3
1
2022
1682060070609_2979
95-100
https://journal.smdc.edu.pk/index.php/journal/article/download/90/56
https://journal.smdc.edu.pk/index.php/journal/article/view/90
INTRODUCTION
Sleep is an essential function of human body. The American Society of Sleep recommends 7 hours of sleep daily for people aged between 18 to 60 years.1 Sleep deprivation is thought to increase early morbidity and mortality, as well as linked with obesity.2 Sleep plays an important role in energy conservation, immunity and cognition.3 Sleep disorders tend to affect memory consolidation, cardiovascular health and many metabolic functions rather negatively.4
College students have relatively poor quality of sleep compared to the general population.5 Stress is one of the factors that affect sleep quality. Previous literature on sleep and mental health have demonstrated a reciprocal and rather a symbiotic relationship between the two.6 Studies done on medical students of Pakistan found a strong association between stress and poor sleep, and show that medical students have higher sleeping difficulties than their non-medical counterparts.7
Physical activity is another entity that has been associated with improved sleep quality, and physical inactivity has been cited as one of the biggest health concern of this century.8 Therapeutic effects of physical activity on mental health are evident by the fact that exercise and physical exertion are the first line interventions for anxiety disorders.9 College students are a chunk of the population who are prone to developing high stress and poor sleep, but research shows that those who indulge in intense physical activity are unlikely to show bad mental health and high stress.10 Much work has been done to establish the prevalence of stress in college students, as well as sleeping difficulties.
The objective of the study was to evaluate the effect of physical activity and stress on the
sleep quality among medical students in Pakistan.
MATERIALS AND METHODS
It was a cross-sectional study that was conducted after approval from the ethics committee of CMH Lahore Medical & Dental College. A total of 250 subjects, aged between 20 to 80 years, both male and female were included in the study from private medical colleges. Participants were made aware of the study objectives before obtaining their consent and anonymity was ensured by excluding their names or any information that may reveal their identity. Non-probability simple convenient sampling technique was adopted to select institutions and study participants. Subjects taking any type of sedatives, tranquilizers, anti-depressants or caffeinated energy drinks were excluded from the study. Data was collected, over a period of two months (Feb 2021 to March 2021), on validated questionnaires in order to acquire information regarding (1) subjects' socio- demographic data (such as age and gender) (2) study variables of the study (i.e. quality of sleep, perceived stress levels and physical activity).The questionnaires were constructed on Google Forms (Google LLC) and the link to these questionnaires was shared with the participants via Whatsapp (Meta Platforms, Inc) and email. Any incomplete forms were excluded.
Godin-Shephard Leisure Time Physical Activity Questionnaire (GSLTPAQ)11 was used to measure the intensity of physical activity. It showed reliability of 0.74 for total LTPA score.
Pittsburgh Sleep Quality Index (PSQI) questionnaire was used to measure the quality of sleep having reliability index of 0.87 and 98.7% sensitivity for sleep disturbances. 12
Perceived stress scale (PSS-10) questionnaire was employed for measuring perceived level of stress.13 It exhibits adequate reliability of 0.78.
Statistical Analysis
Table 1: Descriptive Statistics |
|
Variables
|
mean ± SD |
Age (years) |
22.2 ± 1.4 |
Sleep Quality (total score) |
4.0 ±1.9 |
Physical Activity (total score) |
16.2±10.1 |
Stress (total score) |
15.9 ±7.3 |
Collected forms were interpreted according to each scale's own grading, and values were fed into an SPSS 20 (SPSS Inc, NY, USA)
Table 2: Gender distribution according to Sleep Quality |
||
Gender |
Good Sleep (%) |
Poor sleep (%) |
Male |
57.5 |
40.0 |
Female |
42.5 |
60.0 |
spreadsheet by the study team and the data was analyzed using SPSS 20. A p-value <0.05 was taken as standard to establish statistical significance. Frequency distributions and descriptive statistics were obtained. Chi- square and logistic regression tests were used to check for significant associations.
RESULTS
The mean age of the participants was 22.2 ±
|
||||
Table 4: Association of Physical Activity and Stress with Sleep Quality |
||||
Variables |
S.E. |
p-value |
Odd's Ratio |
95% C.I. for Odd's Ratio |
Physical Activity |
.019 |
0.0965 |
0.99 |
0.962-1.04 1.020-1013 |
Stress |
.027 |
0.008* |
1.081 |
|
Logistic Regression test was applied; p<0.05 considered statistically significant |
Table 3: Comparison of Effect of Physical Activity and Stress on Sleep Quality |
||||
Variables Sleep Quality |
||||
|
Good Sleep n (%) |
Poor Sleep n (%) |
χ2 |
p- value |
Low Stress |
5(26.3) |
14(73.7) |
10.8 |
0.00* |
Moderate Stress |
33(23.6) |
107(76.4) |
|
|
High Stress |
2(3.9) |
49(96.1) |
|
|
Insufficient Activity |
8(15.4) |
44(84.6) |
0.71 |
0.07 |
Moderate Activity |
7(18.4) |
31(81.6) |
|
|
Vigorous Activity |
25(20.8) |
95(79.2) |
|
|
1.4 while the age range was 19-26 years. Mean of each study variable was calculated for the total score obtained using their respective scaling system as per questionnaire guidelines (Table 1). Among the study participants 91(43.3%) were males and 119 (57.7%) were females stress and 25 of the 40 good sleepers were physically very active. On the other hand 49 of the 170 poor sleepers had high stress and 44 of the 170 poor sleepers showed sedentary routine (Table 3).Chi- squared test reveals a significant effect of stress level on sleep quality (P=0.000*). On the other hand, frequency of good sleepers is seen to increase by almost three times with increasing physical activity, however, this difference is non-significant (p=0.07) (table 3). Logistic regression model was fitted to the data to test the research hypothesis regarding the relationship between poor sleep and stress as well as physical activity. According to the model, the log of the odds of student having poor sleep was positively related to higher stress levels (p < .05), but a non-significant relation is seen with physical activity (p>
0.05) (table 4). In other words, increasing stress level directly causes poor sleep, but the hypothesized inverse, or relieving, effect of physical activity may be due to some indirect way.
DISCUSSION
Sleep deprivation is quite prevalent in students all over the world, with studies showing that up to 24% of university students in the United Kingdom14, while around 49 % in Taiwan reported getting less than 7 hours of sleep.15 Our study reflects this trend of sleep deprivation with about 36.7% reporting less than 6 hrs of sleep and about 31.9 % reporting 6-7 hrs of sleep. This prevalence of inefficient sleep in the youth exposes them to a large variety of health related issues 4.The younger generations already face many risks due to devolving technology and the fast food diets making the sedentary lifestyles and poor nutrition the new normal. If not addressed early, this may predispose them lifelong morbid conditions.
College students are quite vulnerable to stressors by virtue of their transitional status
i.e. from high school to university, and teenage to maturity.16 Anxiety is the most reported mental health problem amongst by young people.17 A Lund university study reported that students with higher stress also showed poor sleep 18, supported by a bidirectional link observed in previous studies between sleep disturbances and anxiety, indicating that one contributes to the other.6 Whereas physical activity is said to improve sleep time and sleep efficiency. Exercise an hour or so before sleeping leads to increased deep sleep and shorter REM sleep.19 The problem of poor sleep seems multifaceted and cannot be dealt with in an isolated manner. The effect of stress and physical activity on sleep appears intertwined and has to be addressed simultaneously.
The effect of physical activity on relieving harmful effects of stress on mental and physical health are such that increasing physical activity is one of the first
recommendations for stress management.9,20
Now it could be that the positive effect of physical activity on sleep, as shown by an almost three times increase in frequency of good sleepers with increasing physical activity, is actually because of its relieving effect on stress, or there could be a direct relation between physical activity and sleep; or it could be that both these paths are involved. Our results showed an indirect effect of physical activity on sleep quality. Stress buffering hypothesis suggests that physical activity lowers adverse effects of stress on health, both physical and mental, which must include sleep distortion as well,21,22 as we said before that stress and sleep have a significant relationship. So the stress buffering hypothesis tries to explain how physical activity indirectly effects sleep. Wusnch et al. cites similar findings in their study, reporting that at times of very high stress students seemed to have lost positive effects of physical activity,23 thus insinuating that the positive effects of physical activity are due to its effect on stress. The cross-sectional design of this study limits its ability in making inferences. We recruited relatively small sample using the convenient sampling technique, and only included students from Lahore, therefore we cannot generalize these results to the whole medical student body of Pakistan. Our study was conducted during the COVID'19 lockdown and so its results may have been skewed by its effect on stress levels and physical activity of the individuals. Lastly, the use of self-reported questionnaire in our study may lead to response bias because of misreporting by the subjects.
CONCLUSION
There was a significant association between poor sleep and high stress levels whereas increasing physical activity showed a decline in frequency of poor sleep, however this
difference was non-significant. It can be
inferred that this positive effect of increasing physical activity on quality of sleep could be indirectly due to its relieving effect on stress. This knowledge may be important for health professionals and administrators in developing strategies to increase productivity by controlling stress related poor outcomes. Controlled experimental studies are needed to further verify the deductions made here.
Conflicts of interest
All authors and co-authors declare that they have no conflict of interests.
Contributors
MF: Study design, Manuscript writing and Analysis corrections
SJR: Data Collection, Literature Review NZA: Data Collection, Primary draft writing MFM: Data Collection, Revised the
manuscript
HA: Acquisition of Data & Data Analysis
JMM: Data Analysis, Data Interpretation
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