Abstract

Background: Insomnia is a common complaint with potentially significant medical and psychological complications as well as affecting the quality of life. Objectives: To estimate the prevalence of insomnia and define its determinants among family medicine residents at joint program in Makkah city 2020. Material and methods: Cross-sectional analytical study has been conducted among all family medicine residents enrolled in joint program of Family Medicine in Makkah city, during September 2020. A validated questionnaire was used based on Pittsburgh Sleep Quality Index (PSQI) and Pittsburg Insomnia Symptoms questionnaire in addition to demographic and personal characteristic of the residents. Results: The study included 158 resident physicians out of a total 161 invited to participate with a response rate of 98.1%. Majority (93%) aged between 25 and 30 years and females represent 58.2% of them. Overall, poor sleep quality, based on PSQI was observed among majority of the participants (87.3%). All underweight, majority (97.9%) of overweight and 88.2% of obsess subjects compared to 80.2% of normal subjects expressed poor sleep quality, p=0.020.All current smokers compared to 84.8% of non-smokers had poor sleep quality, p=0.021. Majority (93.9%) of residents who never practiced physical exercise compared to 77.8%) of practicing exercise almost daily had poor sleep quality, p=0.020. Conclusion: Poor sleep quality is a very common problem prevailing among family medicine residents in Makkah Al-Mukarammah, with some identified modifiable associated factors.

1. Introduction

Insomnia is one of the commonest symptoms for which adults seek medical advice. It affects one in ten individuals, representing a societal burden and imposes impact on public health ¹.

Patients with insomnia have difficulty initiating sleep, difficulty maintaining sleep, or waking up early in the morning without the ability to return to sleep, and they also suffer from significant daytime symptoms such as fatigue, sleepiness, inattention, mood disturbance, or impaired performance ².

Insomnia is correlated with impaired mood, subjective functioning, and quality of life. Chronic insomnia is a common problem, often associated with negative waking mood or function. As such, heightened clinical attention and clinical research appear warranted ³.

Insomnia, depending on its duration, is described as short-term or chronic. Short-term insomnia usually lasts a few days or weeks and occurs in response to an identifiable stressor and usually symptoms exist for less than three months while in chronic insomnia, insomnia symptoms occur at least three times/week and last for at least three months ⁴.

A recent systematic review including 4 studies revealed that insomnia affecting almost 38.9% of healthcare workers during the COVID-19 pandemic ⁵:

In Makkah (Saudi Arabia), a high rate (77%) of insomnia has been reported previously among family medicine residents ⁶. However, lower rate (29.2%) was reported among family physicians in another study carried out in Jeddah ⁷.

In a recent study carried out in the United States, younger healthcare workers, those working in a COVID-facing environment and hours worked were the significant determinants of insomnia ⁸. A recent Saudi study carried out among family physicians revealed that the determinants for insomnia were years in practice, emotional stress, chronic disease, bad moods and loss of interest in things interested before ⁷.

This study aims to estimate the prevalence and some determinants of insomnia among family medicine residents at joint program in Makkah city 2020.

2. Material and Methods

A cross-sectional analytical study included all family medicine residents (males and females) enrolled in joint program of Family Medicine in Makkah city, Kingdom of Saudi Arabia during September 2020 was conducted. Makkah is the holy city for all Muslims, and located in the western area of Saudi Arabia.

A validated questionnaire was used based on Pittsburgh Sleep Quality Index (PSQI) and pittsburg Insomnia Symptoms questionnaire ⁹. Permission from the University of Pittsburgh was requested to use the questionnaire. It is composed of two main sections; Demographic and personal characteristic of family medicine residents: Age, gender, level of residency (R1-R4), marital status, smoking status (Not smoker, 1-10 cigarettes/day, 11-20 cigarettes/day and >20 cigarettes/day), taking sedatives or stimulant medications, past medical history and past psychiatric history and PSQI: this measures the quality and patterns of sleep. It differentiates ‘poor’ from ‘good’ sleep by measuring in ten questions, seven areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication and daytime dysfunction over the last month. Scoring of answers is based on a 0 to 3 scale, whereby 3 reflect the negative extreme on the likert scale. A global of ‘5’ or greater indicates a ‘poor’ sleeper.

The questionnaires was distributed to candidates of the joint program of family medicine during the half day release course (HDRC) which is held every Tuesday in the center of the program during the study period which is one month. As there is a large number of residents attending the HDRC at the same time, they are divided into four groups. Each group consists of candidates and has their meeting in a different hall. At the beginning of the lecture of the HDRC, the researcher himself distributed the questionnaires to the residents then will be collected back at the end of the lecture. During the 1^st and 2^nd weeks, he distributed questionnaires to groups A & B and groups C & D, respectively. If the participants are not completed, the researcher did the same procedure again during the next 2 weeks, till achieving the targeted number.

Approval from the joint program of family medicine in Makkah was obtained. Permission from the Directorate of Health Affairs of the Holy Capital Primary Health Care was obtained (Institutional Research Board “IRB” Committee) and consent from the participants was taken through the sentence (By answering the questions of this questionnaire, you are agreeing to participate in the study).

The Statistical Package for Social Sciences (SPSS) software version 26.0 was used for data entry and analysis. Frequency and percentage were used to describe variables and Chi-square test or Fischer exact test (in case of small frequencies) were applied to test for the association between overall sleep quality and possible associated factors and considering p values as significant if less than 0.05.

3. Results

The study included 158 resident physicians out of a total 161 invited to participate with a response rate of 98.1%. Table 1 presents their personal and demographic characteristics. Majority of them (93%) aged between 25 and 30 years. Females represent 58.2% of them. More than half of them (56.3%) were singles and have normal body mass index (54.4%). There were almost equally distributed over the four residency level.

Prevalence of current smoking among the family medicine residents, Makkah city was 16.4%; among them 3.8% smoked more than twenty cigarettes per day. A considerable proportion of them (40.5%) never practicing physical exercise while only 11.4% practiced it almost daily. Most of them consumed 1-2 cups of coffee and tea daily (63.3% and 53.1%, respectively). Majority of them (88.6%) never take sedatives or stimulant medications. Among those who reported taking these medications, melatonin ranked first (6.3%). History of chronic diseases was mentioned by 15.8% of the resident physicians. Table 2

About 45.6% of the participants described their sleep quality as fairly good whereas 26.6% and 10.1% described it as fairly bad and very bad, respectively.

About a third (35.4%) of the participants stayed between 16 and 30 minutes in bed to fall asleep each night in the past month whereas 12% of them stayed more than one hour. Moreover, more than one-quarter of them (27.8%) cannot get to sleep within 30 minutes three times or more a week in the past month.

Only 12% of the participants sleep actually more than 7 hours per night each day in the past month while 30.4% of them reported sleeping for less than five hours each night.

Habitual sleep efficiency was less than 65% among 34.8% of the participants while it was 85% or above among another 34.8% of them.

The commonest reported sleep troubles (three times or more in a week) in the past month, with the exception of sleep latency were waking up in the middle of the night or early morning (16.5%), having to get up to use the bathroom (13.3%), cough or snore loudly (7%) and feel too hot (6.3%).

Only 3.8% of the participants reported using sleep medications three times or more a week to help in sleep in the past month.

Having troubles staying awake while driving, eating meals or engaging in social activities in frequencies of three times or more a week were reported by 5.1% of the participants in the last month. Additionally, 10.1% of them reported that three times or more a week, this problem has it been for them to keep up enthusiasm to get things done.

Overall, poor sleep quality, based on PSQI was observed among majority of the participants (87.3%) as illustrated in Figure 1.

All underweight, majority (97.9%) of overweight and 88.2% of obsess subjects compared to 80.2% of normal subjects expressed poor sleep quality, p=0.020. Other studied factors (age, gender, marital status and residency level) were not significantly associated with sleep quality as seen in Table 3.

All current smokers compared to 84.8% of non-smokers had poor sleep quality, p=0.021. Majority (93.9%) of residents who never practiced physical exercise compared to 77.8%) of practicing exercise almost daily had poor sleep quality, p=0.020. Coffee and tea drinking, taking sedatives or stimulant medications and history of chronic disease were not significantly associated with sleep quality. Table 4

4. Discussion

Insomnia is an avoidable disorder and can be effectively managed, despite of its adverse sequelae on an individual`s quality of life, productivity, mood and morbidity; through preventive measures in the form of health education and counseling ¹⁰. The present study was conducted to estimate the prevalence of insomnia and its gender difference among family medicine residents at joint program in Makkah city 2020.

In the current study, poor sleep quality was reported among majority of the respondents (87.3%), which is higher than the figure reported previously by Alahdal, et al (2017) among Family Medicine residents at Joint Program in Makkah Al Mukarramah and Jeddah Cities (77%) ⁶. The high rates reported in both Saudi studies among family medicine residents are alarming and should be treated promptly. They may be attributed to the fact that young less experienced physicians, like our target population are usually less likely to have relaxation after long working hours as suggested by Söderström M, et al ¹¹. Additionally, some authors suggested that thinking too much about sleep deprivation and its impact in next day among persons suffering from insomnia, if they don`t sleep enough exaggerate the situation ¹² and create a hyperactive state, which increase the activation of the hypothalamic–pituitary–adrenal (HPA) axis, ¹² and this could be the situation among participants in this study.

Lower figures of insomnia have been reported by others. Among primary care physicians in Spain, 18.8% met diagnostic criteria for insomnia diagnosis ¹³. Among nurses, the prevalence of at least one type of reported sleep disturbance was 69.7% ¹⁴. In a systematic review and meta-analysis carried out among healthcare workers, insomnia prevalence was estimated at 38·9% across 4 studies ¹⁵. Comparison between these studies, including the present one should be taken with caution, although they used almost the same tool to assess sleep quality, due to variations in the demographics of the participants in these studies as well as carrying our these studies in different cultures. However, despite of these factors, it is considered very high among our population.

In the present study, 88% of the Family Medicine resident physicians sleep 7 hours or less per night. This figure is much higher than that reported among adult population in Saudi Arabia (33.8%) ¹⁶. This finding again showed how much young physicians differed from general population in this regards

The current study revealed no gender difference as regards sleep quality. However, several studies reported that females were more likely to have poor sleep quality compared to males and attributed this to differences between males and females in work and family responsibilities ^{16, 17, 18, 19}.

In accordance with others ^{20, 21, 22}, poor sleep quality was more reported among smokers than non-smokers in the present survey. It has been suggested that cigarette smoking may impact sleep quality in various methods. First of all, the direct influence of nicotine as a stimulant. Secondly, the desire of smokers to have nicotine may awaken them causing insomnia and additionally, smoking near bedtime may lead to sleep latency ²¹. Nicotine also increase the likelihood of obstructive sleep apneaand affecting adversely the circadian clock ²³.

In agreement with other studies ^{21, 24}, the present survey revealed an association between physical inactivity and poor sleep quality. The mechanism through which physical activity helps sleep is not clear; however, some theories were suggested. The first one indicated that physical activity produces changes in body temperature as during the activity, the temperature rises and afterward it drops and this drop mimics a temperature change that happens before sleep, when body temperature decreases which may send signal to central nervous system that it’s a sleep time. Physical activity may lead to release of endorphins that help sleeping through relieving of anxiety and depression symptoms which are associated with insomnia ²³. Physical activity might adjust the internal body clock and circadian rhythms through secretion of serotonin hormone involved in the sleep-wake cycle ²⁴.

In the present study, there was higher rate of poor sleep quality among overweight/obese subjects from one side and normal BMI subjects from the other side. The same has been observed by others ^{25, 26}. Interestingly, also the present survey revealed higher rate of poor sleep quality in underweight subjects compared to normal subjects. In Germany, Crönlein T, et al reported an association between lower BMI and chronic insomnia among Caucasian population ²⁷. Also, Huang, et al (2013) observed the same among Asian population ²⁸.

Some limitations of the current study should be addressed. First of all, conduction the study among family medicine residents in one program in one Saudi city could affect our ability to generalize the study`s findings over other places and cities in Saudi Arabia. Second, is the cross-sectional design adopted in this study that proves only association and not causality between dependent and independent variables. Finally, the tool used to collect data in the present study was self-administered and subjected to bias. However, researches have indicated that self-administered tools of assessing insomnia are highly correlated with objective measures. Despite of those limitations, the study has some strength, including the very high response rate reaching (98.1%), which minimizes the possibility of selection bias. Also, the study has identified some associates of insomnia among family medicine residents that could be of importance to higher authorities to put a plane for reducing the rate of poor sleep quality among this vulnerable population.

In conclusion, poor sleep quality is a very common problem prevailing among family medicine residents in Makkah Al-Mukarammah. Poor sleep quality was more observed among none-smokers resident physicians, physically inactive and those with abnormal body mass index (underweight/obese or underweight).

According to the present study`s findings, the following are recommended:

1) Screening for early poor sleep quality among Family Medicine residents through a simple valid tool such as PSQI.

2) Exploring of the association between poor sleep quality, both diagnosed and self-reported and medical mistakes is warranted.

3) Interventional studies are needed that minimizes burnout and improve sleep quality and clinical practice of residents.

4) Minimizing the problem of smoking among resident physicians through health education and smoking cessation clinics

5) Encourage resident physicians to practice physical exercise on regular basis and providing time and place for that.

6) Enhancing weight management among residents physicians and setting programs for that

References