Original Article

Poor sleep quality and its related risk factors among university
students
Xiaohong Liu1#, Lin Lang2#, Rui Wang3#, Wangyang Chen1, Xiaohua Ren1, Yi Lin1, Guanqing Chen1,
Chenchen Pan1, Wenying Zhao1, Tinghui Li1, Chunlei Han4, Lianping He1, Yuanlong Gu5
1
School of Medicine, Taizhou University, Taizhou, China; 2Department of Surgery, Shanghai New Hongqiao International Medical Center,
Shanghai, China; 3Training Center for Comprehensive Quality and Ability of College Students, Anhui Institute of Information Technology, Wuhu,
China; 4School of public health and management, Binzhou medical university, Yantai, China; 5Department of Oncology, Taizhou Municipal Hospital,
Taizhou, China
Contributions: (I) Conception and design: L He, X Liu, Y Gu, C Han; (II) Administrative support: W Chen, X Ren; (III) Provision of study
materials or patients: R Wang, L He, L Lang; (IV) Collection and assembly of data: Y Lin, G Chen, C Pan, W Zhao, T Li; (V) Data analysis and
interpretation: L He, R Wang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
#
These authors contributed equally to the work.
Correspondence to: Lianping He. No.1139 City Avenue, School of Medicine, Taizhou University, Taizhou 318000, China. Email: [email protected];
Yuanlong Gu. Department of Oncology, Taizhou Municipal Hospital, Taizhou 318000, China. Email: [email protected].

Background: Poor sleep quality is a major health problem worldwide. In universities, poor sleep quality
can effect student’s ability to study and have a serious impact on their psychological and physical well-being.
The aim of this study was to explore the quality of sleep among university students and identify risk factors
associated with poor sleep quality.
Methods: A cross-sectional study was conducted and the Pittsburgh sleep quality index scale was used to
measure sleep quality. The overall score of the PSQI ranges from 0 to 21, with a score of 4 or less indicating
good sleep quality, a score of 5–10 indicating fairly good sleep quality, 11–15 indicating fairly bad sleep
quality, and a score of 16–21 indicating poor sleep quality.
Results: A total of 1,317 subjects were enrolled in the study. Most subjects were female (64.6%) and rural
based (69.2%). Low intensity sports activity more than once per week was reported by 81.9% of subjects
and 59.8% reported they participated in high-intensity sports more than once a week. In addition, 72.8% of
subjects took a nap more than three times per week.
Conclusions: We found that physical activity and taking a nap may be important factors in improving
sleep quality and preventing sleep disorders among university students.

Keywords: Exercise; risk factors; sleep; students; universities

Submitted Jan 31, 2021. Accepted for publication Apr 04, 2021.
doi: 10.21037/apm-21-472
View this article at: http://dx.doi.org/10.21037/apm-21-472

Introduction One study found that many university students sleep less
than 6 hours every day, which is less than the 8–10 hours
Poor sleep quality is a major health problem worldwide (1-3). recommended by the National Sleep Foundation (11).
In universities, poor sleep quality can effect student’s ability Approximately one-third of students suffer from insomnia,
to study and have a serious impact on their psychological and with about 40% reporting they wanted to sleep during the
physical well-being (4-8). The physical and mental health daytime (11,12). Some studies have found that elite sport
problems of university students caused by poor sleep quality is associated with sleep quality (13). The Pittsburgh sleep
have been the subject of several research studies (9,10). quality index (PSQI) was adopted to measure sleep quality.

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(4):4479-4485 | http://dx.doi.org/10.21037/apm-21-472
4480 Liu et al. Poor sleep quality and its related risk factors

The PSQI scale consists of seven factors: subjective sleep indicating good sleep quality, a score of 5–10 indicating
quality, sleep duration, sleep latency, sleep efficiency, sleep fairly good sleep quality, 11–15 indicating fairly bad sleep
disturbances, use of sleep drugs, and daytime dysfunction. quality, and a score of 16–21 indicating poor sleep quality.
However, little is known on the relationship between In this study, a total score of PSQI over 5 was defined as
different degrees of physical activity intensity and sleep poor sleep quality.
quality among university students.
This objective of this study was to evaluate sleep quality Physical activity
and identify risk factors associated with poor sleep quality Low-intensity sports were considered activities such as
among university students. We results revealed that physical walking or tai-chi, which lasted 20 minutes or more,
activity and nap may be important factors in improving and high-intensity sports as those such as playing ball or
sleep quality and preventing sleep disorders in this group. running, lasting 20 minutes or more.
The results should attract public attention towards the
promotion of sleep quality through physical activities and
Data analysis
encourage more research on the relationship between nap
and sleep quality. SPSS20 (Inc., Chicago, IL, USA) was used for data
We present the following article in accordance with the processing and statistical analysis. Independent sample
STROBE reporting checklist (available at http://dx.doi. t-test was used for continuous variables, while chi-square
org/10.21037/apm-21-472). test was used for categorical variables such as gender,
parents’ education, family income, and physical activity
intensity. P<0.05 was defined as statistical significance.
Methods

Study design
Results
A cross-sectional study was conducted involving 1,317 subjects
General characteristic of the subjects included
(466 males and 851 females), aged 16–24 years. All procedures
performed in studies involving human participants were in A total of 1317 subjects were enrolled. Most subjects were
accordance with the Declaration of Helsinki (as revised in female (64.6%) and rural (69.2%) (Table 1). Almost 82%
2013). Informed consent was obtained from all individual of female subjects engaged in low-intensity sports more
participants included in the study. The study was approved than once per week and 59.8% of rural subjects engaged in
by institutional ethics board of Wannan Medical College. high-intensity sports more than once per week. In addition,
All subjects provided written informed consent to participate 72.8% of all subjects took a nap more than three times per
in the study. The study was approved by institutional ethics week. The family income was less than ¥10,000 in 25.1% of
board of Wannan medical college. respondents.

Measurement Descriptive statistics of the components of the PSQI

General demographics Table 2 shows descriptive statistics of the components

Self-administered questionnaires consisting of general of the PSQI, revealing 31.5% of students considered
demographics (age, gender, parents’ education, family their subjective sleep quality to be very good, and 34.4%
income, nap habits, and physical activity) were used. obtained a score of 0 for sleep latency. The distribution of
the PSOI score was showed in Figure 1. The sleep duration
Sleep quality factor shows that 74.7% of students slept more than 7 hours
The Pittsburgh sleep quality index (PSQI) was adopted every day, and 87.5% obtained a sleep efficiency rating of
to measure sleep quality. The PSQI scale consists of more than 85% using the formula actual sleep time/actual
seven factors: subjective sleep quality, sleep duration, time in bed. Only 0.7% of students scored 19 or more for
sleep latency, sleep efficiency, sleep disturbances, use of sleep disorders, and 10.3% used sleep medicines. In the last
sleep drugs, and daytime dysfunction. The overall score category of daytime dysfunction scores, 7.5% of students
of the PSQI ranges from 0 to 21, with a score of 4 or less scored more than 5 meaning they were unable to study

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(4):4479-4485 | http://dx.doi.org/10.21037/apm-21-472
Annals of Palliative Medicine, Vol 10, No 4 April 2021 4481

Table 1 Subject characteristics

Table 1 (continued)
N (%) or mean ±
Variable N (%) or mean ±
standard deviation Variable
standard deviation
Age (years) 19.5±1.3
Nap, n (%)
Gender, n (%)
Never 62 (4.7)
Male 466 (35.4)
Almost no (< once a week) 83 (6.3)
Female 851 (64.6)
Sometimes (1 to 2 times per week) 213 (16.2)
Father education, n (%)
Often (3 to 4 times per week) 416 (31.6)
Primary school and below 245 (18.6)
Everyday 542 (41.2)
Middle school 904 (68.6)
Missing data 1 (0.1)
College and above 167 (12.7)
Pittsburgh sleep quality index (PSQI) score, n (%)
Missing data 1 (0.1)
<5 904 (68.6)
Mother education, n (%)
≥5 397 (30.1)
Primary school and below 586 (44.5)
Missing data 16 (1.2)
Middle school 628 (47.7)

College and above 103 (7.7)

Missing data 2 (0.2) during the daytime (Table 3).

Location, n (%)

Rural 912 (69.2) Correlation of sleep quality with characteristics of subjects

Urban 404 (30.7) The correlation of sleep quality with characteristics of
Missing data 1 (0.1) subjects was analyzed by chi-square test. The results
showed that sleep quality was associated with high-intensity
Income (RMB), n (%)
sports, low-intensity sports, and naps. No association was
<10,000 331 (25.1) found between sleep quality and gender, parental education,
10,000–30,000 430 (32.6) location, or income (Table 3).
30,000–60,000 395 (30.0)

>60,000 156(11.8) Discussion

Missing data 5 (0.4) The purpose of this study was to assess the risk factors affecting
Low-intensity sports, n (%) the sleep quality of university students in a cross-sectional
study and to speculate the correlation between these factors
Never 239 (18.1)
and sleep quality. It was found that physical activities and nap
1 to 2 times per week 722 (54.8)
were associated with sleep quality among university students.
3 to 4 times per week 271 (20.6) While most studies have paid attention to the relationship
More than 5 times per week 85 (6.5) between competitive physical activity and sleep quality, this
study found that both high-intensity and low-intensity physical
High-intensity sports, n (%)
activity may improve sleep quality. We speculate that physical
Never 529 (40.2) activities to different degrees may consume university students’
1 to 2 times per week 609 (46.2) physical strength inducing fatigue reducing stress, both of
3 to 4 times per week 127 (9.6) which may improve sleep quality.
In our study, the rate of poor sleep quality among
More than 5 times per week 52 (3.9)
university students was 30.1%, in comparison to 54.7%
Table 1 (continued) found in the study by Cheng et al. (14). Whilst this

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(4):4479-4485 | http://dx.doi.org/10.21037/apm-21-472
4482 Liu et al. Poor sleep quality and its related risk factors

Table 2 Description statistics of the components of Pittsburgh Mean =4.56

250
sleep quality index (PSQI) Std. Dev =2.558
N=1.301
Item Frequency Percentage
200
Subjective sleep quality

Very good 415 31.5

150

Frequency
Fairly good 713 54.1

Fairly bad 167 12.7

100
Very bad 17 1.3

Sleep latency 50
0 453 34.4

1–2 576 43.7 0

0.00 5.00 10.00 15.00
3–4 248 18.8 PSQI score

5–6 33 2.5 Figure 1 Distribution of the PSQI score

Sleep duration (hours)

>7 984 74.7

discrepancy may be due to the use of different measurement
6–7 290 22.0 methods between the two studies, it may also be due to our
5–6 27 2.1 consideration of naps as a factor influencing sleep quality.
<5 12 0.9
While no previous studies have confirmed a relationship
between nap and sleep quality, our results indicate that naps
Sleep efficiency (%)
allow students to more successfully complete their daytime
>85 1,152 87.5 learning tasks and reduce lethargy, both of which could
75–84 121 9.2 contribute to improving quality of sleep.
Finally, 43 students reported having used sleep
65–74 23 1.7
medication, among which nine used sleep medicine more
<65 15 1.1 than three times per week, although the reasons for this were
Sleep disturbances score not explored. The possible reasons may be that there are too
0 245 18.6 many curriculums need to do for university students.
A potential limitation of this study is that it was conducted
1–9 911 69.2
in a single location and the results may not be transferable to
10–18 143 10.9 other contexts. In addition, assessing the relationship between
19–27 9 0.7 physical activity and sleep quality among university students
Use of sleep medication
should include other factors such as caffeine and tobacco
intake, body mass index, and major area of study. Finally, as a
Not during the past month 1177 89.4
cross-sectional study, the results only provide correlation and
Less than once a week 92 7.0 causal relationships cannot be inferred.
Once or twice a week 34 2.6 In summary, the results suggest that the incidence of poor
sleep quality in university students is high, and more attention
Three or more times a week 9 0.7
should be paid to the physical and mental health of this
Daytime dysfunction score
group. Promoting their participation in physical activities and
0 260 19.7 developing effective work-rest programs is encouraged.
1–2 507 38.5

3–4 445 33.8 Conclusions

5–6 99 7.5 This study could pave the way for cohort studies on

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(4):4479-4485 | http://dx.doi.org/10.21037/apm-21-472
Annals of Palliative Medicine, Vol 10, No 4 April 2021 4483

Table 3 The relationship between sleep quality and subject characteristics

Variable PSQI score <5 PSQI score ≥5 Chi-square P

Gender 0.22 0.64

Male 318 145

Female 586 252

Father education 0.31* 0.58

Primary school and below 165 78

Middle school 622 270

College and above 116 49

Mother education 1.04* 0.31

Primary school and below 388 188

Middle school 446 177

College and above 68 32

Location 0.13 0.72

Rural 621 277

Urban 282 120

Income 0.55* 0.46

<¥10,000 227 98

¥10,000–30,000 290 136

¥30,000–60,000 272 120

>¥60,000 114 40

Low-intensity sports 6.51* 0.01

Never 143 88

1 to 2 times per week 503 215

3 to 4 times per week 198 71

More than 5 times per week 60 23

High-intensity sports 5.67* 0.02

Never 335 187

1 to 2 times per week 445 159

3 to 4 times per week 88 36

More than 5 times per week 36 15

Nap 12.98* <0.01

Never 37 25

Almost no (< once a week) 45 36

Sometimes (1 to 2 times per week) 142 70

Often (3 to 4 times per week) 286 122

Everyday 394 143

* represents linear-by-linear association.

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(4):4479-4485 | http://dx.doi.org/10.21037/apm-21-472
4484 Liu et al. Poor sleep quality and its related risk factors

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Cite this article as: Liu X, Lang L, Wang R, Chen W, Ren

X, Lin Y, Chen G, Pan C, Zhao W, Li T, Han C, He L, Gu Y.
Poor sleep quality and its related risk factors among university
students. Ann Palliat Med 2021;10(4):4479-4485. doi: 10.21037/
apm-21-472

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(4):4479-4485 | http://dx.doi.org/10.21037/apm-21-472