Sleep education improves knowledge but not sleep quality among medical students

Abstract

Study Objectives:

Poor sleep quality, often resulting from poor sleep hygiene, is common among medical students. Educational interventions aimed at improving sleep knowledge are beneficial for sleep quality in healthy populations. However, sleep education is often given minimal attention in medical school curriculums. The aim of the study was to explore whether a short educational intervention could improve sleep knowledge, and consequently sleep quality, among medical students.

Methods:

We recruited preclinical- and clinical-stage medical students during the 2017–2018 academic year. Students completed a demographic survey, the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Assessment of Sleep Knowledge in Medical Education (ASKME) questionnaire. Students then attended a lecture on the physiology and importance of sleep. To assess the efficacy of the intervention, questionnaires were repeated 4 months thereafter.

Results:

A total of 87 students (31 preclinical) with a mean age of 25.86 years (standard deviation [SD], 3.33), 51 of whom were women, participated in the study. At baseline, students had poor sleep quality with a PSQI mean score of 5.9 (SD, 2.37), without significant sleepiness, and a mean ESS score of 8.86 (SD, 4.32). The mean ASKME scores were consistent with poor sleep knowledge at 11.87 (SD, 4.32). After the intervention, the mean ASKME results improved to 14.15 (SD, 4.5; P < .001), whereas sleep quality did not. The effect was similar in preclinical and clinical medical students.

Conclusions:

Sleep knowledge was inadequate among medical students, who also experienced poor sleep quality. A short educational intervention improved sleep knowledge but was insufficient at improving sleep quality. Further studies are needed to determine which interventions may provide benefit in both sleep knowledge and sleep quality.

Citation:

Mazar D, Gilleles-Hilel A, Reiter J. Sleep education improves knowledge but not sleep quality among medical students. J Clin Sleep Med. 2021;17(6):1211–1215.

BRIEF SUMMARY

Current Knowledge/Study Rationale: Poor sleep quality and lack of sufficient knowledge of sleep medicine are common among medical students. Because educational interventions aimed at improving sleep knowledge have been beneficial in healthy populations, we sought to explore whether such an intervention would improve sleep knowledge, and consequently sleep quality, among medical students.

Study Impact: Students had poor sleep knowledge and sleep quality. A short educational intervention improved knowledge but was insufficient at improving sleep quality; therefore, further studies are needed to determine which interventions may provide benefit in both sleep knowledge and sleep quality.

INTRODUCTION

Poor sleep quality is considered a health problem and is a common phenomenon among medical students around the world. ^1–4 Sleep is often impaired because of poor sleep habits and sleep hygiene resulting from the intense learning, long hours, and high academic demands, in addition to the emotional challenges imposed by clinical exposure. ¹

Poor sleep hygiene refers to factors that interfere with sleep such as a poor sleep environment, irregular sleep routines, and exposure to bright lights and stimulating activities before bedtime. ⁵ Measures to improve sleep hygiene include regular exercise, stress management, noise reduction, regular sleep timing, and avoidance of caffeine, nicotine, alcohol, and daytime napping. ⁶ Poor sleep hygiene can lead to insufficient sleep that is associated with obesity and metabolic syndrome, ^7–9 immune dysfunction, ¹⁰ depression, ¹¹ and cognitive impairments. ¹² Insufficient sleep in young adults may cause persistent psychological distress ¹³ and overall poor self-rated health. ¹⁴ Studies have shown an association between poor sleep habits and lower academic achievements in medical students. ^2,15–17 Furthermore, as students advance into internships and residencies, there is clear evidence of the deleterious effects of sleep deprivation on both health and cognitive functioning. ¹⁸ A recent study of the effects of chronic and acute sleep deprivations in residents has shown a dose-dependent effect on cognitive functions and behavior with impulsive behaviors. This effect is particularly worrisome because it may lead to medical errors and may in fact harm patients. ¹⁹

However, despite the importance of sleep as a pillar of a healthy lifestyle, limited attention is given to the subject of sleep education and sleep hygiene in medical schools, with the majority of students graduating with minimal knowledge of sleep. In fact, a 2011 worldwide study of 106 medical schools in 10 countries revealed that on average, less than 2.5 hours were dedicated to sleep education over the entire course of time spent in medical school. Furthermore, 27% of schools reported no time at all spent on sleep education. ²⁰

Employer-initiated interventions, such as educational programs to improve the sleep of workers, can improve workers’ sleep duration and sleep quality and mitigate self-reported sleepiness complaints. ²¹ Several studies have shown that short educational sessions are beneficial in such healthy populations. One Japanese study among 391 high-technology company employees with a mean age of 34 years showed that a short educational session on sleep hygiene could improve sleep and daytime sleepiness. ²² A 2012 study conducted in New Zealand on the effect of sleep hygiene intervention for adolescents concluded that a 90-minute sleep hygiene educational session, in which participants were handed a written guide with rules and practices for better sleep, improved sleep quality significantly. ²³

The aim of the current study was to examine whether a short educational intervention could improve sleep knowledge and quality among medical students and to assess differences between preclinical and clinical students. We hypothesized that the intervention would be more effective in preclinical students because they are expected to be slightly younger and have a regular schedule.

METHODS

This was a prospective interventional study conducted at the Hebrew University–Hadassah Medical School in Jerusalem, Israel, between October 2017 and April 2018. The study population included medical students who were recruited voluntarily by email and text messages. The study was approved by the local ethics committee, and all participants gave informed written consent before participation (HMO 0353-17).

Study protocol

Students were recruited based on their year in medical school: third-year medical students, representing preclinical students (years 1–3 of medical school), and fifth-year medical students, representing clinical stage students (years 4–6 of medical school). Students initially completed 4 questionnaires: the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), the Assessment of Sleep Knowledge in Medical Education (ASKME) questionnaire, and a demographics questionnaire. After completing the questionnaires, students attended a formal, didactic session on sleep physiology and its importance, geared toward topics most pertinent to medical students. The session covered the 2-process model of sleep regulation, a discussion of sleep needs and the results of insufficient sleep, and a brief discussion of delayed sleep phase disorder, insomnia, and hypersomnia. The lecture was delivered by a sleep medicine physician (JR), emphasizing the importance of proper sleep habits and hygiene and offering specific evidence and recommendations for medical students and newer physicians. Four months after the lecture, once all clinical students were fully enrolled in clinic studies and sufficient time had passed to allow for stabilization of sleeping habits, ²³ the 3 sleep-related questionnaires were administered again.

Study questionnaires

The PSQI and ESS are questionnaires on self-reported sleep quality and sleepiness (respectively). Both have been validated in a wide range of population-based and clinical studies including studies of university students. ^4,24–26 Knowledge of sleep medicine was assessed using the ASKME survey, designed as a standardized measure for the assessment of medical education on sleep. ²⁷ Medical students and sleep specialists were among those initially tested, showing that the survey discriminates between individuals with varied levels of education, experience, and specialty training. ²⁷ The demographic questionnaire included age, sex, marital and parental status, accommodation, body mass index, physical activity, and smoking status. Medical student employment in Israel is often medicine-related such as for physician assistants, but many students have odd jobs in such areas as food service. On the demographic questionnaire, students were asked whether they were employed, how many hours per week, and whether their job included night shifts.

Statistical methods

The primary outcome of interest was the change in PSQI, ESS, and ASKME scores before and after the intervention. Secondary outcomes included an analysis of the influence of students’ characteristics such as age, marital status, employment, and year in medical school on the effect of intervention. Only students who completed both pre- (baseline) and postintervention questionnaires were included in the final analysis. Before the study, we calculated that a sample of 90 students would be sufficient to detect a small-medium size effect (d = 0.3) with a power of 80% and an alpha error of 5%. Paired tests were used to compare the effect of the intervention. Independent tests were used to compare the characteristics of preclinical and clinical students. Categorical variables were compared using the chi-square test and were followed by a Fisher exact test, when appropriate. Association between variables was assessed by a Pearson correlation coefficient. All tests applied were 2-tailed, and a P value ≤ 5% was considered statistically significant. Results throughout the study are shown as mean and standard deviation (SD).

RESULTS

Participant characteristics

A total of 87 medical students participated in the intervention and completed both baseline and postintervention questionnaires. The students’ mean age was 25.86 (33.33) years, 51 (59%) of whom were female. The average body mass index was 22.63 (2.96). Twenty-five students (29%) were married and of these students 12 (50%) had children. A majority of students 73 (84%) reported being physically active, 15 (17%) were smokers, and 66 (76%) were employed, working an average of 12.8 hours per week ( Table 1 ).

Table 1.

Participant characteristics.

	Total (n = 87)	Preclinical Students (n = 31)	Clinical Students (n = 56)	P
Age (y), mean (SD)	25.86 (3.33)	24.52 (2.79)	26.61 (3.4)	.004
Sex, female	51 (58.6)	23 (74.2)	28 (50.0)	.028
Marital status				.077
Single	62	26 (83.9)	36 (64.3)
Married, no children	13	4 (12.9)	9 (16.1)
Married, with children	12	1 (3.2)	11 (19.6)
Living status				.071
Lives alone	5 (5.7)	1 (3.2)	4 (7.1)
Lives with roommates	40 (46.0)	16 (51.6)	24 (42.9)
Lives with spouse	39 (44.8)	11(35.5)	28 (50.0)
Lives with parents	3 (3.4)	3 (9.7)	0 (0.0)
Physical activity				.108
Not active	14 (16.1)	2 (6.5)	12 (21.4)
Moderately active	37 (42.5)	17 (54.8)	20 (35.7)
Very active	36 (41.4)	12 (38.7)	24 (42.9)
Smoking status (nonsmoker)	72 (82.8)	24 (77.4)	48 (85.7)	.327
Employment (h/wk), mean (SD)	12.84	12.52 (7.23)	13.01 (8.66)	.818

P values shown comparing preclinical- with clinical-stage students. Results shown as number (percentage) unless otherwise indicated. SD = standard deviation.

Baseline sleep questionnaire results

Sleep-related results are shown in Table 2 . At baseline, students had poor sleep quality (PSQI ≥ 5), with a mean PSQI score of 5.9 (2.37). However, they did not, however, experience increased sleepiness, with ESS scores within the normal range (< 10; mean, 8.86 [4.32]). Their ASKME scores were 11.87 (4.32), consistent with poor knowledge of sleep medicine.

Table 2.

Effect of the intervention on sleep quality and sleep education.

	Questionnaire	Baseline	Postintervention	P
Total (n = 87)	PSQI	5.9 (2.37)	6.01 (2.53)	.63
	ESS	8.86 (4.32)	8.45 (4.32)	.26
	ASKME	11.87 (4.32)	14.15 (4.5)	< .001
Preclinical students (n = 31)	PSQI	5.65 (2.4)	5.9 (2.3)	.48
	ESS	7.42 (3.4)	6.48 (3.4)	.07
	ASKME	11.10 (4.0)	13.00 (4.4)	.02
Clinical students (n = 56)	PSQI	6.04 (2.3)	6.07 (2.3)	.90
	ESS	9.66 (4.6)	9.54 (4.4)	.80
	ASKME	12.30 (4.4)	14.79 (4.4)	.002

P values shown comparing baseline with postintervention. Results shown as mean (SD). ASKME = Assessment of Sleep Knowledge in Medical Education, ESS = Epworth Sleepiness Scale, PSQI = Pittsburgh Sleep Quality Index, SD = standard deviation.

Students in the preclinical stage were on average 2 years younger than those in the clinical stage, and more of them were women. No other significant differences were observed in their demographic characteristics ( Table 1 ). Similarly, most of the baseline sleep parameters were comparable between students in the preclinical and clinical stages. Notably, however, mean ESS scores were 7.42 (3.4) vs 9.66 (4.6) in the preclinical and clinical student groups, respectively, with a total of 27 (48%) clinical students with a preintervention ESS score of ≥ 10. This result was consistent with increased sleepiness levels and compared with only 8 (25%) of the preclinical students (P = .0195).

The effect of educational intervention

The ASKME scores postintervention were significantly higher, 14.15 (4.5), consistent with improved knowledge of sleep medicine. No improvement was seen in either sleep quality or daytime sleepiness, as measured by the PSQI and ESS tools ( Table 2 ). In the comparison of preclinical- and clinical-stage students, the results were similar to the results of the general analysis; after our intervention there was a small increase in the knowledge of sleep medicine, in both preclinical and clinical students, with no significant changes in sleep quality or sleepiness. The difference between the 2 groups on the sleepiness scale remained slightly increased, whereas a trend for improvement appeared only in the preclinical group (P = .07).

DISCUSSION

This is the first study attempting to improve sleep quality and associated daytime function in medical students through better knowledge of sleep medicine. In agreement with prior literature, we found poor self-reported sleep quality in medical students in all stages of medical school and evidence of excessive daytime sleepiness in students in the clinical stage of their studies. Although the intervention to improve sleep knowledge through a short educational session was successful, it was not accompanied by an improvement in sleep quality.

Medical students tend to experience insufficient sleep, poor sleep quality, and excessive daytime sleepiness, ^{2–4,15,17,28} and our findings are in line with the current literature. Sleep health and sleep quality are determined by many factors that are often disturbed in medical students. Such factors include poor sleep hygiene with excessive caffeine consumption, alcohol use, smoking, watching television in bed, and being physically inactive. ⁴ Sleep quality seems to worsen as students progress to the clinical stage of their studies, ^29,30 although this is not a consistent finding. ⁴ This trend emphasizes the need to address sleep early for medical students. Whereas medicine is clearly a high-risk occupation with poor sleep patterns, shift work, acute and chronic sleep deprivation, ¹⁹ and stress and fatigue that are at times the result of the physicians’ own violation of work-hour restrictions, ³¹ one hopes that addressing these issues may have a beneficial effect.

In the current study, we tested the hypothesis that improving sleep knowledge would improve sleep quality. As mentioned earlier, in other settings, educational interventions aimed at improving knowledge of sleep were also effective in improving sleep quality. ²² For example, prepartum sleep education improves women’s sleep postpartum. ³² However, Ahmed et al ³³ showed that sleep knowledge associated with advancing medical education was not sufficient in medical students. In their study, sleep knowledge improved with advancing education year, but sleepiness and dysfunctional beliefs about sleep did not. Because demands on students increase with ongoing education, we assumed that maintaining proper sleep would be harder as the medical school years progressed. We therefore examined these parameters within each group, assuming that the intervention would be more successful in the preclinical-stage students. However, despite the change observed in knowledge postintervention, no such change occurred in sleepiness or sleep quality within either group.

There are several possible explanations for our intervention’s failure whereas similar interventions have been successful in other populations. ^22,23 As noted above, one possible explanation is the lack of the effect of knowledge itself on sleep in the specific population of medical students. Another possibility is a flaw in the intervention itself. The intervention may have been too short, limited by the students’ schedule and voluntary participation during a recess period. The lecture may have overemphasized sleep medicine knowledge, leading to the positive change on the ASKME questionnaire, and not emphasized sleep hygiene enough. The timing of the intervention, targeted to students in the third year of their studies, may have been too late in the course of medical school. Similarly, the Sleep, Alertness, and Fatigue Education in Residency program, targeting medical interns who were sleep-deprived, failed to improve sleep through educational measures. ¹⁸ The authors concluded that given the nature of the job and its demands, it is likely that medical practitioners have insufficient free time and are unlikely to dedicate as much time as is needed for sleep or sleep hygiene. It is possible that medical students experience a similar predicament.

This study’s key strength is its prospective nature. However, it has a few limitations. First, the intervention was not structured to improve sleep hygiene or quality but rather sleep knowledge, leading to improvement in the latter domain only. Second, our study was not powered to detect effects of small size. Finally, sleep quality was assessed through self-report, albeit with validated questionnaires, and it is possible that some objective sleep parameters improved postintervention.

CONCLUSIONS

This prospective interventional study shows that despite poor sleep quality and daytime sleepiness, an educational intervention in the form of a lecture, addressing the main topics of sleep medicine and suggestions on how to improve sleep quality, is insufficient to improve sleep quality in medical students. Further studies are needed to identify effective interventions to improve sleep quality and associated daytime functioning in medical students.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. The authors report no conflicts of interest.

ABBREVIATIONS

ASKME

Assessment of Sleep Knowledge in Medical Education

ESS

Epworth Sleepiness Scale

PSQI

Pittsburgh Sleep Quality Index

SD

standard deviation