Magnitude of poor Sleep Quality and Associated Factors among Health Sciences Students in Jimma University, Southwest Ethiopia, 2017

Background: Sleep disorders have been notified as one of the main health problems in the society. Most university students suffer from poor sleep quality which is a direct cause for daytime malfunction. There is a scarcity of data about sleep quality and its associated factors among university students in Ethiopia. The main aim of this study is to determine the magnitude of poor sleep quality and its associated factors among health sciences students in Jimma University, Southwest Ethiopia. Methods: A cross-sectional study was conducted from May27 to June 27; 2017.Multi-stage sampling technique was used to select 422 students. Data were collected using a semi-structured, pre-tested, self-administered questionnaire. EpiData version 3.1 and SPSS Version 20 for Windows were used for data entry and data analyses respectively. Frequencies, means, and proportions were used for descriptive data analysis. Multiple logistic regression was used to assess the association between poor sleep quality and independent variables. Statistical significance was taken at P< 0.05. Results: A total of 404 students completed and


Introduction
Sleep is a naturally recurring state characterized by unconsciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles [1]. It is very important for growth and repair, memory consolidation and restorative processes to occur in the body [2,3]. Getting sufficient sleep is one of the crucial things that we can do to keep our body healthy [4]. It is required for optimal wellbeing and function of key cognitive functions related with academic performance in school [5,6]. However, the standard of living and environmental factors are causing sleep disturbance [7]. The National Sleep Foundation's recommend adolescents to get 8.5-9.25 hours of sleep and adults to get 7-9 hours of sleep [5,6]. When students join university, they begin new living styles and most students modify their sleeping time and sleeping habits [8,9]. Which could be as a predisposing factor, for the increment of poor sleep quality among university students [10].
A study conducted to characterize sleep patterns and predictors of poor sleep quality in a large population of college student's shows over 60% were categorized as poor sleepers by the PSQI measurement [11]. The finding of different studies shows the prevalence of poor sleep quality among Asian medical student range from 19-74.2% [12][13][14][15][16]. Other studies conducted among Nigerian medical student shows the prevalence of sleep quality were 70% [17]. The prevalence of poor sleeps quality among colleges Ethiopian student by Lemma et al has been reported to be 55.8% [18]. Another study conducted in Debre Berhan University shows the prevalence of insomnia was 61.6% [19]. According to the findings of different studies female students get poor sleep quality relative to male students [3,10,12,20,21]. Another study showed that there was no statistically significant difference in sleep quality between males and females [22].
A study that evaluated the relationship between poor sleep quality and consumption of substances such as, alcohol, khat and cigarette showed a statistically significant association with poor sleep quality [20]. A study conducted in Jimma Ethiopia shows that chat chewers are more predisposed for poor sleep quality than non-chewers [23] Similarly, khat chewer students were classified as poor sleepers compared to those who did not chew khat. Khat chewing, especially at a higher quantity, also increased the risk of poor sleep quality, long sleep latency, poor sleep efficiency and sleep medicine use [20]. Students who reported the use of caffeinecontaining drinks per week were 1.48-times more likely to report long sleep latency compared to nonusers [20]. Smoking was positively correlated with poor sleep quality, Students who reported smoking cigarette had long sleep latency, poor sleep efficiency and sleep medicine use compared to nonsmokers [12,24].
Research conducted on the association of sleep quality and academic performance so far shows that poor quality sleep is associated with lower academic performance [25,26]. A study reported that there was statistically significant association between the use of electronic devices and poor sleep quality [8]. Prolonged Users of social networking, such as Face book had poorer sleep quality than Non-users [22]. Another study also found a positive relationship between the use of a mobile phone for playing games and chatting in bed with long sleep latency and severity of sleep disorders [24]. Limited number of studies was done to determine sleep quality and associated factors among medical students in Africa particularly in Ethiopia, there is scarcity of data that determine the magnitude and predictors of poor sleep quality, Therefore, we conduct this study so that it could fill the mentioned gaps by determining the prevalence of poor sleep quality and its associated factors among medical students.

Methods and Materials
The study was conducted at Jimma University, which is located in Jimma town 352 km Southwest of Addis Ababa, using a crosssectional study designs to determine the magnitude of sleep quality and associated factors among health science undergraduate regular students from May 27-June 27, 2017. The sample size was determined using the single population proportion formula, taking the following assumptions based on the previous study in the country that estimated prevalence of poor sleep quality among university students to be 52.7% [20], with confidence of 95%, margin of error 5%, and non-response rate of 10% were leading the final study sample of 422 student subjects. To reach at this sample the researchers deployed a Multi-stage sampling technique following which students from all courses of graduation were included in the study in order to maintain the representativeness of the sample. Students were stratified by field of study and batch (year of study).  Traditions (3%). Majority of the participants were single (96%).

Socio-Demographic Characteristics
Concerning field of study: medicine (53.2%), pharmacy (10.6%), nursing (18.1%), anesthesia (4.2%), environmental health (6.4%), and medical laboratory (7.4%).The proportion of poor sleep quality was highest among medicine students (56%) followed by pharmacy students (53.7%). In terms of study year, there were a high proportion of students who were studying in the fourth year (21.8%) and second year (20.3%). The proportion of participants categorized to have poor sleep quality was highest among sixth- year students (65.5%) followed by the fifth year (56%) and second- year students (56%). (SD=±0.48) ( Table 1).    had pain/discomfort during sleep less than once a week (Table 3). Those who use an electronic device for more than 2 hours (63.2%) had poorer sleep quality compared to those who use 1-2 hours (41%), and those who use less than 1 hour (34%) a day (Table 4).

Association Variables
The odds of poor sleep quality according to participants' sociodemographic characteristics; substance use and an electronic device use were examined in the study. From a total of 15 variables initially considered to be probably associated with sleep quality; bivariate logistic regression analysis found 7 variables which fulfill the criteria (p<0.25). Age, monthly income, academic performance, alcohol consumption, cigarette smoking, khat chewing, and electronic device use were p-value<0.25 that enter to multiple logistic regression (   Research indicates an association between irregular selfreported sleep patterns and increased alcohol consumption. Specifically, self-report of insomnia is associated with a twofold increase in self-reported alcohol abuse. [31] Whereas this study disagrees with the study done among large portion of college student by revealed that tension and stress accounted poor sleep quality, whereas alcohol and caffeine consumption, were not significant predictors of sleep quality [32]. Current khat chewers' participants had increased risk of poor sleep quality than non-chewers. This finding agrees with the study conducted in Jimma town and Yemen [33,34] this could be the result of sympathomimetic effects of khat (Catha edulis) which has amphetamine like effect Which causes psycho-stimulation and euphorigenic effects by impairing the sleep center [34,35]. This study also investigated the use of an electronic device in relation to the quality of sleep among health science students. Most of the participants in this study reported the use of an electronic device.
In this study population, using an electronic device for >2 hours increased the risk poor sleep quality. Use of electronic devise for prolonged time showed relation with poor sleep quality, study conducted among southern Taiwan and Iran students demonstrated significant negative association between the degree of internet addiction and sleep quality [36,37] The possible mechanism for the negative effect of electronics use on sleep is that the light produced by electronic devices may disturb circadian rhythms by inhibiting melatonin hormone, resulting in the inability to start sleep at the right time and the brightness of the light that is projected onto the retina from computers or mobile screens send signals to hypothalamus which is thought to be factors that trigger changes in sleep patterns [38].

Limitation and Strength of the Study
Even though we deployed a Multi-stage sampling technique we didn't use design effect. Second, use of a self-administered survey that relied on subjective measures of sleep quality and other covariates may have introduced some degree of error in reporting behavioral covariates, and the period of the semester when the survey was administered could have influenced the sleep quality.
However, we believe that by the use of the anonymous questionnaire and validated instrument might overcome these issues.

Conclusion
This study provides strong evidence that poor sleep quality is vastly prevalent among Jimma university health science students.
The findings in this study show that alcohol consumption, khat chewing, duration of electronic device use and academic performance are statistically significant predictors of poor sleep quality which have a big impact on student's wellbeing. As sleep good quality may be a marker for health status and quality of life, prospective studies are needed to be done.

Conflict of Interests
The authors have not declared any conflict of interests.