JRHS 2014; 14(3): 198-204

Copyright© Journal of Research in Health Sciences

Sleep Patterns and Disorders among University Students in Lebanon

Shafika Assaad (PhD)a, Christy Costanian (MSc)b*, Georges Haddad (MD)c, Fida Tannous (MSc)d

a Department of Biology-Neuroscience, Faculty of Sciences, Lebanese University, Beirut, Lebanon

b Department of Epidemiology and Population Health, Faculty of Health Sciences, American  University of Beirut, Beirut, Lebanon 

c Department of Psychiatry, La Croix Hospital, Beirut, Lebanon

d Department of Biology, Faculty of Sciences, Beirut Arab University, Beirut, Lebanon

* Correspondence: Christy Costanian (MSc), E-mail: christycostanian@gmail.com

Received: 09 March2014, Revised: 11 April 2014, Accepted: 21 April 2014, Available online: 12 April 2014


Background: Insufficient sleep is a significant public health issue with adverse medical consequences. Sleep disturbances are common among university students and have an effect on this groups overall health and functioning. The aim of this study was to investigate sleep habits and disorders in a population of university students across Lebanon. 

Methods: This was a cross-sectional study carried out in 2012 among 735 students aged 18-25 years old, enrolled at six universities across Lebanon. The Pittsburg Sleep Quality Index (PSQI) was used to assess sleep quality and habits.

Results: Less than half of the total study population (47.3%) were good sleepers (PSQI<5). Upon bivariate analysis, males experienced more sleep difficulties than females (57.8% vs. 40.8%). The majority (60%) of males vs. 40% of females had trouble performing daily activities more than once per week (P=0.02). Results of the multivariate analysis revealed that reporting poor sleep quality was strongly associated with daytime dysfunction and sleep- enhancing medication use especially more than once per week.

Conclusions: This is the first study to describe the nature of sleep problems among university students in Lebanon. This study suggests that sleep problems among Lebanese college students were common and such problems may interfere with daily performance. Findings from this study have important implications for programs intended to improve academic performance by targeting sleep habits of students.

Keywords: Sleep disorders, Sleep deprivation, PSQI, University students, Lebanon


A lack of sufficient sleep and poor sleep quality are major public health issues worldwide with adverse health consequences. It is recommended that adolescents (1017 years old) sleep for 8.59.5 hours per night and those persons 18 years of age obtain 79 hours of sleep per night 1. Yet a significant proportion of college students do not follow these guidelines by sleeping <6 hours per night. Lack of sleep has an effect on the endocrine, immune, and nervous systems and is associated with an increased risk of cardiovascular factors including obesity, diabetes, impaired glucose tolerance, and hypertension2. Moreover, insufficient sleep is important in influencing body weight regulation and metabolism3. Sufficient sleep plays a role in improving memory and has been implicated with good scholastic attainment 4,5. A cross-sectional survey conducted among Chilean college students found a positive correlation between adequate sleep duration and self-rated happiness and quality of life, respectively 6. Furthermore, insufficient sleep has been linked with poor academic performance, substance use, mood disorders, and physical inactivity7. Additionally, short sleep duration may lead to frequent medication use and alcohol consumption to aid sleep as well as stimulant use to increase daytime alertness8.

Sleep disorders among university students is an important topic for investigation9. However, few studies, focusing on this group of individuals, have been conducted. However, most studies focus on young children, adolescents, older adults or on a certain category of patients10. Todays university students experience great psychological pressure due to the changing career market and an increased job competition 11. Such stress and anxiety can cause sleep problems. In fact, a significant number of university students sleep quality and quantity might be altered after enrollment2. Studies examining sleep patterns and behavior conducted in the Middle East and North Africa (MENA) region remain scarce, limited to specific populations and small in sample size13. For example, Suleiman and colleagues14 reported poor sleep quality as being highly prevalent among nursing students in Jordan. Another study by Sweileh and colleagues15 reported that sleep problems were common among 400 Palestinian undergraduate students and were comparable to European counterparts.

Sleep disturbances among university students in Lebanon have received minimal attention and little is known about the nature of the sleep habits and difficulties in this population. For the purpose of this study, sleep problems or disturbances were defined as any difficulty in falling asleep or failure to maintain sleep due to noise, nocturnal eating or snoring. Sleep habits were defined as behavior pertaining to time to bed, time to rise, duration of night sleep and consumption of sleeping pills16.

The aim of this cross-sectional study was to describe and assess sleep patterns and sleep quality among university students in Lebanon, a small, middle-income country of the MENA region.


Study Setting and Sample

This cross-sectional study was conducted at six major universities in Greater Beirut and its suburbs, between June and December 2012 (n=1000, 73.5% response rate). Participants were chosen from five major private universities, the faculties of which were located in a single campus, and from six randomly selected faculties from the (public) Lebanese University, each within its own campus. A total of 1000 undergraduate students were randomly selected, with 735 (410 males and 325 females) participating in this survey.

The inclusion criteria were: men and women 18-25 years old, and enrolled as a current student in the bachelors program at each of the respective universities. Students who had respiratory problems such as sleep apnea, those with incomplete information on sleep quality, those below age 18 or above age 25 as well as pregnant, lactating females were excluded from the study. Participants were recruited through direct contact with one of the investigators at the university campus at the beginning of the semester prior to final exams and the end-of-semester work load after distribution of flyers.

After screening for inclusion and exclusion criteria, the subjects were invited to participate in the study. The questionnaire required less than 10 min to fill out. Proportionate random samples were selected based on the number of students in each university/faculty, and participants were asked to complete a self-administered anonymous questionnaire, which detailed characteristics on age, gender, and sleep quality, the outcome of interest. This research was reviewed and approved by the institutional review board.

Data Collection and Variable Specification

A self-administered questionnaire was used to collect information for this study. The questionnaire ascertained demographic information including age and sex. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI), a 19-item self-reported questionnaire that evaluates sleep quality within the past month. The PSQI, a retrospective tool is comprised of seven components that assess sleep habits and these included: sleep duration (in hours), sleep disturbance, sleep latency, estimates of habitual sleep efficiency, use of sleep-enhancing medication, daytime dysfunction due to sleepiness, and overall perceived sleep quality16,17 Participants rate nine aspects of their sleep so that six specific component scores (e.g., sleep latency), as well as a summary global Sleep Quality Index (SQI), can be calculated. The sample was divided into good or poor sleepers according to the SQI of the PSQI (a score of 5 points was categorized as poor). Previous studies have documented the reliability and validity of the PSQI for detecting sleep disturbances17.

Each sleep component could be given a score ranging from 0 to 3, with 3 referring to the greatest disturbance 16,17. Subsequently, these scores are summed to yield a global sleep quality score (range 0 to 21) with higher scores indicating poor sleep quality in the last month. Participants with a global score 5 were classified as poor sleepers. Those with a score < 5 were classified as good sleepers. This classification is consistent with prior studies of college students 18. In accordance with PSQI sleep quality subscales, subjective sleep efficiency, sleep latency, sleep medication use, and daytime dysfunction due to sleepiness, a dichotomous variable of optimal and suboptimal sleep quality was computed. Specific categories were sleep latency (30 versus <30 minutes); estimates of poor sleep efficiency such as daytime dysfunction due to sleepiness ( once per week versus <once a week); and sleep medication use during the past month ( once per week versus <once a week).

Statistical Analysis

Frequency distributions of sleep quality and other components of sleep among study participants were examined. Characteristics were summarized using means and standard deviations for continuous variables and counts and percentages for categorical variables. Chi-square test and Students t-test were used to determine bivariate differences for categorical and continuous variables, respectively. The distributions of PSQI scores among male and female students, as well as the sex-specific prevalence of poor sleep quality were also estimated according to the PSQI classification. Prevalence estimates and risk of suboptimal dichotomous sleep quality subscales were also obtained. Multivariable logistic regression estimated the odds ratios (OR) and 95% confidence intervals (95% CI) for the associations between reporting poor sleep quality and having a poor PSQI score in unadjusted and adjusted models. . All analyses were performed using SPSS Statistical Software for Windows (IBM SPSS Version 18, Chicago, Illinois, USA). All reported 𝑃 values are two-sided and deemed statistically significant at 𝛼=0.05.


A total of 735, out of approximately 1000 students were recruited. Approximately 56% of the 735 participants were male and the overall mean age was 20.6 ±1.8 years. Table 1 depicts the patterns of sleep quality and quantity in the overall study sample. The average sleep latency (the amount of time that it takes to fall asleep, measured in minutes) was 24.64 ± 1.1 minutes among respondents. The average duration of sleep reported by students was 6.67 ±1.67 hours. Less than half of the total study population (47.3%) were good sleepers (PSQI<5). Around 42% of participants could not fall asleep within 30 minutes of going to bed during the last past month and those also scored poorly on the PSQI scale. Over a quarter of the students surveyed had not experienced bad dreams as a sign of sleep disturbance while sleeping more than once per week. Around 30% of participants experienced a lack of enthusiasm more than once per week, and 28% had trouble staying awake while driving, eating, and engaging in social activity more than once per week, as indicators of daytime dysfunction.

Table 2 summarizes the distribution of PSQI sleep components subscales for male and female students, respectively. The mean sleep latency in males was 19.78 ±4.32 minutes, whereas in females, the mean was 21.23 ±1.64 minutes (P=0.001), while the mean sleep duration in males was 7.75 ±1.64 minutes, whereas in females, the mean was 8.51 ±1.52 minutes (P=0.001) (results not shown). More than 50% of students (53.2%) reported being poor sleepers, with males experiencing more sleep difficulties than females (57.8% vs. 42.2%).

With regards to sleep behavior, over 50% of males in our study woke up in the middle of the night or very early morning (P=0.042), and this trend was also seen in females at 46%.The majority of males (67.3%) reported that they coughed or snored loudly more than once per week while almost 33% of females reported similar issues (P<0.001). More males than females experienced disturbances in the form of feeling too hot (63.3% vs. 37.6%) and feeling pain (55.6% vs. 44.4%) more than once a week while asleep and this was statistically significant (P<0.001) (Table 2). On the other hand, more females than males reported feeling too cold (55.5% vs. 44.5%) and having bad dreams (53% vs. 47%) more than once a week while asleep, and these results proved also to be statistically significant (P<0.001). Over half of males in this study population vs. 48.4 % of females reported troubles with maintaining enthusiasm more than once per week (P=0.013), also 60% of males and 40% of females had trouble performing daily activities more than once per week (P=0.024). Almost 60% of males and 41.3% of females reported taking sleeping medications more than once per week.

We evaluated the odds of poor sleep quality as determined by the PSQI score according to participants demographic and other sleep characteristics. Results of the multivariate logistic regression of the association between a poor PSQI score and other variables are shown in Table 3. All of the variables that were shown to be statistically significant in the bivariate analysis were included in the multivariate model. There was no major difference between the unadjusted, age and gender adjusted and adjusted models. Daytime dysfunction, sleep quality and sleep medication remained statistically significant in both bivariate and multivariate analysis throughout the study. Although this result was not statistically significant, compared with males, females were less likely to be poor sleepers OR=0.67 (95% CI: 0.42, 1.05; P=0.821) in the fully adjusted model. As an indicator of sleep disturbance, those who felt too hot more than once per week while asleep were 1.3 times more likely to score poorly on the sleep score OR=1.29 (95% CI: 1.04, 3.40; P=0.035), than those who did never felt hot. Moreover, those who had experienced pain more than once per week were almost 2 times more likely to be classified as poor sleepers OR=2.34 (95% CI: 1.03, 4.85; P=0.024). In terms of daytime dysfunction, students who had trouble maintaining enthusiasm for more than once in the past month were almost 3 times more likely to score as poor sleepers compared with those who reported having no trouble OR=2.50 (95% CI: 2.08, 4.54; P=0.001). Furthermore, those who had trouble performing daily activities more than once per week were significantly more likely to be poor sleepers than their counterparts OR=9.09 (95% CI: 4.76, 12.3; P=0.001).

Finally, students who often take sleep-enhancing medication, were significantly more likely to be scored as poor sleepers, with those who take medications less than once per week having almost 7 times the odds of having a poor PSQI score OR=6.50 (95% CI: 2.9, 14.5; P=0.002), and those who take medications once or more per week having 14 times the odds of scoring poorly in the PSQI OR=14.1 (95% CI: 3.1, 15.6; P=0.001), compared to those who do not take sleep-enhancing medications.

Table 1: Sleep quality patterns in the overall study sample (n=735)

Table 2: Association between sleep quality, habits and problems with gender in the sample (n=735)

Table 3: Association between various indicators of sleep quality and a poor PSQI Score (n=735) using unadjusted odds ratio (UAOR) and adjusted odds ratio (AOR)


This study aimed to describe the sleep habits and sleep problems among university students in Lebanon. More than half of the students surveyed reported being poor sleepers, with males significantly experiencing more sleep difficulties than females. Findings of this study indicate that around 42% of participants could not fall asleep within 30 minutes of going to bed during the last past month. Results of the multivariate analysis revealed that students who often took sleep-enhancing medication were significantly more likely to be scored as poor sleepers with those who take medications once at least once per week had14 times the odds of being scored as poor sleepers.

Sleep patterns and habits

Our study revealed that the average duration of night sleep among Lebanese university students was 6.67 ±1.6 hours. A similar study among Palestinian undergraduate students by Sweileh and colleagues reported an average duration of sleep of 6.4 ±1.1 hours15. This result was also comparable with a study among Korean college students who had a sleeping duration of 6.7 ±1.3 hours 19. Our results showed that 42% of the participants needed more than 30 minutes to fall asleep. Our results were consistent with the National Sleep Foundations that indicates sleep difficulties. Data from this study was similar to that obtained by studies among college students in USA where more than 40% of the American student population have difficulty falling asleep or have night waking 20. Studies conducted across various countries demonstrated that many college students are at risk for developing sleep disorders, and those at risk may also have a poor academic performance. In fact, sleep timing was strongly associated with academic performance than total sleep time and other pertinent factors 21.

Sleep problems and the role of stress

Complaints about sleep problems are common among university students in this study for around 53% of students evaluated their sleep quality as satisfactory or poor. An explanation for this finding might lie in the role of stress as a most significant risk factor in sleep quality as previously shown 22. Perceived stress can serve as a predisposing, precipitating, and perpetuating factor for sleep difficulties in this special group of the population. First, the college lifestyle encompasses events and situations that enhance stress-related sleeping difficulties (e.g. erratic schedules, high-stress periods like midterm and final exams). Second, university students may be more susceptible to arousal-related sleep difficulties because of ongoing changes and maturation in the neuroendocrine system.

The Hypothalamic-Pituitary-Adrenal (HPA) axis is still developing during adolescence and continues to develop in late adolescence. As a result, cortisol secretion at perisleep onset increases 23. This neuroendocrine hyperactivity could pay a role in both the hyper arousal observed in delayed sleep onset as well as increasing anxiety and depression24. Third, college students may have not developed yet sufficient coping strategies for handling stressful events, and therefore may tend to internalize, ruminate, and worry more 25. Thus, biological factors could predispose stress-induced sleep difficulties, while stressful events common in this population trigger more instances of sleep disturbances, and rumination and worry can perpetuate the sleep difficulty.

Gender differences in sleep quality

More males in our study were poor sleepers compared with females. A likely explanation for the poor sleep quality among males might be attributed to the effect of testosterone. Testosterone levels have been shown to reduce time slept and induce sleep apnea 26. Our results showed that sleepiness during the day was common in Lebanese college students. Most students in our study experienced daytime sleepiness with more than half reported having trouble performing daily activities and maintaining enthusiasm due to a lack of sleep at least once per week. Lower prevalence rate of daytime sleepiness was reported among adults in Europe. In four European countries, 23% of young adults reported having daytime naps 27.

The role of sleep enhancing medications

The vast majority of students in our study rarely used medication to enhance sleep. This rate is very similar to that reported from other countries in the region 28. However, our results demonstrated that students who took sleeping pills within the last week were significantly more likely to identify as poor sleepers. The tendency for older adolescents and young adults to self-medicate sleep-wakefulness causes alarm self-administration of over the counter (OTC) medication in an older adolescent population has been found to be related with psychological distress. Sleep-medication use results in its users entering the vicious cycle of the stimulantsedation loop, whereby caffeine and other stimulants will be consumed to repel daytime sleepiness resulting from sedation, and the subsequent use of depressants to oppose the stimulants effects 29.


The findings of this study are considered in light of the following limitations. Because of the cross-sectional nature of the study, the temporality of certain associations cannot be established with confidence. This survey may be limited by underreporting of sleep problems as social desirability bias may have affected students responses, as this was a relatively educated population that may be mostly aware of proper sleep hygiene. Furthermore, this study reported sleep patterns and problems within the past month which might not be consistent with students general sleep behavior, also the period of the semester in which this study was conducted might have affected students sleep quality. Other limitations include the fact that the questionnaire was self-reported and no sleep diary was included which may have affected the accuracy of our results. Furthermore, other factors affecting sleep such as Body Mass Index (BMI), level of studies, amount of physical activity, place of residence, overcrowded homes, sharing the room with other students, watching TV and internet use were not included in this survey. The inclusion of such potential confounders could have resulted in a lengthy questionnaire which might have had an effect on the students willingness to participate.


Despite of the caveats above, this epidemiological study is among the first to determine the prevalence of sleep problems and to examine sleep behavior and patterns among this group of participants in Lebanon. Most universities included in the study are located in Beirut, which comprises more than 50% of university students in Lebanon, and are believed to reflect the varied religious and socioeconomic diversity of all university students in Lebanon. Therefore, the relatively large and representative sample size allows for the generalizability of our results to the university student population. Furthermore, the assessment of sleep quality was done using the PSQI which is a valid, reliable and widely used instrument that has been also translated into Arabic 30. Lastly, it is important to note that Lebanon has continuously been facing insecurity and political conflict, and these factors do not seem to be present in countries where other studies have been conducted and such contextual factors are expected to have an adverse effect on sleep quality. Sleep problems may confer vulnerability to longer-term distress in the presence of ongoing political violence and other environmental stressors, and so any intervention program targeting sleep quality in such a setting as this should be tailored to the needs of the population.


Sleep problems among Lebanese college students were common and such problems may interfere with daily performance, such as driving and academics. These findings highlight a growing need for professionals to focus on the quality as well the quantity of sleep when promoting physical and mental wellbeing among young adults. Findings from this study highlight the need for formulating awareness programs intended to improve academic performance by targeting sleep habits among university students, as troubled sleep and chronic insomnia are associated with substantial decrements in the quality of life. More descriptive studies with large sample sizes are needed to fully explore the factors related to students sleep behavior in Lebanon. Future studies that include objective measurement of sleep and multiple sleep latency testing are needed as those would add to the understanding of the scope and dimensions of sleeping patterns and disorders in this population.

Conflict of interest statement

The authors declare that have no competing interests.


No financial support was provided


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