Sleeping Patterns among Medical Students in the Middle East: Identifying Areas for Intervention

Aims: The objective of the study was to describe the Arabian Gulf University medical students’ sleeping patterns and to provide recommendations for promoting healthy and better sleeping patterns among the students. Study Design and Place of Study: A cross sectional study was conducted on medical students enrolled at the Arabian Gulf University in the Kingdom of Bahrain. Methodology: A self-administered anonymous questionnaire was used, which included questions on demography and sleeping patterns. Results: Of the 535 medical students who were enrolled in years 1-4, 443 responded to the questionnaire thus resulting in a 82.8% response rate. The study showed that 40.2% of the medical students were attending the College without sleep at all for at least one day during the week. There were significant differences by gender, nationality, and accommodation status. Conclusion: Sleeping patterns cluster among students according to gender, nationality and accommodation status. Urgent interventions are needed to promote healthy sleeping patterns among medical students. Original Research Article Alzayani and Hamadeh; AIR, 5(6): 1-7, 2015; Article no.AIR.17208 2


INTRODUCTION
Insufficient sleep, or sleep deficiency, which is defined as state of inadequate or mistimed sleep, is a growing and underestimated determinant of health [1]. Insufficient sleep and irregular sleep/wake patterns, which have been documented in younger adolescents are also present at alarming levels among the university student population [2]. University students are at risk for sleep disorders that might lead to academic failure [3]. Universities should acknowledge that students' sleeping patterns are significant concerns that need educational programs and interventions [4]. Studies in the Arabian Gulf region have addressed specific lifestyle behaviors of health professionals such as health-promoting lifestyle [5,6,7]. Arabian Gulf University (AGU) students are valuable advocates for families as they are able to offer practical help in lifestyle behavior changes, communication, and community-resource use [8].
AGU is a regional university established in 1983 and based in the Kingdom of Bahrain. It has two colleges, the College of Medicine and Medical Sciences (CMMS) and the College of Graduate Studies. AGU accepts students of both genders from the Gulf Cooperation Council (GCC) countries (Bahrain, Saudi Arabia, Kuwait, Oman, UAE and Qatar), where students are admitted based on their country's quota. Thus, AGU provides a unique opportunity to suggest guidelines to medical schools in the GCC countries. The CMMS follows a problem-based, student-centered and community-oriented curriculum. The problem-based learning (PBL) curriculum integrates basic medical sciences with related professional skills training, and community health activities. Students generate learning needs while discussing health problems. Those learning needs are used to lead students for self-directed learning activities [9]. The program is of six years duration divided into three phases: the basic Sciences Phase: Phase I (Year 1), Phase II (Pre-clerkship Phase: Years 2-4) and Phase III: (Clinical Clerkships Phase: Years 5 and 6). At CMMS, English is the language of instruction [10]. The aim of the study was to describe the Arabian Gulf University AGU medical students' sleeping patterns and to provide recommendations for promoting healthy and better sleeping patterns among the students.

METHODS
A cross sectional study was conducted among AGU Years 1 to 4 medical students, during May 2009. A census of all AGU Years 1 to 4 medical students (535) who were enrolled during the academic year 2008-2009, was obtained from the Admission and Registration Unit. A self administered anonymous questionnaire in the English language was used, which included questions on demography and sleeping patterns. The questionnaire was abridged from the adult questionnaire of the United Arab Emirates Health and Lifestyle Survey 2000 [11], which was validated and field tested. "The questionnaire was distributed to the students in the following manner: For Year 1 students, the questionnaires were distributed at the beginning of the Biostatistics class. As Years 2 to 4 students are divided into groups of 8-10 students in the tutorial sessions which are held twice per week, hence those students were given the questionnaires by their respective tutors during their first session. The respective tutors were briefed about this process by a covering letter, which was kept along with the questionnaires in the tutorial boxes that contain the teaching materials. These boxes were collected from the medical education office by tutors before the tutorial sessions and returned back after the tutorial sessions. The completed questionnaires were put in sealed envelopes by the students and returned to the tutor who placed them in the tutorial boxes. The questionnaires were resent in the following week to the tutors for them to give students who were absent the day of data collection during the tutorial session. A covering letter was enclosed in the tutorial box to the respective tutors instructing them to distribute the questionnaires only to the students who were absent in the previous tutorial session" [12]. Data entry and analysis were done using the Statistical Product and Service Solutions (SPSS), Version 17.0. Descriptive statistics and the chi-square test was applied when appropriate.

RESULTS AND DISCUSSION
Of the 535 medical students who were enrolled in years 1-4, 443 responded to the questionnaire thus resulting in a 82.8% response rate. Students were from the same region but from different countries. The study showed that 40.2% of the medical students attended the college without sleeping during the night at all for at least one day per week (Fig. 1). There were significant differences by gender, nationality accommodation status. Fig. 2 shows that among male students, over half (51.4%) of the Saudi and 41.5% of the Kuwaiti attended the college without sleeping during the night at all for at least one day during the week compared to 34.1% of the Bahraini and none of the Omani ( Among female students, 52.1% of the Saudi and 51.8% of the Kuwaiti students attended the college without sleeping at all for at least one day during the week compared to 21.4% of the Bahraini, 42.1% of the Omani female students and none of the Emirati (P = .001). Analysis of sleeping patterns by accommodation status showed statistically significant differences (P < .001) whereby students living with their families had the lowest percentage (29.3%) of students attending the college without sleep at all for at least once per week, compared to those who lived in university housing (47.7%), with relatives (55.6%), with friends (47.9%) or liv alone (46.8%) (Fig. 4). Moreover, 41.9% among 3 1). There were significant nationality, and accommodation status. Fig. 2 (Fig. 5).
The study showed that 40% of the medical students were attending the college without sleep at all for at least one day during the week. There were significant differences by gender, nationality and accommodation status, but not by medical year. A similar finding was reported [13] where by many students had sleep problems that interfered with their daily performance. However there were no differences between students in different years of study for time to fall asleep, number of nights staying awake, or total time slept each night. The gender difference was explained by [14] as they concluded that gender differences in circadian typology and in biological rhythms have been revealed by using biological measurements as females were significantly more morning oriented than males. The results of this study are similar to what has been established in other studies regarding improper sleep scheduling and insomnia among university students [15,16].

college attendance without night sleep at all per week
; Article no.AIR.17208 e university housing and 50% of those who lived alone attended the college without sleeping at all for at least one day during the week, compared to 36.4% of those who lived with their families and 38.9% of those = .04). A similar pattern was observed among females, where by 49.2% in university housing and 53.3% of those who lived with friends, attended the college without sleeping at all for at least one day during the week, compared to 26.8% of with their families, 33.3% with relatives and 44.4% of those who lived by The study showed that 40% of the medical students were attending the college without sleep at all for at least one day during the week. There nificant differences by gender, nationality and accommodation status, but not by medical year. A similar finding was reported [13] where by many students had sleep problems that interfered with their daily performance. However ween students in different years of study for time to fall asleep, number of nights staying awake, or total time slept each night. The gender difference was explained by [14] as they concluded that gender differences in circadian typology and in biological rhythms have been revealed by using biological measurements as females were significantly more morning oriented than males. The results of this study are similar to what has been established in other studies regarding improper a among university week Fig. 2. Frequency of weekly college

Fig. 3. Frequency of weekly college
The study has the following limitations, questionnaire focused on events that happened during the past. Hence, the possibility of recall bias could not be excluded. Further, the response rates varied according to gender, nationality and medical year, which might limit The study has the following limitations, the questionnaire focused on events that happened during the past. Hence, the possibility of recall bias could not be excluded. Further, the response rates varied according to gender, nationality and medical year, which might limit the generalization of the results. In addition, the study did not include students in the clerkship phase (Years 5 and 6), thus the results are applicable to the students in earlier medical years.
; Article no. AIR.17208 at night at all by nationality at night at all by medical year e results. In addition, the study did not include students in the clerkship 5 and 6), thus the results are applicable to the students in earlier medical  sleeping patterns as part of a healthy lifestyle among medical students to improve their wellbeing. We recommend that the admission policy to the medical school should include information about students' behavioral patterns in order to facilitate early intervention. The universities in GCC countries should consider having policies on the promotion of the students' wellbeing and healthy behavioral patterns and to reinforce knowledge regarding healthy sleeping behaviors throughout the medical curriculum, especially that the AGU curriculum is of spiral nature. Provide counseling services at the university and university housings for healthy and better sleeping patterns. This will help to the early identification of students with unhealthy behavioral patterns by their academic advisors for intervention.

ETHICAL CONSIDERATIONS AND PRIVACY OF PARTICIPANTS
The Academic Committee of the Masters of Science in Health Policy and Population Studies program approved the research protocol. Study participation was on a voluntary basis and participants were assured of the confidentiality of the study by having the questionnaire anonymous and keeping the completed ones in sealed envelopes.