K. Lashkaripour 1, N.M, Bakhshani *2, S. Mafi 3

Sleep Quality Assessment of Medicine Students and Physician (Medical) Assistants K. Lashkaripour 1, N.M, Bakhshani *2, S. Mafi 3 1 Department of Psychiatry& Psychology, Zahedan University of Medical Sciences- Baharan Psychiatric Center, Zahedan, IR Iran 2 Research Center for Health of Children and Adolescences. Department of Clinical Psychology, Zahedan University of Medical Sciences- Baharan Psychiatric Center, Zahedan, IR Iran 3 Zahedan University of Medical Sciences Correspondence: Nour Mohammad Bakhshani, Research Center for Health of Children and Adolescences. Department of Clinical Psychology, Zahedan University of Medical Sciences- Baharan Psychiatric Center, Zahedan, IR Iran, P.O. Box: 9819713955,Zahedan, IR Iran. Abstract Introduction and Purpose: As a significant health variable, sleep is one of the basic needs of human and has an influential role in their quality of life, and their physical and mental health. As a subgroup of young adults and a fraction that the health of the society is inevitably dependent upon whose mental and physical health, medicine students are more prone to the risk of sleep disorders due to their special occupation and education. Thus, with regard to the importance of sleep disorders among medicine students and assistance, this issue is addressed in this research. Materials and Methods: This is a descriptive - analytic research that is conducted during the academic year 2010-2011 in Zahedan University of Medical Sciences. The subjects were 340 medicine students and specialized assistants who were selected from among various grades via quota sampling. The data were gathered using demographic questionnaire and Pittsburgh Sleep Quality Index (PSQI) and were analyzed using SPSS software. Findings: From 340 individuals who attended this study, 212 (62.4%) had poor sleep quality. Based on this research, poor sleep quality was more prevalent among women than men, and more common in 30 + age group. Moreover, prevalence of poor sleep quality was more seen among resident students, those living in dormitories, married individuals, and students with an average degree of more than 17 (out of 20). Discussion and Conclusion: Regarding the prevalence of poor sleep quality among medicine students and physician assistants, it is necessary to consider their sleep estate, and conduct more analyses to diagnose, treat, and improve their sleep quality. Keywords: Sleep quality, specialized assistants, Medicine students, Pittsburgh Sleep Quality Index COPY RIGHT 2012 Institute of Interdisciplinary Business Research 443

1. Introduction Sleep is one of the important elements of daily cycle and is referred to as the source of energy, mental improvement and pacifier. As Shakespeare put it: Sleep is the second servant of the nature s glorious feast and the premier banquet of the life meal (Njafi M, 2000). Sleep is a circadian rhythm and a complex biological pattern. When sleep-wake pattern follows the biological clock of the body, it has adapted itself to daily biological cycles. Accordingly, sleep leads to physical and mental rehabilitation of the individual (Farhadinasab & Azimi, 2008). Sleep is one of the important needs; a need that plays a significant role in human s life quality and their activities when they are awake. It is a major factor associated with the physical and mental health of individuals. The quality of nighttime sleep can affect the cognitive performance and concentration level of an individual in conducting daily activities. Such effect is to the extent that nighttime sleep deprivation (dyssomnia) reduces individual s ability in dealing with daily tensions and increases the incidents of depressive and anxiety disorders (Beck, Schwartz, Towsley, Dudley, & Barsevick, 2004; Dogan, Ertekin, & Dogan, 2005; Farhadinasab & Azimi, 2008). Almost 70% of those referring to psychiatric clinics complain of sleep disorder; a percentage that cannot be neglected. Such disorder and irregularity in sleep-wake pattern of the individual not only causes manifest mental and physiological depression, but also leads to derangements of their social and occupational activities. Sleep deprivation is a major risk factor associated with driving accidents, occupational accidents due to tiredness, job loss, family problems, poor health, metabolic and ductless gland disorders (Beck et al., 2004; Costa e Silva, 2006). Reports indicate that about 30% of adults suffer from sleep disorders and 5% of the society members endure daily napping periods (Ghoreishi & Aghajani, 2008; Kaplan & Sadock, 1988; Wallace M, 2005). In America, for instance, one out of 7 individuals suffers from chronic sleep-wake disorder. Moreover, since sleeping drugs are among the mostly used medicine (Njafi M, 2000), one can conclude that sleep disorders are one of the most prevalent mental disorders. Given the high prevalence of sleep related diseases (about 20%), sleep medicine keeps a special stance in modern medicine, whereas it has drawn much attention in advanced countries (Nojomi, Ghalhe Bandi, & Kaffashi, 2009). For example, epidemiological studies in Western Europe, the US, and Japan have reported a 10-48% prevalence of insomnia symptoms (Nojomi et al., 2009), and since sleep disorder is a preliminary symptom of a mental disease, precise sleep control is assumed as an important part of clinical activity. As a subgroup of young adults, medicine students are more prone to the risk of sleep disorders due to their special occupation and education conditions, including high levels of stress, work pressures, as well as nighttime activities at some stages. A huge number of studies about sleep medicine, particularly those conducted in the last decade, have considered sleep quality of medicine students and respective problems. The results from these studies clearly indicate that sleep disorders are very common among this group, whereas 58-64% of students have reported a good sleep quality and 12-40.6% have reported an poor sleep quality (Ghoreishi & Aghajani, 2008; Veldi, Aluoja, & Vasar, 2005). In terms of gender, male medicine students have had more poor sleep quality compared to female medicine students COPY RIGHT 2012 Institute of Interdisciplinary Business Research 444

(Nojomi et al., 2009). Nevertheless, in some studies, no significant difference is observed with respect to gender (Feng, Chen, & Yang, 2005). Generally, disorders such as nightmare, daytime fatigue, and sleep disturbances are observed among females, whereas sleep latency is more seen among males (Eller, Aluoja, Vasar, & Veldi, 2006). Overall, recent studies indicate the high prevalence of sleep disorders among medicine students (Eller et al., 2006; Feng et al., 2005; Loayza et al., 2001; Nojomi et al., 2009; Veldi et al., 2005). Such students suffer more from poor sleep. For example, in the study conducted by Preisegolaviciute et al. in Lithuania, medicine students suffered more from poor sleep compared to law students, the reason being long hours of studying and before bedtime reading (Preisegolaviciute, Leskauskas, & Adomaitiene, 2010). Since poor sleep quality among medicine students can be accompanied by many psychological disorders, such as depression and anxiety symptoms, neurocognitive disorders, learning disorders, and most importantly educational performance disruption, this study addresses the sleep quality of medicine students of Zahedan University as a subset of academic population of Iran a group that, based on the nature of their future job, will have a huge responsibility in providing medical services. 2. Methodology This is a descriptive-analytical study that is conducted on 340 medicine students and specialist assistants in Zahedan University of Medical Sciences in the academic year of 2010-2011. Subjects were selected using quota sampling method. Data were gathered using demographic questionnaire and Pittsburgh Sleep Quality Index (PSQI). Inclusion criteria were: 1- specialist assistant or medicine student at medicine department, and 2- staying more than one academic term with the university. Exclusion criteria were: 1- Physical disease history, 2- A background of psychological disease or treatment with neurotic and mental medicine, and 3- Disqualified students or those who are not spending the first semester. PSQI is a proper tool for measuring the quality and pattern of individuals sleep. It distinguishes proper sleep from poor sleep through assessing seven features of individuals sleep during the last month. The features include: C1: Subjective sleep quality, C2: Sleep latency, C3: sleep duration, C4: Habitual sleep efficiency, C5: Sleep disturbances, C6: Use of sleep medications, C7: Daily dysfunction (Feng et al., 2005). The responses are scored based on a 0-3 scale. PSQI has a high reliability, with a Cronbach s alpha of 0.83. The scores of this index range from 0 to 21. A sum score of 5 or above indicates poor sleep (Backhaus, Junghanns, Broocks, Riemann, & Hohagen, 2002; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989; Ghoreishi & Aghajani, 2008; Ohayon, Caulet, & Priest, 1997). The study was conducted after obtaining the authorization from ethic committee of the university and the students responded to the questions if they were willing to do so. After filling the questionnaires, the data were analyzed using SPSS software. 3. Results This study aimed at assessing the sleep quality of specialist assistants and medicine students of Zahedan University of Medical Sciences. 340 subjects participated in the study, of whom 140 were male (41.2%), 200 were female (58.8%). 94 (27.6%) were in the 30+ age group, 124 (36.5%) in the 24-29 age group, and 122 (35.9%) were in the age group of 24 COPY RIGHT 2012 Institute of Interdisciplinary Business Research 445

and less. Table 1shows the demographic characteristics of the sample and the prevalence of poor sleep quality based on those characteristics. Poor sleep quality was mostly prevalent among women, age range of 30 and above, residences, married individuals, dormitory residents, and those with a good educational estate having an average score of above 17, and among surgery assistants (Table 1). Table 1: Presentation of the studied variables and sleep quality Frequency Good Sleep Quality Poor Sleep Quality Frequency Percent Variable Frequency Percent Frequency Percent Gender male 140 41.2 57 40.7 83 59.2 female 200 58.8 71 35.5 129 64.5 18-23 122 35.9 36 29.6 86 70.4 Age 24-29 124 36.5 76 61.2 48 38.8 > 30 94 27.6 16 17 78 83 basic sciences and 80 23.5 22 27.5 58 72.5 Grade physiopathology apprenticeship 50 14.7 18 36 32 64 residency 40 11.8 6 15 34 85 assistance 170 50 82 48.2 88 51.7 single 215 63.2 87 40.4 128 59.5 married 125 36.8 41 32.8 84 67.2 with family 87 25.6 35 40.2 52 59.7 Place of dormitory 243 71.5 88 36.2 155 63.7 Living fellow students 10 2.9 5 50 5 50 > 17 18 5.3 4 22.2 14 77.7 Average 15-17 108 31.8 30 27.7 78 72.2 Score < 15 44 12.9 12 27.2 32 72.7 n/a (assistants) 170 50 82 48.2 88 51.8 internal medicine 35 19 14 40 21 60 women s diseases 24 14 13 54.2 11 45.8 Specialty pediatric 13 8 6 46.2 7 53.8 Field of infectious Assistants diseases 12 7 8 66.7 4 33.3 surgery 19 11.9 5 26.3 14 73.7 radiology 20 12.1 10 50 10 50 ophthalmology 25 15 16 64 9 36 anesthesiology 22 13 10 45.5 12 54.5 The results of comparing the average sleep quality scores of medicine students and assistants based on gender showed no significant difference (P = 0.128). However, in investigating the seven characteristics of sleep, there were significant differences in terms of gender: In C4 = sleep efficiency (P = 0.006), C5 = sleep disturbances (P = 0.001), and C7 = daily dysfunction (P = 0.001) significant differences were observed between the two genders, COPY RIGHT 2012 Institute of Interdisciplinary Business Research 446

whereas sleep efficiency and sleep disturbances were more prevalent among men, and daily dysfunction was more prevalent among women. In terms of marital status, there was a significant difference between married and single students only with respect to C5 = sleep disturbances (P = 0.009), whereas married individuals complained of sleep disturbances more than single students. The comparison of sleep quality scores with respect to subscales showed a significant difference in terms of C2 between dormitory residents and those living in houses with their students friend (P = 0.046), whereas those living in dorms complained more of sleep latency. In the intergroup comparison, there was also a significant difference in terms of C3 between dorm residents and those living with their families (P = 0.043), whereas those living in dorms slept more. With respect to C4, a significant difference was also observed between dorm residents and those living with their families, whereas those living with their families experienced a more efficient and quality sleep (P = 0.013). In the intergroup comparison of C6, there was a difference again between dorm residents and those living with their families, whereas dorm residents used more sleep medications (P = 0.002). In the intergroup comparison of C7, there was a difference between dorm residents and those living with their families, whereas dorm residents complained more of daily dysfunction (P = 0.048). The comparisons also showed that there was a significant difference between assistants and basic sciences and physiopathology students (P < 0.001), between assistants and aprentices (P = 0.032), and between assistants and residents (P = 0.001). Compared to the other three groups, assistants complained less of the sleep disturbances. In terms of C6, there was a significant difference between the residents and the basic sciences and physiopathology department (P = 0.030), between assistants and the basic sciences and physiopathology department (P = 0.011), whereas basic sciences and physiopathology students used more sleeping medications compared to other groups. Data analysis based on the age of students showed a significant difference in terms of the seven subscales (P < 0.05). The comparison of assistants sleep based on their fields of study indicated a significant difference, whereas there was a difference between radiology and surgery departments (P = 0.002), radiology and women departments (P = 0.009), radiology and anesthesiology departments (P = 0.001) who did not worked a shift in the surgery room, whereas radiology department assistants had a more quality sleep compared to the three departments of surgery, women s diseases, and anesthesiology. On the other hand, there was a statistically significant difference between ophthalmology and surgery departments (P = 0.002), ophthalmology and women departments (P = 0.013), and ophthalmology and anesthesiology departments (P = 0.002). Similar to radiology department, ophthalmology department experienced a more quality sleep compared to surgery, women s diseases, and anesthesiology departments. COPY RIGHT 2012 Institute of Interdisciplinary Business Research 447

4. Discussion A finding of this research showed that poor sleep quality is prevalent among medicine students and assistants of the university and about 62.4% of the subjects suffered from poor sleep. This rate is higher than that reported in other universities (about 12-40%) (Feng et al., 2005; Ghoreishi & Aghajani, 2008; Nojomi et al., 2009; Veldi et al., 2005). This higher rate among the students of Zahedan University of Medical Sciences might be due the special weather conditions, torrid weather, and the fact that most of the students are non-natives who live away from their families, especially in dorms (74.4% are native and 25.6% are native students). In comparing the sleep quality in terms of gender, it was seen that poor sleep quality was more prevalent among women than men. This finding is in line with that of the study conducted by Feng et al. in China in 2005. However, it differs from the results of the study by Nojoomi et al. at Iran University of Medical Sciences (Feng et al., 2005; Nojomi et al., 2009; Veldi et al., 2005). It is may be because cultural differences, specific climatic conditions, and the presence of more women in student dorms can be stressor factors and might be related to poor sleep quality. In the present study, poor sleep quality was prevalent among residents, basic sciences and physiopathology students, apprentices, and assistants, respectively. Nevertheless, no significant difference was observed among various educational grades. In the study conducted by Ghoreishi et al. in Zanjan University of Medical Sciences, the highest rate of poor sleep quality was reported by the residents. The study conducted by Feng et al. in China also reported poor sleep quality among various educational grades (Feng et al., 2005). In this study, it was revealed that married individuals complained more of sleep disturbances. Results from Zanjan University are also similar to our findings; while poor sleep quality is more prevalent among married individuals than bachelors. This might be because of economic problems of married individuals, concerns associated with being far from family and children (emotional conditions) (Ghoreishi & Aghajani, 2008). Poor sleep quality was more prevalent among those living in dorms (63.78%). Zanjan University, where poor sleep quality was more prevalent among those living in dorms than other groups (37.6%) (Ghoreishi & Aghajani, 2008). The differences between the rates of poor sleep quality between the dorms residents of the two universities might be due to the differences between dormitory conditions. This study showed that students living in dorms have a longer sleeping time, whereas those living home with their families had more efficient and quality sleep. Those living in dorms complained more of sleep latency and daily dysfunction. In terms of age, poor sleep quality was seen to be more prevalent among students and assistants with 30 years or more of age. These individuals complained more of sleep latency and sleep disturbances, and used more sleep medications. Nevertheless, they reported a longer sleeping time and more efficient sleep. Individuals with less than 24 years of age complained more of daily dysfunctions. More prevalence of poor sleep quality among higher age group is probably due to economic and family problems, marital status, and daily concerns of this group compared to other groups. In the present study, 51.7% of assistants suffered from poor sleep quality. The highest complaint rate was seen in the surgery department, whereas radiology and ophthalmology COPY RIGHT 2012 Institute of Interdisciplinary Business Research 448

departments were placed in a better position compared to other groups, both statistically and based on the average sleep quality score. This may be because of less intense work shift and, probably, less stress experienced by this group. A study conducted in Kentucky, America in 2007 showed that inadequate sleep is accompanied by poor performance of the residents (Njafi M, 2000). Since surgery residents need more concentration and solace to fulfill their tasks, sleep disorders and, consequently, poor performance can bring about numerous negative complications for patients. Generally, the results of the present study shows the prevalence of poor sleep quality among medicine students and assistants. Since poor sleep quality is accompanied by poor performance (Njafi M, 2000) and also because medicine students and assistants will have a serious responsibility associated with the nature of their career, and their life quality has a direct relationship with their efficiency, it is necessary to take into account their sleep hygiene and consider interventions for improving the sleep quality of this population. Acknowledgement We need to thank the research council of Medicine Department of Zahedan University, the ethic committee on research, the specialist assistants in different specialized fields and medicine students at every educational grade that helped us in conducting this research. COPY RIGHT 2012 Institute of Interdisciplinary Business Research 449

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