Abstract: towards the use of sleep aids. Results:



Background: Sleep disorders affect large
number of population worldwide. They may be associated with reduced sleep
duration or quality, and may affect cognitive functions and quality of life. Objectives:
The study was conducted to evaluate the Saudi
people’s sleep problems and assess their attitude toward medical treatments. Method: Cross
sectional based-survey was conducted among Saudi public during November – December
2017. The questionnaire included
3 parts, the first identify the socio-demographic data of the participants, the
second assess the public sleep habits and sleep disorders, and the third assess the
current practice and attitudes of
Saudi general population towards the use of sleep aids. Results: 40.7% of the respondent reported
short duration of sleep (less than 6 hr), 42.4% reported 7-8 hr and only 16.9% reported
more than 8 hr. The most common
sleep disorder reported by the participants was difficulty of falling
asleep. There
was an association between time of sleep during the night and ages of patients,
gender and marital status (P<0.05). 57% of the participants documented the use of only behavioral strategies to cope with sleep problems, while 92.9% reported that they did not seek medical help for their sleep problems. 78.1% had never used sleep aids. About 49.4% of the participants showed negative attitude toward the use of sleep aids while about 40.3% were hesitating and only 10.3% of the participants reported positive attitude. Conclusion: Even with high percentage of sleep problems among Saudi public, seeking medical help for sleep disorders was very rare and the attitude toward the use of sleep aids was mostly negative.   Keywords: Attitude, Saudi public, sleep aids, sleep disorders, sleep duration.     Background and Review of Literature Sleep is a fundamental, essential and haemostatic regulated process in the body. It is defined as a period of decreased activity and response to any environmental stimuli (Millstein et al., 2011). Sleep have important role in maintaining health. Long term disturbance in sleep increases the risk of many diseases.  Continuity of sleep can be assessed by determining its duration, the time taken to fall asleep, and the sleep quality (Irwin, 2015). Any problems in sleep hygiene may lead to sleep disorders. Sleep disorders are significant public health problem affect large number of population. They are defined as disturbance in the sleep pattern which may be caused by different reasons like current life style, exposure to stress, or decreased physical activity (Morin and Jarrin, 2013). Many studies showed that sleep disorders may be associated with a variety of psychiatric diseases (Soehner et al., 2013), cognitive dysfunction and reduced quality of life (Roumelioti et al., 2016). Insomnia is the most common type of sleep disorders and it is showed to be one of the predictors for suicidal ideation (Ribeiro et al., 2012). Symptoms of sleep disorders can differ depending on the severity and type. They may also vary when sleep disorder is a result of another condition. General symptoms of sleep disorders include difficulty falling or staying asleep, daytime fatigue, urge to take naps during the day, irritability or anxiety, lack of concentration, and depression. (https://www.healthline.com/health/sleep/disorders#symptoms)             Major sleep disturbances include insomnia; obstructive sleep apnea; hypersomnias, including narcolepsy; circadian rhythm sleep disturbances; parasomnias; and sleep-related movement disorders, like restless legs syndrome (Thorpy, 2012). Different forms of sleep deprivation may lead to a decline of cognitive functions. Studies which covering the acute effects of sleep deprivation on the brain conclude that the behavioral deficits in most cases regenerate after two nights of complete sleep. However, chronic sleep deprivation may increase the risk of some neurodegenerative diseases like Alzheimer's disease and dementia (Bobi? et al., 2016). Sleep disorders may also increase the risk of many other health problems such as depression, and hypertension. There is an association between sleep disorders especially chronic insomnia, and increasing risk of Parkinson's disease (Hsiao et al., 2017) Sleep problems affect people's daily activities in many ways; include feeling of tiredness during the day, problems in concentration, memory and attention, anxiety and aggression (Ram et al., 2010; Coulombe et al., 2010). Sleep problems may also affect person's appetites and leads to increase in fat intake and weight gain (Greer et al., 2013).   Continuous and long sleep was found to be associated with better diet and hormone profile (Al-Disi et al., 2010). About 15% of people who have short duration of sleep showed high risk of cardiovascular diseases incidence, and about 23% have higher risk of congestive heart failure compared to people who have normal sleep. People with adequate sleep showed lower five years risk of coronary artery calcification (Hoevenaar-Blom et al., 2011).       A study about the prevalence of short duration sleep among Saudi adolescences showed that about 31% of the participants had sleep duration less than 7 hours per day, while 50% reported less than 8 hours (Al-Hazzaa, 2012). Adolescents in Saudi Arabia have higher percentage of poor sleep habits than in other countries (Merdad et al. 2014).   Another study assessed the sleep duration among Saudis, reported that 33.8% had short sleep duration, and this accompanied with different medical problems as obesity, hypertension, diabetes mellitus, and depression (Ahmed et al., 2017).  Both studies showed that almost one third of Saudis have short duration of sleep (less than 6 hours per day) while the optimal duration of sleep for healthy individuals is about 7-8 hours (Yang et al., 2017). A total of 85.9% of residents in King Fahd University Hospital in Saudi Arabia have acute sleep deprivation while 63.2% have chronic type, and many of them reported a strong association between sleep problems and symptoms of depression (Al-Maddah et al., 2015). Excessive day time sleep among workers in Australia showed significant effect on their productivity (Ng et al., 2014). Where in United Status, fifty to seventy million adults have chronic sleep disorders, forty million of workers reported that they sleep less than six hours daily and about 35.3% sleep less than 7 hours, 37.9% fall  asleep during the day and 4.7% feeling sleepy while they driving (Morbidity and mortality weekly report, 2011).  Chronic untreated sleep deficiency may lead to serious problems such as motor vehicle crashes and injuries (Rajaratnam et al., 2011), has serious effects on societal health, mortality, and productivity. Among Workers, poor sleepers shows less engagement in work tasks and less self control in work (Barber et al., 2013). In another study, 8 % of bus drivers reported falling asleep while driving, and 7% of them experience accidents (Vennelle et al., 2010). Increase public education and awareness toward these disorders and their treatment may significantly improve public health attitudes and show great economic benefits (Wells and Vaughn, 2012). Studies indicated that there are many socio-economic factors affect sleep pattern and these factors should be considered in the solution of sleep problems. Sleep disturbance is reported to be higher in high income individuals and those with higher educational levels. Also unemployed individuals show better sleep than employed ones. On the other hand, married individuals generally have less sleep quality than unmarried (Grandner et al., 2010). Many factors may affect the individual sleep pattern. They may be physiologic, pathologic or behavioral factors. In many cases, sleep disorders develop as a result of an underlying disease. Respiratory problems, nocturia, and chronic pain diseases are the most common. Inadequate sleep hygiene (irregular sleep-wake schedule, inappropriate sleep environment), alcohol, excessive caffeine and using technology before going to bed are considered as important factors (Hershner and Chervin, 2014). In addition, Anxiety, depression and lower socioeconomic status are also important and may lead to sleep difficulties (Güne? and Arslanta?, 2017). A systematic review investigated the role of negative cognition, social isolation, and unhelpful emotional regulation strategies on sleep problems and suicidal thoughts as well (Littlewood et al., 2017). Use of technology, include using mobiles or smartphones, electronic games, television or internet is shown to have a negative effect on sleep. It is the most common cause of short sleep duration and lateness in sleep among children and adolescences (Cain and Gradisar, 2010). 72% of adolescences and 67% of American young adults use electronic devices for at least an hour before going to sleep and most of them reported poor sleep quality (Gradisar et al., 2013). Using technology and electronic media is reported as a risk factor for both sleep disturbances and depression (Lemola et al., 2015). Caffeine is a mild stimulant, improves alertness, reduces fatigue and can improve daily performance, but it may lead to poor night sleep and reduce sleep quality if taken late before sleep (Van Dongen and Kerhkof, 2011).  Age also play an important role in changing sleep pattern. Many studies ensure that sleep disorders increase with age. Elderly people often report sleep disturbances as difficulty of sleeping, sleepless, and night wakefulness (Crowley, 2011) Sleep disorders are serious health problems and need to have more public and medical attention. Improvement of sleep will improve many aspects of life; include physical, psychiatric and economic status, daily activity performance, and cognitive functions. Diagnosis and effective treatment of sleep disorders are not yet well studied. A study conducted among African Americans reported undiagnosed sleep disorders including insomnia by 93.3% and sleep apnea by 97.6% (Atsjournals.org, 2017). For proper diagnosis of sleep disorder, type of sleep disorder must be clearly identified by the physician through clinical history and careful physical examination. In some cases referral to a sleep laboratory is needed for further evaluation. The physician should then discuss the type of disorder with the patient in order to achieve the most effective treatment (Panossian, & Avidan., 2009) In order to effectively treat sleep disorders, public should be aware about the seriousness of this condition and seek for the medical help. Cognitive behavioral therapy (CBT) and pharmacological treatment show the same efficacy in treatment of complicated sleep problems (Buysse et al., 2011). Non-pharmacological treatment with CBT is considered the first line treatment as it is the most effective in long term management of mild to moderate insomnia than drugs. CBT also shows to have more effect in reducing psychiatric symptoms related to insomnia. Around 70% of people who treated with CBT showed long improvement in sleep pattern. CBT includes different approaches started with removal or decrease of all anxiety and psychological factors influence sleep, scheduling time of sleep, sleep education and avoidance of stimulants. CBT showed to be more preferred by patients and have high efficacy in treatment of sleep disturbances (Rourke and Anderson, 2014). Patients on CBT should be educated about strategies that will improve sleep hygiene such as using bed only for sleep.  The patient should be informed to leave the bed after 20 minute of trying to fall asleep and not return back unless he feels sufficient sleepy. Other strategy includes reducing time spent on bed during day. All these strategies may help patients in controlling his sleep problem (Neikrug and Ancol-israel, 2010).   Sleep hygiene education treatment may also include exercise, management of stress,  sleeping in a quite place, avoid noises, scheduling of sleep time ,avoidance of stimulants drinks (coffee, tea, alcohol …etc) and avoiding of naps during day (Irish et al., 2015). Public and medical clinic both needs to be educated about these strategies to reduce the sleep problems in society. Physical activities have also positive effects on sleep. People who are physically active show improvement in their sleep duration and quality, and improving in their sleep efficiency more than people with decreased activity (Reid et al., 2010). A study conducted in 2010 showed that people who were physically fit but not active have poor sleep pattern than who were physically active (Gerber et al., 2010). So, daily exercise is recommended to improve sleep quality in public. Also the use of natural products as sleep aids is a common practice, including chamomile, kava, and valerian.  It may reflect the common perception that natural products are necessarily beneficial for sleep and without risks (Sánchez-Ortuño, et al., 2009) Physicians cannot easily apply CBT to all patients as it takes considerable delayed onset and effects. So, sleeping aids are preferentially prescribed in clinical practice (chung and youn, 2017). A Study among population in United States reported that about 19 million (10%) of the participants have been used a sleep aid medications (Vaidya, 2014; Mitchell, 2012) All prescription sleeping pills have side effects, which vary depending on the specific drug, the dosage, and how long the drug lasts in the body. Common side effects include prolonged drowsiness, headache, muscle aches, constipation, dry mouth, trouble concentrating, dizziness, unsteadiness, and rebound insomnia. Other effects may include drug tolerance, dependence and withdrawal symptoms (https://www.helpguide.org/articles/sleep/sleeping-pills-and-natural-sleep-aids.htm)        A review was published at 2011 about the use of sleep aids medicines in Saudi Arabia concluded that the knowledge and attitudes of general public towards sleep aids is one of the obstacles facing the practice of treatment. In this study, Saudi public have been developed their own ideas and myths about sleep aids because they get their information from any sources even if the information is not authentic. Many people thought that their sleep disorder is a part of their nature and not take sleep disorder as a serious problem (BaHammam, 2011). Further studies are still needed to identify the Saudi public sleep habits, evaluate their sleep condition, identify the most strategies used to cope with sleep problems, most reasons that affect sleep pattern, and to assess public attitudes toward the use of sleep aids and seeking for  medical help     Aim and objectives Aim The study was aimed to assess the attitudes of Saudi population suffering from sleep disorders towards the use of sleep aids. Objectives   -To evaluate participants sleeping habits, identify any sleep problems and the strategies to cope with them -To identify the attitudes of patients towards medical treatment of sleep disorders and the public concerns about using sleep aids. Materials and Methods Study design       A cross sectional questionnaire based-survey was conducted in Saudi Arabia during November-December 2017 on Saudi adult people. Data collection tool      A structured, self-administered questionnaire was developed based on extensive literatures review. It was designed in English, translated to Arabic and then distributed using Survay Monkey on social media. The questionnaire included three main parts: The first covered the socio-demographic data of the participants: age; gender; marital status, educational level and the current medical conditions if any.  The second included questions to assess the public sleep habits and sleep disorders among participants, and the third was composed entirely of closed questions assess the current practice and attitudes of the participants towards sleep problems by asking about strategies to cope with sleep problem; reasons of these problems; impact of sleep problem on the participant's daily activity; seeking medical help and the use of sleep aids. Data analysis       Data was processed using the Statistical Package for Social Science software SPSS (version 21.0). Descriptive statistics were used for all variables. Association between variables was assessed using chi-square test and the level of significance was considered at P < 0.05.  

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