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Causes and consequences of sleepiness among college students - PMC

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Daytime sleepiness, sleep deprivation, and irregular sleep schedules are highly prevalent among college students, as 50% report daytime sleepiness and 70% attain insufficient sleep. The consequences of sleep deprivation and daytime sleepiness are…

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Sleep quality and sleep deprivation: relationship with academic performance in university students during examination period - PubMed

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The beginning of the university brings together maturational, psychosocial and academic changes that make university students more prone to suffer from insufficient or poor quality sleep, which can negatively influence their academic performance. The period of taking exams is a key part of the acade …

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Abstract

Background

The prevalence of sleep deprivation among college students is increasing and has a few associated factors.

Methods

The present study analyzed 2,142 college students from 28 provinces in China. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep duration. Binary logistic regression was conducted to explore the sleep deprivation related factors. Age and gender were controlled as covariates.

Results

Among the 2,142 college students (27.7% male, 72.3% female), 1,620 (75.6%) reported the average sleep duration was below 7 h per day for one month, 49.3% (1,055/2,142) slept 6∼7 h (contains 6 h), 21.0% (449/2,142) slept 5∼6 h (contains 5 h), and 5.4% (116/2,142) slept <5 h. Age increased the risk of sleep deprivation, the adjusted odds ratio = 1.05 (95% CI [1.01∼1.10]). The adjusted odds ratio (A-OR) for sleep deprivation was higher for students of more than 60 min nap duration per day (A-OR = 2.35, 95% CI [1.45∼3.80]), and age growth (A-OR = 1.05, 95% CI [1.01∼1.10]). In contrast, A-ORs were lower among sleeping inconsistency between work and rest days (A-OR = 0.61, 95% CI [0.49∼0.75]), accustomed to staying up late (A-OR = 0.45, 95% CI [0.36∼0.57]), staying up late to work or study (A-OR = 0.62, 95% CI [0.49∼0.78]), stress (A-OR = 0.75, 95% CI [0.58∼0.98]), and repeated thoughts in bed had (A-OR = 0.79, 95% CI [0.62∼0.99]).

Conclusions

Sleep deprivation is extremely common among healthy college students in China. It is necessary to perform methods maintaining enough sleep due to the current high incidence of sleep deprivation. Controlling the nap duration and getting enough sleep on rest days to replace missing hours of sleep on workdays might improve college students' sleep.

Keywords: Sleep deprivation, Sleep duration, Risk factor, College students

Introduction

In recent years, sleep deprivation is prevalent with the increasing social competition and the convenience of entertainment and socializing. The American Academy of Sleep Medicine and the Sleep Research Society recommend that adults aged 18-60 years should have at least 7 h of sleep per night ( Watson et al., 2015). In the United States, more than 90 million people reported that they slept less than 6 h per day ( Yong, Li & Calvert, 2017). In 2004, 28.6% of Americans slept less than 6 h, while it grew to 32.9% in 2017 ( Sheehan et al., 2019). Sleep deprivation occurs in any age range, and it is a growing problem in the youth population, including college students ( Kansagra, 2020). The prevalence of sleep deprivation among college students is about 70% in the United States (N5 = 1,125, N6 = 191, N7 = 237) ( Lund et al., 2010; Buboltz Jr, Brown & Soper, 2001; Tsai & Li, 2004), about 49.6% in Saudi Arabia (N8 = 805) ( Althakafi et al., 2019), and about 52.7% in Lebanon (N9 = 735) ( Assaad et al., 2014). A good night's sleep plays a vital role in maintaining body balance and promoting one's physical and mental health. Previous studies showed that lack of adequate sleep is associated with a higher risk of disease and even death ( Pan et al., 2014; Liu et al., 2018). The disorders include but are not limited to, hypertension ( Matenchuk, Mandhane & Kozyrskyj, 2020), obesity ( Larcher et al., 2015), obstructive sleep apnea, vascular disease ( Grandner et al., 2014), stroke, myocardial infarction, depression, anxiety, psychosis ( Sondrup et al., 2022), attention, memory and cognitive impairment ( Kim et al., 2022; Newbury et al., 2021; Wei, Duan & Guo, 2022). Sleep deprivation not only affects the quality of sleep but also the work status and life status ( Pires et al., 2016). As a risk factor for a variety of disorders, it is important to prevent the incidence of sleep deprivation.

Sleep deprivation is associated with multiple factors. Previous studies have reported the factors are age ( Wei, Duan & Guo, 2022; Pires et al., 2016), gender ( Zhang et al., 2008), race/ethnicity ( Zhang et al., 2008; Zhang et al., 2006; Gangwisch et al., 2006), dietary habits ( Zheng et al., 2016; Buysse et al., 1989; Becker et al., 2018), lifestyle (smoking, drinking, internet/smartphone use, physical activity, and sedentary behavior) ( Zhang et al., 2008; Zhang et al., 2006; Gangwisch et al., 2006; Zheng et al., 2016; Buysse et al., 1989), economic status ( Wei, Duan & Guo, 2022; Zhang et al., 2008; Mohammadbeigi et al., 2016), serious illness ( Yan et al., 2021), and sleep environment ( Mohammadbeigi et al., 2016).

However, there are few reports on the prevalence and influencing factors of sleep deprivation among college students in China. This study aims to estimate the prevalence of sleep deprivation among healthy college students in China and to identify associated factors. Such findings may be used to highlight the issue of sleep deprivation among college students in the country and to guide future educational/behavioral/policy changes that can improve sleep sufficiency in this important subgroup of the population.

Methods

Study design and the participants

The survey was conducted from July 31, 2021, to March 16, 2022. The cross-sectional survey design and snowball sampling method were conducted. The data was collected by questionnaire star, an online questionnaire survey platform anonymously. The questionnaire was transmitted through WeChat or Tencent QQ, which were close to 100% of the applications used by Chinese college students. The participants were healthy college students from 28 provinces of China, including Beijing, Shandong, Jiangsu, Xinjiang, Ningxia, etc. The study excluded students who were on night shifts to avoid sleep disruptions due to night work or had sleep deprivation due to sleep-related disorders. Validation questions were set to ensure the validity of the questionnaire responses. A total of 2289 questionnaires were returned, including 147 invalid questionnaires with incorrect answers to the validation questions and more than 1/3 vacancies. In total, 2142 valid questionnaires were analysed in this study.

Study tool

A self-assessment questionnaire including socio-demographic and sleep information was used to collect data. Socio-demographic information included age, gender, body mass index (BMI), marital status, nationality, education level, and grade. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality. There is good reliability and validity in the Chinese version of PSQI ( Zheng et al., 2016; Lopresti et al., 2020). It can check for sleep quality in patients and healthy people ( Buysse et al., 1989; Yan et al., 2021; Akman et al., 2015; Yilmaz, 2020). The PSQI, a 19-item self-reported questionnaire, measures seven areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, daytime dysfunction over the past month ( Buysse et al., 1989). The Likert score for each category in the PSQI is 0-3. The total score is the sum of the scores of 7 aspects, ranging from 21 to 100, with higher scores indicating much worse sleep quality.

The questionnaire also contained some questions that may be related to sleep duration, including smoking, drinking, nap duration, sleep duration on workdays and rest days (same, workdays >rest days, rest days day >workdays), taking time away from sleep for recreation (yes or no), refreshing drinks (such as coffee, tea and others) interfering with sleep (yes or no), accustomed to staying up late (yes or no), staying up late to work or study (yes or no), the dormitory environment affects sleep (yes or no), relationship issues (yes or no), stressed out state (yes or no), repeated thoughts in bed (yes or no), mood problems (yes or no), desire to coordinate multiple life roles (yes or no).

Sleep deprivation defining

Currently, there is no specific definition of sleep deprivation. According to the National Sleep Foundation (NSF), young adults aged 18-25 and adults aged 26-64 are not recommended to sleep <7 h per day ( Hirshkowitz et al., 2015). In the present study, sleeping less than 7 h was considered as sleep deprivation.

Health status determination

Health status was determined by the following two questions in the questionnaire. Question 1: "Are you suffering from or have been diagnosed mental or physical illness?" Question 2: "Are you in a good physical and mental state currently?" Participants were considered to be healthy if the answer to the first question is "No" and the answer to the second question is "Yes".

Ethics

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Binzhou Medical University (2021-262). Informed consent was given before the information collected. Data were collected anonymously.

Sample size determination

Sample size of participants was estimated by a standardized formula: N = Z α p(1 − p)/ δ ². As recommended, 0.05 was set to be the significance level, Z α (statistic of significance test) was 1.96, and 0.1 was the estimated acceptable margin of effort for proportion. According to a study about 18,211 undergraduate university students from 24 low-and middle-income and two high-income countries, the overall prevalence of short sleep duration was around 39% ( Peltzer & Pengpid, 2017). The P (Prevalence) was set as 0.39 in our study. The minimum sample size for current study was 592.

Statistical analysis

The Kolmogorov-Smirnov one-sample test was performed to examine the normality of the data set. Since the data was non-normal distribution, the continuous variables were described for the median and interquartile range, and the categorical variables were described for percentages. The participants were divided into sleep deprivation and non-sleep deprivation groups, according to sleep duration less or more than 7 h, and differences in socio-demographic and sleep-related factors were compared between the two groups by using the Mann-Whitney U test for continuous variables and the chi-square test for categorical variables. Analysis of covariance (ANCOVA) was conducted to control the effects of age and gender on sleep duration. Binary logistic regression was conducted to explore the sleep deprivation related factors. Univariate logistic regression was performed firstly. If the p-value was less than 0.10, the factor was included in a multivariate logistic regression model. The backward method was used to select the factors in the final logistic regression model, and an adjusted odds ratio was computed. The goodness of fit was assessed by the Hosmer-Lemeshow test, and 95% confidence interval (CI) was reported. SPSS 22.0 was conducted for all statistical analyses. P-values were double-tailed with a significance level of 0.05.

Results

Sample characteristics

A total of 2,142 participants were obtained for analysis. A large proportion (55.4%, 1,187) of participants was from Shandong, but the survey was completed by respondents in 27 out of the 34 China provinces. Of the 2,142 individuals, 1,549 (72.3%) were females, and 593 (27.7%) were males. The mean (SD) age was 18.9 ± 2.3 years (range = 16-35 years). Junior college students made up the majority of the sample (59.4%), followed by undergraduates (34.9%). A considerable percentage of college students were in their freshman year (42.7%) or sophomore years (32.8%). Most of these students are ethnic Han (95.6%), and a few are of other ethnicities (4.4%). Almost all students were single (99.0%) and only a very few students were married (1.0%). Furthermore, few proportions of students reported smoking (2.0%) and drinking behavior (11.4%). Table 1 shows the socio-demographic, smoking, and drinking characteristics of participants.

Table 1. Sample characteristics.

Socio-demographic

Categories

Participants

Smoking, drinking and sleep condition

Categories

Participants

Prevalence of sleep deprivation

Daily sleep duration of college students was 6.4 h (standard deviation (SD) = 1.0, ranging from 3 to 12 h). 75.6% (1620) college students reported sleep deprivation (sleep duration <7 h). Among 1620 sleep deprivation respondents, 1,055 (49.3%) reported a sleep duration 6∼7 h (contains 6 h), 449 (21.0%) reported 5∼6 h (contains 5 h), 116 (5.4%) reported <5 h. Furthermore, 24.4% (522) college students reported healthy sleep time: 7∼8 h (contains 7 h) have 460 (21.5%), 8∼9 h (contains 8 h) have 46 (2.1%) and ≥9 h have 16 (0.7%).

Furthermore, nap duration was common, with 953 (44.5%) students taking a nap 16∼30 min, 514 (24.0%) 31∼60 min, and 95 (4.4%) >60 min. A total of 1,242 (58.0%) students slept longer on rest days, 215 (10.0%) longer on workdays, and 685 (32.0%) were consistent.

Factors associated with sleep deprivation

According to whether they slept <7 h, the subjects were divided into two groups: sleep deprivation and non-sleep deprivation. Two groups compared socio-demographics and sleeping characteristics, found in the two groups (sleep-deprived students and non-sleep-deprived students) had significant differences in age ( p < 0.001), nap duration ( p < 0.001), and sleeping duration on workdays and rest days ( p < 0.05). Since age and gender were significantly associated with sleep duration, they were controlled as covariates and analyzed. The result showed that nap duration was also different between the sleep deprivation group and non-sleep deprivation group ( F = 4.791, p < 0.01). However, there was no significant difference in BMI, education level, grade, marital status, nationality, smoking and drinking between sleep deprivation and non-sleep deprivation groups (all p > 0.05) with/without adjusting for the effects of the age. The details are shown in Table 2.

Table 2. Comparison of sleep-deprivation and non-sleep-deprivation groups among healthy college students in China.

Sleep deprivation (N = 1,620)

Non-sleep deprivation (N = 522)

Z or χ ²

P value

Age (median (IQR))a

19.0 (17.0∼20.0)

19.0 (18.0∼20.0)

−3.944

0.000***

BMI (median (IQR))a

21.0 (19.1∼23.7)

21.0 (19.0∼23.4)

−0.935

0.350

If smoking, the number of cigarettes smoked per day (median (IQR))a

5 (1.0∼7.0)

4 (3.0∼14.0)

0.402

0.695

Then binary logistic regressions were used to examine socio-demographic and sleep-associated factors. In adjusted models, sleep deprivation was associated with age, nap duration, sleeping duration on work and rest days, accustomed to staying up late, staying up late to work or study, stressed out state, repeating thoughts in bed.

Age increased the risk of sleep deprivation (A-OR = 1.05, 95% CI [1.01∼1.10]). Compared to less than 15 min, and more than 60 min nap duration was more likely to be sleep deprivation (A-OR = = 2.35, 95% CI [1.45∼3.80]). Compared with sleeping consistency, sleeping inconsistency between work and rest days had 40% (A-OR = 0.61, 95% CI [0.49∼0.75]) lower odds of sleep deprivation. Accustomed to staying up late and staying up late to work or study had 54% (A-OR = 0.45, 95% CI [0.36∼0.57]) and 37% (A-OR = 0.62, 95% CI [0.49∼0.78]) significantly lower risk of sleep deprivation compared with sleeping normally separately.

High-stress 24% (A-OR = 0.75, 95% CI [0.58∼0.98]) reduced odds of sleep deprivation. Repeated thoughts in bed had 21% (A-OR = 0.79, 95% CI [0.62∼0.99]) lower risk of sleep deprivation.

In unadjusted models, the sleep deprivation was also associated with education, relationship issues, dormitory environment, mood problems, and desire to coordinate multiple life roles. Table 3 presents the results of crude odds ratio and adjusted odds ratio (A-OR) of binary logistic regressions on factors associated with sleep deprivation. The results are depicted in Fig. 1.

Table 3. Result of binary logistic regression on factors associated with sleep deprivationa.

Variables

Crude OR (95% CI)

P

Adjusted OR (95% CI)

P

Figure 1. The results of prevalence and the factors of sleep deprivation among Chinese college students of the present study.

Discussion

To the best of our knowledge, this is the first study to report the prevalence of sleep deprivation among healthy college students in China. The prevalence of sleep deprivation estimated by the present study is the highest reported figure to date. More than three-quarters of the sample (75.6%) reported a sleep duration that did not meet the National Sleep Foundation's recommendations. Furthermore, this study also assessed the associated factors for sleep deprivation.

Sleep deprivation is widespread among college students

The mean value of sleep duration of college students in this study was 6.4 ± 1.0 h. The National Sleep Foundation (NSF) recommends no less than 7 h per day of sleep for adult's ages 18-64 ( Hirshkowitz et al., 2015). The mean sleep duration of college students in this study was below the recommended standard. In addition, the prevalence of sleep deprivation was 75.6% in this study, which indicates sleep deprivation is extremely common among college students. The prevalence of sleep deprivation among Chinese college students is close to the United States, and higher than Malaysia (58.1%) ( Naito, Yun Low & Yuen, 2021), Pakistan (57%) ( Luqman et al., 2020), Lebanon (52.7%) ( Assaad et al., 2014), Japan (52%) ( Matsushita et al., 2014), and Saudi Arabia (49.6%) ( AlFakhri et al., 2015). The above data illustrates that the average sleep duration of college students decreased in both developed and developing countries. Two explanations were proposed for this phenomenon. First, due to the nation's rapid economic development, especially the establishment of logistical supply chains and internet-based technologies, which give people access to media and entertainment conveniently, people are sleeping shorter ( Fang et al., 2021). Secondly, most Chinese college students are free from the supervision of their parents and start to live independently when they go to college. They prefer to sleep less when facing schoolwork and the abundant after-school life alone. Apparently, young people's lifestyles and behaviors have largely changed, and their sleep seems to be affected by rapid transformation and social changes ( Naito, Yun Low & Yuen, 2021).

The prevalence of sleep deprivation among college students in China is significantly higher than Chinese population. Fang et al. (2021) reported the prevalence was 23.6%, 25.3%, 28.9%, 31.9%, and 33.1% in 2004, 2006, 2009, 2011, and 2015 respectively among the Chinese population. It suggests that sleep deprivation is more severe among college students. In this regard, we have analyzed several possible reasons. Firstly, freshmen and sophomores face new challenges, such as being solely responsible for themselves, new schedules, unfamiliar environments, social obligations, roommate disagreements, dietary problems, financial burdens, and academic stress ( Luqman et al., 2020). The senior students confront with graduation, career choice and master's entrance examinations. For the postgraduate group, it is common to stay up late for scientific work or paper writing based on our observations. In addition, graduate students also have to face the pressure of income, marriage and childbirth due to their age. These factors above force students to reduce the duration or change the habits of sleep, resulting in sleep deprivation ( Trockel, Barnes & Egget, 2000). Secondly, the majority of students living in dormitories had a later bedtime and early wake-up time, longer sleep latency, and shorter total sleep duration ( Lima, Medeiros & Araujo, 2002). Thirdly, based on the researcher's observations and previous studies ( Christensen et al., 2016; Hale & Guan, 2015; Whiting et al., 2021; Mireku et al., 2019; Albqoor & Shaheen, 2021), it was shown that some college students stay up even all night for entertainment and socializing, such as playing games, watching movies, TV shows or entertainment programs, shopping online, chatting on cell phones, etc. These facts may explain current the higher incidence of sleep deprivation among college students in China.

The prevalence of sleep deprivation among college students is significantly higher than adolescents in China. Previous studies showed that the prevalence of sleep deprivation among Chinese adolescents was 51% ( Chen et al., 2014). Compared to adolescent students, college students are less likely to have parents monitoring their sleep duration ( Noor et al., 2022). Therefore they have more time (at the expense of sleep) to do what they want to do. The prevalence of sleep deprivation among college students is similar to some high-pressure work groups. For instance, the working population was 71.3% ( Visvalingam et al., 2020), and the military was 72% ( Luxton et al., 2011). Among the groups with high prevalence of sleep deprivation, some unavoidable factors may contribute to the occurrence of sleep deprivation, such as commuters staying up late and getting up early to work ( Visvalingam et al., 2020), and military drills for soldiers regardless of the time of day ( Luxton et al., 2011). For most college students, getting up early for class and sleeping late may be a reason for the higher prevalence of sleep deprivation.

The prevalence of sleep deprivation in this study was 55.0% in females and 20.6% in males. Previous studies have shown similar results: Becker report showed that female college students had a higher prevalence of sleep deprivation than male ( Becker et al., 2018). It should be reminded that more female participants than male in the sample may have contributed to the higher prevalence of female sleep deprivation. However there was no statistical difference in the prevalence of the two groups. In addition, there were more women who slept normally in this study.

Factors associated with sleep deprivation

Healthy sleep is extremely important for college students. Chronic sleep deprivation may have an impact on cognition (memory, attention, alertness, etc.) ( Alhola & Polo-Kantola, 2007), mental state ( Liu et al., 2013), physical activity ( DePorter, Coborn & Teske, 2017), and more. The ability to prevent adverse effects depends on identifying the relevant factors and implementing the necessary interventions to minimize the growth rate of sleep deprivation. Our study also identified the risk and protective factors for sleep deprivation.

Sleep deprivation may have been caused by an increase in age and nap duration

Our results indicated the risk of sleep deprivation increases with age, which was consistent with previous studies. Fox et al. (2018) have demonstrated that sleep deprivation was more likely to occur with age. The study by Ohayon et al. (2004) had shown that several sleep-related factors decreased with age, including the total sleep time, sleep efficiency, slow-wave sleep, and rapid eye movement sleep. Several possible explanations might be related to the phenomenon. First, a reduction in sleep duration with age could be attributed to changes in sleep structure and a reduction in acute sleep needs ( Skeldon, Derks & Dijk, 2016; Lee & Sibley, 2019). Also, the study by Grandner (2022) had shown that sleep becomes more erratic, as age increasing. The majority of the sample in this study was from medical universities. Seniors need to deal with heavier coursework or clinical practice. This leads to the possibility that they may sacrifice some sleep time to study or work. In addition, some college students use their bedtime to relax and release the tension of the day at night ( Acharya, Acharya & Waghrey, 2013). The seniors have psychological stress in areas such as job hunting. They tend to sleep less to meet higher demands in academics, facing fierce social competition.

The current study found that napping for more than 60 min per day increased the risk of sleep deprivation. This finding was consistent with that of Dhand & Sohal (2006) who suggested that naps of less than 30 min confer several benefits, whereas longer naps might reduce productivity and sleep inertia and affect physical health. The study by Dhand & Sohal (2006), Mead et al. (2022) and Hays, Blazer & Foley (1996) showed that long naps might reduce subsequent night sleep. Although daytime napping was thought to delay sleep and contribute to shorter nighttime sleep, it had also been found to be a mechanism to compensate for sleep deprivation during weekdays and weekends ( Gradisar et al., 2008; Malone et al., 2016). However, some studies ( Monk et al., 2001; Pilcher, Michalowski & Carrigan, 2001; Campbell, Murphy & Stauble, 2005) did not find long naptime affecting nighttime sleep, which differs from above findings. Therefore, the increased risk of sleep deprivation due to long naps needs to be further explored.

Sleep duration inconsistency between workdays and rest days, accustoming to staying up late, staying up late to work or study, repeated thoughts in bed, and stressed out state are protective factors of sleep deprivation

Compared with sleeping consistency, sleeping inconsistency between work and rest days had 40% lower odds of sleep deprivation. It suggests sleeping inconsistency between work and rest days might be a protective factor for sleep deprivation. For people who are inconsistent, more sleep is an important way to restore energy and strength. Getting more sleep on rest days can ease the strain of the workday. As Lund et al. (2010) reported that the rest day's wake-up time could be delayed due to lack of pressure to go to class. Zhang et al. (2020) found that longer rest days catch-up sleep appeared to help adults recover from moderate sleep loss on workdays. For students who sleep more on workdays, workday routine may allow them to get enough sleep. Therefore they may use more time to relax on their rest days. Less sleep is likely to be no less than 7 h, both on weekdays and on rest days.

The results of this study showed that those accustomed to staying up late and staying up late to work or study were less likely to have sleep deprivation. This finding was unexpected and not the same as previous research ( Ahrberg et al., 2012; Orzech, 2013; Gariépy et al., 2019). One possible reason is that the students who stayed up late often had a correspondingly delayed wake-up time, and their overall sleep time did not decrease. This sleep pattern is similar to the healthcare workers who worked at home during the COVID-19 pandemic. Some students even sleep longer to compensate for the effects of sleeping late.

In general, stress and repeated thoughts in bed may affect sleep. Such as Almojali et al. (2017) reported that students who were not suffering from stress were less likely to have sleep problems. One unanticipated finding detected by this study was stress and repeated thoughts in bed reducing the risk of sleep deprivation. Two possible reasons may explain this result. The subjects of this study were healthy college students without psychiatric and psychological problems. Such individuals are able to relieve stress through exercise, recreation, and socialization. They are able to tolerate stress in normal limits without developing sleep disorder. In addition, school closure management due to COVID-19 pandemic may explain this phenomenon. A study from a US college student population showed the sleep duration was significantly longer, bedtime and wake time were significantly later during the COVID-19 pandemic ( Benham, 2021), which indicated that COVID-19's stress on sleep duration may not be entirely negative. A study from India showed relative to the before lockdown condition, undergraduate and postgraduate university students were more extensive feelings of sleepiness, with significantly increased daytime nap duration, and depressive symptomatology, during the phase of the pandemic ( Majumdar, Biswas & Sahu, 2020). Similar to that, our investigation was conducted during the COVID-19 pandemic. During the period, the school was in closed management and students may feel stressed. On the other hand, due to online learning, students were relatively free to spend their time. They had not to wake up on time due to strict class time, which gave them the ability to sleep longer. As Benham (2021) reported students stay up late and also get up late. Therefore the sleep duration is likely to be adequate. In addition, there may be some other potential factors that influenced the results. We are going to conduct semi-quantitative personal interviews with the aim of finding evidence that would explain this result.

Measures should be undertaken to promote a healthy sleep

It is necessary to perform methods maintaining enough sleep due to the current high incidence of sleep deprivation among college students. On an individual basis, the daytime hours should be rationalized, and the nap duration should be controlled; get enough sleep on rest days to replace missing hours of sleep on workdays; posters about "the importance of adequate sleep" or "going to bed" in the dorm could be put up; a time for lights out is set negotiating with your roommates; the electronics are not bring to bed. On a college basis, administrators could try measures to make sure students have a good sleep-work balance. The special "lunchroom" is provided to encourage students napping. Sleep education activities could be conducted, such as carrying out sleep health lectures or blackboard competitions. Credit courses with sleep self-assessment are offered. The emails with the content of sleep relaxation techniques, a self-administered sleeps restriction protocol, etc. could be sent to students regular weekly by college. The special sleep teams could be set up to counsel students with sleep problems and make regular return visits by college ( Hershner & Chervin, 2014).

Finally, it is important to indicate that our study has some limitations. This is a cross-sectional design. It was difficult to determine true exposure-outcome relationships. Therefore, the results are hypothesis generating and further large scale longitudinal studies are needed to validate our findings. Furthermore, the question assessing sleep duration and health status based on self-reported and responses are subjective. Self-reported sleep duration may be sometimes imprecise due to night-to-night differences in sleep and difficulty in distinguishing accurate sleep duration from time in bed. Although the students determined the health status according to the physical examination and a psychological assessment conducted annually. Subjective measurement methods are prone to measurement and recall bias, which can affect the validity and accuracy of reported sleep durations and health status. Therefore, in future research, the preferred method to accurately assess sleep duration is an objective measurement such as sleep actigraphy or polysomnography. Furthermore, the lack of a universal definition for defining sleep deprivation means that different studies use different sleep duration to define the outcome, making comparisons between studies difficult.

Conclusions

This study revealed a high prevalence of sleep deprivation among healthy college students in China. Also, the study examined socio-demographics and factors that may have an impact on sleep comprehensively. Sleep deprivation may have been caused by an increase in age and nap duration. Sleep duration inconsistency between workdays and rest days, accustoming to staying up late, staying up late to work or study, repeated thoughts in bed, and stress may be protective factors of sleep deprivation which needs to be confirmed by longitudinal studies or personal interviews. Considering the current situation of widespread sleep deprivation among college students, it is necessary to implement multi-party interventions in cooperation with society, schools, and college students themselves. Such as rationalizing daytime hours, controlling nap duration, getting enough sleep on rest days to replace missing hours of sleep on workdays. Promoting college students and public awareness of the importance of adequate sleep and the consequences of sleep deprivation would be the basic way to solve the high prevalence of sleep deprivation.

Supplemental Information

Acknowledgments

We would like to thank the teacher Nai Bao Hu from Binzhou Medical University, who provided the application of statistical to analyze data.

Funding Statement

This work was supported by the National Nature Science Foundation (81703983). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Additional Information and Declarations

Competing Interests

The authors declare there are no competing interests.

Author Contributions

Congcong Guo analyzed the data, authored or reviewed drafts of the article, and approved the final draft.

Songzhe Piao analyzed the data, authored or reviewed drafts of the article, and approved the final draft.

Chenyu Wang analyzed the data, prepared figures and/or tables, and approved the final draft.

Lili Yu performed the experiments, prepared figures and/or tables, and approved the final draft.

Kejun Wang analyzed the data, prepared figures and/or tables, and approved the final draft.

Qian Qu performed the experiments, prepared figures and/or tables, and approved the final draft.

Cuiting Zhang analyzed the data, prepared figures and/or tables, and approved the final draft.

Xiaofei Yu conceived and designed the experiments, authored or reviewed drafts of the article, and approved the final draft.

Human Ethics

The following information was supplied relating to ethical approvals ( i.e., approving body and any reference numbers):

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Binzhou Medical University (2021-262).

Data Availability

The following information was supplied regarding data availability:

The raw measurements are available in the Supplementary File.

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Associated Data
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The prevalence and associated factors of sleep deprivation among healthy college students in China: a cross-sectional survey

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The prevalence of sleep deprivation among college students is increasing and has a few associated factors. The present study analyzed 2,142 college students from 28 provinces in China. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) ...

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(Elizabeth von Oehsen/The Washington Post)
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There are countless reasons to stay up late in college. Here's one goodreason to go to bed.

The less a student sleeps every night, the lower their grade-point average will be, according to a two-year study of the sleep habits of more than 600 college freshmen that was published Monday in the Proceedings of the National Academy of Sciences.
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Researchers found that every lost hour of average nightly sleep at the start of an academic term was associated with a 0.07-point drop in a student's end-of-term GPA. When a student slept less than six hours a night, the effect of lost sleep on a student's grades was even more pronounced, said David Creswell, the lead author of the study and a professor in psychology and neuroscience at Carnegie Mellon University.

"You're accumulating this sleep debt," Creswell said. "And that has a pretty negative role in terms of people's academics."

Sleep, especially undisturbed sleep, helps the brain process and retain information it has learned. And when someone is sleep-deprived, attention span and memory also are impaired.

But students have a number of "competing pressures" to stay up late in college, especially in their freshman year, which is often the first time students are living away from home, Creswell said. The average student in the study fell asleep about 2:30 a.m. Barely any of the students went to bed before midnight. And, on average, they slept 6½ hours a night.

Just one hour of extra sleep each night can lead to better eating habits

Sleep recommendations vary

Sleep recommendations shift by age, and the amount of sleep an individual actually needs can vary person to person. In general, for teenagers, the recommendation is eight to 10 hours of sleep. For those 18 to 25 years old, it drops to seven to nine hours.

Creswell said he doesn't want to "lecture" students about the findings but, according to the research, it appears that getting enough shut-eye does boost a student's GPA.

"A lot of students say, 'I should just stay up a lot later and study a lot longer,' " Creswell said. "Well, what we're showing here is that sleep may be your friend, in terms of helping consolidate this information."

Creswell and the team of researchers conducted five studies, recruiting college freshmen taking courses in a range of majors at Carnegie Mellon, the University of Notre Dame and the University of Washington. To monitor sleep, the students wore either a Fitbit Flex or a Fitbit HR for the entire academic term, a spring semester or a winter quarter, depending on the school, Creswell said.

Creswell said they avoided studying students' sleep habits around final exams and term papers because they assumed that the average student's sleep would just continue to drop off.

"We really wanted to look at this critical period in the semester where you're starting to establish sleep patterns," Creswell said. "Because once you start to hit midterm and finals period, you're sort of too late in the game for actually doing effective intervention."

After controlling for other factors - such as whether a student takes naps, their number of class credits and their GPA the previous term - the researchers found that average nightly sleep continued to predict a student's end-of-term GPA. What time a student went to bed and whether their bedtime varied day to day did not seem to play a role, Creswell said.

A similar study of 100 engineering students at the Massachusetts Institute of Technology published in 2019 found the same association between a student's grades and the amount of sleep they were getting. That study also showed it was tough to make up for bad sleep habits. There was no improvement in scores among students who made sure to get a good night's sleep right before a big test.

Insufficient sleep may create 'sleep debt'

It's not clear why less sleep would cause someone to have a lower GPA, Creswell said. Sleeping for longer, uninterrupted periods of time allows for REM sleep, a period of unconscious rapid eye movement that corresponds with high activity in the brain. Creswell said he suspects a regular pattern of insufficient sleep creates a "sleep debt" over time, leaving students unable to concentrate.

"These college students are going to class with a ton of sleep debt, and they're having trouble staying focused and learning in college classrooms," Creswell said. "Those things can really harm your ability to really engage with the material."

Aric Prather, a psychologist at the University of California at San Francisco, and author of the book, " The Sleep Prescription," said the findings could inform systemic changes at universities, campaigns or workshops to help students have a better night's sleep.

"There are multiple pathways to get to a GPA, and sleep is like the glue that holds our lives together in lots of domains," Prather said. "When that whittles away, or is less sticky, bad things happen."

Grace Pilch, an 18-year-old freshman who lives in a dorm at Pennsylvania State University, said she needs to get at least eight hours of sleep to function in class and during workouts at the gym.

"I can always tell if I didn't get enough sleep," Pilch said.

Pilch, who's majoring in graphic design, said she cares more about getting enough sleep in college than she did in high school because "the classes are expensive," and she wants to do well. Pilch said she has around a 3.8 GPA so far. And she and her roommate are in bed by 11 p.m. during the week.

"But I do go out with my friends," Pilch said. "Sleep is important, grades are important, but it's also important to make connections."

3 ways to stop waking up frequently during the night and improve sleep

Academic success early on in college has been shown to predict whether students stay in school or drop out years later, and campus programs to address sleep habits could help freshmen during a "critical period" in school, Creswell said.

"We could really teach them, in that first year of college, better sleep patterns that could help them with their academic achievement," Creswell said.

At the University of Pennsylvania in Philadelphia, 200 students and staff members have enrolled in a seven-week online course on building better sleep habits. Rebecca Huxta, the director of public health and wellness at the university, saidthat since starting the program, participants have reported an overall decrease in symptoms of insomnia.

Roxanne Prichard, a professor of psychology at the University of St. Thomas in St. Paul, Minn., said that she finds students "have been exhausted since puberty," and they've "grown accustomed" to always feeling lethargic.

"Fundamentally, it comes down to: If we're not sleeping well, all systems are not a go," Prichard said. "Our body is not prepared for the day ahead of us and what we're asking it to do if we don't have that good, basic chunk of nighttime sleep."

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The less college students sleep, the worse their grades, study finds

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Researchers found there was a "more pronounced" negative effect on a student's GPA when they slept less than six hours a night.

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At the same time, today's teens are maturing in an era of ubiquitous electronic media, and they are fervent participants. Some 92 percent of U.S. teens have smartphones, and 24 percent report being online "constantly," according to a 2015 report by the Pew Research Center. Teens have access to multiple electronic devices they use simultaneously, often at night. Some 72 percent bring cellphones into their bedrooms and use them when they are trying to go to sleep, and 28 percent leave their phones on while sleeping, only to be awakened at night by texts, calls or emails, according to a 2011 National Sleep Foundation poll on electronic use. In addition, some 64 percent use electronic music devices, 60 percent use laptops and 23 percent play video games in the hour before they went to sleep, the poll found. More than half reported texting in the hour before they went to sleep, and these media fans were less likely to report getting a good night's sleep and feeling refreshed in the morning. They were also more likely to drive when drowsy, the poll found.

The problem of sleep-phase delay is exacerbated when teens are exposed late at night to lit screens, which send a message via the retina to the portion of the brain that controls the body's circadian clock. The message: It's not nighttime yet.

Yuan, a clinical associate professor of pediatrics, said she routinely sees young patients in her clinic who fall asleep at night with cellphones in hand.

"With academic demands and extracurricular activities, the kids are going nonstop until they fall asleep exhausted at night. There is not an emphasis on the importance of sleep, as there is with nutrition and exercise," she said. "They say they are tired, but they don't realize they are actually sleep-deprived. And if you ask kids to remove an activity, they would rather not. They would rather give up sleep than an activity."

The role of parents

Adolescents are also entering a period in which they are striving for autonomy and want to make their own decisions, including when to go to sleep. But studies suggest adolescents do better in terms of mood and fatigue levels if parents set the bedtime - and choose a time that is realistic for the child's needs. According to a 2010 study published in the journal Sleep, children are more likely to be depressed and to entertain thoughts of suicide if a parent sets a late bedtime of midnight or beyond.

In families where parents set the time for sleep, the teens' happier, better-rested state "may be a sign of an organized family life, not simply a matter of bedtime," Carskadon said. "On the other hand, the growing child and growing teens still benefit from someone who will help set the structure for their lives. And they aren't good at making good decisions."

They say they are tired, but they don't realize they are actually sleep-deprived. And if you ask kids to remove an activity, they would rather not. They would rather give up sleep than an activity.

According to the 2011 sleep poll, by the time U.S. students reach their senior year in high school, they are sleeping an average of 6.9 hours a night, down from an average of 8.4 hours in the sixth grade. The poll included teens from across the country from diverse ethnic backgrounds.

American teens aren't the worst off when it comes to sleep, however; South Korean adolescents have that distinction, sleeping on average 4.9 hours a night, according to a 2012 study in Sleep by South Korean researchers. These Asian teens routinely begin school between 7 and 8:30 a.m., and most sign up for additional evening classes that may keep them up as late as midnight. South Korean adolescents also have relatively high suicide rates (10.7 per 100,000 a year), and the researchers speculate that chronic sleep deprivation is a contributor to this disturbing phenomenon.

By contrast, Australian teens are among those who do particularly well when it comes to sleep time, averaging about nine hours a night, possibly because schools there usually start later.

Regardless of where they live, most teens follow a pattern of sleeping less during the week and sleeping in on the weekends to compensate. But many accumulate such a backlog of sleep debt that they don't sufficiently recover on the weekend and still wake up fatigued when Monday comes around.

Moreover, the shifting sleep patterns on the weekend - late nights with friends, followed by late mornings in bed - are out of sync with their weekday rhythm. Carskadon refers to this as "social jet lag."

"Every day we teach our internal circadian timing system what time it is - is it day or night? - and if that message is substantially different every day, then the clock isn't able to set things appropriately in motion," she said. "In the last few years, we have learned there is a master clock in the brain, but there are other clocks in other organs, like liver or kidneys or lungs, so the master clock is the coxswain, trying to get everybody to work together to improve efficiency and health. So if the coxswain is changing the pace, all the crew become disorganized and don't function well."

This disrupted rhythm, as well as the shortage of sleep, can have far-reaching effects on adolescent health and well-being, she said.

"It certainly plays into learning and memory. It plays into appetite and metabolism and weight gain. It plays into mood and emotion, which are already heightened at that age. It also plays into risk behaviors - taking risks while driving, taking risks with substances, taking risks maybe with sexual activity. So the more we look outside, the more we're learning about the core role that sleep plays," Carskadon said.

Many studies show students who sleep less suffer academically, as chronic sleep loss impairs the ability to remember, concentrate, think abstractly and solve problems. In one of many studies on sleep and academic performance, Carskadon and her colleagues surveyed 3,000 high school students and found that those with higher grades reported sleeping more, going to bed earlier on school nights and sleeping in less on weekends than students who had lower grades.

Sleep is believed to reinforce learning and memory, with studies showing that people perform better on mental tasks when they are well-rested. "We hypothesize that when teens sleep, the brain is going through processes of consolidation - learning of experiences or making memories," Yuan said. "It's like your brain is filtering itself - consolidating the important things and filtering out those unimportant things." When the brain is deprived of that opportunity, cognitive function suffers, along with the capacity to learn.

"It impacts academic performance. It's harder to take tests and answer questions if you are sleep-deprived," she said.

That's why cramming, at the expense of sleep, is counterproductive, said Pelayo, who advises students: Don't lose sleep to study, or you'll lose out in the end.

The panic attack

Chloe Mauvais, 16, hit her breaking point at the end of a very challenging sophomore year when she reached "the depths of frustration and anxiety." After months of late nights spent studying to keep up with academic demands, she suffered a panic attack one evening at home.

"I sat in the living room in our house on the ground, crying and having horrible breathing problems," said the senior at Menlo-Atherton High School. "It was so scary. I think it was from the accumulated stress, the fear over my grades, the lack of sleep and the crushing sense of responsibility. High school is a very hard place to be."

We hypothesize that when teens sleep, the brain is going through processes of consolidation - learning of experiences or making memories. It's like your brain is filtering itself.

Where she once had good sleep habits, she had drifted into an unhealthy pattern of staying up late, sometimes until 3 a.m., researching and writing papers for her AP European history class and prepping for tests.

"I have difficulty remembering events of that year, and I think it's because I didn't get enough sleep," she said. "The lack of sleep rendered me emotionally useless. I couldn't address the stress because I had no coherent thoughts. I couldn't step back and have perspective. ... You could probably talk to any teen and find they reach their breaking point. You've pushed yourself so much and not slept enough and you just lose it."

The experience was a kind of wake-up call, as she recognized the need to return to a more balanced life and a better sleep pattern, she said. But for some teens, this toxic mix of sleep deprivation, stress and anxiety, together with other external pressures, can tip their thinking toward dire solutions.

Research has shown that sleep problems among adolescents are a major risk factor for suicidal thoughts and death by suicide, which ranks as the third-leading cause of fatalities among 15- to 24-year-olds. And this link between sleep and suicidal thoughts remains strong, independent of whether the teen is depressed or has drug and alcohol issues, according to some studies.

"Sleep, especially deep sleep, is like a balm for the brain," said Shashank Joshi, MD, associate professor of psychiatry and behavioral sciences at Stanford. "The better your sleep, the more clearly you can think while awake, and it may enable you to seek help when a problem arises. You have your faculties with you. You may think, 'I have 16 things to do, but I know where to start.' Sleep deprivation can make it hard to remember what you need to do for your busy teen life. It takes away the support, the infrastructure."

Sleep is believed to help regulate emotions, and its deprivation is an underlying component of many mood disorders, such as anxiety, depression and bipolar disorder. For students who are prone to these disorders, better sleep can help serve as a buffer and help prevent a downhill slide, Joshi said.

Rebecca Bernert, PhD, who directs the Suicide Prevention Research Lab at Stanford, said sleep may affect the way in which teens process emotions. Her work with civilians and military veterans indicates that lack of sleep can make people more receptive to negative emotional information, which they might shrug off if they were fully rested, she said.

"Based on prior research, we have theorized that sleep disturbances may result in difficulty regulating emotional information, and this may lower the threshold for suicidal behaviors among at-risk individuals," said Bernert, an instructor of psychiatry and behavioral sciences. Now she's studying whether a brief nondrug treatment for insomnia reduces depression and risk for suicide.

Sleep deprivation also has been shown to lower inhibitions among both adults and teens. In the teen brain, the frontal lobe, which helps restrain impulsivity, isn't fully developed, so teens are naturally prone to impulsive behavior. "When you throw into the mix sleep deprivation, which can also be disinhibiting, mood problems and the normal impulsivity of adolescence, then you have a potentially dangerous situation," Joshi said.

Some schools shift

Given the health risks associated with sleep problems, school districts around the country have been looking at one issue over which they have some control: when school starts in the morning. The trend was set by the town of Edina, Minnesota, a well-to-do suburb of Minneapolis, which conducted a landmark experiment in student sleep in the late 1990s. It shifted the high school's start time from 7:20 a.m. to 8:30 a.m. and then asked University of Minnesota researchers to look at the impact of the change. The researchers found some surprising results: Students reported feeling less depressed and less sleepy during the day and more empowered to succeed. There was no comparable improvement in student well-being in surrounding school districts where start times remained the same.

With these findings in hand, the entire Minneapolis Public School District shifted start times for 57,000 students at all of its schools in 1997 and found similarly positive results. Attendance rates rose, and students reported getting an hour's more sleep each school night - or a total of five more hours of sleep a week - countering skeptics who argued that the students would respond by just going to bed later.

For the health and well-being of the nation, we should all be taking better care of our sleep, and we certainly should be taking better care of the sleep of our youth.

Other studies have reinforced the link between later start times and positive health benefits. One 2010 study at an independent high school in Rhode Island found that after delaying the start time by just 30 minutes, students slept more and showed significant improvements in alertness and mood. And a 2014 study in two counties in Virginia found that teens were much less likely to be involved in car crashes in a county where start times were later, compared with a county with an earlier start time.

Bolstered by the evidence, the American Academy of Pediatrics in 2014 issued a strong policy statement encouraging middle and high school districts across the country to start school no earlier than 8:30 a.m. to help preserve the health of the nation's youth. Some districts have heeded the call, though the decisions have been hugely contentious, as many consider school schedules sacrosanct and cite practical issues, such as bus schedules, as obstacles.

In Fairfax County, Virginia, it took a decade of debate before the school board voted in 2014 to push back the opening school bell for its 57,000 students. And in Palo Alto, where a recent cluster of suicides has caused much communitywide soul-searching, the district superintendent issued a decision in the spring, over the strenuous objections of some teachers, students and administrators, to eliminate "zero period" for academic classes - an optional period that begins at 7:20 a.m. and is generally offered for advanced studies.

Certainly, changing school start times is only part of the solution, experts say. More widespread education about sleep and more resources for students are needed. Parents and teachers need to trim back their expectations and minimize pressures that interfere with teen sleep. And there needs to be a cultural shift, including a move to discourage late-night use of electronic devices, to help youngsters gain much-needed rest.

"At some point, we are going to have to confront this as a society," Carskadon said. "For the health and well-being of the nation, we should all be taking better care of our sleep, and we certainly should be taking better care of the sleep of our youth."

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Among teens, sleep deprivation an epidemic

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Sleep deprivation increases the likelihood teens will suffer myriad negative consequences, including an inability to concentrate, poor grades, drowsy-driving incidents, anxiety, depression, thoughts of suicide and even suicide attempts.

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College students’ insomnia linked more strongly with loneliness than screen time | Newsroom

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CORVALLIS, Ore. – Being lonely is a bigger hurdle to a good night’s sleep for college students than too much time at a computer or other electronic screen, a new study by Oregon State University suggests.

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Frontiers | The effect of sleep quality on learning engagement of junior high school students: the moderating role of mental health

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IntroductionA good quality of sleep is not only an important guarantee for students’ academic life, but also an important founding condition for their physic…