Objective: To estimate the occurrence rate of sleep deprivation and to identify the environmental, staff-related and patient-related factors associated with SD among general ward patients of a tertiary care hospital in Pakistan.Methods: In a cross-sectional study, a pre-tested questionnaire was administered to 108 patients admitted into the general medical and general surgical wards of Aga Khan University Hospital, Karachi.Results: In all, 50 (46.3%) respondents felt deprived of adequate sleep in the hospital. Worry about illness disturbed the night-time sleep of 47 (43.5%) patients; most of these had SD (70%) (p \u3c 0.001). Other patients\u27 noise disturbed 31.5% of study subjects and a significant majority (68%) of these had SD (p = 0.003). Over 17% of study subjects reported cell phone\u27s ringing as a disturbing factor; more by those with SD (68%) compared to those with no SD (32%); again the difference was significant (p = 0.003). Physical discomfort and presence of cannula were reported as disturbing factors by 41.7% and 28.7% of the study subjects respectively but these were not significantly associated with SD.CONCLUSION: Our study revealed that sleep deprivation occurs commonly among general ward patients in tertiary care setting. Factors found to be associated with SD were amenable to modification to a greater extent

Ali, Rehmat

Khuwaja, Ali Khan

Salahuddin, Farah F

Saleem, Ayesha

Shafiq, Majid

Shah, Zaman

Shaikh, Kashif Shakoor

Siddiqi, Maham

Siwani, Rizwan A

English

eCommons@AKU

eCommons@AKUCommunity Health Sciences Department of Community Health SciencesDecember 2006Sleep deprivation and its associated factors amonggeneral ward patients at a tertiary care hospital inPakistanMajid ShafiqAga Khan UniversityFarah F. SalahuddinAga Khan UniversityMaham SiddiqiAga Khan UniversityZaman ShahAga Khan UniversityRehmat AliAga Khan UniversitySee next page for additional authorsFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chsRecommended CitationShafiq, M., Salahuddin, F. F., Siddiqi, M., Shah, Z., Ali, R., Siwani, R. A., Saleem, A., Shaikh, K. S., Khuwaja, A. K. (2006). Sleepdeprivation and its associated factors among general ward patients at a tertiary care hospital in Pakistan. Journal of Pakistan MedicalAssociation, 56(12), 614-617.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/641AuthorsMajid Shafiq, Farah F. Salahuddin, Maham Siddiqi, Zaman Shah, Rehmat Ali, Rizwan A. Siwani, AyeshaSaleem, Kashif Shakoor Shaikh, and Ali Khan KhuwajaThis article is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/641Students’ CornerSleep Deprivation and its associated factors among general ward patients at aTertiary Care Hospital in PakistanMajid Shafiq1, Farah F. Salahuddin2, Maham Siddiqi7, Zaman Shah4, Rehmat Ali5, Rizwan A. Siwani6, Ayesha Saleem7,Kashif Shakoor Shaikh8, Ali Khan Khuwaja9Medical College1-8 and Department of Community Health Sciences9, Aga Khan University, Karachi.AbstractObjective: To estimate the occurrence rate of sleep deprivation and to identify the environmental, staff-relatedand patient-related factors associated with SD among general ward patients of a tertiary care hospital inPakistan.Methods: In a cross-sectional study, a pre-tested questionnaire was administered to 108 patients admitted intothe general medical and general surgical wards of Aga Khan University Hospital, Karachi.Results: In all, 50 (46.3%) respondents felt deprived of adequate sleep in the hospital. Worry about illness dis-turbed the night-time sleep of 47 (43.5%) patients; most of these had SD (70%) (p<0.001). Other patients' noisedisturbed 31.5% of study subjects and a significant majority (68%) of these had SD (p=0.003). Over 17% of studysubjects reported cell phone's ringing as a disturbing factor; more by those with SD (68%) compared to thosewith no SD (32%); again the difference was significant (p=0.003). Physical discomfort and presence of cannulawere reported as disturbing factors by 41.7% and 28.7% of the study subjects respectively but these were notsignificantly associated with SD. Conclusion: Our study revealed that sleep deprivation occurs commonly among general ward patients in terti-ary care setting. Factors found to be associated with SD were amenable to modification to a greater extent(JPMA 56:614;2006).IntroductionSleep is an essential part of the normal human circa-dian rhythm. It is essential for maintenance of physical, sex-ual and mental functions of the body. Studies well documentthe negative effects of sleep deprivation (decreased vigi-lance, impaired decision-making, reduced concentration,irritability, sleepiness, increased fatigue, and difficulty inthinking clearly). Sleep deprivation (SD) is also well recog-nized as a stressor, affecting human health in many adverseVol. 56, No. 12, December 2006 614ways including memory impairment and prolonged treat-ment spans of patients suffering from various illnesses.1-4This may result in increased costs from prolonged hospital-ization for the patients admitted to a hospital. It has beennoted in various hospital-based studies that nocturnal inter-actions of health care providers with in-patients have actu-ally been counter-beneficial as they leave patients withfewer opportunities of continuous sleep.1,3,5A tertiary care center offers a suitable setting tostudy the occurrence of SD among inpatients and its associ-ation with patients' perceptions about the disease, environ-ment and the nocturnal care being provided to them. Notonly is there a wide range of diseases presenting to such acenter, an extensive socio-demographic and ethnic varietyof patients is also seen due to a scarcity of such facilities ina developing country like Pakistan. While studies have reported that patients admittedinto tertiary care centers have been seen to sleep poorly,with identified causes being largely preventable,5,6 there islittle data to comment on the situation at tertiary care cen-ters in Pakistan.With this background, a study was carried out by agroup of medical students of The Aga Khan University,Karachi with the objectives of estimating the frequency ofSD among general ward patients of a tertiary care hospitaland investigating for associations between SD and variousenvironmental, health personnel-related and patient-relatedfactors relevant to the hospital ward setting, thereby paving. Patients and MethodsIn a cross-sectional study, 108 consecutive patientsadmitted into the general medical (n=79) and general surgi-cal (n=29) wards of Aga Khan University Hospital(AKUH), Karachi during August 2004 were interviewed.All patients who met the selection criteria during this timeperiod and gave informed verbal consent were interviewed.Those patients who were aged >15 years and who had spentat least two consecutive nights in the ward were included.Patients who were excluded from the study were those whohad been on any medications with sedative or other centralnervous system effects during the past three days (notedfrom each patient's medical records), those with alreadydiagnosed sleep disorders, those who were mentally chal-lenged or unable to respond clearly and those admitted inthe semi-private, private or specialist wards (e.g. obstetricsand gynecology wards or the intensive care unit). A self-designed questionnaire was used as the infor-mation collecting tool. Face-to-face administration of thequestionnaire was performed by a group of pre-trained med-ical students. After it was formulated in English, the ques-tionnaire was translated into the local language (Urdu) inorder to limit interviewer bias. Finally, in order to identifyand correct any discrepancies during the translation process,the questionnaire was back-translated by a group of investi-gators not involved in the original translation. The question-naire was pre-tested on a group of patients admitted in thesemi-private wards of the same hospital.  The questionnaire's first section recorded patientdemographics, diagnosis and the medications on record.Queries on various aspects of the hospital ambience wereasked in the next section. The patients were asked whetherthe presence of any of these was significant enough to causea disturbance during their sleep at night-time. Similar ques-tions were asked in the context of attributes and behaviourof the hospital staff and aspects of the patient's own life andpersonality. "Sleep deprivation" was thought to be best assess-able using patient's own perception of the same. Patientswere asked a straight-forward question at the end of thequestionnaire: "do you feel that you are deprived of ade-quate sleep in the hospital?" Possible responses to this ques-tion were "yes" and "no". Data were entered and analyzed in the StatisticalPackage for Social Sciences (SPSS) 13.0 software.Frequencies of all variables were generated. For patientsdisturbed by each variable, a division was made betweenthose who said that they were deprived of adequate sleep inthe hospital and those who said they were not. The chi-square test was applied to test the association of SD withdifferent variables. A p-value of <0.05 was taken as the cri-terion for significant association. ResultsDemographic profile of the study subjects is given inTable 1. A total of 108 patients participated in the study,with a preponderance of males, 71 (65.7%) and of thosewith age above 40 years, 62 (57.4%) of the 108 study sub-jects 53 (49%) had schooling of up to six years and 55(51%) had schooling of more than six years. Urdu was iden-tified as the mother tongue by 52 (48.1%) subjects, followedby Sindhi and other local languages.  In total, 50 (46.3%) subjects felt deprived of ade-quate sleep during their hospital stay (Figure). Associationsof different factors with sleep deprivation are described inTable 2.  Of the total of 108 study subjects, worry about ill-ness was disturbing the night-time sleep of 47 (43.5%).Thirty-three of these patients (i.e. 70% of 47) had SD while14 did not; the difference was statistically significant(p<0.001). Other patient's noise was disturbing the sleep of34 (31.5%) study subjects; 23 of these had SD while 11 didnot. This difference was statistically significant (p=0.003).Cell phone's noise was reported as a disturbing factor by 615 J Pak Med Assoc19 (17.6%) study subjects; significantly more commonly bythose with SD (13) compared to those with no SD(p=0.003). Physical discomfort and presence of a cannulawere reported as disturbing factors by 45 (41.7%) and 31(28.7%) study subjects respectively but these were not seento be significantly associated with SD. A small number of patients (six in total) said thattheir night-time sleep was disturbed by lighting conditions;this was not found to be associated with SD. Other aspectsof the hospital environment (including bedding, tempera-ture, etc) were not associated with SD either. DiscussionIn addition to various physical and mental illnesses,SD is associated with delayed recovery from illness7, there-by placing an additional burden on finances and resources.Therefore, by taking steps to prevent or overcome it, theoverall burden of disease could possibly be reduced. Itbecomes all the more important to quantify the burden ofSD among in-patients in a developing country, where opti-mal channeling of limited resources is crucial. The estimated occurrence rate of SD among the gen-eral ward in-patients in this study was 46.3%. This is high-er than the community based value of 20.4%, reported byHublin et al8 for the Helsinki population. However, it isarguable that the higher occurrence of SD among this studywas largely due to effects of their respective illnesses. In ahospital-based study, no less than 65% of the studiedpatients slept badly in the hospital.9 According to Redekeret al,10 64% cardiac surgery patients reported sleep distur-bances even 4 weeks after the operation. However, cardiacsurgery patients may be considered to be near the end of aspectrum of patients requiring hospital admission. Studies of sleep patterns implicate the environmentof hospital as an important cause in preventing adequatesleep.11-13 Environmental factors include lighting, tempera-ture, and bedding, among others. Honkus VL has shown thatlight may significantly contribute towards a patient's inabil-ity to sleep.14 Electric lighting in the hospital environmentis found to be inappropriate for the maintenance of normalneuroendocrine rhythms in humans.15 which results in sleepdisturbance. Only six (5.5%) patients interviewed in thisstudy said that the lighting disturbed their night-time sleepand only two among these patients said they were sleepdeprived. Likewise, other environmental aspects mentionedabove were not associated with SD either. One possibleexplanation for this discrepancy could be that this studyinvestigated disturbances in the patients' sleep at night-timeonly (when the lighting would be considerably dimmer.In this study, noise from mobile phones and noisefrom other patients were most significantly associated withSD. This is consistent with results of previous studies donein nursing homes and intensive care units where noise wasthe major factor associated with SD.6,15 However, thesources of noises identified from those studies are different.Some of the factors identified by them are noises fromequipment, nursing staff conversations and alarms. ATable 1. Demographic characteristics of study subjects (n=108).Characteristic Number (%)Age (years)< 40 > 40SexMaleFemaleEducation (in years)< 6> 6Ethnicity (Mother tongue)UrduSindhiPunjabiGilgiti/ChitraliPashtoOther (Persian, Seraiki, etc.)46 (42.6)62 (57.4)71 (65.7)37 (34.3)53 (49.1)55 (50.9)52 (48.1)14 (13.0)10 (9.3)8 (7.4)6 (5.6)18 (16.7)Table 2. Association of major disturbing factors with SD amongstudy subjectsDisturbing factorNo. ofpatientsn (%)SD + ven (%)SD - ven (%) p-valueWorry about illness Physical discomfort Other patients' noise Cannula Cell phones' noise47 (43.5)45 41.7)34 (31.5)31 (28.7)19 (17.6)33 (70)22 (49)23 (68)18 (58)13 (68)14 (30)23 (51)11 (32)13 (42)6 (32)<0.0010.6480.0030.120.003Figure: Occurence of SD among the study subjects54%46%SDNot SDVol. 56, No. 12, December 2006 616number of factors may be responsible for this difference.Firstly, this study setting was of general medical and surgi-cal wards rather than nursing homes or critical care units.Besides, patient expectations and attitudes may be differentin the South Asian setting. For instance, some patients mayfeel grateful at any human presence around them  and maynot deem the nurses' activities intrusive on any count.Although it was not found to be significantly associ-ated with SD, the presence of a cannula did disturb a sub-stantial number of patients' night-time sleep. Other studieshave also revealed that venous cannulas and urinarycatheters may be sources of significant discomfort in manypatients.6A stressful event often precipitates disturbances insleep. Being in the hospital and undergoing surgery are clas-sic examples. Intrinsic factors such as fear and stress mayprecipitate or perpetuate sleeping disorders.7 In our studytoo, worry about illness was seen to be associated with SD.On the other hand, physical discomfort caused by thepatients' pathological conditions was not associated. The possibility of recall bias may be counted as alimitation of this study. It is possible that patients who weresleep deprived were able to recall and narrate their hospitalexperiences more clearly than those who were not.Secondly, this study was carried out in only one hospital,which may not be a true representative of all tertiary carehospitals. And since it was a private hospital, it is possiblethat the overall occurrence of SD may be even higher inother hospital setups than what was observed in this study.This study suggests a high occurrence of SD amongthe admitted patients in a tertiary care hospital of Pakistan.This warrants extensive studies for more accurate estima-tion of the same. Patients' worry about illness has also been seen to beassociated with SD. This factor can be ameliorated bygreater communication between the health care providersand the patients. In conclusion, sleep deprivation appears to be a verycommon problem among our in-patients, with many of theassociated factors being modifiable. However, more studiesare needed on this subject with a larger sample size and rep-resentative hospitals and patients. This would enable us togather truly applicable results and to formulate hospitalpolicies accordingly.AcknowledgementsAuthors wish to thank the administration of AKUHgeneral wards for granting permission to interview their in-patients as well as have access to their medical records. Weare grateful to those patients who gave their informed con-sent for participation in this study. We are also grateful toDr. Bilal Iqbal, Assistant Professor at Department ofCommunity Health Sciences, AKU, for offering his usefuladvice during the stages of study planning and data analy-sis.References1. Alvarez GG, Ayas NT. The impact of daily sleep duration on health: a reviewof the literature. Prog Cardiovasc Nurs 2004;19: 56-9.2. Guan Z, Peng X, Fang J. SD impairs spatial memory and decreases extra cel-lular signal-regulated kinase phosphorylation in the hippocampus. Brain Res2004;1018:38-47.3. Perla E. Psychiatric problems and sleep disorders in surgical intensive care. Apolygraphic study: 8 cases. Agressologie 1989;30: 603-16.4. Schulze G. Sleep protects excitatory cortical circuits against oxidative dam-age. Med Hypotheses 2004;63: 203-7.5. Tamburri LM, DiBrienza R, Zozula R, Redeker NS. Nocturnal care interac-tions with patients in critical care units. Am J Crit Care 2004;13:102-12.6. Calvete VR, Garcia AMB, Uriel LP, Fernandez LV, Medin CB. Patients' sleepin intensive care units and sleep-modifying factors. Enferm Intensiva 2000;11:10-16.7. Adam K, Oswald I. Sleep helps healing. Br Med J 1984;289: 1400-1.8. Hublin C, Kaprio J, Partinen M, Koskenvuo M. Insufficient sleep--a popula-tion-based study in adults. Sleep 2001;24: 392-400.9. Kuivalainen L, Ryhanen A, Isola A, Merilainen P. Sleep disturbances affect-ing hospital patients. Hoitotiede 1998;10: 134-43.10. Redeker NS, Ruggiero JS, Hedges C. Sleep is related to physical function andemotional well-being after cardiac surgery. Nurs Res 2004;53: 154-62.11. Reid E. Factors affecting how patients sleep in the hospital environment. Br JNurs 2001;10: 912-15.  12. Olofsson K, Alling C, Lundberg D, Malmros C. Abolished circadian rhythmof melatonin secretion in sedated and artificially ventilated intensive carepatients. Acta Anaesthesiol Scand 2004;48: 679-84.13. Wood AM. A review of literature relating to hospital with emphasis on thesleep of the ICU patient. Intensive Crit Care Nurs 1993;9: 129-36.14. Honkus VL. SD in critical care units. Crit Care Nurs Q. 2003;26: 179-89.15. Stevens RG, Rea MS. Light in the built environment: potential role of circadi-an disruption in endocrine disruption and breast cancer. Cancer CausesControl 2001;12: 279-87.16. Schnelle JF. The nighttime environment, incontinence care, and sleep disrup-tion in nursing homes. J Am Geriatr Soc 1993;41: 910-4. 617 J Pak Med Assoc

Sleep deprivation and its associated factors among general ward patients at a tertiary care hospital in Pakistan

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Sleep deprivation and its associated factors among general ward patients at a tertiary care hospital in Pakistan

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