (33.8)46 (47.9)50 (52.1)0.090
       Yes188 (66.2)110 (58.5)78 (41.5)
      Satisfied with college life
       No139 (48.9)74 (53.2)65 (46.8)0.575
       Yes145 (51.1)82 (56.6)63 (43.4)
      Satisfied with yourself
       No128 (45.1)51 (39.8)77 (60.2)0.000
       Yes156 (54.9)105 (67.3)51 (32.7)
      Satisfied with place where you live
       No92 (32.4)49 (53.3)43 (46.7)0.696
       Yes192 (67.6)107 (55.7)85 (44.3)

      3.4 Risk factors for poor sleep quality

      The results of the multivariate logistic regression showed that participants doing exercise for <3 days/week (AOR: 1.81, 95% CI: 1.01–3.23), spending ≥8 h screen time/day (AOR: 2.02, 95%: 1.12–3.66), having anxiety symptoms (AOR: 3.61, 95% CI: 1.72–7.57), and those who were not satisfied with own self (AOR: 2.69, 95% CI: 1.35–5.38) were more likely to report poor sleep quality after adjustments were made for other confounding variables. The results are presented in Table 4.
      Table 4Risk factors for poor sleep quality among the respondents (n = 284).
      VariableBSEAOR (95% CI)p-value
      Exercise per week
       <3 days0.5930.2961.81 (1.01–3.23)0.045
       ≥3 daysR1
      Screen time per day
       ≥8 h0.7040.3032.02 (1.12–3.66)0.020
       <8 h R1
      Soft drink consumption per week
       More than once0.1510.3781.16 (0.55–2.44)0.689
       Nil/Once R1
      Depression
       Present0.5900.3641.80 (0.88–3.68)0.020
       Absent R1
      Anxiety
       Present1.2850.3773.61 (1.72–7.57)0.001
       Absent R1
      Stress
       Present0.8220.5922.28 (0.71–7.26)0.165
       Absent R1
      Satisfied with family life
       No0.5340.3681.71 (0.83–3.51)0.146
       Yes R1
      Satisfied with yourself
       No0.9900.3532.69 (1.35–5.38)0.005
       Yes R1
      Note – B: Unstandardized coefficient; AOR: adjusted odds ratio; CI: Confidence Interval; R: Reference category; Model χ2 statistic = 78.177 (p < 0.001) and Hosmer-Lemeshow p value = 0.698 show that the model fits and support the existence of the relationship between independent variables and the dependent variable. Classification table reports that 73.6% of the cases can be expected to be classified correctly by the model.

      4. Discussion

      The present study explored that 45% of the undergraduate medical students studying at KIIT University had poor sleep quality during Covid-19 lockdown period. Saguem et al. In their study observed a high prevalence (72.5%) of poor sleep quality among medical students during their Covid-19 home confinement.
      • Saguem B.N.
      • Nakhli J.
      • Romdhane I.
      • Nasr S.B.
      Predictors of Sleep Quality in Medical Students during COVID-19 Confinement.
      Consistent with our result, 44% of Kathmandu medical college students had poor sleep quality.
      • Sundas N.
      • Ghimire S.
      • Bhusal S.
      • Pandey R.
      • Rana K.
      • Dixit H.
      Sleep quality among medical students of a tertiary care hospital: a descriptive cross-sectional study.
      In an earlier study, Basu et al. showed a higher rate (63.5%) of poor sleep quality among undergraduate medical students
      • Basu M.
      • Saha S.K.
      • Majumder S.
      • Chatterjee S.
      • Misra R.
      A study on sleeping pattern among undergraduate medical students of a tertiary care teaching hospital of Kolkata.
      whereas Goyal et al. in their study observed that about 30% medical students had poor sleep quality scores.
      • Goyal N.
      • Gupta S.K.
      Sleep quality among medical students.
      In another study conducted among undergraduate medical students in Ethiopia, the prevalence of poor sleep quality was found to be 62%.
      • Wondie T.
      • Molla A.
      • Mulat H.
      • et al.
      Magnitude and correlates of sleep quality among undergraduate medical students in Ethiopia: cross –sectional study.
      Higher proportion (70.4%) of medical students of Abdulaziz University, Saudi Arabia were found to have poor sleep quality.
      • NK I.
      • FA B.
      • YM M.
      • et al.
      Sleep quality among medical students at king Abdulaziz university: a cross-sectional study.
      The variation between different studies might be influenced by variability in methodologies, different study locations, different socio-cultural habits, and different academic pressures among different population groups. Consistent with the findings of our study, other studies have also shown that a higher proportion of female students were poor sleepers than their male counterparts.
      • Sundas N.
      • Ghimire S.
      • Bhusal S.
      • Pandey R.
      • Rana K.
      • Dixit H.
      Sleep quality among medical students of a tertiary care hospital: a descriptive cross-sectional study.
      ,
      • Basu M.
      • Saha S.K.
      • Majumder S.
      • Chatterjee S.
      • Misra R.
      A study on sleeping pattern among undergraduate medical students of a tertiary care teaching hospital of Kolkata.
      ,
      • NK I.
      • FA B.
      • YM M.
      • et al.
      Sleep quality among medical students at king Abdulaziz university: a cross-sectional study.
      In the present study, among the PSQI components, sleep disturbance was the most common (85.2%), followed by daytime dysfunction (73.2%), longer sleep latency (42.6%), and use of sleep medication (14.8%).
      In our study, the odds of having poor sleep quality was 1.8 times higher among the students who were less frequently engaged in exercise (<3 days in a week) compared to those who were doing exercise for ≥3 days/week. The results are in accordance with those of previous studies.
      • Ma C.
      • Zhou L.
      • Xu W.
      • Ma S.
      • Wang Y.
      Associations of physical activity and screen time with suboptimal health status and sleep quality among Chinese college freshmen: a cross-sectional study.
      ,
      • Wunsch K.
      • Kasten N.
      • Fuchs R.
      The effect of physical activity on sleep quality, well-being, and affect in academic stress periods.
      • Mahfouz M.S.
      • Ali S.A.
      • Bahari A.Y.
      • et al.
      Association between sleep quality and physical activity in Saudi Arabian University students.
      • Wu X.
      • Tao S.
      • Zhang Y.
      • Zhang S.
      • Tao F.
      Low physical activity and high screen time can increase the risks of mental health problems and poor sleep quality among Chinese college students.
      Studies have shown that physical activity influences sleep through complex interactions involving physiological and psychological pathways.
      • Chennaoui M.
      • Arnal P.J.
      • Sauvet F.
      • Leger D.
      Sleep and exercise: a reciprocal issue?.
      Physical activity benefits sleep regulation by increasing slow-wave sleep in children
      • Dworak M.
      • Wiater A.
      • Alfer D.
      • Stephan E.
      • Hollmann W.
      • Strüder H.K.
      Increased slow wave sleep and reduced stage 2 sleep in children depending on exercise intensity.
      and promotes sleep quality by improving mental well-being.
      • Stein C.
      • Fisher L.
      • Berkey C.
      • Colditz G.
      Adolescent physical activity and perceived competence: does change in activity level impact self-perception?.
      We observed in our study that students spending more screen time had poor sleep quality than their counterparts. In an earlier study, Natrajan et al. showed a strong association between poor sleep quality and increased duration of screen time.
      • Natarajan A.
      • Kanagamuthu R.
      • Reddy M.S.
      • Sindhuja A.S.
      Assessment of influence of screen time on quality of sleep among dental students.
      Various studies have shown the detrimental effect of screen time on sleep.
      • Ma C.
      • Zhou L.
      • Xu W.
      • Ma S.
      • Wang Y.
      Associations of physical activity and screen time with suboptimal health status and sleep quality among Chinese college freshmen: a cross-sectional study.
      ,
      • Wu X.
      • Tao S.
      • Zhang Y.
      • Zhang S.
      • Tao F.
      Low physical activity and high screen time can increase the risks of mental health problems and poor sleep quality among Chinese college students.
      ,
      • Foerster M.
      • Henneke A.
      • Chetty-Mhlanga S.
      • Röösli M.
      Impact of adolescents' screen time and nocturnal mobile phone-related awakenings on sleep and general health symptoms: a prospective cohort study.
      This might be explained by the concept of time displacement
      • Magee C.A.
      • Lee J.K.
      • Vella S.A.
      Bidirectional relationships between sleep duration and screen time in early childhood.
      which means longer screen time consumes time that could have been used for other activities including exercise which may benefit sleep quality.
      • Magee C.A.
      • Lee J.K.
      • Vella S.A.
      Bidirectional relationships between sleep duration and screen time in early childhood.
      Also, arousals induced by the media contents might cause difficulty in falling asleep. Moreover, blue light (short-wavelength enriched light) emitted by electronic devices reduces or delays the melatonin production in the evening thereby decreasing the feelings of sleepiness.
      In this study, students having anxiety symptoms were more likely to have poor sleep quality than those who did not have anxiety. Similar results have been reported in earlier studies.
      • Lemma S.
      • Gelaye B.
      • Berhane Y.
      • Worku A.
      • Williams M.A.
      Sleep quality and its psychological correlates among university students in Ethiopia: a cross-sectional study.
      ,
      • Al-Khani A.M.
      • Sarhandi M.I.
      • Zaghloul M.S.
      • Ewid M.
      • Saquib N.
      A cross-sectional survey on sleep quality, mental health, and academic performance among medical students in Saudi Arabia.
      This underscores the importance of students’ mental health status as it is strongly linked to sleep quality.
      Additionally, this study found that being satisfied with self independently decreased the risk of poor sleep quality. Students not being satisfied with themselves had 2.7 times higher odds of poor sleep quality than their counterparts. Ness et al. in their study conducted in university students revealed that better sleep quality was associated with life satisfaction.
      • Ness T.E.B.
      • Saksvik-Lehouillier I.
      The relationships between life satisfaction and sleep quality, sleep duration and variability of sleep in university students.
      Similarly, in another study, better sleep quality was significantly associated with better satisfaction life, thus the well-being of the students.
      • Mohd Zaid N.
      • A Rahman N.
      • Haque M.
      The Association between sleep quality and well-being amongst allied health sciences students in a public university in Malaysia.
      Although, the present study included undergraduate medical students from a single centre, but they represent diverse geographical and sociocultural backgrounds. There are several limitations pertaining to this study that need to be highlighted. First, the causal relationship between poor sleep quality and its associated factors cannot be established due to cross-sectional study design. Second, as the data were based on self-rating measurements, it might introduce recall bias. Third, the findings may not be generalized to other paramedical students as this study focused only on medical students. Finally, differences in sleep quality of the students at different times could not be found as we did not have any baseline data of the students before Covid-19 pandemic.

      5. Conclusion

      Poor sleep quality was prevalent among undergraduate medical students during their home confinement at the time of Covid-19 pandemic. The risk factors included physical inactivity, more screen time/day, anxiety symptoms, and being dissatisfied with oneself. The findings could be helpful in designing appropriate interventional strategies that aim to improve sleep quality among medical students.

      Source of funding

      None.

      Declaration of competing interest

      All the authors hereby declare that they have no conflicts of interest.

      References

        • Statement on the second meeting of the International Health Regulations
        • World Health Organization (WHO)
        Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV).
        (Published online 2020)
        • Cucinotta D.
        • Vanelli M.
        WHO declares COVID-19 a pandemic.
        Acta Biomed. 2020; 91: 157-160https://doi.org/10.23750/abm.v91i1.9397
        • Xiong J.
        • Lipsitz O.
        • Nasri F.
        • Lui L.M.W.
        • Gill H.
        • Phan L.
        Impact of COVID-19 Pandemic on Mental Health in the General Population: A Systematic Review. vol. 277. Elsevier Connect, 2020: 55-64
        • Ammar A.
        • Trabelsi K.
        • Brach M.
        • et al.
        Effects of home confinement on mental health and lifestyle behaviours during the COVID-19 outbreak: insights from the ECLB-COVID19 multicentre study.
        Biol Sport. 2021; 38: 9-21https://doi.org/10.5114/biolsport.2020.96857
        • Azad M.C.
        • Fraser K.
        • Rumana N.
        • et al.
        Sleep disturbances among medical students: a global perspective.
        J Clin Sleep Med. 2015; 11: 69-74https://doi.org/10.5664/jcsm.4370
        • Preisegolaviciute E.
        • Leskauskas D.
        • Adomaitiene V.
        Associations of quality of sleep with lifestyle factors and profile of studies among Lithuanian students.
        Medicina (B Aires). 2010; 46: 482-489https://doi.org/10.3390/medicina46070070
        • Saguem B.N.
        • Nakhli J.
        • Romdhane I.
        • Nasr S.B.
        Predictors of Sleep Quality in Medical Students during COVID-19 Confinement.
        Encephale, 2021https://doi.org/10.1016/j.encep.2021.03.001 (Published online)
        • Altena E.
        • Baglioni C.
        • Espie C.A.
        • et al.
        Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy.
        J Sleep Res. 2020; 29https://doi.org/10.1111/jsr.13052
        • Cao W.
        • Fang Z.
        • Hou G.
        • et al.
        The psychological impact of the COVID-19 epidemic on college students in China.
        Psychiatr Res. 2020; 287: 112934https://doi.org/10.1016/j.psychres.2020.112934
        • Wang C.
        • Pan R.
        • Wan X.
        • et al.
        Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in China.
        Int J Environ Res Publ Health. 2020; : 17https://doi.org/10.3390/ijerph17051729
        • Giri P.
        • Baviskar M.
        • Phalke D.
        Study of sleep habits and sleep problems among medical students of pravara Institute of medical sciences loni, Western Maharashtra, India.
        Ann Med Health Sci Res. 2013; 3: 51-54https://doi.org/10.4103/2141-9248.109488
        • Lemma S.
        • Gelaye B.
        • Berhane Y.
        • Worku A.
        • Williams M.A.
        Sleep quality and its psychological correlates among university students in Ethiopia: a cross-sectional study.
        BMC Psychiatr. 2012; 12https://doi.org/10.1186/1471-244X-12-237
        • Hsu M.F.
        • Lee K.Y.
        • Lin T.C.
        • Liu W Te
        • Ho S.C.
        Subjective sleep quality and association with depression syndrome, chronic diseases and health-related physical fitness in the middle-aged and elderly.
        BMC Publ Health. 2021; : 21https://doi.org/10.1186/s12889-021-10206-z
        • Ma C.
        • Zhou L.
        • Xu W.
        • Ma S.
        • Wang Y.
        Associations of physical activity and screen time with suboptimal health status and sleep quality among Chinese college freshmen: a cross-sectional study.
        PLoS One. 2020; 15https://doi.org/10.1371/journal.pone.0239429
        • Buysse D.J.
        • Reynolds C.F.
        • Monk T.H.
        • et al.
        The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.
        Psychiatr Res. 1989; 28 (Psychiatry Res. 1989;28:193-213): 193-213
        • Lovibond S.H.
        • Lovibond P.F.
        Manual for the Depression Anxiety & Stress Scales.
        second ed. Psychology Foundation, 1995
        • Sundas N.
        • Ghimire S.
        • Bhusal S.
        • Pandey R.
        • Rana K.
        • Dixit H.
        Sleep quality among medical students of a tertiary care hospital: a descriptive cross-sectional study.
        J Nepal Med Assoc JNMA. 2020; 58: 76-79https://doi.org/10.31729/jnma.4813
        • Basu M.
        • Saha S.K.
        • 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 Publ Health. 2019; 9: 118-124https://doi.org/10.5530/ijmedph.2019.4.26
        • Goyal N.
        • Gupta S.K.
        Sleep quality among medical students.
        Int J Community Med Public Heal. 2020; 7: 274-278https://doi.org/10.1016/j.eurpsy.2016.01.2216
        • Wondie T.
        • Molla A.
        • Mulat H.
        • et al.
        Magnitude and correlates of sleep quality among undergraduate medical students in Ethiopia: cross –sectional study.
        Sleep Sci Pract. 2021; 5https://doi.org/10.1186/s41606-021-00058-2
        • NK I.
        • FA B.
        • YM M.
        • et al.
        Sleep quality among medical students at king Abdulaziz university: a cross-sectional study.
        J Community Med Health Educ. 2017; 7https://doi.org/10.4172/2161-0711.1000561
        • Wunsch K.
        • Kasten N.
        • Fuchs R.
        The effect of physical activity on sleep quality, well-being, and affect in academic stress periods.
        Nat Sci Sleep. 2017; 9: 117-126https://doi.org/10.2147/NSS.S132078
        • Mahfouz M.S.
        • Ali S.A.
        • Bahari A.Y.
        • et al.
        Association between sleep quality and physical activity in Saudi Arabian University students.
        Nat Sci Sleep. 2020; 12: 775-782https://doi.org/10.2147/NSS.S267996
        • Wu X.
        • Tao S.
        • Zhang Y.
        • Zhang S.
        • Tao F.
        Low physical activity and high screen time can increase the risks of mental health problems and poor sleep quality among Chinese college students.
        PLoS One. 2015; 10https://doi.org/10.1371/journal.pone.0119607
        • Chennaoui M.
        • Arnal P.J.
        • Sauvet F.
        • Leger D.
        Sleep and exercise: a reciprocal issue?.
        Sleep Med Rev. 2014; 20: 59-72https://doi.org/10.1016/j.smrv.2014.06.008
        • Dworak M.
        • Wiater A.
        • Alfer D.
        • Stephan E.
        • Hollmann W.
        • Strüder H.K.
        Increased slow wave sleep and reduced stage 2 sleep in children depending on exercise intensity.
        Sleep Med. 2008; 9: 266-272https://doi.org/10.1016/j.sleep.2007.04.017
        • Stein C.
        • Fisher L.
        • Berkey C.
        • Colditz G.
        Adolescent physical activity and perceived competence: does change in activity level impact self-perception?.
        J Adolesc Health. 2007; 40 (462.e1-462.e8)https://doi.org/10.1016/j.jadohealth.2006.11.147
        • Natarajan A.
        • Kanagamuthu R.
        • Reddy M.S.
        • Sindhuja A.S.
        Assessment of influence of screen time on quality of sleep among dental students.
        Ann Int Med Dent Res. 2020; 6: 1-4https://doi.org/10.21276/aimdr.2020.6.5.PH1
        • Foerster M.
        • Henneke A.
        • Chetty-Mhlanga S.
        • Röösli M.
        Impact of adolescents' screen time and nocturnal mobile phone-related awakenings on sleep and general health symptoms: a prospective cohort study.
        Int J Environ Res Publ Health. 2019; 16https://doi.org/10.3390/ijerph16030518
        • Magee C.A.
        • Lee J.K.
        • Vella S.A.
        Bidirectional relationships between sleep duration and screen time in early childhood.
        JAMA Pediatr. 2014; 168: 465-470https://doi.org/10.1001/jamapediatrics.2013.4183
        • Al-Khani A.M.
        • Sarhandi M.I.
        • Zaghloul M.S.
        • 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; 12https://doi.org/10.1186/s13104-019-4713-2
        • Ness T.E.B.
        • Saksvik-Lehouillier I.
        The relationships between life satisfaction and sleep quality, sleep duration and variability of sleep in university students.
        J Eur Psychol Stud. 2018; 9: 28-39https://doi.org/10.5334/jeps.434
        • Mohd Zaid N.
        • A Rahman N.
        • Haque M.
        The Association between sleep quality and well-being amongst allied health sciences students in a public university in Malaysia.
        Adv Hum Biol. 2018; 8: 195-200https://doi.org/10.4103/aihb.aihb_22_18