Sleep is a core determinant of learning, cognitive performance, emotional stability, metabolic function, and biological immunity. In higher education, particularly within medical training, adequate sleep is necessary for optimal consolidation of memory, decision-making, and critical thinking. However, higher education environments frequently lead students to adopt irregular sleep-wake schedules influenced by intensive study routines, clinical obligations, overnight call duties, and lifestyle shifts. Consequently, global health authorities recognize fatigue and sleep disruption among healthcare trainees as both a public health issue and a medical safety risk. [15,32] Epidemiological surveys show that approximately one-third of the global adult population reports symptoms of insomnia. Medical students represent an exceptionally vulnerable cohort, with global prevalence estimates for sleep disturbances ranging from 19% to 90%. In India, medical education is marked by high academic loads, frequent examinations, long study schedules, and emotionally taxing patient-care exposures. [2] Sleep disturbances stem from an interplay of predisposing intrinsic factors (such as hyperarousal of the hypothalamic-pituitary-adrenal axis), precipitating acute stressors (such as examinations), and perpetuating pre-sleep cognitions (such as bedtime rumination or active screen engagement). Sleep loss rapidly produces excessive daytime sleepiness (EDS), executive cognitive impairment, and mood lability. Over prolonged periods, sleep debt is linked to metabolic imbalance, cardiovascular risk, psychological burnout, and academic underperformance. [33,34] Despite the growing body of literature on sleep hygiene, baseline population dynamics vary across geographic regions. Punjab presents a unique socio-cultural environment undergoing rapid lifestyle transitions. This cross-sectional investigation was designed to systematically assess sleep duration, sleep quality, associated lifestyle determinants, and downstream academic and personal impacts among undergraduate medical students at Government Medical College (GMC), Amritsar.

Study Design and Setting A descriptive, cross-sectional institutional study was conducted at Government Medical College, Amritsar, Punjab, over a period of one month. Study Population and Eligibility The study population comprised undergraduate MBBS students enrolled across all training phases (Phase 1, Phase 2, Phase 3 Part 1, Phase 3 Part 2) and completing internship rotations at GMC Amritsar. Inclusion Criteria: All MBBS students enrolled at GMC Amritsar who voluntary provided informed consent to participate. Exclusion Criteria: Students who declined participation, those with incomplete questionnaire submissions, or those hospitalized due to acute physical illness during the data collection window. Sample Size Calculation Sample size was calculated using Cochran’s formula for unknown/large populations: n=(Z^2⋅P⋅Q)/e^2 Where Z=1.96 (for a 95% confidence interval), P=0.625 (estimated prevalence of poor sleep quality among Indian medical trainees based on existing literature), Q=1-P=0.375, and e=0.05 (acceptable margin of error). n=((1.96)^2×0.625×0.375)/(0.05)^2 =(3.8416×0.234375)/0.0025≈361 Adjusting for a finite target population (N≈800 medical students across batches): n'=n/(1+((n-1)/N) )=361/(1+(360/800) )=361/1.45≈249 The target minimum sample size was set at n=249. A total of 249 valid, complete responses were collected. Sampling and Data Collection Instrument A convenience sampling strategy was applied. Data were gathered through a predesigned, semi-structured electronic survey administered via Google Forms. The tool contained four core sections: Section A (Demographics): Age, gender, academic year, residence, family structure, parental occupation, monthly income, and room-sharing status. Section B (Sleep Metrics & PSQI): Subjective sleep parameters based on the Pittsburgh Sleep Quality Index (PSQI) framework, including bedtimes, sleep latency, morning wake times, total nighttime duration, frequency of nighttime awakenings, and self-rated sleep quality. [30] Section C (Lifestyle Determinants): Pre-bedtime screen usage, dinner timings, late-night high-sugar/fried food consumption, caffeine/stimulant intake, physical exercise frequency, smoking/alcohol habits, and perceived emotional/academic stress. Section D (Functional & Academic Impacts): Daytime sleepiness during lectures/clinical postings, concentration deficits, daytime fatigue, napping behavior, class attendance, and perceived academic degradation. Statistical Analysis Collected data were compiled into spreadsheets, cleaned, and analyzed using standard descriptive statistical methods. Categorical metrics were expressed as absolute numbers (n) and relative percentages (%). Ethical Considerations The study protocol, participant information sheet (Annexure II), and consent form (Annexure I) were reviewed and approved by the Institutional Ethics Committee of GMC Amritsar. Electronic informed consent was obtained from all participants prior to survey completion, ensuring anonymity and voluntary participation.

Participant characteristics A total of 249 undergraduate medical students completed the survey. Participants were 18-26 years old, and 95.0% were aged 20-23 years. Females constituted 63.0% (157/249) of the sample. Phase 3 students formed the largest academic subgroup (57.0%). Most participants lived at home (76.0%), belonged to a nuclear family (66.0%), and slept in a single room (71.0%) (Table 1). Table 1 Participant characteristics (N = 249) Characteristic Category n (%) Age 20-23 years 237 (95.0) Sex Female 157 (63.0) Male 92 (37.0) Academic phase Phase 1 30 (12.0) Phase 2 47 (19.0) Phase 3 142 (57.0) Phase 3 Part 2 or internship 30 (12.0) Residence Home 189 (76.0) Hostel 35 (14.0) Private accommodation or flat 25 (10.0) Family type Nuclear 164 (66.0) Joint 70 (28.0) Extended 15 (6.0) Sleeping room Single 177 (71.0) Shared 72 (29.0) Counts not explicitly reported in the source manuscript were calculated from N = 249 and rounded to the nearest whole number. Sleep pattern and subjective sleep quality Late sleep timing was common: 48.4% reported going to bed between 11:00 PM and 1:00 AM and 38.4% after 1:00 AM. More than half (57.2%) reported 5-7 hours of nightly sleep, while 16.0% reported less than 5 hours. Difficulty initiating sleep within 30 minutes at least once per week was reported by 46.8%, and 31.2% reported waking during the night or early morning at least once per week. Sleep medication use was reported by 11.2% (27/249). On the PSQI subjective sleep-quality item, 27.2% rated their sleep as fairly bad or very bad (Table 2 and Figure 1). Table 2 Reported sleep characteristics Domain Response n (%) Bedtime Before 9:00 PM 5 (2.0) 9:00-11:00 PM 40 (16.0) 11:00 PM-1:00 AM 121 (48.4) After 1:00 AM 96 (38.4) Wake time 4:00-5:00 AM 10 (4.0) 5:00-6:00 AM 30 (12.0) 6:00-7:00 AM 108 (43.2) After 7:00 AM 114 (45.6) Sleep latency <10 minutes 62 (24.8) 10-20 minutes 92 (36.8) 20-30 minutes 57 (22.8) >30 minutes 46 (18.4) Nightly sleep duration <5 hours 40 (16.0) 5-7 hours 143 (57.2) 7-8 hours 66 (26.4) >8 hours 13 (5.2) Subjective sleep quality Very good 49 (19.6) Fairly good 138 (55.2) Fairly bad 56 (22.4) Very bad 12 (4.8) Sleep medication Any reported use 27 (11.2) No use 222 (88.8) Values are reproduced from the source manuscript. Bedtime, wake-time, latency, duration, and subjective-quality category totals exceed N = 249 and must be verified against the raw dataset before submission. Subjective sleep quality is one PSQI component and should not be labelled as the global PSQI score Lifestyle and behavioural factors In-bed electronic-device use was reported by 94.0% (234/249). Immediate pre-sleep use was reported by 56.3% of device users. Emotional stress affected sleep to some degree in 76.7% of participants. Daily exercise was reported by 16.5%, whereas 49.0% exercised rarely or never. Smoking and alcohol use were reported by 5.6% and 8.8%, respectively (Table 3). Table 3 Lifestyle and behavioural factors Factor Reported response % Electronic devices in bed Yes 94.0 Screen cessation among users Immediately before sleep 56.3 Dinner timing 8:00-10:00 PM 83.1 Late-night refined or fried food Sometimes, often, or always 87.1 Pre-bedtime caffeine Rarely or sometimes 61.9 Exercise Daily 16.5 Rarely or never 49.0 Smoking Yes 5.6 Alcohol use Yes 8.8 Emotional stress affecting sleep Sometimes, often, or always 76.7 Percentages are based on the source manuscript. Denominators may vary for conditional questions. Daytime and academic consequences Sleepiness during lectures or clinical postings was reported sometimes or often by 69.4% of participants. Reduced classroom concentration (86.0%) and daytime fatigue (90.4%) were common. Daytime napping was reported by 78.7% (196/249), most commonly for 1-2 hours. Nearly three-quarters reported a negative academic impact (73.9%) and missing a lecture or clinical posting because of insufficient sleep (73.9%) (Table 4 and Figure 2). Table 4 Daytime functioning and perceived academic consequences Outcome Definition used in the survey summary % Sleepiness in lectures or clinical postings Sometimes or often 69.4 Reduced class concentration Any reported impact 86.0 Daytime fatigue Occasional, frequent, or persistent 90.4 Daytime napping Reported napping 78.7 Negative academic impact Slight, moderate, or severe 73.9 Missed lectures or clinical postings Rarely, sometimes, or often 73.9

This study evaluated sleep patterns, sleep quality, and determinants among medical undergraduates at GMC Amritsar. Demographic findings show a female-predominant cohort (63.0%) in their early twenties, reflecting general enrollment trends in Indian medical institutions. Third-year (Phase 3) students represented the largest respondent group (57.0%), consistent with observational studies noting higher participation rates among mid-course medical students. Unlike multicenter trials where hostel residence predominates, 76% of our sample lived at home, reflecting regional demographics around Amritsar. A major finding is the high prevalence of delayed sleep phase schedules. Over 86% of students went to bed after 11:00 PM, with 38.4% retiring after 1:00 AM. This circadian phase delay aligns with findings by Gradisar et al. and Hirshkowitz et al., who noted that young adults are prone to late sleep schedules that reduce total sleep time and disrupt circadian rhythms. Wake-up patterns were similarly delayed (88.8% waking after 6:00 AM), matching trends described by Roenneberg et al. and Lund et al., where academic work and late-night routines shift waking times. [19,20,21,22] Sleep duration was lower than recommended guidelines. The National Sleep Foundation recommends 7–9 hours of sleep per night for young adults. In our cohort, 73.2% slept fewer than 7 hours per night, and 16.0% received fewer than 5 hours. These results match findings by Hershner & Chervin and Shad et al. (ICMR project), which documented widespread sleep restriction among Indian medical students compared to non-medical peers. [20,23,12] Screen exposure before bed was a clear contributor to delayed sleep onset. Bedtime electronic device use was reported by 94.0% of respondents, with 56.3% using screens immediately before trying to fall asleep. Blue spectrum light exposure suppresses nocturnal melatonin secretion, delays circadian timing, and increases cognitive arousal. [26,27] Subjectively, 27.2% of participants rated their sleep quality as poor (“fairly bad” or “very bad”). While lower than the 58% to 72.9% poor-sleeper rates reported in study-heavy or pre-exam cohorts by Ahrberg et al. and Shad et al., this value still indicates substantial sleep dissatisfaction. [2,12] The downstream cognitive consequences of sleep debt were evident across parameters: [24,32] • 86.0% of students reported impaired classroom concentration. [23,32] • 69.4% experienced sleepiness during lectures or clinical rotations. [23] • 73.9% noted negative impacts on academic performance, consistent with findings by Shaukat et al. and Curcio et al.. [10,32] To offset nighttime sleep deficits, 78.7% of students relied on daytime naps, with 55.2% napping for 1–2 hours. While short naps (≤20 minutes) can temporarily improve alertness, extended daytime naps (>60 minutes) can reduce homeostatic sleep drive and worsen nighttime insomnia. [28,29] Finally, 76.7% of participants reported that emotional and academic stress impaired their sleep. Stress activates the hypothalamic-pituitary-adrenal axis, elevating cortisol levels and autonomic arousal, which interferes with sleep continuity. [33,34] Figure 3 represent the consequential interconnected sleep Hygiene cycle due to various reasons.

This study demonstrates that poor sleep quality, delayed sleep schedules, and insufficient sleep duration are common among undergraduate medical students at GMC Amritsar. Key drivers include late-night electronic device usage, erratic dietary timing, and emotional/academic stress. The resulting sleep debt is associated with excessive daytime sleepiness, reduced concentration, classroom absenteeism, and perceived academic decline. Recommendations To improve sleep quality and well-being among medical undergraduates, the following measures are recommended: 1. Institutional Sleep Hygiene Education Curricular Integration: Incorporate structured modules on sleep medicine and circadian physiology early in Phase 1 training. Screen Deprivation Awareness: Encourage stopping screen use at least 60 minutes before bedtime to allow normal melatonin release. [26,27] Nap Regulation: Educate students to keep daytime naps short (≤20"--" 30 minutes) in the early afternoon to avoid disrupting nighttime sleep drive. [28,29] 2. Structural & Academic Scheduling Balanced Timetabling: Design class and clinical posting schedules to avoid early morning starts immediately following late-night hospital duties. Exam Workload Distribution: Encourage steady study habits using structured time-management methods (e.g., the Pomodoro technique) to discourage overnight cramming before exams. 3. Stress Reduction and Counseling Institutional Support: Provide accessible, confidential mental health counseling services to help students manage academic anxiety and emotional stress. Mindfulness Initiatives: Offer workshops on relaxation techniques, yoga, and stress management within the campus framework. 4. Lifestyle and Environmental Modifications Sleep Environment: Promote quiet, dark, and temperature-controlled sleeping spaces, reserving the bed strictly for rest rather than study or device use. [5] Dietary Adjustments: Limit heavy meals, fried foods, and caffeinated beverages within 3–4 hours of bedtime. [5] Statement of Data Availability & Ethical Disclosures Ethics Approval: Approved by the Institutional Ethics Committee, Government Medical College, Amritsar. Funding: Self-funded departmental project; no external funding was received. Conflicts of Interest: The authors declare no conflicts of interest.

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