A cross sectional survey was conducted on medical students at Dow Medical College and Mechanical Engineering student at NED University of Science and Technology. Questionnaires with an attached consent form were randomly distributed among the students. Sleep behavior was assessed using the Basic Nordic Sleep Questionnaire, while academic performance was assessed by the subjects’ self reported GPA/percentage of the last university exam, or by a personal assessment rated on a 7 point scale ranging from very poor to excellent. A personalized sleep report was emailed to each eligible participant.
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Results: A total of 1160 forms were distributed, of which 930 valid forms were received- a response rate of 80.2%. Data was analyzed using the SPSS 15.0 software. Students of both institutions reported similar, poor sleep patterns. The three significant aspects of sleep, i.e. excessive sleepiness during the daytime, the duration of sleep at night, and the quality of sleep were correlated to the academic performance of the subjects. Each of the above mentioned factors were statistically evaluated in relation to academic performance, and each garnered an insignificant status (p<0.05).
Conclusion: A comparison between selected aspects of sleep and academic performance revealed no significant association between the two.
Sleep behavior is a term that describes the qualitative and quantitative aspects of sleep and their associated repercussions in individuals. It is common knowledge that undergraduate programs, especially of Medicine and Engineering demand long and tedious hours of and study and practical work by students. This often leads to students developing poor sleeping habits in attempts to give their academics their due time and effort. During exams and tests in particular, many students pull all-nighters to do some last minute revision and often survive on very few hours of sleep per day, particularly on the night before the exam. All students wish to pass their exams with good grades. But students are generally unaware of how far such sleeping habits will really help them. Therefore, personalized sleep reports were sent to them via email adapted from the “Sleep disorders screening survey”. 4
Among studies carried out worldwide on the association of sleep and academic performance, only three studies were found to have been conducted on undergraduate students, two of which were conducted on medical students1,2. A study on medical students, entitled, ‘Daytime sleepiness and academic performance in medical students’1 sought to correlate sleepiness measured using the Epworth sleepiness scale with grades obtained in exams at the end of that school period. The study demonstrated a negative correlation between academic performance and excessive daytime somnolence, but did not relate academic performance to other aspects of sleep behavior such as quality of sleep, and sleep timings. The other study, titled ‘The sleep habits, personality and academic performance of medical students’2 demonstrated a significant association between sleep timings and quality, and academic performance
The significance of our study lies in that only a single research paper correlating sleep with academic performance in undergraduate students could be retrieved from a Pakistani medical journal3. Hence, it seems that there is a dearth of information regarding this issue specifically in the context of Pakistani institutions.
The objective of this study was to analyze the interplay between sleep behavior and academic performance in undergraduate students of selected institutions in Karachi, in order to ascertain the specific sleeping habits that are associated with varying degrees of academic performance, and thus aid undergraduate students in planning their daily schedules in a manner that will accommodate a healthy sleeping routine, and will at the same time ensure highflying grades in their exams.
A cross sectional survey was conducted on MBBS students at Dow Medical College and Mechanical Engineering students at NED University of Engineering and Technology. The sample sizes for both institutions, calculated at a confidence level of 95%, and a confidence interval of 6 are as follows:
DMC: population enrolled in one batch = 306 (approx.); sample size=143 per batch (x5), i.e. 715
NED: population enrolled in one batch = 187 (approx.); sample size=
110 per batch (x4), i.e. 440
Questionnaires were randomly distributed to students in their classes, who were not selectively chosen from any particular list, and questionnaires were collected when filled. The sampling remained purposive by handing out questionnaires to every second student entering the lecture hall. A consent form was attached to each questionnaire, requiring written consent from the participants. The form also presented an introduction to the study, ensured participants of the confidentiality of the information they provide, and offered students the incentives of: 1. being entitled to a free entry in a lucky draw to win a Rs.1,000 voucher to purchase a book(s) of their choice from a bookstore, and 2. being given a personalized report on their sleep behavior, and expert advice on how to improve it in order to boost academic performance, for free via email. This served to motivate students to participate in the research, and ensured that those who chose not to participate were not skewed toward a particular category.
The personalized sleep reports were adapted from the ‘Sleep disorders screening survey’4, and were approved by a Psychiatrist. Expert advice for improving sleep was adapted from an article on the ‘Healthy Sleep’ Web Site, a production of WGBH Educational Foundation and the Harvard Medical School Division of Sleep Medicine6.
Sleep behavior was assessed for its qualitative and quantitative aspects at 2 independent times: during regular college days, and during exams/ pre-exam preparatory leave. The Basic Nordic Sleep Questionnaire7 was used for this purpose. A number of sleep evaluation scales and questionnaires have been developed8, each evaluating particular aspects of sleep, such as sleepiness, sleep disorders, quality and timings of sleep, during a fixed period. The Basic Nordic Sleep Questionnaire was specifically chosen because it is a comprehensive questionnaire that analyzes both quantitative and qualitative aspects of sleep behavior, and also has the added advantage of having a suitable number of questions (21), so students could willingly afford the time to fill in the questionnaire. Academic performance was assessed through self-reported GPA/ percentage of the last semester/ annual exam undertaken, and the subjects’ personal assessment of their academic stature on a 7-point scale.
The names and roll numbers of the subjects were not taken to ensure confidentiality. The research was not confined to a particular gender, year or age group. Inclusion criterion was therefore any undergraduate student of the selected programs at the institutions. Students who did not appear in the last semester/ annual examination for any reason were, however, excluded from the research. Forms in which the respondents did not report their GPA and did not respond to the question on academic stature based on personal assessment, were not considered for data analysis. Furthermore, forms in which responses to the sleep behavior section of the questionnaire were incomprehensible were also not considered. Data was entered on SPSS version 15, and analyzed under the supervision of a statistician.
The study has been registered at the Research Department of Dow University of Health Sciences, (registration number SR 71) and approved by IRB. Official permission for reproducing the Basic Nordic Sleep Questionnaire for data collection has also been acquired from the international publisher, Wiley-Blackwell.
Table 1 presents the number of questionnaire forms that were distributed to each class, the number of valid filled forms that were received, and the response rates for each class.
It should be noted that the questionnaires were distributed once to students of every class of DMC and NED, containing questions regarding sleep behavior during normal college days and during exams/pre exam preparatory leave. At the end, students were required to answer a self assessment of their academic performance and give their latest GPA.
The actual response rates were slightly higher, as 33 forms that were improperly filled were disregarded for data analysis. Thus, 963 students participated in the study, of which the responses of 930 were considered valid for data analysis. Of all the (valid) respondents, 61.6% were females, 35.3% were males, and 3.1% did not state their gender.
Table 2 presents the mode responses of the questions in the questionnaire. As can be seen from the table, the mode responses to most questions were the same in both institutions. Notable exceptions are as follows. Most DMC students reported that during regular college days, they felt excessively sleepy in the morning right after awakening and/or during daytime, never, or less than once per month. On the contrary, most NED students reported feeling excessively sleepy after awakening on 1-2 days per week. The same response was observed, daily or almost daily during daytime. Furthermore, while most DMC students reported taking sleep naps daily or almost daily, most NED students take a nap never or less than once per month.
The mean time respondents stay awake in bed before going to sleep is nearly the same in both institutions, a cumulative average of 22.1 minutes during regular college days, and 5.5 minutes during exams/ pre exam preparatory leave. The sleeping and awakening times at night also do not present an appreciable difference in the two institutions. It is, however, noteworthy that most students in both institutions sleep at or after midnight, and generally wake up early in the morning.
The mean sleep nap duration is 1.83 hours during regular college days, and slightly less during exams/ pre exam preparatory leave (1.46).
Most respondents did not report problems with their sleep. Of those that did, the problems were generally related to bad dreams, difficulty in falling asleep and interrupted sleep.
The vast majority of students did not report using sleeping pills. 26 students reported using them during regular college days and 43 during exam/ pre exam preparatory leave indicating the increased prevalence of sleep problems during that time.
Possible correlations between academic performance and three aspects of sleep behavior during exams/ pre exam preparatory leave were analyzed:
quality of sleep,
excessive sleepiness during daytime,
duration of sleep per night.
1st year NED students had not appeared in any annual exam, so their personal assessment was taken as an indicator of their academic performance. Several NED students of the other years had reported a GPA, even though they are officially issued percentages by their institution. For such students, the GPAs were converted to percentages using a standard conversion chart. However, because it could not be determined what formula the students had used to convert their percentages, to minimize errors, their academic performance based on personal assessment was considered to be a more reliable indicator. Students were required to report personal assessment on a 7-point scale ranging from very poor to excellent. A response of satisfactory/ average or better was considered to be academic performance equal to or above class average. For DMC students, mean class GPAs, as enlisted in Table 1, were considered.
The results are displayed in the figure.
The first bar displays the percentage of students who slept well and scored equal to or above their class average (64.58%), and the second bar represents the percentage that did not sleep well and scored equal to or above their class average (64.05%). These results demonstrate that there is no statistically significant relation between quality of sleep and academic performance (p<0.05).
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The 3rd bar displays the no. of students who, never or less than once per month, felt excessively sleepy, and scored equal to or above class average (67.77%). The following bar represents the no. of students who sometimes felt excessively sleepy during daytime, but still scored equal to or above class average (62.7%).
Similarly, the 5th and 6th bars represent students who sleep more and less than the mean no. of hours at night, respectively and scored equal to or above class average (67.64 and 60.73, respectively). The statistics suggest that there is no significant relation between daytime sleepiness or duration of sleep at night, and academic performance (p<0.05).
Sleep is a naturally recurring state characterized by reduced or lacking consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. Sleep behavior is a term that describes the qualitative and quantitative aspects of sleep and their associated repercussions in individuals.
In this modern era where workload and stress are increasing day by day, it is quite common to find university students trying to juggle their academic studies within a 24 hour timeline. It is, therefore conventional for students to stay up late during normal days as well as during exam days to cover up their coursework. This in turn can have implications on their quality of sleep, daytime sleepiness and other aspects of sleep behavior.
As the results show, most of the responses received were the same for students in both institutions, implying a striking similarity in their sleep behaviors. Most students from both institutions indicated that their quality of sleep was well, without being awakened at night never or less than once per month. This indicates that even though students are getting less hours of sleep, the quality of sleep is strong enough to help get them through the day. As is well known, most medical and engineering students tend to have a busy schedule the entire day. However, they are able to rest peacefully at night. The quality of sleep far outweighs the quantity.
Furthermore, students from both institutions presented with roughly the same hours of sleep every night; having slept at midnight and awakened during weekdays at 6 -7 AM, giving a 6-7 hours sleep. Research presents with an average of 7-9 hours of sleep sufficient to help the individual get through with the next day. 
However, some sleep behaviors were found to be distinct among students of the 2 institutions. Firstly, DMC students reported a greater frequency of sleep naps. Because students from both institutions reported nearly the same duration of sleep at night, this may be an indication that medical students are exposed to more tedious hours of study and workload, as they have to divide their college timings in lectures, laboratory work and rigorous clinical postings. Therefore, DMC students required afternoon naps more often to regain their energy as to continue their studies and daily activities in the evening.
Secondly, there was a minority of students that reported problems with their sleep, such as bad dreams, difficulty in falling asleep and interrupted sleep. It is unclear whether the prevalence of these problems is the same as in the general student population in the country or not, since studies concerning this could not be retrieved. Nevertheless, sleep problems in the minority of students can be attributed to anxiety associated with increasing workload and/ or attaining and maintaining their required grades. This explanation may be further corroborated by the finding of increased use of sleeping pills during preparatory leave or exams during which stress levels escalate. 
At DMC, it was found that 3rd year students reported the highest mean GPA compared to those of other batches. Similarly, it is also appreciated that in NED, had a higher mean percentage than that of 2nd and 3rd years. (Note: 1st year students had not appeared in an annual exam so a mean percentage could not be calculated).
Worldwide studies have been carried out on the association of sleep and academic performance, 2 of which 1,2 were conducted on undergraduate medical students. The first research entitled “Daytime sleepiness and academic performance in medical students” 1 correlated sleepiness measured using the Epworth sleepiness scale with grades obtained in exams at the end of the school period. Although this study showed a negative correlation between academic performance and excessive daytime somnolence, it did prove that the academic performance of those students did get affected by excessive daytime somnolence. (Somnolence is defined as the inability to maintain an adequate level of wakefulness, or as an excessive degree of daytime sleepiness)
The second study, entitled “The sleep habits, personality and academic performance of medical students” 2 demonstrated a significant association between sleep timings and quality, and academic performance. It illustrated that those students who rose early and went to bed early were able to achieve far better than those students who slept and rose quite late. In addition, this study also found that the academic performance was not related to the long-term differences in the amount of sleep; a finding that also runs parallel with our findings.
The questionnaires required subjects to answer questions pertaining to their sleep behavior during regular college days, and during exams/ pre-exam preparatory leave. Subjects may have been unable to exactly recall the amount of quality of sleep they have and may have given an estimate that may range from slightly inaccurate to misleading. Furthermore, subjects may have been unwilling to provide accurate information on certain personal questions, such as the problems they have with their sleep, and the factors that influenced their GPAs/ percentages, even though their names or roll numbers were not taken, and they were assured of the confidentiality of the information they provide. Moreover, in order to judge academic performance, the subjects’ self reported GPA had to be relied upon, as it was not feasible to send such a large number of forms to the Examination Department to verify. Sample size might not have been a limitation because of a considerably large sample size (was taken (1150), corresponding to a confidence limit of 95%, and a confidence interval of 6. For NED students, personal assessment had to be considered a reliable indicator of academic performance because of the limitation discussed in the section on results.
A comparison of the sleep behaviors of the students of two different institutions while taking into account their academic performance revealed that the two factors did not relate to each other in any way studied. In this study, three aspects of sleep behavior were considered to be significant: whether the subject felt sleepy during the daytime, the duration of sleep at night and the quality of sleep. Academic performances were then compared to these three factors. The popular belief that students follow a healthy sleeping pattern in order to achieve better grades could thus not be proved. In addition, a very small percentage of respondents reported some problems with their sleep including bad dreams, difficulty in falling asleep or intermittent sleep. Nevertheless, the study still concludes that the students of the two institutions have unhealthy sleeping patterns that may affect other aspects of their lives besides academic achievements.
We are grateful to Dr. Raza-ur-Rehman, Assistant Professor, Department of Psychiatry, Civil Hospital, Karachi, for supervising the study. Further, we are grateful to Dr. Imran Chaudhry, University of Manchester, U.K, for assisting us with the design of the study and for proofreading the project’s proposal. Jaweria Nawed, Mechanical Engineering student, NED, assisted us in data collection at NED.
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