Sleep quality is associated with stress in secondary school students

Between February and March 2022, a total of 634 school students (295 boys and 339 girls) with a mean age of 16.0 ± 1.2 years were enrolled in this study. The prevalence of poor sleep quality (PSQI scores > 5) was 27.6% (175 out of 634), while good sleep quality (PSQI score ≤ 5) was 72.4% (459 out of 634). Regarding the perception of academic stress, more than half of the students (56.1%) reported either neutral or affirmative responses (choosing neutral or agree). Specifically, 15.1% of the students strongly agreed, 21.0% agreed, 20.0% were neutral, 21.3% disagreed, and 22.6% strongly disagreed with perceiving academic stress. For mental stress assessing by DASS-21, 66.9% of the students did not present mental stress symptoms (scores ≤ 14), while the remaining 33.1% had mental stress symptoms of varying degrees, including mild (14.7%), moderate (12.1%), severe (4.6%), and extremely severe (1.7%).

Our study observed a significant association between binary sleep quality with both perceived academic stress and presence of mental stress symptoms in the five categories (Chi-square test, P < 0.05), as shown in Fig. 1. Specifically, the prevalence of poor sleep quality was lowest among students who strongly disagreed with experiencing academic stress, at 19.6%, and increased gradually and significantly as the level of perceived academic stress increased. The prevalence of poor sleep quality was 21.5%, 24.4%, 32.3%, and highest at 45.8% among students who were disagreed, neutral, agreed, and strongly agreed with experiencing academic stress, respectively. Similarly, the prevalence of poor sleep quality increased gradually and significantly as mental stress symptoms severity increased, with the lowest prevalence at 21.9% in the absence of mental stress symptoms and the highest at 54.5% among students who reported severe mental stress symptoms.

Table 1 presents the descriptive statistics of the study participants stratified by the level of perceived academic stress in the three categories. Out of 634 students, 229 (36.1%) perceived high levels of academic stress with a mean age of 16.17 years. Significant differences were observed in age (P = 0.013) and family type (P = 0.041) between the three group. A statistically significant higher proportion of students among those who agreed to have academic stress reported failing in exams (33.2%), having stress symptoms (42.8%), and having poor sleep quality (38.0%), while the proportion was lower for those who were neutral (26.8%, 35.4%, and 24.4%, respectively) or disagreed (13.7%, 19.1%, and 20.5%, respectively) about experiencing academic stress. However, there were no significant differences in sex, BMI, caste, residence, father’s education, mother’s education, grade, TV watching, phone usage, MET score and sedentary time between the three academic stress groups.

Table 1 Characteristics of secondary school students stratified by perceived academic stress (n = 634)

Table of Contents

Association between poor sleep quality with stress subscale’s statements among students

In the adjusted models, we found statistically significant associations between sleep quality and three subscale items related to stress. Students who indicated even a modest degree of feeling touchy were associated with almost 1.5 times higher risk of experiencing poor sleep quality compared to their counterparts. Similarly, individuals who faced difficulties in winding down or frequently experienced agitation were found to have nearly double the risk of encountering poor sleep quality compared to their counterparts (Fig. 2).

Note

All models are adjusted for age, sex, body mass index, caste group, residence, family type, father and mother education, grade of study, recent exam results, television watching, mobile usage period, MET score and sedentary minutes. OR: Odds ratio; aOR: adjusted odds ratio; CI: confidence interval. All models included one random effect: school.

Binary association between sleep quality with stress in students

We observed statistically significant associations between binary sleep quality and academic stress in the three categories, with students who perceived academic stress being more likely to have poor sleep quality compared to those who didn’t perceive academic stress in unadjusted model 1 (crude OR(cOR) = 2.38, 95% CI: 1.60, 3.53), model 2 adjusted for demographic and academic variables (aOR = 2.37, 95% CI: 1.55, 3.60) and model 3 further adjusted for screen time and lifestyle variables (aOR = 2.33, 95% CI: 1.52, 3.56). Likewise, statistically significant associations between sleep quality and mental stress symptoms were found, with student who presented symptoms of mental stress being more likely to have poor sleep quality compared to those who didn’t have mental stress symptoms in unadjusted model 1 (cOR = 2.28, 95% CI: 1.59, 3.27), model 2 adjusted for demographic and academic variables (aOR = 2.06, 95% CI: 1.41, 3.01) and model 3 further adjusted for screen time and lifestyle variables (aOR = 1.97, 95% CI: 1.34, 2.89) (Table 2).

Table 2 Binary associations of sleep quality with academic stress and mental stress symptoms among secondary school students (n = 634)

Impact of stress on sleep quality

The multivariable models showed similar results when including perceived academic stress and mental stress status in the same model. In all three models tested, the students who agreed to perceive academic stress (cOR = 2.04, 95% CI: 1.36, 3.07; aOR = 2.10, 95% CI: 1.37, 3.23; aOR = 2.09, 95% CI: 1.35, 3.22) and with presence of mental stress symptoms (cOR = 2.01, 95% CI: 1.39, 2.91; aOR = 1.82, 95% CI: 1.23, 2.68; aOR = 1.74, 95% CI: 1.18, 2.58) were significantly more likely to have poor sleep quality compared to their counterparts (Table 3).

Table 3 Multivariable associations of sleep quality with academic stress and mental stress symptoms among secondary school students (n = 634)

link