Sleep hygiene practices and sleep quality among medical students in Egypt: a cross-sectional study

Abstract

Background

Sleep is an important component of human biological functioning and is necessary for optimal health and the maintenance of cognitive and psychological functions. Sleep hygiene is a collective term for the behaviors and environmental factors associated with good sleep.

Objectives

To assess the prevalence of poor sleep hygiene practices and poor sleep quality among medical students and to test the hypothesis that poor sleep hygiene is correlated with poor sleep quality.

Methods

This cross-sectional study was conducted among 504 medical students at Tanta University, Egypt, using a random two-stage cluster sampling technique. Two validated questionnaires were used, the Pittsburgh Sleep Quality Index (PSQI) and the Sleep Hygiene Index (SHI), in addition to a sociodemographic section.

Results

The prevalence of poor sleep quality among the study participants was 71.2%. A total of 93.6% of the participants reported having poor sleep hygiene. There was a statistically significant positive correlation between sleep hygiene practices and sleep quality (r = 0.366, p < 0.001). The prevalence of poor sleep quality was the highest among students in the first grade (83.6%) and decreased to 66.0% among students in the fifth grade (p = 0.012). Using the bed for activities other than sleeping or sex; thinking, planning, or worrying when in bed; and doing important work before bedtime were the three most prevalent negative sleep hygiene practices, affecting 59.3%, 58.9%, and 54% of the participants, respectively.

Conclusion

Poor sleep hygiene practices and poor sleep quality are highly prevalent among Egyptian medical students. Medical students in their early academic years had a greater prevalence of poor sleep quality. Future educational programs on sleep hygiene are needed to raise awareness and possibly improve overall sleep quality in this population.

Introduction

Sleep is an integral part of our lives. Good sleep quality is necessary for maintaining both physical health and mental wellbeing (Clement-Carbonell et al. 2021; Scott et al. 2021). Good sleep quality is a condition where an individual is subjectively satisfied with his overall sleep, can initiate sleep rapidly, is able to maintain sleep with sufficient sleep duration, and is attentive or has a sense of refreshment upon awakening (Nelson et al. 2022).

University students generally and medical students specifically are vulnerable to sleep disturbances and poor sleep quality (PSQ) owing to increased academic load, economic stresses that force some students to have part-time jobs, and increased amounts of time spent on studying or extracurricular activities, in addition to environmental factors such as reduced parental guidance, lack of support systems, and freedom to choose their own bedtime and sleep patterns (Nadeem et al. 2018; Basu et al. 2019; Rique et al. 2014). All these factors are associated with alterations in different aspects of sleep, such as a reduction in sleep time, phase delays in sleep–wake timing, poor sleep quality, and deterioration of daytime functioning (Kabrita et al. 2014).

Sleep deprivation and PSQ are associated with decreased attention, concentration, and memory, all of which are essential for effective learning and retention of medical knowledge (Vallejo and Silvestre 2023). In addition, PSQ increases individuals’ susceptibility to anxiety, depression, and various sleep disorders, such as insomnia, which further affects the academic performance and learning capacity of medical students (Baglioni et al. 2016; Gardani et al. 2022).

To maintain a healthy sleep period, a person can follow a set of behaviors and environmental factors that positively influence sleep quality and lead to alertness during the daytime, known collectively as sleep hygiene (Mastin et al. 2006). Some good sleep hygiene practices include having consistent sleep time; avoiding the consumption of caffeinated drinks late in the day; and avoiding strenuous physical or mental activities, hunger, thirst, or large mixed meals before bedtime. Good environmental factors for sleep hygiene include avoiding light exposure before bedtime and creating quiet, cool, comfortable, and dark sleeping environments (Bruce et al. 2017). Good sleep hygiene is important for students, as it helps them reduce daytime sleepiness, fall asleep more easily, and align themselves with their circadian rhythm. All of these factors are essential for optimizing mental health and endocrine function (Baranwal et al. 2023). Moreover, improper sleep hygiene practices and PSQ have been linked with poor academic performance among university students (Gomes et al. 2011).

Assessment of sleep hygiene practices is important for assessing the degree to which medical students apply these principles and developing targeted awareness and training programs regarding sleep hygiene to potentially enhance their quality of sleep and, hence, their overall health, academic performance, and learning capacity. However, limited research has assessed this topic in Middle Eastern and North African countries, including Egypt, leaving a gap in understanding the relationship between sleep hygiene and sleep quality in this population. Egyptian medical students were reported to have high levels of stress and limited capacity to recover from stressful conditions, which could influence their sleep (Mohammed et al. 2024). In addition, sleep problems and disorders such as insomnia, parasomnia, and chronic sleep deprivation were reported to be highly prevalent among these students (Ez Elarab et al. 2014). Therefore, we conducted this study to assess the prevalence of sleep hygiene practices and sleep quality among medical students based on a sample from Tanta University, Egypt, and to examine whether sleep hygiene is translated into better quality of sleep in this population. We hypothesize that poor sleep hygiene practices and poor sleep quality are highly prevalent among medical students in this population and that medical students with poor sleep hygiene practices report poor sleep quality compared with those with good sleep hygiene practices.

Methods

This observational cross-sectional study was conducted on undergraduate medical students enrolled at the Faculty of Medicine, Tanta University, Egypt. The community surrounding Tanta University has only eight cities, and the rest are mostly rural communities. The targeted population included students from all five academic years during the 2023–2024 academic year, with a total of 6258 medical students. The sample size was calculated via Epi Info 7 software (Atlanta, Georgia, USA). Using a confidence interval of 95% and setting an expected prevalence of 50%, with a margin of error of 5% and 80% power, the calculated minimum sample size was 363. We added a design effect of 1.5, as the sample was taken from different clusters that increased the sample size to 546.

A random two-stage cluster sampling technique was used in which students from all five academic years were divided into five groups corresponding to their academic year and classified again according to their attendance subgroups in each academic year. Students were selected from different academic years according to the proportion of students in each year. As the students were not equally distributed, one subgroup (110–125 students) from the first three years and two subgroups (50–60 students each) from the last two years were randomly selected via computer software and sampled. The two-stage cluster sampling technique ensured adequate representation of students across all academic years while maintaining randomization. There were no exclusion criteria for participation in this study.

After the study aims were explained, a self-administered questionnaire was administered to the participants. Two validated questionnaires were used: the Pittsburgh Sleep Quality Index (PSQI) and the Sleep Hygiene Index (SHI). In addition, a sociodemographic section was added for questions about age, gender, academic year, and residence, whether urban or rural. Rural residences in Egypt are generally characterized by being quieter, with limited activities taking place at night. This could influence sleep hygiene practices and sleep quality by promoting earlier sleep times or reducing exposure to nighttime disturbances commonly found in urban settings. We conducted a pilot study on 15 medical students who were not included in the study sample. All the participants reported that all the questions were clearly understood; hence, no further modifications were needed.

Sleep hygiene index (SHI)

The SHI is a validated tool used to examine sleep hygiene practices in daily life via a 13-item self-reported index (Mastin et al. 2006). Students were requested to report the extent to which they engage in a certain behavior or the extent to which they are exposed to an environmental factor that could affect their sleep, such as taking daytime naps, going to bed at different times, and sleeping in an uncomfortable bed or an uncomfortable bedroom. Each item on the SHI uses a five-point Likert scale ranging from never (0) to always (Nadeem et al. 2018). Thus, the cumulative scores for all 13 items range from 0 to 52. A total score exceeding 16 was previously deemed suitable for detecting inadequate sleep hygiene habits among university students, exhibiting a sensitivity of 77% and a specificity of 47.5%. Cronbach’s alpha for the SHI was found to be 0.64 with satisfactory construct validity (Seun-Fadipe et al. 2018).

Pittsburgh sleep quality index (PSQI)

The PSQI is a validated instrument that assesses an individual’s quality of sleep during the preceding month. The assessment has 19 self-rated questions and five supplementary questions to be completed by a roommate or bed partner. These five supplementary questions are not used in the total PSQI score calculation and were not included in this study questionnaire, as the sleep partner or roommate would not have been available at the time of questionnaire administration. The total PSQI score ranges from 0 to 21 and is calculated after the 19 self-rated questions are converted into 7 components, each of which is ranked from 0 (no problem) to 3 (severe problem). The seven components included subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep medications, and daytime dysfunction. For the global PSQI score, participants with a total score greater than 5 out of 21 were deemed to suffer from PSQ, whereas participants with a total score less than or equal to 5 were considered to have good sleep quality. This cutoff score demonstrated a sensitivity of 89.6% and a specificity of 86.5% in identifying individuals with PSQ (Buysse et al. 1989). Cronbach’s alpha for the PSQI was found to be 0.736, with high internal homogeneity (Manzar et al. 2015a, b).

Ethical considerations

Ethical approval was obtained from the Scientific Research Ethics Committee of the Faculty of Medicine at Tanta University (approval code: 3626PR717/5/24). Before the questionnaires were administered, verbal consent was obtained from all participants in addition to an explanation of the study’s objectives. Participation in the research was both voluntary and anonymous, as no personal identifications were gathered.

Statistical analysis of data

The data were organized, tabulated, and statistically analyzed via SPSS Version 24 (IBM SPSS Statistics for Windows; IBM Corp., Armonk, New York, USA). Categorical variables are reported as numbers and percentages, whereas continuous variables are presented as mean ± standard deviation (SD). The chi-square test was used to examine relationships between categorical data derived from the SHI, the PSQI, and demographic variables. Pearson’s correlation test was used to assess the linear relationship between the total scores of sleep hygiene and sleep quality, as it quantifies the strength and direction of the correlation between continuous variables. For all the statistical analyses, a significance level of P ≤ 0.05 was used.

Results

The sampling technique resulted in 565 medical students, of whom 504 participated and completed the questionnaire (response rate = 89.2%). A total of 277 participants were male (54.96%). The participants’ mean age was 20.15 ± 1.49 years (ranging from 17 to 24 years). A total of 303 (60.12%) participants were from urban areas. The distribution of study participants from the first to the fifth academic year was 116 (23.02%), 114 (22.62%), 95 (18.85%), 85 (16.87%), and 94 (18.65%), respectively.

Table 1 shows the sleep characteristics of the participants. Almost two-thirds of the participants subjectively rated their sleep quality as fairly or very good (62.1%). The mean sleep duration was 7.28 ± 1.74 h, and 43.4% of the participants slept for more than seven hours. The mean sleep latency was 34.55 ± 31.66 min, and most of the participants took < 30 min to fall asleep (70.6%). This table also shows that most of the participants had poor sleep hygiene practices (93.7%) and poor sleep quality (71.2%). Figure 1 shows a highly significant moderate correlation between the SHI total score and the PSQI total score (r = 0.366, 95% CI = 0.284–0.444, p ≤ 0.001).

Table 1 Sleep characteristics among the medical students

Fig. 1

Correlation between sleep quality and sleep hygiene practice among Tanta university students

Table 2 shows that more than 40% of the participants reported that sleep latency, sleep disturbance, and daytime dysfunction represented moderate to severe problems (46.0%, 40.5%, and 46.8%, respectively). The use of sleep medications was a moderate to severe problem among only 13.3% of the participants, which means that 13.3% of the participants used sleep medication at least once a week over the past month. This problem was significantly more common among males (16.2%) than females (9.7%) (p = 0.031).

Table 2 The Pittsburgh Sleep Quality Index Subscales in relation to gender

Table 3 shows the frequencies of different sleep hygiene items in relation to sex. Nearly one-third of the participants frequently or always go to bed and get out of it at different times each day (38.7% and 37.5%, respectively). Going to bed at different times was never or rarely done by 31.4% of males compared to 22.5% of the females (p = 0.049). Nearly half of the participants frequently or always do things that wake them up before bedtime or use their beds for things other than sleeping (50.6% and 59.3%, respectively), and 54% had to do important work before bedtime. Among females, 64.8% went to bed while thinking, planning, or worrying about something that was significantly higher than 54.2% among males (p = 0.003). Vigorous exercise before bedtime was frequently or always reported by 18.1% of the males, which was significantly greater than the 8.8% reported among females (p ≤ 0.001). Sleeping on an uncomfortable bed was frequently or always reported by 12.3% of males, which was significantly greater than the 8.4% reported by females (p = 0.002). Among the participants, 41.1% frequently or always stayed in bed longer than they should two or three times a week.

Table 3 Frequency of different sleep hygiene practices among Tanta university students in relation to gender

Table 4 shows the distribution of participants in relation to demographic characteristics, PSQI scores, and SHI scores. Males show slightly higher levels of poor sleep hygiene and quality compared to females but with no significant difference. In addition. No significant differences in the level of sleep hygiene and quality in relation to residence. Poor sleep hygiene rates ranged between 91.6% and 95.6% among students in different academic years, with no significant differences. Sleep quality showed a gradual decline with advancement in the academic years. It started with 83.6% among students in the first grade and decreased to 66.0% among students in the fifth grade. These differences were statistically significant (p = 0.012). The PSQI showed significant association with the use of sleep medication where those whose sleep medication use was moderate to severe problem showed good level of sleep quality by only 1.5% as compared to 33.0% among those whose sleep medication problem was absent or a limited problem (p < 0.001). Meanwhile, sleep medication did not significantly affect the sleep hygiene index score.

Table 4 Distribution of participants in relation demographic characteristics, PSQI and SHI

Discussion

According to the PSQI, the observed prevalence of PSQ was comparable to that reported by Saudi medical students (74.2%), Indian medical students (72.9%), and Pakistani medical students (77%) (Siddiqui et al. 2016; Arora et al. 2015; Waqas et al. 2015). The prevalence was greater than that reported in a sample of university students from the USA (55.3%) (Cates et al. 2015). The underlying reason for the variation in prevalence across different countries could be the variability in sampling techniques, cultural habits, or the socioeconomic status of the populations. Previous studies conducted in Egypt reported prevalence rates of 58.5% and 55.7% (Ahmed Salama and University 2017; Fawzy and Hamed 2017). As the PSQI assesses sleep quality over the past month, the timing of the study relative to the academic year and exam schedules could explain some of this variability. We conducted this study at the end of the semester, approximately one month before the beginning of the final exam. Consequently, students could be subjected to longer study durations and overnight preparation for exams, which could affect their sleep quality during that month. A previous study conducted on university students in Greece reported similar findings, in which sleep quality was assessed during the pre-exam and exam periods, and the prevalence of PSQ increased from 59 to 98% (Bouloukaki et al. 2023).

In this study, sleep latency and daytime dysfunction were the most problematic components of sleep quality, which is similar to the findings of previous studies conducted on university students (Andrijevic et al. 2018; Felix et al. 2017). Increased levels of daytime dysfunction were found to be related to depression and fatigue, potentially serving as a mechanism through which depression impacts the health of university students (Eun-Jung Shim Hae-lim Noh JYH sol M and Hahm 2019). The mean sleep latency in this study slightly surpassed the 30 min recommended by the National Sleep Foundation’s sleep quality recommendations (Ohayon et al. 2017).

In this study, we found significant differences in the prevalence of PSQ across academic years. Early-year medical students had a higher prevalence of PSQ than late-year students. This finding aligns with the results of a similar study conducted in Saudi Arabia, where younger medical students (≤ 21 years) reported higher rates of PSQ (Ibrahim et al. 2017). This may be attributed to the difficulty in adapting to the new university environment in the earlier years. This could also be a result of older students developing better coping skills to meet university requirements. Previous studies revealed a significantly greater prevalence of PSQ in females than in males, which is attributed to the close association between sleep disturbances and psychogenic problems, such as anxiety and depression, which are more common in females (Fawzy and Hamed 2017; Elsheikh et al. 2023; Surani et al. 2015). In this study, there was no statistically significant difference in the prevalence of PSQ in relation to sex, which may be attributed to the comparable sleep hygiene scores between males and females in this population.

Our results revealed that the percentage of medical students who subjectively rated their sleep quality as poor was much lower than the actual prevalence of PSQ based on the PSQI. Similar findings have been reported in other studies conducted on university students (Becker et al. 2018; Lemma et al. 2012; Manzar et al. 2015a, b). This could indicate a lack of awareness regarding the characteristics of good sleep and the importance of using validated assessment tools, such as the PSQI, instead of relying on participants’ self-reports.

Using the SHI and the proposed cutoff value of 16, most participants were identified as having poor sleep hygiene practices. A previous study using the same parameters was performed on medical students in Qatar, and the prevalence of poor sleep hygiene practices was reported to be 79% (Ali et al. 2023). Another study from India reported that 75% of medical students had poor sleep hygiene practices (Massarat Begum, Dimple Siri Chandana Puchakayala 2022). These differences could be due to differences in the sampling techniques and awareness levels of the students. There is limited knowledge about medical students’ awareness of good sleep hygiene practices in our population, and whether their awareness is translated into practice. Sleep hygiene practices can also vary across cultures and regions, potentially affecting sleep quality. Compared with other regions, Egypt is a country within the Middle East region that has the latest bedtime and the shortest nocturnal and 24-hour total sleep duration (Jeon et al. 2021). This pattern may be influenced by cultural norms such as late-night socializing and late dinners, which are common in this region. Unlike Western cultures, where sleep is confined to a single block of time each day, polyphasic sleep and daytime naps are common in the Middle East (Airhihenbuwa et al. 2016; Al-Abri et al. 2020). This could be due to the fajr prayer, which is an Islamic practice performed at dawn. After this prayer, individuals may either return to sleep, especially during shorter summer nights, or take daytime naps later in the day (Bahammam 2011). Additionally, the hot weather in this region, particularly during the summer, may also be a contributing factor to daytime naps since it limits outdoor activities, leading to daytime sleepiness (Al Lawati et al. 2023). Furthermore, there is a lack of public awareness about sleep problems and a scarcity of sleep-promoting resources in this region compared with those in Western countries, which could impact sleep quality (Safwan et al. 2023; Abdulah 2020).

Among the 13 SHI questions, using the bed for activities other than sleeping or sex; thinking, planning, or worrying when in bed; and doing important work before bedtime were the three most prevalent negative sleep hygiene practices. A similar pattern has been found in other studies conducted on university students from Australia and Qatar, highlighting the special importance of educating medical students globally about avoiding these habits (Humphries et al. 2022); Ali et al. 2023). Future educational programs should focus specifically on these three highly prevalent habits. These programs could educate students about the importance of solely using the bed for sleep and encourage them to have a designated study area. Students could be educated about the importance of having a regular sleep schedule so that they can fall asleep rapidly and avoid thinking or worrying when in bed. Moreover, students could be educated about different relaxation techniques, such as deep breathing and meditation, that could help them fall asleep rapidly (Jerath et al. 2019; Liu et al. 2021). Students could benefit from time-management workshops. These workshops could help them prioritize their tasks, thus reducing the need to perform important tasks before bedtime. These educational programs could be added to university curricula and should focus on how good sleep hygiene practices can improve sleep quality. This, in turn, can boost mental health, academic performance, and long-term success, motivating students to adopt healthier practices. Universities could also implement policies to mitigate academic stress and enhance the quality of sleep, possibly by spreading out exam schedules, providing accessible mental health support, and conducting regular sleep assessments.

There was a statistically significant difference in the participants’ responses to four of the 13 questions in relation to sex. For males, it is more important to educate them about avoiding strenuous physical activity before they sleep and the importance of having comfortable beds. Females should be advised to have regular bedtimes, possibly by having a sleep schedule, and to avoid thinking, planning, or worrying when in bed.

PSQ was positively correlated with poor sleep hygiene practices, and this correlation was statistically significant. Other studies have also demonstrated a statistically significant correlation between sleep hygiene practices and sleep quality in medical students (Brick et al. 2010); Massarat Begum, Dimple Siri Chandana Puchakayala 2022); Gellis et al. 2014). Despite the observation that the correlation was modest, we believe that in further studies, the cofactors that may affect this relationship should be studied to provide a clearer level of correlation. This could aid in improving students’ sleep quality by improving their sleep hygiene practices.

Limitations

To the best of our knowledge, this study represents the first comprehensive investigation of sleep hygiene practices and their association with sleep quality among medical students in North African countries, including Egypt. Although this study provides novel findings for this population, several limitations are evident. The cross-sectional study design limited our ability to determine causal relationships between sleep hygiene practices and sleep quality. Future studies could employ a longitudinal design to monitor participants’ sleep hygiene practices over an extended duration, facilitating the establishment of definitive causal and temporal relationships between sleep hygiene practices and sleep quality. Our study did not include measures of mental health disorders such as anxiety and depression. Previous studies have demonstrated that anxiety is associated with PSQ. Therefore, anxiety may serve as a confounding variable for the observed prevalence of PSQ. In this study, the correlation between sleep hygiene practices and sleep quality was moderate. This correlation may be influenced by individual differences, including stress levels, lifestyle factors, and genetic predispositions. Stress is known to impair sleep, whereas individuals experiencing higher levels of stress may struggle to maintain good sleep quality regardless of their sleep hygiene habits. Genetic predispositions play a crucial role in shaping sleep patterns and susceptibility to sleep disorders. Future research should investigate these factors in more detail to provide precise correlation estimates. Although we used random sampling techniques, this was a monocentric cross-sectional study conducted on medical students from Tanta University. There are slight variations in educational systems and institutional environments across different Egyptian universities, which may influence sleep hygiene practices and sleep quality. Future multicenter studies could offer a more representative and comprehensive perspective. Finally, although we used a validated tool for measuring sleep hygiene, the SHI, this tool does not assess the impact of screen time before bedtime, which is highly prevalent among young adults and affects sleep quality.

Conclusion

This study revealed that poor sleep hygiene practices and poor sleep quality are highly prevalent among medical students in Egypt. Medical students in their earlier academic years had a greater prevalence of poor sleep quality. These findings highlight the need for future educational programs on good sleep hygiene practices and the importance of good sleep quality. Educational programs on good sleep hygiene practices should be integrated into medical school curricula, with a focus on prevalent negative practices such as using the bed for non-sleep activities, irregular sleep schedules, and worrying in bed. These programs can include workshops on relaxation techniques, such as meditation and deep breathing, and time management skills to help students prioritize tasks and reduce pre-sleep stress, particularly during exams. Future research is needed to investigate the causal relationship between sleep hygiene and sleep quality; assess the role of confounding factors such as anxiety, depression, and screen time; and explore variations across different academic institutions. Expanding these efforts through multicenter studies will provide a better understanding of the problem and help guide effective interventions.