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All content in this area was uploaded by Abdullah Dhaifallah Alotaibi on Jan 13, 2020
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© 2020 Journal of Family and Community Medicine | Published by Wolters Kluwer - Medknow 23
The relationship between sleep quality,
stress, and academic performance
among medical students
Abdullah D. Alotaibi, Faris M. Alosaimi, Abdullah A. Alajlan, Khalid A. Bin
Abdulrahman
Abstract:
BACKGROUND: Sleep is essential for the body, mind, memory, and learning. However, the
relationship between sleep quality, stress, and academic performance has not been sufciently
addressed in the literature. The aim of this study was to assess the quality of sleep and psychological
stress among medical students and investigate the relationship between sleep quality, stress, and
academic performance.
MATERIALS AND METHODS: This cross-sectional study targeted all medical students in their
preclinical years at a Saudi medical college in 2019. All students were asked to complete an electronic
self-administered questionnaire comprising the Pittsburgh Sleep Quality Index (PSQI), the Kessler
Psychological Distress Scale (K10), questions on the students’ current overall grade point average,
and other demographic and lifestyle factors. The associations between categorical variables were
analyzed using Pearson’s Chi‑squared test at 0.05 signicance level.
RESULTS: The mean PSQI score was 8.13 ± 3.46; 77% of the participants reported poor quality
of sleep and 63.5% reported some level of psychological stress (mean K10 score: 23.72 ± 8.55).
Poor quality of sleep was signicantly associated with elevated mental stress levels (P < 0.001) and
daytime naps (P = 0.035). Stepwise logistic regression model showed that stress and daytime nap
were associated with poor sleep quality. Whereas, poor sleep or stress did not show any signicant
association with academic performance.
CONCLUSION: Poor sleep quality was signicantly associated with elevated levels of strees.
However, they did not show any statistically signicant relationship with academic performance.
Keywords:
Academic performance, medical education, medical students, sleep, sleep quality, stress
Introduction
Sleep, an essential therapeutic part of
human physiology, has been well
established as critically important for
functioning, mental health, and good quality
of life.[1] Sleep deprivation has a wide range
of harmful effects on human biology and is
associated with fatigue, daytime sleepiness,
and reduced neurocognitive performance.[2]
Cognitive performance in students, including
concentration and estimated efforts to
complete tasks, is negatively affected by
sleep deprivation.[3] The prevalence of poor
sleep quality varies between countries. Using
the Pittsburgh Sleep Quality Index (PSQI), it
has been reported to be as low as 19% in a
Chinese study and as high as 55.8% in a study
in Ethiopia.[4,5]
Sleep is vital for the enhancement of
working memory capacity and memory
consolidation.[6] A meta‑analysis of
seventy studies concluded that acute sleep
Address for
correspondence:
Dr. Abdullah Dhaifallah
Alotaibi,
College of Medicine, Imam
Mohammad Ibn Saud
Islamic University, Othman
Bin Aan Road Al‑Nada,
P.O. Box 7544,
Riyadh 13317-4233,
Saudi Arabia.
E‑mail: adhotb@
gmail.com
College of Medicine, Imam
Mohammad Ibn Saud
Islamic University, Riyadh,
Saudi Arabia
Original Article
Access this article online
Quick Response Code:
Website:
www.jfcmonline.com
DOI:
10.4103/jfcm.JFCM_132_19
How to cite this article: Alotaibi AD, Alosaimi FM,
Alajlan AA, Bin Abdulrahman KA. The relationship
between sleep quality, stress, and academic
performance among medical students. J Fam
Community Med 2020;27:23‑8.
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the
new creaons are licensed under the idencal terms.
For reprints contact: reprints@medknow.com
Received: 30-06-19
Revised: 27-09-19
Accepted: 15‑10‑19
Published: 13-01-20
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Alotaibi, et al.: Sleep, stress, and performance
24 Journal of Family and Community Medicine - Volume 27, Issue 1, January-April 2020
deprivation harms most cognitive domains, such as
simple attention, intricate attention, working memory,
and short‑term memory.[7] A prospective study from the
1990s identied prolonged psychological stress in college
students who had reported symptoms of insomnia.[8]
A delayed circadian rhythm also leads to poor sleep
quality, especially during examination periods, and
both have been found to negatively affect academic
performance.[9,10] Stress, another factor prevalent among
medical students, worsens the quality of sleep.[11]
Increased levels of stress have been found to be related
to lower academic performance; however, appropriate
coping strategies have been shown to help students deal
with the negative impact of psychological distress.[12‑14]
Very few studies in Saudi Arabia have addressed the
relationship between sleep quality, stress, and academic
performance of medical students, and their ndings
on the impact of sleep on academic performance are
variable,[15‑18] although poor sleep quality as high as
76% has been reported.[18] Nevertheless, the majority
of Saudi medical students think that the quality of
their sleep is good.[18,19] Multiple local data sources
have also suggested high stress levels in medical
students.[18,20,21] The current study aims to assess sleep
quality and psychological stress in medical students in
their preclinical years and investigate the relationship
between sleep quality, stress, and academic performance.
Materials and Methods
This observational, cross‑sectional study was conducted
at the College of Medicine at Imam Muhammad
Ibn Saud Islamic University (IMSIU), Riyadh,
Saudi Arabia, between February and June 2019. The
study targeted all medical students in their preclinical
phase (1st, 2nd, and 3rd years). In this phase, the college
follows an outcome‑based, community‑oriented,
integrated system in which students attend lectures
and are engaged in problem‑based learning (PBL) small
group tutorials. Students are evaluated during and at the
end of each body system block.
An electronic self‑administered questionnaire was
distributed by six well‑trained data collectors, two for
each academic year. To ensure adequate representation
of the study population, the link was restricted to groups
of invitees only. A total of 230 participants were required
to obtain a 95% condence level and a 5% margin of error.
The link was open from April 7, 2019, to May 7, 2019,
and reminders were sent every 3 days.
Ethical approval from the Institutional Review Board
of IMSIU was obtained for the study. Participants were
informed of the objectives of the study, and informed
written consent was obtained from them. They were
free to withdraw from the study at any stage; their
information was kept condential and used for research
purposes only.
The questionnaire had items on demographic and
lifestyle characteristics (age, gender, marital status,
work status, residency, academic level, and frequency
of caffeine intake and daytime naps) and measures
of sleep quality, psychological distress, and academic
performance.
Sleep quality was assessed using the global score of the
PSQI[22] which starts with four questions on bedtime, sleep
latency, wake‑up time, and the total hours of actual sleep
during the last month. Then, there were 14 questions in
a scale form on several suggested factors that troubled
sleep such as the utilization of sleep medications,
daytime sleepiness, enthusiasm for productivity, and a
concluding self‑rating question of the overall quality of
sleep in the past month. Finally, the global PSQI score
was calculated using seven components formed from the
content items. The PSQI is considered a cornerstone tool
for the measurement of sleep quality.[22,23]
The Kessler Psychological Distress Scale (K10) was
used to investigate the prevalence and levels of stress in
medical students. The K10 has ten questions that assessed
anxiety and depressive symptoms during the previous
month. Items on a 5‑point scale had scores ranging from
10 to 50. Scores from 20 to 24 were considered mild
distress, 25–29 were moderate, and 30 or higher were
severe. The K10 is a popular global tool for assessing
nonspecic psychological distress in population‑based
studies.[24]
Academic performance was measured using the
student’s current overall grade point average (GPA).
Self‑reported overall GPA has been frequently used
as a measurement of academic achievement in similar
studies. Furthermore, high reliability and correlation
with GPAs reported by the academic registry had been
established.[25,26] We classied GPA according to the
grading system at IMSIU (out of 5.0, the grades 4.5–5.0
are excellent, 3.5–4.49 are very good, and <3.5 are good,
pass, or fail).
Data were imported into Microsoft Excel 2016 and
analyzed using the Statistical Package for the Social
Sciences (SPSS), Version 25.0 (REL. 2017; IBM Corp.,
Armonk, NY., USA). Categorical variables were
presented as frequencies and percentages and continuous
variables as means and standard deviations. The
associations between categorical variables were
analyzed using Pearson’s Chi‑squared test ± continuity
correction. To determine the predictors of poor
sleep quality in medical students, a simple logistic
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Alotaibi, et al.: Sleep, stress, and performance
Journal of Family and Community Medicine ‑ Volume 27, Issue 1, January‑April 2020 25
regression analysis was initially used to explore the
data. Multivariable stepwise binary logistic regression
analysis was then performed. The odds ratios (OR) and
95% condence intervals (95% CI) were calculated, and
the Hosmer–Lemeshow test was used to assess model
goodness of t. Statistical signicance for all associations
was considered to be at P < 0.05.
Results
The characteristics of the study participants are presented
in Table 1. The total number of participants was 282;
64.5% were male, 61% were aged 21–24 years, and 36.5%
were aged 18–21 years. The majority of students were
single (n = 276, 97.9%), did not have a job (n = 223, 79.1%),
and were living with their families (n = 269, 95.4%).
For the academic level, 39% of the respondents were in
their 1st year, 25.9% in their 2nd year, and 35.1% in their
3rd year. Most students were rated very good (32.6%; GPA:
3.5–4.49) or excellent (33%; GPA: 4.5–5.0) in their academic
performance; about one‑third were good or below (34.4%;
GPA: <3.5). Assessed dietary habits included frequency of
caffeine consumption; 61.7% of the respondents consumed
caffeine daily, 18.8% consumed it weekly (2–5 times per
week), and 19.5% consumed every 2 weeks or less.
The prevalence of poor sleep quality of the participants
was 77% (n = 217, mean PSQI score: 8.13 ± 3.46). The
period from 00:00 to 1:59 was the most frequent for
bedtime (n = 145, 51.4%) followed by the period from 2:00
to 3:59 (n = 73, 25.9%); only 19.1% had a usual bedtime
before midnight. The average total hours of sleep were
5.87 ± 1.56 per night. However, >43% reported having
a daytime nap. The overall total hours of actual sleep
ranged from 2 to 12.
Distress was also prevalent: 63.5% of the students
exhibited positive distress on the K10 (n = 179). More
than 41% of the respondents had either a moderate or
severe level of distress, and approximately one‑fourth
had a severe level of distress. Mild and moderate levels
were 22% and 17.4%, respectively. The K10 scores
covered the entire possible range, from 10 to 50, with a
mean score of 23.72 ± 8.55.
Table 2 presents the associations of poor sleep quality and
stress with GPA, work status, and other variables in the
study. A greater proportion of participants who had poor
sleep quality reported distress compared to participants
who did not have poor sleep quality (68.7% and 46.2%,
respectively; P = 0.002). The prevalence of poor sleep
quality also increased with each distress level: 67.7% for
mild distress, 87.8% for moderate distress, and 94.1% for
severe distress (P < 0.001). Taking a daytime nap showed
a statistically signicant association with poor sleep
quality, with 81.9% of the participants who took daytime
naps reporting poor sleep quality compared to only 70.5%
of the participants who did not take naps (P = 0.035).
In contrast, poor sleep quality was nearly the same
between the genders and academic levels. Similarly, there
was no difference in the distress suffered by students who
took daytime naps and those who did not or between
Table 1: Characteristics of medical students in
preclinical years (n=282)
Characteristics N (%)
Gender
Male 100 (64.5)
Female 182 (35.5)
Age (years)
18-<21 103 (36.5)
21-<24 172 (61.0)
≥24 7 (2.5)
Marital status
Single 276 (97.9)
Married 6 (2.1)
Residency
With family 269 (95.4)
University/private 13 (4.6)
Academic level
1st year 110 (39.0)
2nd year 73 (25.9)
3rd year 99 (35.1)
Caffeine intake
Daily 174 (61.7)
Weekly 53 (18.8)
<1/week 55 (19.5)
Work
Yes 59 (20.9)
No 223 (79.1)
Daytime nap
Yes 122 (43.3)
No 160 (56.7)
GPA
4.5-5 93 (33.0)
3.5-4.49 92 (32.6)
<3.5 97 (34.4)
Poor sleep quality
Yes 217 (77.0)
No 65 (23.0)
Bedtime
Before 22:00 6 (2.1)
22:00-23:59 48 (17.0)
00:00-1:59 145 (51.4)
02:00-3:59 73 (25.9)
04:00 or later 10 (3,5)
Distress
Well 103 (36.5)
Mild 62 (22.0)
Moderate 49 (17.4)
Severe 68 (24.1)
Work includes nonconstant, part-time, and full-time jobs. GPA=Grade point
average
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Alotaibi, et al.: Sleep, stress, and performance
26 Journal of Family and Community Medicine - Volume 27, Issue 1, January-April 2020
students who worked and those who did not. Students’
current overall GPAs also did not show significant
associations with poor sleep quality or distress level.
The multivariable stepwise binary logistic regression
analysis to predict poor sleep quality in the participants
is shown in Table 3. High levels of distress were
highly associated with poor sleep quality. For
instance, normal (OR = 0.108, 95% CI: 0.036–0.325) and
mild (OR = 0.112, 95% CI: 0.035–0.358) distress showed
signicant negative associations with poor sleep, but
there was no signicant difference between the moderate
distress level and the high distress level, which was used
as a reference (OR = 0.383, 95% CI: 0.101–1.458, P = 0.159).
Compared to students who took daytime naps, those who
did not nap had only 0.453 times the odds of reporting
poor sleep quality (95% CI: 0.250–0.821, P = 0.009).
Discussion
In the present study, 77% of the participants had a poor
quality of sleep. This result is similar to other studies
in Saudi Arabia (76% and 74.2%).[18,27] However, a
study from the Southern region of Saudi Arabia had a
different result (29.7%).[28] Internationally, the quality
of sleep of medical students has generally been found
to be better: 50.9% in the United States,[29] 55.8% in
Ethiopia,[5] 19% in China, and 40% in Lithuania.[4] The
prevalence of stress in participants in the current study
was 63.5%, which is also higher than similar local and
international studies. For instance, a prevalence of about
53% was found in two colleges in Riyadh[18,20] and 41.9%
in Malaysia.[30]
Examination periods increase both stress and poor sleep
quality of medical students.[10,31] Ahrberg et al. found
that the quality of sleep of students in the 5 weeks
preceding examinations was signicantly worse than in
the semester or 4 weeks afterward.[10] This could be an
explanation for the high prevalence of poor sleep quality
in the present study, since students were enrolled in a
3–6‑week block systems in which they were assessed by
weekly PBL sessions, mid‑block and nal examinations,
and tutorial and seminar assessments.
Table 2: Characteristics of the medical students in their preclinical years by sleep quality and stress (n=282)
Characteristics Poor sleep quality P-Value Stress P-Value
YES
N (%)
NO
N (%)
YES
N (%)
NO
N (%)
Gender
Male 141 (77.5) 41 (22.5) 0.894 98 (53.8) 84 (46.2) <0.001
Female 76 (76) 24 (24.0) 81 (81.0) 19 (19.0)
Academic level
1st year 86 (78.2) 24 (21.8) 0.780 74 (67.3) 36 (32.7) 0.503
2nd year 54 (74.0) 19 (26.0) 43 (58.9) 30 (41.1)
3rd year 77 (77.8) 22 (22.2) 62 (62.6) 37 (37.4)
Caffeine intake
Daily 140 (80.5) 34 (19.5) 0.206 110 (63.2) 64 (36.8) 0.753
Weekly 38 (71.7) 15 (28.3) 32 (60.4) 21 (39.6)
<1/week 39 (70.9) 16 (29.1) 37 (67.3) 18 (32.7)
Work
Yes 51 (86.4) 8 (13.6) 0.076 39 (66.1) 20 (33.9) 0.750
No 166 (74.4) 57 (25.6) 140 (62.8) 83 (37.2)
Daytime nap
Yes 131 (81.9) 29 (18.1) 0.035 102 (63.7) 58 (36.3) 1.000
No 86 (70.5) 36 (29.5) 77 (63.1) 45 (36.9)
GPA
4.5-5 74 (79.6) 19 (20.4) 0.117 52 (55.9) 41 (44.1) 0.175
3.5-4.5 64 (69.6) 28 (30.4) 61 (66.3) 31 (33.7)
3.49≥ 79 (81.4) 18 (18.6) 66 (68.0) 31 (32.0)
Sleep quality
Poor 149 (68.7) 68 (31.3) 0.002
Not poor 30 (46.2) 35 (53.8)
Distress
Well 68 (66.0) 35 (34.0) <0.001
Mild 42 (67.7) 20 (32.3)
Moderate 43 (87.8) 6 (12.2)
Severe 64 (94.1) 4 (5.9)
Work includes nonconstant, part-time, and full-time jobs. GPA=Grade point average
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Alotaibi, et al.: Sleep, stress, and performance
Journal of Family and Community Medicine - Volume 27, Issue 1, January-April 2020 27
Poor sleep quality was significantly associated
with the level of stress in medical students in this
study (P < 0.001). This association has been widely
reported.[10,14,31] Morin et al. found that participants who
had symptoms of insomnia were more stressed than
noninsomniacs.[14] They also concluded that there was
either a direct or indirect relationship between insomnia
and stress, nighttime arousal, and emotional responses
to stress. Notably, stress was more prevalent in female
students in this study (P < 0.001), but no signicant
association between gender and sleep quality was found.
In spite of the expected start of the first lecture of
the day (8:00 am), the majority of students (80.8%)
reported that they had gone to bed at midnight or later.
Similarly delayed bedtime was found in other local
universities (12:06 am ± 1.58; 1:53 am ± 3:51; and 77.2%
at midnight or later).[15,18,19] In a study from Thailand,
54% of the students reported a bedtime between 10.00
pm and 12.00 am, but during examination periods, 41%
of the students would go to bed between 2:00 am and
4:00 am.[32]
Taking a daytime nap not only increases afternoon
alertness but also negatively affects sleep quality in
young adults.[33,34] However, in our study, daytime
naps showed a signicant association with, and were
predictive of, poor sleep quality. This suggests that
napping by participants in this study was more likely
to be compensated for insufcient nighttime sleep than
planned, and habitual compensatory daytime naps are
frequently used to cope with altered circadian rhythms.[9]
The negative impact of poor sleep quality and stress on
academic performance has been well reported in the
literature.[9,10,12] However, surprisingly, in this study,
academic performance showed no statistically signicant
association with sleep quality or stress levels. This result
is similar to data reported by Alqarni et al., Al‑Zahrani
et al., and Abdulghani et al.[16,17,21] Conversely, some local
studies have concluded that sleep disorders negatively
affect academic performance.[15,35] This inconsistency
in local studies may draw attention to the new trends
in sleep–wake habits and their relationship to the
professional life of young adults in Saudi Arabia. This
point, as well as the cultural aspects (sleep–wake patterns
in hot countries), should be taken into consideration in
future studies.
This study was based in a single institution, so the
specic environment of that institution may have had
an impact on the accuracy of the generalizability of
the results. The cross‑sectional design, which collected
responses at a single point in time, could not provide
a causal relationship between variables. Furthermore,
since students were asked about their sleep quality and
stress in the previous month, there could have been
recall bias. We recommend that future studies continue
to investigate different psychological and behavioral
parameters of medical students and their impact on
academic performance and assess the role of different
medical pedagogies and ways of assessment in that
relationship. In the meantime, sleep quality and levels
of stress in medical students could be improved with
campaigns on sleep education, counseling on time
management, and plans for treatment.[36‑38]
Conclusion
This study showed that the quality of sleep in medical
students in their preclinical years was poor and
their stress levels elevated, with these two variables
signicantly associated. Furthermore, stress and daytime
naps were signicant predictors of poor sleep quality.
Stress was more prevalent among females. Surprisingly,
academic performance did not show any statistically
signicant association with sleep quality or stress levels.
Researchers and medical educationists are encouraged
to continue to assess students’ well‑being, methods of
education, and factors that affect academic performance
and in the meantime improve students’ sleep quality
through counseling and educational campaigns.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.
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