Sleep quality and associated factors among patients with chronic illness at South Wollo Zone Public Hospitals, Northeast Ethiopia

Background: Pathological and nighttime sleep deprivations have substantial adverse eff ects on regulation of weight, sugar and blood pressure because of endothelial dysfunction, sympathetic nervous system stimulation, regulation and activation of systemic infl ammation. Thus, this study was aimed to assess quality of sleep among patients with chronic illness and its associated factors at South Wollo Zone Public Hospitals, Northeast Ethiopia.


Background
Sleep is a universal need of all higher life forms including humans [1]. Adequate quality and duration of sleep like diet and exercise positively in luences many aspects of health including physical, cognitive, and emotional health [2]. Excess or restricted sleep duration from the normal sleep duration may produce or result from serious problems that affect health and well-being [3].
As to the 2015 National Sleep Foundation Guideline, the recommended sleep duration is 7 to 9 hours for young adults and adults, and 7-8 hours of sleep is for older adults [3]. Despite this fact, the public attention to sleep quality is low [4]. The quality and duration of sleep are disturbed by crowded urbanization, long work schedule, night and shift work, spending more time in watching television and using internet and disease conditions [1].

Study area and period
The study was conducted at South Wollo Zone Public Hospitals which are found at Northeast direction of Ethiopia from January 1 st 2019 to February 30 2019. There are 10 district hospitals and one Comprehensive Specialized Hospital (Dessie Comprehensive Specialized Hospital) in South Wollo Zone. District hospitals include Boru Meda Hospital, Hidar 11 Hospital, Mekane Selam Hospital, Tenta Hospital, Wogdi Hospital, Saint Hospital, Mekedela Hospital, Delanta Hospital, Jamma Hospital, and Woreilu Hospital. The population is now estimated to reach more than three million. The largest ethnic group reported in South Wollo Zone is the Amhara (99.3%); all other ethnic groups made up 0.67% of the population. Amharic is spoken as a irst language by 98.65%; the remaining 1.35% spoke all other primary languages reported. 70.89% are Muslim, and 28.8% of the populations practice Ethiopian Orthodox Christianity. The study was conducted from April 15 2020 till June 15 2020.

Study design
Institutional based cross sectional study design was employed.

Population
All patients with chronic illness who are on follow up in South Wollo Zone Public Hospitals were sources of population. All selected patients with chronic illness who are on follow up in South Wollo Zone Public Hospitals during data collection period were study populations.

Inclusion and exclusion criteria
On follow up patients with chronic illness and who are 18 years and above were included. In contrast, patients with chronic illness who have history of hospital admission in the past one month, patients with chronic illness who have history of acute infection in the past one month and Patients with chronic illness who are seriously ill were excluded.

Sample size determination
Sample size is calculated by using EPI info version 7 with 95% con idence level, 4% margin of error and proportion of poor sleeper among patients with heart failure. Proportion, which is 81.65%, is taken from study conducted on sleep quality of heart failure patients at Jimma University Specialized Hospital Chronic illness follow up clinic in 2015 [18]. The total sample size was taken by adding 10% nonresponse rate of the calculated sample size which is 312.
Although poor sleep quality contribute to poor health and diminished wellbeing, it is given little attention by public [4,5]. Chronic sleep deprivation is estimated to affect between 7.5% -20% of the general population [6] however patients with chronic illness do not bring sleep issues while they are coming to health institution for follow up [7]. As a result of this, poor quality of sleep among patients with chronic illness is often unrecognized and untreated [8,9].
Poor sleep quality results in different physiological disturbances such as hormonal luctuations, immunologic dysfunction, and metabolic alterations [10]. Different articles across the world showed that a large number of patients with chronic illnesses such as diabetes, hypertension and heart failure have poor sleep quality [11][12][13]. Pathological and night time sleep deprivations have substantial adverse effects on regulation of weight, sugar and blood pressure because of endothelial dysfunction, sympathetic nervous system stimulation, regulation and activation of systemic in lammation [2,3] which increases further complication of chronic illnesses [14,15]. Studies show that poor sleep quality impaired exercise capacity of patients; results adverse prognosis of the disease [14]; impaired functional outcomes [16,17], daily functions [18], self-care behavior of patients; and increases the burden of the disease [8]. All these increases the health care expenditure of one's country; and leads to poor control of disease, and poor quality of life [7,19].
Poor sleep quality has not only being associated with various diseases but also leads to occupational accidents [7], poor performance, higher health care utilization, car crash injuries [1], falls especially in older adults [20], suicidal ideation [21].
Poor quality of sleep can have a negative impact on psychological health, physical functioning and quality of life [22] among patients with chronic illness. Studies shows that poor sleep quality impaired exercise capacity of patients, results adverse prognosis disease [14], impaired functional outcomes [16,17], daily functions [18], self-care behavior of the patients, and increases the burden of the disease [8]. These increases health expenditure of one's country; and leads to poor control of disease, and poor quality of life [7,19]. Thus, identifying and treating co existing sleep problems among patients with chronic illness will improve the treatment outcome of chronic illnesses [23].
Poor sleep quality is a neglected public problem in Ethiopia that lowers the functional outcome of individuals especially individuals with chronic illness. It is unrecognized and under attention factor that affects the self care behavior, daily function of patients and increases the adverse prognosis of chronic illnesses such as hypertension, heart failure and diabetes. Despite this fact, there is no adequate study which assessed the quality of sleep among patients with chronic https://doi.org/10.29328/journal.cjncp.1001036 Non response rate -10% of 312  31.2~ 32 Total sample size = 312+32 = 344

Sampling technique and procedure
The study utilized strati ied random sampling technique. Initially, patients with chronic illness were strati ied into Diabetes Mellitus (DM), hypertensive, heart failure, epilepsy, chronic obstructive pulmonary disease and others based on their diagnosis. After that, the total sample size was allocated for each stratum based on their proportion. Then, study participants were selected by systematic sampling in every k th value which is 7 from each stratum. K value was calculated from the proportion of sample in each stratum to the total population for each respected stratum. The irst patient was selected by simple random sampling from patients who are coming for follow up during data collection period. After that, data were collected in every 7 th patient from each stratum until the total sample size is achieved.
K value is calculated as follows: Good sleep quality: after calculating the global score of sleep quality, the global score of PSQI which is ive and below [21,24].
Inactive: are those individuals who do not meet criteria for minimally active or Health Enhancing Physical Activity (HEPA) [25].

Inadequate dietary diversity: Study participants who
scored below the mean of dietary diversity score.
Health Enhancing Physical Activity: Vigorous-intensity activity on at least 3 days achieving a minimum of at least 1500 Metabolic Equivalent (MET) -minutes/week or 7 or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum of at least 3000 MET-minutes/week [25].
Minimally active: 3 or more days of vigorous activity of at least 20 minutes per day or 5 or more days of moderateintensity activity or walking of at least 30 minutes per day or 5 or more days of any combination of walking, moderateintensity or vigorous intensity activities achieving a minimum of at least 600 Metabolic Equivalent (MET) -min/week [25].
Poor sleep quality: after calculating the global score of sleep quality the global score PSQI which is above ive [21,24].
Sleep quality: is the degree to which restful sleep is maintained during the night and the individual feels refreshed on waking and throughout the day [22].
Chronic illness is an illness that makes the patient to have follow up.

Data collection tool and procedures
Data collection tool: The data were collected structured questionnaire. It has 3 parts. The irst part asked about socio demographic data of study participants. The second part measured sleep quality by Pittsburgh Sleep Quality Index (PSQI) questionnaire which is a golden standard to measure sleep quality. It has 19 items with seven components. Component 1 is subjective sleep quality; Component 2 is sleep latency; Component 3 is sleep duration; Component 4 is habitual sleep ef iciency; Component 5 is sleep disturbances; Component 6 is use of sleep medicine; and Component 7 is daytime dysfunction. Validity and reliability of the PSQI is checked in Ethiopian population [26]. Its reliability in this study was 0.65. The third part focused on factors that affect sleep quality of patients with chronic illness which includes dietary diversity, physical activity, substance use, alcohol use, support from any one and health education about sleep hygiene. Medication adherence, dietary practice and physical activity will be screened by standardized questionnaire which are validated in Ethiopian population.
International Physical Activity Questionnaire (IPAQ -7) which is also standardized questionnaire used to assess physical activity of patients with chronic illness. It is validated in Ethiopian population [27].
All parts of the questionnaire were prepared in English version initially and translated into Amharic then back to English to check their consistency. Additionally, weight and height of the patient were measured by data collectors during data collection.

Data collection procedures:
After preparing the questionnaire, 4 BSc nurses for data collection and 1supervisor were recruited. Two days training was given for each of them on meaning of every items of the questionnaire and the techniques of data collection such as ways of greeting, ways of taking consent and ways of addressing ambiguous items. After this, data were collected by face to face interview and height and weight were measured during data collection by data collectors. Supervisor and principal investigator monitored closely the data collection process.

Data quality assurance
The quality of data were assured by training data collectors and supervisor, carefully designing questionnaire, monitoring the data collection process and checking completeness of data during data collection time. In addition to these, before reached to the respondents, all questionnaires were pre tested on 5% of the sample size at Kemissie General Hospital to address confusing items and to increase the quality of data since it modi ies the ambiguity items.

Data processing and analysis procedure
After data collection, completely collected data were entered in to epi data version 3.1 and exported to Statistical Package for Social (SPSS) version 25 for analysis. The results of study were presented by using different data presentation tools and binary logistic regression model will be enrolled by considering 95% con idence level and p value of 0.05. Multivariable binary logistic regression was done by taking variables that have p value of < 0.2 from bivariable logistic regression to identify factors associated with sleep quality. The Hosmers and Lemeshow test for model itness was 0.393.

Ethical consideration
Before data collection period, ethical clearance and approval was obtained from College of Medicine and Health Sciences Ethical Committee. A supportive letter was given to the Hospitals and permission was obtained from Hospital Manager to implement the study. Prior to interviewing the respondents, the aim and objectives of the study were clearly explained to the participants and oral informed consent was obtained. Additionally, participants were informed about the right to ask question and stop response in anywhere. Con identiality and anonymity were ensured throughout the execution of the study.

Sociodemographic characteristics of respondents
A total of 344 study participants were participated with 100% response. Among these respondents, 168(48.8%) were female, 135(39.2%) did not read and write and 210(61%) were from urban areas. Over one ifth of the total respondents (21.8%) were government and nongovernmental employee. Near to one fourth of the respondents (24.7) had above 3400ETB of monthly income. Body mass index was high higher than the normal for 70(20.3%) study participants (Table 1).

Disease characteristics
Among the total respondents, the duration of disease for 56(16.3%) was above 6 years. One ifth of the respondents (70) were adherent to their medication. Majority of them 319(92.7) were taking below 5 drugs. One the other hand, 213(61.9%) of them had good perception to the prognosis of their illness ( Table 2).

Level of physical activity, dietary practice and education about sleep hygiene
Among 344 patients with chronic illness, 274 (79.65%) of  Table 3).

The pittsburgh sleep quality index (PSQI) subscale scores
Among the total study participants, near to one third (31.7%) of them got sleep after 30 minutes. More than one fourth of them slept for less than 7 hours. Less than half of the study participants had habitual sleep ef iciency of more than 85% however 296(86%) of them did not face day time dysfunction (Table 4).

Overall sleep quality
From the total 344 patients with chronic illness, 124(36%) of them had poor sleep quality.

Factor associated with sleep quality
Variables that have associations with poor sleep quality at p value of p < 0.2 in bivariable logistic regression were sex, age, educational status, residence, marital status, occupation, family size and perception to prognosis of illness. However, only age of respondents, educational status, residence and perception of patients to prognosis of their disease were signi icantly associated with poor sleep quality. According to the result, study participants whose age is above 65 years were 5 times more likely develop poor sleep quality compared with study participants whose age is 18-24 years (AOR -4.52; 95% CI: 1.63 -12.49; p -0.004). Patients whose educational status is certi icate were 6 times more likely develop poor sleep quality compared with patients who do not unable to read and write (AOR -5.61; 95% CI: 1.15 -27.22; p -0.032). Patients whose residence is rural develop poor sleep quality 2 times more likely compared with patients who lived in urban area (AOR -1.93; 95% CI: 1.04 -3.58; p -0.036) ( Table 5).

Discussion
Patients with chronic illness have compromised quality of life because of their disease condition and poor sleep quality. However, their quality of sleep is not recognized and screened while they are coming to health institution for their follow up. This study was conducted to assess the level of sleep quality and its associated factors among patients with chronic illness in South Wollo Zone Public Hospitals. According to the inding, among the total study participants, 36% (95% CI: 30.8% -40.7%) of them poor sleep quality. The inding of this study is in line with study conducted in Debre Markos Referral Hospital among patients with diabetes, hypertension and heart failure (36.5%) [28] and study conducted at Korean patients (38%) [29].
However, the inding of this study is lower than the pooled prevalence of poor sleep quality among Ethiopian population (53%) [30], study conducted in Jimma among type 2 diabetes patients (55.6%) [31], study conducted in Jimma town among community dwelling adults (63%) [32], study conducted in Addis Ababa among epileptic patients (65.4%) [33], study conducted in Wadila district among pregnant mothers (68.4%) [34] and among diabetes patients (55.4%) [35]. The difference might be because of the difference in study  Not during the past month 296 86 Less than once a week 31 9 Once or twice a week 7 2 Three or more times a week 10 2.9 Age is associated with poor sleep quality. In this study, study participants whose age is above 65 years were 5 times more likely develop poor sleep quality compared with study participants whose age is 18-24 years. The possible justi ication might be due to physiological deterioration such as cortical atrophy [36]. This inding is supported by a study conducted at Jimma Town [32], study conducted in Wadila district [34].
Educational status of study participants also had association with poor sleep quality. In this study, patients whose educational status is certi icate were 6 times more likely develop poor sleep quality compared with patients who do not unable to read and write. This inding is similar with the study conducted at Saudi Arabia [35].
Patients whose residence is rural develop poor sleep quality 2 times more likely compared with patients who lived in urban area. This might be due to less comfortable sleeping room and condition. In addition, patients in rural area are exposed to physical work. A study conducted at Northwest Ethiopia among diabetes, hypertension and heart failure patients supported the inding of this study [28].
Patients who had poor perception towards the prognosis of their illness had poor sleep quality 4 times more likely compared with patients with good perception. This could be hopelessness and minimal self-care practice for the management of their illness [37].
According to American sleep foundation, the duration of sleep should be 7 -9 hours for adult individuals. In this study, only 65.4% of study participants had sleep duration of 7 hours and above. The habitual sleep ef iciency should be 85% and above for adults. But, in this study, less than half of the total respondents had sleep ef iciency as to the recommendation. The possible justi ication for this discrepancy could be sleep disturbance as a result of nocturia, orthopnea, awaken from bad dreams, pain [38], dyspnea [39]. Some medication taken for chronic illness such as alpha adrenergic drugs (clonidine), angiotensin receptor antagonist drugs and antiarrhythmics drugs also decreases habitual sleep ef iciency and sleep duration [40].

Conclusion and recommendations
In this study, more than one third of patients with chronic illness had poor sleep quality. One third of study participants had sleep duration of less than the recommendations(less than 7 hours). More than half the study participants had poor sleep habitual ef iciency. Age, educational status, residence, and perception of prognosis of disease were factors that have associations with poor sleep quality among patients with chronic illness. Health care providers who are doing in chronic illness follow up clinic should be initiated to assess and screen those patients with poor sleep quality. Training on screening of sleep quality should be given to health care providers. In addition, screening of sleep quality should be added as a routine activity in follow up of patients with chronic illness. Researches should undertake extensive and further study on sleep quality of patients with chronic illness separately.

Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki. Before data collection period, ethical clearance and approval was obtained from Wollo University College of Health Science Research and Ethical Committee. A supportive letter was given to the South Wollo Health Department and permission was obtained from hospital manager to implement the study. Prior to interviewing the respondents, the aim and objectives of the study were clearly explained to the participants and oral informed consent was obtained since ethical approval committee waived written consent. Additionally, participants were informed about the right to ask questions and stop response in anywhere.

Availability of data and materials
The dataset will not be shared in order to protect the participants' identities but is available from the corresponding author on reasonable request.

Author's contribution
AE conceived and designed the study, performed analysis and interpretation of data. SA and AA advised and supervised the design conception, analysis, interpretation of data and made critical comments at each step of research. AE drafted the manuscript. All authors read and approved the inal manuscript. Con identiality and anonymity were ensured throughout the execution of the study.