|Year : 2019 | Volume
| Issue : 1 | Page : 21-25
A study to assess the relationship among sleep, physical health, psychological health, and quality of life among undergraduate students
Vallabhaneni Pujitha1, Molangur Umashankar2, Bipeta Rajshekhar3, Reshaboyina Lakshman Rao4
1 House Surgeon, Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
2 Professor of Psychiatry and Head, Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
3 Associate Professor of Psychiatry, Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
4 Professor of Community Medicine and Head, Department of Community Medicine, Osmania Medical College, Hyderabad, Telangana, India
|Date of Web Publication||20-Jun-2019|
Prof. Molangur Umashankar
Department of Psychiatry, Gandhi Medical College and Hospital, Musheerabad, Secunderabad - 500 003, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Context: The sleep is an important biological function, and the students are especially vulnerable to sleep-related problems which may have an impact on their health and well-being.
Aims: The aim of this study was to assess the quality of sleep (QoS) and to study the relationship among QoS, physical health, psychological health, and quality of life (QoL) in undergraduate (UG) students.
Settings and Design: In a cross-sectional study, 625 UG students filled out a semi-structured questionnaire.
Subjects and Methods: The participants were administered the Pittsburgh Sleep Quality Index, WHO-5 Well-Being Index (WHO-5), and Rotterdam Symptom Checklist.
Analysis Used: The data were compared using percentages and proportions.
Results: A higher number of participants were with poor QoS in the categories of poor physical health (P = 0.003) and poor QoL (P = 0.001). The psychological distress in the group with poor QoS was found to be greater than the psychological distress in the group with good QoS (P = 0.001).
Conclusions: In UG students, QoS was found to be positively associated with physical health, psychological health, and QoL. There is a need for longitudinal studies in this field to establish the causality.
Keywords: Health, quality of life, sleep, students
|How to cite this article:|
Pujitha V, Umashankar M, Rajshekhar B, Rao RL. A study to assess the relationship among sleep, physical health, psychological health, and quality of life among undergraduate students. Arch Ment Health 2019;20:21-5
|How to cite this URL:|
Pujitha V, Umashankar M, Rajshekhar B, Rao RL. A study to assess the relationship among sleep, physical health, psychological health, and quality of life among undergraduate students. Arch Ment Health [serial online] 2019 [cited 2021 Apr 14];20:21-5. Available from: https://www.amhonline.org/text.asp?2019/20/1/21/260770
| Introduction|| |
The sleep is a naturally occurring state characterized by altered consciousness, relatively inhibited sensory activity, and inhibition of nearly all voluntary muscles. The quality rather than the quantity of sleep of an individual is found to influence the physical health and also vice versa. The physically fit individuals are known to be less prone to sleep-related disorders, especially insomnia and restless legs syndrome. In turn, irregular and disturbed sleep is found to result in weight loss or weight gain. In India, sleep-related disorders were found in one-fifth of an apparently healthy and productive age group; 25.1% of these participants had BMI >25 kg/m2. The increasing health problems and poorly rated self-health may be strongly linked to declining quality of sleep (QoS).
The psychologically healthy people with positive relations with others, purpose in life, and self-acceptance are found to have relatively more sound sleep than others. Those with childhood trauma (burns, accidents, disasters, war experiences, and physical and emotional abuse) and with psychological problems have reduced sleep time and quality. A lack of a minimum of 6 h of undisturbed sleep results in increased stress, finally resulting in depression, and anxiety., More than the age-related physiological change, the negative impact of psychological and physical health has been found to be far greater on sleep. The self-reported shorter sleep duration is linearly associated with prevalent and persistent psychological distress in young adults (relative risk of 1.14). It has been indicated that sleep can reduce the negative impact of stress, suggesting that restorative sleep can help in the management of anxiety and depressive symptoms.
The quality of life (QoL) includes general well-being of individuals, their environment, physical and mental health, education, and social belongingness. A strong negative association between sleep deprivation and health-related QoL was found.
Rationale of the study
An active social life during night, excessively thinking about future, ambitious daily goals, homework requirements, examinations, lack of healthy and timely diet, lack of physical activity, alcohol and tobacco consumption, increased duration of exposure to video games, internet, and television contribute to irregular sleeping patterns in undergraduate (UG) students. The adverse effects, such as restlessness, irritability, fatigue, increased daytime sleepiness, the decline in attention span, and increased reaction time, may be seen as a result of decreased QoS. Hence, there is a need to target the UG students for the purpose of studying the effect of QoS on their physical health, psychological problems, and QoL.
Aims and objectives
In (UG) students, the aim of this study was (i) to assess QoS and (ii) to study the relationship among QoS, physical health, psychological health, and QoL.
| Subjects and Methods|| |
Design and operational procedure
This study was approved by the Institutional Ethics Committee and was conducted as per the ethical principles laid down by the Declaration of Helsinki. We obtained appropriate permissions from the concerned authorities of respective colleges before the start of the study. This was a cross-sectional questionnaire-based study. All the UG students aged 18 years and above, of both the genders, who were willing to participate in the study were approached in their classrooms. They were explained about the nature of the study. A brief introduction was given regarding the topic. The participants were assured of confidentiality. Those unwilling to take part were requested to leave. The rest of the participants were requested to fill the semi-structured pro forma asking them not to leave any identifying details. All the instruments were then administered in order (as mentioned below). The drop boxes were placed at the exit of the room where they were requested to put in their filled questionnaires in an anonymous manner.
A semi-structured questionnaire consisting of sociodemographic details, personal history, medical history, and substance history was specifically designed for this study.
For subjective assessment of physical health, the participants were asked “How would you describe your health at the present time?” Phelan et al. used this method for older population. This single-item question has a component score ranging from 0 to 7. The higher the score better is the health. Based on the scores, the participants were categorized into three groups – poor (1–3), average (4), and excellent health (5–7).
Pittsburgh Sleep Quality Index
The Pittsburgh Sleep Quality Index (PSQI) is a screening instrument to assess QoS over the previous 30 days. It has 19 items and is used to generate 7 component scores whose sum yields a global score. Apart from the first four open-ended questions, rest are assessed on a 4-point scale. Each component score has a value of 0 (no difficulty) to 3 (severe difficulty). The global score ranges from 0 to 21. Those participants with a score of more than 5 are considered to have a poor QoS.
The Rotterdam Symptom Checklist
The Rotterdam Symptom Checklist (RSCL) is used to measure QoL of cancer patients. It assesses four domains – physical symptom distress, psychological distress, activity level, and overall QoL. RSCL psychological distress subscale can be used in normal individuals too and is measured on a 7-item, 1–4 Likert scale. The total score is then converted into a score on 100 wherein higher score indicates more distress.
WHO-5 Well-Being Index (WHO-5)
The WHO-5, is used to assess subjective QoL. It consists of five items on a six-point scale ranging from 0 to 5. The score is summed and multiplied by 4; a score of 0 indicates worst thinkable well-being and a score of 100 indicates best thinkable well-being. The participants were categorized into three groups – poor, normal, and good QoL based on the score. A score below 13 indicates poor well-being.
The initial sample consisted of 956 UG students of science and arts (BCom, BSc, and BA) starting from the 1st year through the final year attending a degree college. Three hundred and thirty-two students were not able to take part in the study because of examinations. Eleven students had to be excluded because they were <18 years old. The rest of the participants (n = 625) were willing to take part in the study. Of the 625 collected papers, 13 had to be discarded as a result of incomplete filling up of questionnaires. The final sample was 612. The data were entered into entered into an MS Excel sheet (MS Excel (2013) | Microsoft). Analysis was carried out using SPSS 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0, IBM Corp. Armonk, NY, USA). The sample was divided into those with good and those with the poor QoS based on PSQI score. Then, their physical health, psychological health, and QoL were compared using percentages and proportions. The tests of significance used were Chi-square test and unpaired t-test. P < 0.05 was considered statistically significant.
| Results|| |
Sociodemographic data and lifestyle
The mean age of the study sample (n = 612) was 19 years (SD 1.30; range 18–26 years), and the males predominated (66%). On PSQI, 296 out of 612 participants (48.29%) had poor QoS. The association of QoS with the year of study, socioeconomic status, living arrangements, smoking, alcohol use, coffee consumption, regularly skipping sleep in the night (night outs), and changing the place of sleep is depicted in [Table 1].
|Table 1: The association among quality of sleep, sociodemographic data, and other parameters in the undergraduate students (n=612)|
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In [Table 2], the physical health scores, psychological distress scores, and QoL scores of the group of students with poor QoS are compared to the group with good QoS. The more number of students in the category of good QoS were found to have excellent physical health (P = 0.003). The more number of students with good QoS have good QoL (P = 0.001). The psychological distress score of participants with poor QoS (49.72 ± 22.26) was found to be higher than those with good QoS (37.25 ± 20.05) (P = 0.001).
|Table 2: The association among quality of sleep, physical health, quality of life, and psychological distress in the undergraduate students (n=612)|
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| Discussion|| |
Our study assessed QoS among the UG students (n = 612). About 48.29% of our sample had poor QoS, while a previous study on the UGs in Peru found 55% of the UG students with poor QoS. Another study conducted on a group of students found 34% poor sleepers. The high prevalence of poor QoS among UGs could be due to increasing pressure and stress to deal with the fast pace of life. This is taking a heavy toll on their physical and mental health.
More number of participants with poor QoS lived with parents (P = 0.000). Hughes and Gove similarly found that people living with others have poorer QoS than those living alone (provided that the level of psychological well-being is same) because they face constant pressure. The students may similarly face this pressure from their parents to succeed academically in extracurricular activities, to settle down, to secure a good job, and to move out. This stress and pressure may lead to a decline in QoS. The higher rates of caffeine consumption were found in participants with poor QoS (P = 0.0007) in line with the previous studies., Possibly, the stimulant effect of caffeine is responsible for this. Hence, the intake of caffeine products before going to bed at night time should be avoided. Furthermore, poor QoS could be found in participants with previous exposure to any stressful incident in the previous 1 month (P = 0.0001) such as examinations, competitions, death or illness in the family or friends, and financial troubles. When faced with such stressful events, there is a decline in QoS, which can be addressed by counseling. The poor QoS was seen in those who changed their place of sleeping recently (P = 0.0007) maybe as a result of being unaccustomed to the new environment, suggesting that frequent change of place of sleep needs to be avoided to ensure good sleep. The participants with good QoS were found to be higher in the 2nd year of study rather than in the 1st and 3rd year (P = 0.004). This could be the result of increased examination stress in the 3rd (or final)-year students and new college environment in the 1st-year students. There is a need for provision of adequate psychological and academic support to the students to overcome this. We could not find any significant relation between cigarette use and QoS nor in between alcohol consumption and QoS contrary to the findings of previous research.,,, This might be due to the use of standardized scales for the assessment of alcohol and cigarette use in those studies leading to a better assessment of participants' habits.
We found that the physical health was significantly associated with QoS (P = 0.003), as was seen in previous research.,,, The good sleep provides adequate rest to the body; and thus, may lead to improvement of physical health. The UG students with high levels of psychological distress had poor QoS (P = 0.001) which is in line with the previous studies., As in other studies,, in our study too, the students who had better QoS had better QoL (P = 0.001). The better QoS may improve the life of a person physically, psychologically, and socially leading to better mood and vitality, thus improving the QoL.
Strengths and limitations of our study
Our study has certain limitations. The instruments used are not standardized for Indian population. The RSCL psychological distress subscale though validated for use on cancer patients and earlier been used for normal individuals is not standardized in other conditions. The self-reported physical health evaluation scale which is validated for older adults is not standardized for young adults. As we relied on self-report, with no face-to-face interviews, there are chances that the participants might have underestimated the sleep time because of fragmented sleep. Ours being a cross-sectional study, we could only establish association, not the causality. The comorbid illnesses, especially psychiatric morbidity and other confounding factors which could affect QoS, were not taken into consideration.
The strengths of our study are a relatively large sample size, and the participants were taken from various study streams instead of limiting to one.
| Conclusions|| |
A good QoS is found to be associated with good physical health, psychological well-being, and good QoL. Hence, adequate measures to improve sleep quality must be in place. There is a need for awareness programs for UG students regarding the importance of sleep in maintaining their health. The principles of sleep hygiene may be employed not just for those with sleep-related disorders but also for healthy young adults and students. Longitudinal studies are needed to evaluate how the improvement of QoS may lead to improvement in physical and psychological health and QoL.
The authors acknowledge Mr. Sundaresh Peri, the retired lecturer of biostatistics, Kakatiya Medical College, Warangal, India, and Dr. Sameer Valsangkar, senior resident of community medicine, Gandhi Medical College, Hyderabad, India, for their help in statistical analysis. They also wish to thank all the participants of this study and the faculty of the respective colleges for granting permission to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Halsey WD. Macmillian Dictionary for Students. New York: Macmillan; 1981. p. 936.
Pilcher JJ, Ginter DR, Sadowsky B. Sleep quality versus sleep quantity: Relationships between sleep and measures of health, well-being and sleepiness in college students. J Psychosom Res 1997;42:583-96.
Sherrill DL, Kotchou K, Quan SF. Association of physical activity and human sleep disorders. JAMA Intern Med 1998;158:1894-8.
Taheri S, Lin L, Austin D, Young T, Mignot E. Short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. PLoS Med 2004;1:e62.
Panda S, Taly AB, Sinha S, Gururaj G, Girish N, Nagaraja D, et al.
Sleep-related disorders among a healthy population in South India. Neurol India 2012;60:68-74.
] [Full text]
Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: Results of the 2003 National Sleep Foundation Sleep in America Survey. J Psychosom Res 2004;56:497-502.
Phelan CH, Love GD, Ryff CD, Brown RL, Heidrich SM. Psychosocial predictors of changing sleep patterns in aging women: A multiple pathway approach. Psychol Aging 2010;25:858-66.
Bader K, Schafer V. Sleep disturbances following traumatic experiences in childhood and adolescence: A review. Somnology 2007;11:101-10.
Hatzinger M, Hemmeter UM, Brand S, Ising M, Holsboer-Trachsler E. Electroencephalographic sleep profiles in treatment course and long-term outcome of major depression: Association with DEX/CRH-test response. J Psychiatr Res 2004;38:453-65.
Papadimitriou GN, Linkowski P. Sleep disturbance in anxiety disorders. Int Rev Psychiatry 2005;17:229-36.
Lesage S, Scharf SM. Beyond the usual suspects: Approaching sleep in elderly people. J Gerontol A Biol Sci Med Sci 2007;62:53-4.
Glozier N, Martiniuk A, Patton G, Ivers R, Li Q, Hickie I, et al.
Short sleep duration in prevalent and persistent psychological distress in young adults: The DRIVE study. Sleep 2010;33:1139-45.
Hamilton NA, Catley D, Karlson C. Sleep and the affective response to stress and pain. Health Psychol 2007;26:288-95.
Derek G, Johnston R, Pratt G, Watts M, Whatmore S. The Dictionary of Human Geography. 5th
ed. Oxford: Wiley-Blackwell; 2009.
Lo CM, Lee PH. Prevalence and impacts of poor sleep on quality of life and associated factors of good sleepers in a sample of older Chinese adults. Health Qual Life Outcomes 2012;10:72.
Vignau J, Bailly D, Duhamel A, Vervaecke P, Beuscart R, Collinet C, et al.
Epidemiologic study of sleep quality and troubles in French secondary school adolescents. J Adolesc Health 1997;21:343-50.
Eliasson A, Eliasson A, King J, Gould B, Eliasson A. Association of sleep and academic performance. Sleep Breath 2002;6:45-8.
Ohayon MM, Roberts RE, Zulley J, Smirne S, Priest RG. Prevalence and patterns of problematic sleep among older adolescents. J Am Acad Child Adolesc Psychiatry 2000;39:1549-56.
Brand S, Blechschmidt A, Müller A, Sader R, Schwenzer-Zimmerer K, Zeilhofer HF, et al.
Psychosocial functioning and sleep patterns in children and adolescents with cleft lip and palate (CLP) compared with healthy controls. Cleft Palate Craniofac J 2009;46:124-35.
World Medical Association. Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA 2013;5:24-31.
Buysse DJ, Reynolds CF 3rd
, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193-213.
de Haes JC, van Knippenberg FC, Neijt JP. Measuring psychological and physical distress in cancer patients: Structure and application of the Rotterdam Symptom Checklist. Br J Cancer 1990;62:1034-8.
Bech P. Clinical Psychometrics. Oxford: Wiley-Blackwell; 2012.
Wolniczak I, Cáceres-DelAguila JA, Palma-Ardiles G, Arroyo KJ, Solís-Visscher R, Paredes-Yauri S, et al.
Association between Facebook dependence and poor sleep quality: A study in a sample of undergraduate students in Peru. PLoS One 2013;8:e59087.
Kirmil-Gray K, Eagleston JR, Gibson E, Thoresen CE. Sleep disturbance in adolescents: Sleep quality, sleep habits, benefits about sleep and daytime functioning. J Youth Adolesc 1984;13:375-84.
Hughes M, Gove WR. Living alone, social integration, and mental health. AJS 1981;87:48-74.
Karacan I, Thornby JI, Anch M, Booth GH, Williams RL, Salis PJ, et al.
Dose-related sleep disturbances induced by coffee and caffeine. Clin Pharmacol Ther 1976;20:682-9.
Calamaro CJ, Mason TB, Ratcliffe SJ. Adolescents living the 24/7 lifestyle: Effects of caffeine and technology on sleep duration and daytime functioning. Pediatrics 2009;123:e1005-10.
Wetter DW, Young TB. The relation between cigarette smoking and sleep disturbance. Prev Med 1994;23:328-34.
Phillips BA, Danner FJ. Cigarette smoking and sleep disturbance. Arch Intern Med 1995;155:734-7.
Foster JH, Peters TJ. Impaired sleep in alcohol misusers and dependent alcoholics and the impact upon outcome. Alcohol Clin Exp Res 1999;23:1044-51.
Roehrs T, Roth T. Sleep, sleepiness, sleep disorders and alcohol use and abuse. Sleep Med Rev 2001;5:287-97.
Furihata R, Uchiyama M, Takahashi S, Suzuki M, Konno C, Osaki K, et al.
The association between sleep problems and perceived health status: A Japanese nationwide general population survey. Sleep Med 2012;13:831-7.
Lee AJ, Lin WH. Association between sleep quality and physical fitness in female young adults. J Sports Med Phys Fitness 2007;47:462-7.
Li F, Fisher KJ, Harmer P, Irbe D, Tearse RG, Weimer C, et al.
Tai chi and self-rated quality of sleep and daytime sleepiness in older adults: A randomized controlled trial. J Am Geriatr Soc 2004;52:892-900.
Wong ML, Lau EY, Wan JH, Cheung SF, Hui CH, Mok DS, et al.
The interplay between sleep and mood in predicting academic functioning, physical health and psychological health: A longitudinal study. J Psychosom Res 2013;74:271-7.
Augner C. Associations of subjective sleep quality with depression score, anxiety, physical symptoms and sleep onset latency in students. Cent Eur J Public Health 2011;19:115-7.
Tzischinsky O, Shochat T. Eveningness, sleep patterns, daytime functioning, and quality of life in Israeli adolescents. Chronobiol Int 2011;28:338-43.
Brown FC, Buboltz WC Jr., Soper B. Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behav Med 2002;28:33-8.
[Table 1], [Table 2]