Table 3 Synthesis of reported factors associated with the risk of sleep disorders among MENA medical students.

From: Sleep disorders and associated factors among medical students in the Middle East and North Africa: a systematic review and meta-analysis

Factors	Compared groups^d	Mean ± Standard Deviation (SD)/OR/r coefficient	p value/95% CI
Insomnia disorders
Insomnia
Sex	Female versus Male⁶⁹	OR^a: 1.830	95% CI: 1.176–2.847, p-value = 0.007
Sex	Male versus Female⁷⁰	OR adjusted^a: 1.42	95% CI: 0.71–2-83
Age	“There was increase in the frequency of insomnia with increased age”¹²⁵	NR	p-value = 0.008
Academic Year	Preclinical Year (1st-2nd year) versus Early (3rd-6thyear) & Late clinical year (> 7 years)⁶⁹	OR^a: 0.720	95% CI: 0.545–0.949, p-value = 0.020
	2nd year versus 1st year⁷⁰	OR adjusted^a: 2.54	95% CI: 0.60–10.67
	3rd year versus 1st year⁷⁰	OR adjusted^a: 1.76	95% CI: 0.33–8.76
	5th year versus 1st year⁷⁰	OR adjusted^a: 1.32	95% CI: 0.17–10.09
Academic performance	Low mean GPA (< 3.0) versus High mean GPA (> 3.0)⁷²	NR	p-value = 0.001
	Low mean GPA (< 3.0) versus High mean GPA (> 3.0)⁷²	OR^a: 1.59	95% CI: 1.11–2.28, p-value = 0.012
	Students’ GPA⁷³	R = − 0.163	p-value = 0.03
	Perceived very frequently their academic performance affected by insomnia versus ‘do not perceive at all their academic performance affected by insomnia⁷⁰	OR adjusted^a: 5.01	95% CI: 1.69–14.82
	Perceived frequently their academic performance affected by insomnia versus do not perceive at all their academic performance affected by insomnia⁷⁰	OR adjusted^a: 2.16	95% CI: 0.71–6.60
	“Perceived sometimes their academic performance affected by insomnia” versus “do not perceive at all their academic performance affected by insomnia⁷⁰	OR adjusted^a: 1.30	95% CI: 0.48–3.52
	Poor academic performance (GPA ≤ 2.49) versus Good academic per (GPA ≥ 2.50)⁷¹	OR adjusted^c: 1.96	95% CI: 1.35–2.85, p-value < 0.001
Technology use	Internet use more than 12 h daily versus Less than 4 to 8 h⁷⁰	OR adjusted^a: 5.20	95% CI: 1.66–16.26, p-value = < 0.010
Characteristics of residency	Living in high prevalence of Covid versus Low prevalence of Covid⁶⁹	OR^a: 1.370	95% CI: 0.931–2.018, p-value = 0.111
Initial exposure followed by a subsequent experience of dissection	No Insomnia versus Insomnia ¹²²	90.3%versus 9.7%	p-value = 0.001
Stress	Mild stress versus no stress⁷⁰	OR adjusted^a: 0.79	95% CI: 0.27–2.30
	Moderate stress versus no stress⁷⁰	OR adjusted^a: 1.77	95% CI: 0.65–4.84
	Severe stress versus no stress⁷⁰	OR adjusted^a: 1.24	95% CI: 0.28–5.42
	Extremely severe stress versus no stress⁷⁰	OR adjusted^a: 7.18	95% CI: 0.90–17.00
Anxiety	Mild anxiety versus no anxiety⁷⁰	OR adjusted^a: 0.55	95% CI: 0.17–1.77
	Moderate anxiety versus no anxiety⁷⁰	OR adjusted^a: 1.88	95% CI: 0.70–5.03
	Severe anxiety versus no anxiety⁷⁰	OR adjusted^a: 0.61	95% CI: 0.15–2.43
	Extreme severe anxiety versus mild, moderate, severe, or no anxiety⁷⁰	OR adjusted^a: 1.95	95% CI: 0.50–7.57
	Mild versus Moderate versus Severe anxiety⁷⁵	50% versus 72.1% versus 91.5%	p-value < 0.001
Sleep state misperception (paradoxical insomnia)
Academic performance	Poor academic performance (GPA ≤ 2.49) versus good academic performance (GPA ≥ 2.50)⁷¹	OR adjusted^c: 6.40	95% CI: 1.04–39.19, p-value = 0.045
Sleep-Related Breathing Disorders
Obstructive sleep apnea
Sex	Male versus Female⁷¹	OR unadjusted: 1.815	95% CI: 1.242–2.654, p-value = 0.002
Sex	Male versus Female⁷⁰	OR adjusted ^a: 3.52	95% CI: 1.85–6.66, p-value = < 0.001
Age	One year increase in the age⁷⁰	OR adjusted^a: 1.37	95% CI: 1.01–1.85
Academic performance	Low mean GPA (< 3.0) versus High mean GPA (> 3.0)⁷²	OR^a:1.57	95% CI: 1.03–2.39
Academic performance	Poor academic performance (GPA ≤ 2.49) versus Good academic performance (GPA ≥ 2.50)⁷¹	16.8% versus 11.0%	p-value = 0.117
Academic year	3rd year versus 1st Year⁷⁰	OR adjusted^a: 2.61	95% CI: 0.56–12.14
Academic year	2nd year versus 1st Year⁷⁰	OR adjusted^a 1.19	95% CI: 0.26–5.09
Use of technology	Use of internet for 4–8 h daily versus < 4–8 h daily⁷⁰	OR adjusted^a: 2.41	95% CI: 1.14–5.08
Stress	Mild stress versus no stress⁷⁰	OR adjusted^a: 0.55	95% CI: 0.20–1.47
	Moderate stress versus no stress⁷⁰	OR adjusted^a 0.21	95% CI: 0.06–0.74, p-value ≤ 0.050
	Severe stress versus no stress⁷⁰	OR adjusted^a: 0.75	95% CI: 0.15–3.73
	Extremely severe stress versus no stress⁷⁰	OR adjusted^a: 0.22	95% CI: 0.02–1.77
Anxiety	Mild anxiety versus no anxiety⁷⁰	OR adjusted^a: 3.44	95% CI: 1.47–8.07, p-value ≤ 0.010
	Moderate anxiety versus no anxiety⁷⁰	OR adjusted^a: 1.38	95% CI: 0.45–4.20
	Severe anxiety versus no anxiety⁷⁰	OR adjusted^a: 1.69	95% CI: 0.47–5.99
	Extremely severe anxiety versus no anxiety⁷⁰	OR adjusted^a: 32.01	95% CI: 7.45–137.42, p-value ≤ 0.001
Central Disorders of Hypersomnolence
Hypersomnia
Academic performance	Poor academic performance (GPA ≤ 2.49) versus Good Academic per (GPA ≥ 2.50)⁷¹	19.4% versus 23.9%	p-value = 0.176
Narcolepsy
Academic performance	Poor academic performance (GPA ≤ 2.49) versus Good academic performance (GPA ≥ 2.50)⁷¹	OR adjusted^c: 2.03	95% CI: 5.83–15.60, p-value = 0.045
Circadian Rhythm Sleep–Wake Disorders
Circadian Rhythm Sleep–Wake Disorders
Academic performance	Poor academic performance (GPA ≤ 2.49) versus good academic performance (GPA ≥ 2.50)⁷¹	OR adjusted^c: 2.03	95% CI: 1.34–3.08, p-value < 0.001
	Low mean GPA (< 3.0) versus High mean GPA (> 3.0)⁷²	OR^a: 1.71	95% CI: 1.50–2.56, p-value = 0.008
Parasomnias
Nightmares
Sex	Male versus Female⁷¹	OR unadjusted: 0.490	95% CI: 0.263–0.913, p-value = 0.022
Academic performance	Poor academic performance (GPA ≤ 2.49) versus Good academic performance (GPA ≥ 2.50)⁷¹	5.6% versus 4.4%	p-value = 0.458
Sleep walking
Academic performance	Poor academic performance (GPA ≤ 2.49) versus good academic performance (GPA ≥ 2.50)⁷¹	2.0% versus 0.8%	p-value = 0.135
Sleep-Related Movement Disorders
Periodic limb movement disorder/restless leg syndrome
Sex	RLS score in Female versus Male¹³¹	Mean ± SD: 10.86 ± 1.34 & Mean ± SD: 11.57 ± 5.798	p-value = 0.754
Sex	Male versus Female⁷¹	OR unadjusted: 0.521	95% CI: 0.342–0.793, p-value = 0.002
Academic performance	Poor academic performance (GPA ≤ 2.49) versus Good academic performance (GPA ≥ 2.50)⁷¹	11.2% versus 10.2%	p-value = 0.665
Academic performance	“RLS/PLMD was not associated with low academic performance (GPA < 3.0)”⁷²	NR	p-value = 0.152
Combined categories of SDs^e
Academic performance	GPA score in students with SDs versus GPA score in students without SDs⁶⁷	Mean ± SD: 2.72 ± 1.34 versus Mean ± SD: 2.61 ± 1.43	p-value = 0.484
Academic performance	Poor academic performance (GPA ≤ 2.49) versus Good (GPA 2.50–2.99) versus Very good (GPA 3.00–3.49) versus Excellent (GPA 3.50–3.99)/Outstanding (GPA ≥ 4.00) academic performance⁷¹	93.4% versus 82.9% versus 66.8% versus 56.5%	p-value = 0.005
Use of Technology	Time spent watching television and/or on smartphones versus No time spent watching television and/or on smartphones⁶⁷	Mean ± SD: 6.71 h ± 3.83 versus Mean ± SD: 5.90 h ± 3.40	p-value = 0.004
BMI (BMI kg/m²)	BMI in SD group versus BMI in no SD group⁶⁷	Mean ± SD: 24.8 kg/m2 ± 6.45 versus Mean ± SD: 24.8 kg/m2 ± 7.50	p-value = 0.936

Significant results are highlighted in bold (p value ≤ 0.05).
GPA grade point average, OR odd ratio, NR not reported, BMI body max index, RLS restless leg syndrome.
^aAdjustment unknown;
^bModel included age, gender, education, stress, anxiety, use of internet, and academic performance;
^cAdjusted for sex and obesity;
^dThe second group listed refers to the reference group when applicable.
^eThe studies assessed the factor associated with SDs combining obstructive sleep apnea (OSA), Insomnia, Narcolepsy, Restless leg syndrome/Periodic limb movement disorder (RLS/PLMD), Circadian rhythm disorder (CRD), Sleep walking, and Nightmares.

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Table 3 Synthesis of reported factors associated with the risk of sleep disorders among MENA medical students.

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