SLEEP PATTERN AMONG STUDENTS OF MEDICAL COLLEGE , HAIL UNIVERSITY , HAIL , KSA

and Sasikumar Dhanarasu 3 . 1. Students in College of Medicine, Hail University, P.O. Box 2440, Hail, KSA. 2. Professor in Pharmacology & Assisstant Professor in Biochemistry Departments, College of Medicine, Hail University, P.O. Box 2440, Hail, KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

showed the sleep/awake habits characteristics of students, the comparisons between students in 2 nd year, 3 rd year as the two groups studying basic sciences and students that staring clinical sciences (4 th year -6 th year) were done. The number of students that participate in this study were 50 (23.4% from 2 nd year), 47 (22.1% from 3 rd year) and 116 (54.5% from 4 th to 6 th year). The percent of married females and males is 5.1% and 1.8% respectively.
The Sleep/awake habits characteristics among students in different educational levels was shown in Table 1. There was a significant difference among the students in the 2 nd year (19%) and other students in 3 rd year & students in clinical years (4.3%) & (9.5%) respectively in going bed less than 22 o'clock, also between students in the 3 rd year (68.1%) and other students in 2 nd year & students in clinical years (58 %) & (61.2 %) respectively in going bed more than 24 o'clock. But no significant difference was found among all students in the in going bed from 22 to 24 o'clock.
Another significant difference was found between students in the 2 nd year (78%) and other students in 3 rd year (57.4%) & students in clinical years (45.7%) in getting up in the morning < 7 o'clock, but students in clinical years (54.3%) showed high significant difference compared to 2 nd year (22%) & 3 rd year (42.6%) in getting up in the morning > 7 o'clock.
On the other hand, no significant difference was found between all three groups of students participating in the study in answering the following questions about sleep pattern, first, how often do they go to bed later than usual per week, second, how often do they wake up due to noise per week, third, how often do they drink coffee late at night per week (Table 1). Figure 2 showed the effect of BMI on the difficulty to initiate sleep. Normal weight students showed a significance difference that 50% of them had difficulty to initiate sleep, while under-weight students showed 6.6% followed by obese (17%) then over weight (26.4%). On the other hand, 49.1% of normal weight students did not have difficulty to initiate sleep, while obese students showed 7.5% followed by under-weight (14.2%) then over-weight (29.2%). Table 2 did not show any significant differences between gender and parameters of insomnia such as difficulty in initiating sleep, wake up in the middle of nights and wake up early in the morning except in the time taken to fall asleep each night, there was a significant difference. High percent of female students fall in sleep after 5-10 minutes more than male students (18.6% Vs 10.5%) respectively and after 26-40 minutes (30.8% female Vs 19.3% male). On the other hand, high percent of male students fall in sleep after 11-25 minutes more than female (47.4% Vs 25.6%) respectively.
There was no significance difference between different educational levels and parameters of insomnia except in waking up in the middle of nights, there was a significant difference. In Table 2, the significance difference was shown between students in the clinical years waking up in middle of nights one time (47.4%) more than other students, high percent of 2 nd year students waking up 5-7 times in middle of nights (12.0%) more than students. But 3 rd year students were found to wake up >7 times in middle of nights (6.4%) which was more than other students.
1119 Table 3 showed significant differences between gender and some parameters of parasomnia such as bad dreams, speaking during sleep, sleep & eating and snoring. On the other hand no significant difference was observed between gender versus sleep & walking and bruxism. The significance difference was shown between male and female students, as high percent of male students never or rarely had bad dreams (42.1%) compared with female students (28.2%), on the other hand, high percent of female students sometimes (29.5%) and very often (6.4%) had bad dreams when compared with male students (12.3% & 1.8% respectively).
There was no significance difference between parasomnia parameters and educational level except in sleep & walking, as 2 nd year students 14.0% of them sometimes had walking during sleep compared to 3 rd year (4.3%) and clinical year (0.9%) students. On the other hand, clinical year students 91.4% never showed this phenomena compared with 3 rd year (85.1%) and 2 nd year (80.0%) ( Table 3).
Sleep/awake habits characteristics of students versus sleep satisfaction were shown in Table 5. Only significant difference was shown between students in the times to go bed later per week versus sleep satisfaction as 22.2% of students with perfect sleep satisfaction go bed later once per week compared to students with poor sleep satisfaction (2.6%). Also, high percentages of students (55.6%) with perfect sleep satisfaction go bed later 1-2 times per week compared to students with very poor sleep satisfaction (10.0%). On the other hand, high percentages of students (about 40.0%) with poor and very poor sleep satisfaction go bed later 3-5 or > 5 times per week compared to students with perfect sleep satisfaction (5-11%). No significance difference was observed in other parameters about sleep/awake habits characteristics of students versus sleep satisfaction.
Insomnia stratified by demographic versus sleep self -perception (sleep satisfaction & sleeping pills) was shown in Table 5. Only significant difference was observed between students took sleeping pills (78.9%) and difficulty in initiating sleep compared to (46.4%) who did not take sleeping pills. About 77.8% of students having perfect sleep satisfaction and had no difficulty to initiate sleep (significant difference). Also, from the same students (33.3%) fall asleep after 5-10 minutes with perfect sleep satisfaction (significant difference).

-NS no significance difference at (P<0.05) -S * significance difference at (P<0.05) -Number of students without parenthesis -Percentage of students in parenthesis
Discussion:- In this study, the sleep pattern of the medical students, 2 nd year students were found to go to bed earlier than the other students from the 3 rd year to 6 th year. In a previous study of    1124 Also, a significant difference was showed, as 2 nd year students got up earlier than the other students, but Nojomi et al. (2009) found that most of the participants got up at or before 7o'clock in the morning (specially, among residents).
We found no significant between the participants in how often they go to bed later than usual per week, this study agreed with Nojomi et al. (2009). Online survey demonstrated that first year college students went bed later than other students, but only on weekends (Lund et al., 2010) and during weekdays and weekends (Trockel et al.,  2000). Experimental studies have demonstrated that a shift in bedtime by two hours while maintaining the same sleep duration resulted in increased feelings of depression, difficulty in concentration and mood changes (Wolfson  & Carskadon, 2003).
Current study showed a significant contrast between duration of daytime naps among students. The 3 rd year students took longer nap duration than the other students from different years. Also, Nojomi et al. (2009) showed that the majority of subjects had 60 to 120 min daytime naps (specially, among pre-internship). Online survey demonstrated that Students who reported cell phone awakenings also reported spending less time in bed and more time napping during the day (Lund et al., 2010). In the current study, we concluded that there is no significant between students in all three groups and drink coffee late at night. On the other hand, Nojomi et al. (2009) showed that medical residents got an average amount of coffee (1-5 times per week) more than others.
In the insomnia parameters the female students were significantly found to take more time to fall asleep each night than male students, this result was in keeping with the study of This study did not show any significant differences between Educational levels and parameters of insomnia except the 3 rd year students were found to wake up in the middle of nights more often compared to the other medical students. The educational year of student was the second predictor; students enrolled in the basic medical years were about twice more likely to be poor sleepers compared to those in the clinical years (Ibrahim et al., 2017). The mean score of insomnia and parasomnia were a little bit higher in medical residents compared to medical student (but not significant) (Nojomi et al., 2009).
The present study did not show any significant differences between gender and parameters of insomnia when compared with different education levels. According to (Nojomi et al., 2009) they found a significant difference among residents who got up before 7 o'clock. Other study found that women had greater sleep difficulties than men, and that freshmen had shorter sleep than older students (Tsai and Li, 2004).
This study showed a significant correlation in one of the insomnia parameter (difficulty to initiate sleep) and BMI but not with parasomnia parameters, demographics characteristics, Sleep/awake habits. On the other hand, Nojomi In our study, female students had bad dreams when compared with male students. Also, we found that 3 rd year students showed significance difference in sleepwalking (very often) than 2 nd year students and clinical years students. This result coincides with results of the India study which said among various sleep disorders, commonly seen was Insomnia, Narcolepsy, Sleepwalking, Obstructive Sleep Apnea, Circadian Rhythm Disorders, and Nightmares (Jain and Sandeep Verma, 2016).

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In the present study, females were more poor sleepers compared to males, which agree with many previous studies (Mesquita et al., 2010, Fawzy et al., 2017 and Yang et al., 2003). In this current research, snoring was much higher in male than female which was agree with the study of Lamberti (2012), they found that 30% reported snoring with a higher prevalence among men (42%) than women (25%).
This study did not show significant difference between sleep satisfaction and drinking coffee (data not showed). This finding was not agreed with other studies (Ibrahim et al., 2017) who found that consumption of caffeinated beverages was associated with poor sleep quality depending upon one's tolerance and sensitivity to caffeine. Also, Sanchez et al. (2013) was found that the consumption of caffeinated beverages was a risk factor of poor sleep quality, and others found that even one cup of coffee could disrupt an individual's sleep (Nehlig et al. 1992).
In the current study insomnia score was not related to poor sleep quality. on the other hand, study held on Abha, Suadi arabia to identify the predictors of poor sleep among medical students in King Khalid University (KKU) was found that Students going to sleep late (after midnight) were more likely to have poor sleep quality, compared to those who did not go to sleep late (Siddiqui et al., 2016).
Our result showed that wake up early in morning was not parameter of poor sleep. While Ibrahim et al. (2017) showed that students who went to sleep after 24 o`clock and got up early in the morning was unable to concentrate in their classes, and suffering from fatigue, anxiety and depression.
In present study there is a differences in choose timing of sleep behaviorr also have a worthy impact on the quality of sleep a student receives and their academic performances and presence. Also, demonstrates significant relationship between sleep satisfaction and going to bed late > 5 times per week. It also was found in a study by In this research the sleep satisfaction was not associated with wake up due to increase noise. But Matsumoto et al. (2017) found that noise was the strongest risk factor of sleep quantity. Muzet (2007) also said noise louder than 40 dB during sleep can activate autonomic responses and increase cortisol levels on wake-up, thus leading to excessive daytime fatigue, sleepiness, and declining performance. In addition, at around 5 h after sleep onset, sleep is typically in the shallow stages (stage 1-2), which means that people are awoken more easily by noise and their sleep duration is thus cut short. Furthermore, these physical responses did not adapt to chronic exposure to noise, whereas subjective sleep satisfaction can.
The current study showed that students who have difficulty in initiating sleep consumed sleep pills. This finding is similar to previous study of Siddiqui et al. (2016) where the students using medicine to aid sleep had significantly poorer sleep quality scores compared to the students who did not use medication.
In their survey of four universities in Karachi, Pakistan, found a high prevalence of self-medication by students (Zafar et al., 2008), more than 7.6% of their participants reported insomnia as a reason for self-medication, and 10% participants admitted to the misuse of sleeping pills. Concerning insomnia problems compared to self-perceptions (sleep satisfaction), 77.8% of students who had perfect sleep satisfaction did not have difficulty in initiating sleep. Also, from the same students (33.3%) fall in sleep directly after 5-10 minutes which is an indicator of perfect sleep satisfaction. Nojomi et al. (2009) found an association between self-perception (sleep satisfaction) and insomnia where students with "poor" or "very poor" sleep consumed sleeping pills more frequently than others.

Conclusion:-
Sleep disturbances are an important issue among medical students as a result of academic stressors and workload. Students with perfect sleep satisfaction had no difficulty to initiate sleep. The students who have difficulty in initiating sleep, consumed sleep pills. Females were more poor sleepers compared to males and no correlation between sleep satisfaction and drinking coffee.

Recommendation:-
Because of the high prevalence of poor sleep quality among medical students, medical collages need to establish sleep educational program to help their students identify their sleep problems and further to solve these problem through the implementation of stress management courses and offering clinical consultations. Further researches are needed to study the effect of using phones on sleep hygiene and the correlation between the type of medical curriculum and the sleep pattern of medical students.