Sleep is considered a behavioural as well as a physiological process. Sleep is a universal, basic drive that supports a person's overall well-being, including physical and cognitive development and learning. Adults require sleep in order to grow, develop and maintain their health [1,2].

Sleep deprivation and insomnia have been identified as serious public health issues. Sleep deprivation can have major health repercussions; it has been linked to lowered immunity, bad behaviour and psychological and metabolic issues such as diabetes, hypertension, metabolic   syndrome,   and   obesity  [3,4].

In the last few years, there has been a growing attention to sleep and sleeplessness related problems. This interest is mainly due to the recognition that sleepiness and fatigue are becoming endemic in the population. Research has shown diminishing hours of sleep among adults in both developing and developed countries [3,4].

Researchers at the UK’s University of Warwick Medical School conducted large-scale, multinational study of sleep disorders among eight countries in Asia and Africa which showed an overall rate of nearly 17% of the populations in these developing nations suffering from sleep problem. This is a figure not too far from the average 20% of the populations of the developed world that are believed to struggle with sleep problems of one form   or  another  [5,6].

Sleep deprivation     and    the symptoms associated with sleep disorders have been not only overlooked but also misunderstood. While the majority of sleep studies have been conducted in affluent countries, little is known about sleep patterns and practices in developing countries. Adults in Shimla have been reported to have poor sleeping patterns and habits. As a result, we designed this study to assess the sleep patterns & habits of the adult population of Shimla city.

Aims And Objectives

To evaluate the sleep pattern and sleep habits among adult population of Shimla city of Himachal Pradesh.

Study Design

It was a Cross sectional community based study.

Study Area

The study was conducted in Shimla which is the capital city of Himachal Pradesh located in the south-western ranges of the Himalayas at 31.61°N 77.10°E. It has an average altitude of 2,206 meters (7,238 ft) above mean sea level. 

Study Period

The time Duration for the study was 6 months i.e., Nov 2021- April 2022.

Study Population

Adult population having age between 18-60 years of Shimla city were included in the study.

Sample Size Calculation

Though data was available data on the sleeping pattern in non-hilly area, but there was a paucity of data regarding the same in hilly area like Shimla. So, the sample size was calculated by assuming that 50% of the adult population of Shimla city have adequate Sleeping pattern, 5% Absolute error, 95% Confidence level, our sample size came out to be 384. By taking 5% Non-Response Rate our total sample size came out to be 408. So the total sample size of our study was 408.

The equation for calculating sample size is as follows:

N =   Z2 P (1-P)/ e2

Where:

Z:     level of confidence (1.96)

P:    Prevalence of the disease

E:    Margin of error or precision

Sampling Technique 

There are total 34 Municipal wards in Shimla city. We equally divided the sample size according to municipal wards i.e.12 Adult persons from each municipal ward. We took 12 Adult persons from each municipal ward by simple random sampling. For this we selected first house from each ward by simple random sampling. Then we went in anticlockwise direction to select next household to complete sample size of 12 Adult persons from each ward. From each household we selected only one adult person by simple random sampling.

Study Tool

A pre-tested self-administered, anonymous, semi-structured questionnaire was used to evaluate the sleep pattern and sleep habits among adult population of Shimla city:

• Part A: included close ended questions to elicit information regarding basic Socio-demographics of study population including age, sex, education, family type, occupation etc.

• Part B:  included close ended questions regarding sleep pattern and habits

Data Collection Procedure

We provided participant information sheet to every selected adult and also explained them the purpose and objectives of the study. We ensured them for anonymity and confidentiality. After that we administered them the study questionnaire and we advised them to read every question carefully and answer accurately. We also provided them any help if they had any problem in understanding any question. Then we gave 15 minutes to the study participants complete the questionnaire. After completing the questionnaire, we collected it and kept it in safe and secure manner.

Inclusion Criteria 

• Adult person between 18 to 60 years of age 

• Those who had given their consent to participate in the study 

Exclusion Criteria 

• Those who refused to give consent to fill the questionnaire 

Statistical Analysis

The collected Data was thoroughly screened and entered in Microsoft Excel spreadsheet 2007. Statistical analysis was done by using Epi Info 7. Descriptive statistics, frequency percentages were determined for categorical variables. Mean & standard deviation were determined for quantitative variables. 

Ethical Aspects

Objectives of study were explained to the participants during the visit. Informed consent was taken from all the adults participating in the study. Participants were fully assured regarding the confidentiality and anonymity of the information provided by them. Participation in the survey was voluntary, with neither reward nor penalty. All respondents were informed that they were free to continue or quit at any time and the submission of the questionnaire would be regarded as consent to participate.  Confidentiality of information gathered from study subjects was maintained in accordance with the principles embodied in the declaration of Helsinski and International guidelines for ethical review of epidemiological studies.

In the present study a total of 408 adult’s age between 18-60 years selected from all 34 municipal wards of Shimla city were participated with the objective to evaluate the sleep pattern and sleep habits.

Table 1 showed that a total of 408 participants responded to the survey. Out of which, 210 (51.5%) were males  and  198 (48.5%)  were  females.  Among  those, 292 (71.6%)  participants  belong  to  18-30 years  old age  group,  57 (14.0%)  in  31-40  years   old   age   group, 30 (7.4%) were 41-50 years old age group and 29 (7.1%) were51-60 years old age group.  141 (34.6%) Participants had graduate degree followed by 123 (30.1%) participants were having  postgraduate degree whereas 6(1.5%) participants were illiterate.  According to Occupation status, 242 (59.3%) participants did not mentioned their profession i.e they chosen others group whereas 74 (18.1%) were employee, 44 (10.8%) were professional, 29 (7.1%) were businessmen, 18 (4.4%) were farmers and 1 (0.2%) were labourer. According to Religion, majority of the participants 379 (92.9%) were Hindus.

Figure 1 showed that 312(76.5%) participants used mobile for chatting on social media/playing games/ watching movie before going to sleep in bed, 129 (31.6%) stay awake late at night and watch TV before going to sleep in bed.

Among the total 408 participants, 187(45.8%) participants    were    easily    awakened    by   noise, 104 

Table 1: Distribution Of The Participants According To Socio-Demographic Characteristics

Figure 1: Sleeping Pattern and Habits among Study Participants

Figure 2: Distribution of the participants according to Sleeping Associated Habits

(25.5%) participants had problem of snoring, 235 (57.6%) participants slept alone whereas 173 (42.4%) participants slept with family members, 119 (29.2%) participants stated that they had interrupted sleep, 194 (47.5%) participants wake up in the middle of sleep at night, 238 (58.3%) participants  slept with in 2 hour after eating , 156(38.2%) participants had habit of day time sleeping, 258 (63.3%) participants had problem of dreams while sleeping, 145(32.5%) participant reported that they had trouble in sleeping once awake, 94(23%) participants didn’t feel fresh after wake up in the morning and 12(2.9%) participants had habit of using any sleeping pills for sleep.

Figure 2 shows that out of total  408 participants, 128 (31.4%) participants had habit of exercise regularly, 68 (16.7%) participants had habit of doing yoga regularly, 302 (74%)  used mobile for >4 hour  in a day, 127 (31.1%) participants used TV/computer/laptop  for >4 hours in a day, 213(52.2%) participants took 2 or more cups of coffee or tea in a day, 46(11.3%) of the participants had habit of smoking while 59(14.5%) of the participants had habit of consuming alcohol, 26(6.4%) participants were on medications for hypertension, 17(4.2%) participants were on medications for diabetes, 10(2.5%) participants were taking pills for mental/psychiatric disorders and 37(9.1%) participants  were usually taking  pills for any other disorder.

There have been reports of poor sleep patterns & sleep habits among adults in Shimla city. Therefore, this study was planned to evaluate the sleep pattern and sleep habits among adult population in Shimla city.

The introduction of media in bedrooms such as television, video games, internet, and mobile phones were largely held responsible for sleep debt. In the present study, 94 (23%) participants read books or magazines before going to sleep in bed while 314 (77%) participants reported that they did not read books or magazines before going to sleep in bed. 

Regarding the use of mobile, 312 (76.5%) participants reported that they use mobile for chatting on social media/ playing games/watching movie before going to sleep in bed. Whereas, 129 (31.6%) participants stay awaked late at night and watched TV before going to sleep in bed. In contrast to our findings, in   the  study   done   by  Giri   et al. [7] 52% participants were using mobile   for    chatting  on   social   media/playing movie before going to sleep in bed. Also, in the study done by Peter et al. [8], 42.8% participants were using mobile for chatting on social media/playing games/watching movie before going to sleep in bed.

Out of 408 participants, 128 (31.4%) participants have habit of exercise regularly whereas 280 (68.6%) of the participants did not reported for doing exercise regularly.  Similarly, 68 (16.7%) participants have habit of doing yoga regularly. Similar to our findings, in the study done by Giri et al. [7], 24% participants reported physical active.

In contrast to our study, majority of students (67.0%) reported being physically active in the study done by Lemma et al. [9]. This difference may be due to the fact that in our study we had taken population of all age group while in the study done Lemma et al. [9] only college students were included.

Out of 408 participants, 221 (54.2%) participants were not easily awakened by noise, while 187 (45.8%) participants were easily awakened by noise. Whereas, 304 (74.5%) participants reported that they did not have problem of snoring, while 104 (25.5%) participants have problem of snoring. There are many factors influencing our sleep and sleep quality. The room temperature may not be ideal, a person may be suffering from common cold, a partner, children or pets could be disturbing the sleep, the environment can be too noise. Sometimes the reason behind a bad night of sleep is an actual medical condition or a sleep disorder.

Out of 408 participants, majority of the participants i.e., 31 (7.6%)   use mobile for >4 hour  in a dayand 205 (50.2%) of the participants use TV/computer/laptop for <1 hour  in day followed by 76 (18.6%) participants who use TV/computer/laptop for 1-2 hours in a day whereas 38 (9.3%) participants use TV/computer/laptop for 2-3 hours in a day, 35 (8.6%) participants for 3-4 hours in a day and 54 (13.2%) participants use TV/computer/laptop  for >4 hours in a day.

In contrast to our findings, Murugesan et al. [10]. Reported that majority of adolescents64.1%, (345) watched TV in bed and about 23% (125) used their mobile phone in bed .In another study by Apurva Mishra et al. [11], participants using media after 8 pm and sleeping alone were in significant sleep debt. Screen activities such as TV, internet and cellular phones in the bedroom had a negative effect on children’s sleep/wake patterns and duration of sleep.

In this study, 235 (57.6%) participant sleep alone whereas 173 (42.4%) participants sleep with family member and 289 (70.8%) participants stated that they did not have interrupted sleep. Similarly, majority of participant i.e., 214 (525%) did not wake up in the middle of sleep at night followed by 99 (24.3%) participant who wake up one time in the middle of sleep at night. 

Similar to our finding,the study done by Giri et al. [7] more participants were sleeping alone as compare to the participants who were sharing room with family members. Whereas, Murugesan et al. [10].  Reported nearly 80% (430) of adolescents slept along with family membersin the same room and about 76% (410) did not have a separate bedroom to sleep.

Among children bed sharing is studied to increase sleep anxiety and daytime sleepiness. Similar results are found when parents share their bed with a child. Co-sleeping with the child puts the parents into the risk for sleep deprivation and increased stress which furthermore can cause marital conflicts.

In this study , 107 (26.2%) participants have 30-60 min time gap between eating and sleeping which was less as compared to study conducted by Murugesan et al. [10]. where about half the respondents had a heavy meal at dinner time and >75% went to bed within 1 hour of having dinner. Inter group comparison shows that there was statistical significant difference between participants who have >120min time gap between eating and sleeping and those who have 30min-120min/zero tome gap (p = 0.0175)

An experimental study from Brazil showed that having dinner close to the bedtime and late-night snacking can lead to poor sleep quality and sleep interruptions. Adolescents who had greater time gap between dinner and sleep had better quality sleep as indicated by lesser daytime sleepiness.

In this study, 156 (38.2%) participants have habit of day time sleeping. Out of those, 88 (21.6%) participants sleep for 1 hour  in day , 68 (16.7%) participants sleep for 1-2 hours in a day and 18 (4.4%) participants sleep  for >2 hours in a day.  Inter group comparison shows that there was statistical significant difference between the participants who have habit of day time sleeping and who did not have habit of day time sleeping (p = 0.000)

In contrast to our findings, in the study done by John [12] reported 52.1% participants have habit of day time sleeping and in the study done by Peter et al. [8] 20.9% participants have habit of day time sleepiness.

In this study, out of 408 participants, 150 (36.8%) participants reported that they did not have problem of dreams while sleeping whereas 258 (63.3%) participants had problem of dreams while sleeping. Similarly, when asked about trouble of sleeping, once awake, Only 145 (32.5%) participant reported that they had trouble in sleeping once awake. According to the level of freshness, majority of the participants i.e., 314 (77.0%) feel fresh after wake up in the morning. Similar to our findings, in the study done by Al-Wandi et al. [13]. 30.1% participants have difficulty in getting back to sleep once awake. In study conducted by Al-Wandi et al. [13]. Sleep problems, frequent arousals with difficulty getting back to sleep was the most encountered sleep problem among our sample and higher grades had a higher prevalence of this problem.

 This study shows that 46 (11.3%) of the participants had habit of smoking while majority of the participants 362 (88.7%) were non-smokers. Similarly, 59 (14.5%) of the participants had habit of consuming alcohol.

Similar to our findings, in the study done by Lemma et al. [9] nearly a fifth (19.1%) of participants reported drinking at least one alcoholic beverage per month. In contrast to our findingsin the studydone by Giri et al. [7] 724% participants were alcohol consumer. This may be followed by depression, irritability, anorexia and difficulty in sleeping. Research has indicated smoking tobacco can lead to sleep fragmentation, decreased total sleep time and delayed sleep onset latency. 

In this study, 12 (2.9%) participants use any sleeping pills for sleep, 26 (6.4%) participants were on medications for hypertension, 17 (4.2%) participants for diabetes, 10 (2.5%) participants take pills for mental/psychiatric disorder and 37 (9.1%) participants usually take pills for any other disorder. In contrast to our finding, the study done by Lemma et al. [9] reported that 8.5% participants were using sleeping pills and Berhanu et al. [14] reported that 23.7% participants were using sleeping pills.

The reported variations between different studies may be influenced by different socioeconomic demands and cultural habits among the different population groups. 

Limitations

Sleep problems may be worse than those reported in our study, as individuals may give socially desirable answers such as not having sleep problems. Thus, this survey may be limited by under reporting. As this study was conducted with limited resources in only urban population of Shimla city of Himachal Pradesh, the results may not be applicable to rural population but it can only be generalized to urban adult population coming from similar socioeconomic conditions. So, the similar study may be conducted on large sample including rural adult population for wider generalization. Further multi-centric studies based on large sample size, longer period with separate data on weekdays and weekends are needed for wider generalization of study findings.

In our study 3/4th of participants used mobile before going to sleep, used mobile for >4 hour  in a day. 3/5th participants slept alone, slept with in 2 hour after eating and had problem of dreams while sleeping. Almost half participants were easily awakened by noise, didn’t feel fresh after wake up in the morning and took 2 or more cups of coffee or tea in a day. Almost 2/5th had habit of day time sleeping. Almost 1/3rd reported that they had trouble in sleeping once awake, had habit of exercise regularly , watched TV before going to sleep and  used TV/computer/laptop  for >4 hours in a day wake  up after 8 am in the morning. Almost 1/4th participants read books or magazines before going to sleep, had problem of snoring and went to bed for sleep after 12 am. Almost 1/5th Participants had habit of doing yoga regularly. Only few participants had habit of smoking and consuming alcohol and using any sleeping pills.

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