Introduction

Stress represents the “wear and tear” that our bodies endure as we adapt to our constantly evolving surroundings. Although a small amount of stress can be a source of motivation, excessive stress diminishes the ability to cope with day-to-day activities. Medical students undergo several years of intense studies and clinical training to become highly skilled doctors [1]. Medical education is widely recognized as stressful and can negatively affect students’ mental and physical health [2]. Although studies have found that academic factors play a key role in stress, many personal and environmental factors are also responsible [1,3].

The sources of stress in this population are multifaceted, including vast academic curricula, frequent examinations, fear of failure, exposure to suffering and death, and reduced leisure time and sleep [4]. Multiple studies have reported high levels of psychological stress among medical students worldwide, with reported prevalence of 63.8% in Saudi Arabia, 59.7% in Pakistan, and 61.4% in Thailand [4-6]. Chronic stress among medical students is associated with decreased academic performance, emotional exhaustion, reduced empathy, and maladaptive coping mechanisms such as substance use [4].

Sleep quality, defined as an individual’s satisfaction with sleep, is essential for physical restoration and psychological resilience. Poor sleep is characterized by dissatisfaction with sleep duration and continuity and is often accompanied by daytime fatigue, irritability, anxiety, and impaired concentration [7]. Disrupted sleep at night heightens feelings of depression and anxiety while reducing the capacity to handle everyday stressors [8]. Medical students frequently underestimate the impact of sleep deprivation on their mental health, cognitive performance, and academic success, and to maximize study time, many students intentionally curtail their sleep, relegating it to a lower priority [9].

The prevalence of poor sleep quality among medical students is notably high across various countries: 77% in Pakistan, 56% in Ethiopia, and 76% in Saudi Arabia [4,10,11]. These students are susceptible to sleep disruption due to various factors like caffeine consumption, irregular meal timings, social isolation, female sex, and academic stress [9,12].

Stress has a reciprocal relationship with inadequate sleep quality, establishing a detrimental loop that affects the mental well-being of medical students [4]. Although international research has extensively documented stress and sleep disturbances among medical students, there is limited evidence in Bangladesh. Understanding the local context is essential for developing targeted interventions. Therefore, this study was conducted to assess the levels of stress and sleep quality among medical students in Bangladesh and identify the factors influencing these outcomes.

Methods

Ethics statement: This study was approved by the Research Ethics Committee of Parkview Medical College Hospital (Memo# PMC/2024/393). Written informed consent was obtained from all participants.

1. Settings and sample

This cross-sectional study was conducted between October 2024 and March 2025 among undergraduate medical students (first–fifth year) from four medical colleges in Bangladesh: Parkview Medical College, Sylhet Women’s Medical College, Jalalabad Ragib Rabeya Medical College, and Sylhet Osmani Medical College. All students in these medical colleges were considered the sampling unit. The sample size was calculated using the formula z²pq/d², with a p-value of 0.76 derived from a previous study [2]. The estimated sample size was 280. Stratified random sampling was employed to ensure proportional representation. Seventy students were randomly selected from each medical college, including 14 students from each academic year, chosen randomly based on roll numbers. Each academic year (first–fifth) comprised 56 students. Students with self-reported physical or mental illness were excluded. If a selected student was unavailable or refused participation, the next student on the roll was approached.

2. Data collection tool

The interview had four parts: sociodemographic details, factors influencing stress and sleep, the Kessler Psychological Distress Scale (K10), and the Pittsburgh Sleep Quality Index (PSQI). Sociodemographic characteristics included age, sex, accommodation, height, weight, marital status, and study year. Factors potentially influencing stress and sleep-related issues included screen time, dinner time, daytime napping, coffee consumption, physical activity or sports participation, late-night snacking and gaming, parental expectations, having a doctor in the family, academic concern, and decision to pursue medicine.

The K10 is a commonly employed tool in epidemiological research to self-assess the intensity of stress that an individual has faced in the past month [13]. It consists of 10 questions, each using a 5-point Likert scale from “one of the time” to “all of the time,” scored from 1 to 5, accordingly. Scores of 20 or higher distinguish stressed individuals. These scores are categorized as follows: 20 to 24 denotes mild stress, 25 to 29 indicates moderate stress, and 30 to 50 signifies severe stress.

The PSQI is an effective instrument for measuring sleep quality and sleep patterns over the past month among adults. The respondents self-rated seven domains of sleep: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction, based on a 0 to 3 Likert scale, where 3 reflects the negative extreme. Higher PSQI scores indicate poorer sleep quality and greater sleep disturbance. A global sum of >5 indicates a “poor” sleeper [14]. A recent classification denotes 6 to 10 as “moderately poor sleepers” and >10 as “very poor sleepers” [14].

3. Data collection method

The self-report questionnaires were distributed in person, accompanied by an informed consent form and information sheet detailing the study objectives, procedures, and voluntary nature of participation. The information sheet emphasized each participant’s right to withdraw at any point without providing justification and without academic or personal consequences. Confidentiality was strictly maintained by anonymizing all respondents and removing any personal identifiers.

4. Data analysis

Descriptive statistics including frequency, percentage, mean, and standard deviation, were used to measure the objectives, and chi-square tests were used to explore the relationships between stress, sleep quality, and related factors. Data were analyzed using IBM SPSS ver. 25 (IBM Corp., Armonk, NY, USA).

Results

1. Characteristics of the students

Table 1 presents the student characteristics across various variables. The mean age was 22±1.6 years, and 57.1% of the participants were female. Most participants lived in hostels (80.7%). Screen time exceeded 30 minutes for 55% of the participants, and 57.9% had dinner after 9 p.m. Daytime naps were taken by 50.7% of participants, whereas 29.3% drank coffee daily. Only 27.9% of the participants engaged in exercise or outdoor sports. Late-night snacking was common (35.4%) among the participants. High parental expectations were reported by 53.2% of participants, and 66.8% had academic concerns. Approximately one-third (34.6%) of participants had a doctor in the family, and 63.6% independently chose medical studies.

2. Assessment of stress and sleep quality

Table 2 shows stress and sleep quality using the K10 and PSQI. Stress affected 65.7% of the participants and was categorized as mild (27.5%), moderate (22.1%), or severe (16.1%), whereas 34.3% reported no stress. The mean K10 score was 23.51±6.74. Poor sleep quality was prevalent, affecting 72.1% of the participants, with 48.2% experiencing moderately poor sleep and 23.9% experiencing very poor sleep. By contrast, 27.9% of participants reported good sleep quality. The mean PSQI score was 7.96±4.12. The mean sleep duration was 5.7±1.3 hours, with 43.2% sleeping less than 6 hours. Nearly one in five participants (19.3%) used sleep medications.

3. Factors associated with stress

Table 3 presents the factors associated with stress among medical students. Stress was more prevalent in females (71.9%) than in males (57.5%) (p=0.012). Stress varied by study year, being highest in fifth-year (75%) and lowest in first-year students (51.8%) (p=0.041). Students who did not engage in exercise or sports had higher stress levels (69.3%) than those who did (56.4%) (p=0.042). High parental expectations (75.8%, p<0.001) and academic concerns (73.3%, p<0.001) were significantly associated with stress. Parental influence in the decision to pursue medicine was associated with higher stress prevalence (77.5%) than independent decision making (59.0%) (p=0.002). Having a doctor in the family was associated with lower stress levels (p=0.021).

4. Factors associated with sleep quality

Table 4 shows factors associated with sleep quality among medical students. Stress was strongly linked to poor sleep (82.1% vs. 53.1%, p<0.001). Poor sleep was more common in females (76.9%) than in males (65.8%) (p=0.041) and among hostel residents (75.2% vs. 59.3%, p=0.019). Longer screen time before sleep (78.6%, p=0.008), dinner after 9 p.m. (80.2%, p<0.001), and daytime naps (86.6%, p<0.001) were associated with poorer sleep. Daily coffee drinkers (80.5%, p=0.025) and late-night snackers (81.8%, p=0.008) had worse sleep.

Discussion

In this study, the prevalence of stress was 65.7%, with 27.5%, 22.1%, and 16.1% of participants suffering from mild, moderate, and severe stress, respectively. The prevalence of stress in this study aligns with that in other countries: 63.8% in Saudi Arabia, 59.7% in Pakistan, and 61.4% in Thailand [4-6]. Safhi et al. [2] found that 18.7%, 15%, and 31.3% of medical students experienced mild, moderate, and severe stress, respectively, whereas Abdulghani et al. [5] reported prevalences of 20.4%, 18.2%, and 25.2%, respectively. Another study indicated that 28.2% of students had very high stress levels [15]. This variation in stress prevalence might be attributed to the different instruments used to assess stress in these studies, differences in sociocultural environments and medical curricula, or underlying contributing factors.

Our findings align with those of previous studies showing that female students experience higher stress levels than their male counterparts [5,16]. In Bangladesh, female students may have limited access to outdoor activities and social spaces that help mitigate stress, possibly due to cultural restrictions. Additionally, balancing personal and academic responsibilities may contribute to increased stress levels among female students; however, further investigation is required. The medical education system in Bangladesh follows a 5-year program. In our study, stress levels increased progressively with advancing academic years, peaking among fifth-year students. This trend is consistent with a previous study that noted that the transition from preclinical to clinical training increases emotional and academic pressures [11]. A Finland-based study also indicated a steady increase in stress during medical training [17]. This escalation of stress in later years is concerning, as chronic psychological distress can lead to burnout and dropout. A United Kingdom-based study found that one-third of medical students who are psychologically ill never graduate [18].

Consistent with other studies, we found that participation in exercise or sports was associated with lower stress levels [19,20]. Physical activity has been shown to enhance cognitive function and act as a protective factor against psychological distress. A study in Peru further confirmed that increased exercise intensity is linked to reduced stress [21]. In our study, academic concerns were a major source of stress. Stress among medical students is frequently linked to a competitive and high-pressure atmosphere, combined with various academic and professional pressures that frequently result in emotional fatigue and psychological turmoil [22]. A 20-year-long Norwegian longitudinal study found that male physicians with a physician parent reported lower stress levels than their female counterparts [23]. Having a physician in the family was significantly associated with lower stress levels in our study, possibly because these students benefited from insights into medical education and more realistic expectations. Interestingly, we found no sex-based differences in this association. Sayed et al. [15] reported findings similar to ours, whereas Almojali et al. [11] reported contrasting results.

Additionally, students who pursued medical studies because of parental influence experienced significantly higher stress levels, likely driven by the pressure to fulfill parental expectations rather than personal ambitions [24]. In Asian households, the pressure to pursue a career in medicine is significantly stronger, accompanied by an obligation to meet the family’s expectations concerning academic achievement [25]. Students who perceive high parental expectations may exhibit more negative attitudes toward their medical careers by the end of their first year [26]. We found that high parental expectations were significantly associated with stress levels. Our findings align with those of Waqas et al. [4], who identified high parental expectations as one of the most severe stressors experienced by medical students.

Regarding sleep quality, 72.1% of the participants were identified as poor sleepers, 48.2% as moderately poor sleepers, and 23.9% as very poor sleepers. This is comparable to the rates reported in Pakistan (77%) and Saudi Arabia (76%), but higher than those in Ethiopia (56%) [3,7,8]. Owing to academic pressure, medical students often sacrifice sleep to spend more time studying. Within a few days or weeks, a significant sleep deficit can accumulate and impact mood, performance, and overall well-being [27]. Despite recommendations that young adults should sleep 7 to 9 hours per night [28], our participants averaged only 5.7±1.3 hours, with 72.9% sleeping <7 hours, a finding consistent with studies from Saudi Arabia (5.8 hours) and Rwanda (5.5 hours) [11,29]. A Pakistani study indicated an even higher prevalence (87.6%) of students sleeping <7 hours [30]. Chronic sleep restriction has well-documented long-term health consequences, including increased risk of depression, hypertension, metabolic syndrome, and impaired immune function [31]. Self-medication is common among medical students, and awareness does not prevent misuse [32]. In Bangladesh, the over-the-counter sale of sedatives remains common despite regulatory restrictions [33], potentially facilitating access for students. Notably, 19.3% of our participants reported using medications to aid sleep at least once in the past month. This finding is consistent with a New Zealand study that indicated a similar prevalence (18.1%) [14].

A significant finding of the present study is the strong association between stress and poor sleep quality, a relationship widely supported by previous studies [4,8,11,16]. Kashani et al. [27] found that stress was associated with reduced sleep duration, poorer sleep quality, increased risk of sleep apnea, and daytime drowsiness. We found that female students experienced poorer sleep quality than male students. Female medical students suffer more from poor sleep quality, daytime dysfunction, and sleep disturbances [8,12]. Possible explanations for this include hormonal influences and additional family-related responsibilities. In this study, students living in hostels had poorer sleep quality than those living at home, which echoes the findings of Sundas et al. [34]. Students residing in hostels tend to have more late-night gatherings and extracurricular activities [34]. Staying at home allows students to feel comfortable with familiar surroundings, support networks, feelings of safety, and personal space, all of which can lead to better sleep patterns [12]. Due to a lack of time for recreational activities, medical students rely on smartphones, laptops, tablets, and television; however, the overuse of these devices before sleep affects sleep patterns, latency, and duration, all of which are influenced by screen brightness [35]. Our study confirms that prolonged screen exposure before sleep negatively affects sleep quality. Limiting screen time to less than 30 minutes before bedtime has been shown to improve both sleep quality and working memory [36].

Late meals were also associated with poor sleep quality. Students who ate dinner after 9 p.m. or consumed late-night snacks reported poorer sleep, consistent with the findings from another study that identified irregular eating habits and energy-dense nighttime foods as factors that disrupt sleep patterns [37]. Furthermore, sleep deprivation increases cravings for high-calorie, low-nutrient foods, thus establishing a harmful bidirectional cycle [31]. A short daytime nap (approximately 20 minutes) following a restricted night’s sleep can have positive effects, such as improving alertness in the afternoon [38]. However, our results showed that students with biphasic sleep patterns reported poorer sleep quality. The findings of Alotaibi et al. [16] in medical students concur with our result. The duration and timing of naps were not assessed in our study and warrant further exploration.

We found that coffee consumption also affected sleep, with daily coffee drinkers having poorer sleep than occasional drinkers. Although tea consumption is deeply ingrained in Bangladeshi culture, medical students often rely on coffee to boost their alertness and aid their studies at night. Coffee extends the time taken to fall asleep, decreases total sleep, and contributes to repetitive awakenings [39]. Similar findings have been reported regarding Saudi medical students [2]. Ceasing coffee consumption is a key sleep hygiene practice that can be implemented, and educating students on the impact of caffeine on sleep hygiene could be a valuable intervention.

Our study had several limitations. Due to its cross-sectional design, it was not possible to establish causality between stress, sleep quality, and associated factors. Additionally, the reliance on self-reported data may introduce recall and social desirability biases, potentially affecting response accuracy. Although this study used a multicenter approach, the inclusion of additional medical colleges from different regions across Bangladesh would enhance the generalizability of the findings.

This study found a high prevalence of stress and poor sleep quality among medical students in Bangladesh. There were significant links among stress, sleep quality, and the influence of various factors. The presence of stress and poor sleep quality at an early stage is alarming. It is essential for medical colleges in Bangladesh to foster a supportive and less competitive environment and implement structured interventions. Particularly, institutions should implement regular stress management workshops that incorporate mindfulness-based stress reduction, cognitive-behavioral therapy, and guided relaxation exercises. Near-peer teaching programs may reduce academic pressure by fostering collaboration and mentorship. Promoting sleep hygiene education through seminars and integrating wellness modules into the curriculum can further encourage healthier sleep behaviors. Proactive efforts in these areas are critical to safeguard the health and academic success of future physicians.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Acknowledgments

The authors thank all the medical students who participated in the study and the principals of all participating medical colleges for their administrative assistance. The authors especially thank Prof. Dr. Dilip Kumar Bhowmik for scholarly advice and guidance throughout this study.

Funding

None.

Author contributions

Conceptualization, Formal analysis: TKK; Data curation: TKK, RJ, SF; Methodology: TKK, SD; Writing-original draft: TKK; Writing-review & editing: SD, RJ, SF.

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Figure & Data

References

Citations

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