Association Between Sleep Quality, Sleep Duration and Anxiety Among Secondary School Students in Aden, Yemen: A Cross- Sectional Study

Technical Summary: Association Between Sleep Quality, Sleep Duration, and Anxiety Among Secondary School Students in Aden, Yemen

Problem Statement
Sleep quality and duration are critical determinants of adolescent health, influencing neurodevelopment, cognitive function, and psychological well-being. While global evidence links poor sleep to mental health disorders, data remains scarce regarding Yemeni adolescents, a population facing unique stressors including prolonged political instability, economic collapse, and armed conflict since 2014. The humanitarian crisis in Yemen has led to widespread displacement, food insecurity, and disrupted essential services, potentially exacerbating sleep disturbances and anxiety. This study addresses the gap in empirical research by investigating the prevalence of poor sleep quality and clinical anxiety among secondary school students in Aden, Yemen, and examining the associations between these conditions alongside sociodemographic and lifestyle factors.

Methodology

• Study Design and Setting: A school-based cross-sectional study was conducted in Aden Governorate, Yemen, from March to July 2026.
• Participants: The study included 483 secondary school students (Grades 10–12) selected via a multistage stratified cluster sampling approach. The sample included both public (60.7%) and private (39.3%) schools.
• Instruments: Data were collected using a self-administered structured questionnaire in Arabic comprising:
  • Sociodemographics and Lifestyle: Age, sex, school type, residence, family income, living conditions, work status, smoking, Qat chewing, and Shammah use.
  • Sleep Quality: The validated Arabic version of the Pittsburgh Sleep Quality Index (PSQI). Poor sleep quality was defined as a global PSQI score > 5. The scale demonstrated acceptable internal consistency (Cronbach's α = 0.79).
  • Anxiety: The validated Arabic version of the Generalized Anxiety Disorder-7 (GAD-7) scale. Clinical anxiety was defined as a score ≥ 10. The scale demonstrated excellent internal consistency (Cronbach's α = 0.88).
• Statistical Analysis: Analyses were performed using IBM SPSS Statistics v26.0 and R v4.3.2. Methods included descriptive statistics, Chi-square tests, Spearman's correlation, and multivariable logistic regression (binary and ordinal) to identify independent predictors. Non-parametric tests were utilized due to non-normal distributions of PSQI and GAD-7 scores.

Key Results

• Prevalence:
  • Poor Sleep Quality: 68.3% (n=330) of students exhibited poor sleep quality.
  • Clinical Anxiety: 43.9% (n=212) met the criteria for clinical anxiety (GAD-7 ≥ 10).
  • Sleep Duration: The mean sleep duration was 6.8 ± 1.4 hours. Only 32.5% of students slept more than 7 hours, while 5.6% slept less than 5 hours.
• Associations:
  • Sleep Quality and Anxiety: A statistically significant positive association was found between poor sleep quality and higher anxiety levels (χ² = 21.76, p = 0.009).
  • Sleep Duration and Anxiety: A significant negative correlation was observed between sleep duration and anxiety scores (Spearman's r = -0.21, p = 0.002), indicating that shorter sleep duration correlates with higher anxiety. Students sleeping < 5 hours had the highest mean GAD-7 scores (12.1 ± 5.8).
  • Sociodemographic Factors:
    • Sex: Female students had a significantly higher prevalence of poor-to-severe sleep quality (p < 0.001) and significantly shorter sleep duration compared to males (p = 0.041).
    • School Type: Public school students had a significantly higher prevalence of poor sleep quality compared to private school students (p < 0.001).
    • Living Conditions: Students living with only one parent (father or mother) showed significantly higher anxiety levels (p = 0.042).
• Predictors:
  • Multivariable Logistic Regression (Poor Sleep Quality): Independent predictors included female sex (aOR = 0.57), attending private school (aOR = 0.60), and higher GAD-7 scores (aOR = 1.07 per point increase).
  • Ordinal Logistic Regression (Anxiety Severity): Poor sleep quality was identified as the strongest predictor of higher anxiety severity (aOR = 1.73, p = 0.007).

Key Contributions and Claims of Significance

• First Empirical Evidence: This study claims to be the first comprehensive investigation assessing the triad of sleep quality, sleep duration, and anxiety among secondary school students in Aden, Yemen, providing new epidemiological data from a conflict-affected, underrepresented population.
• Contextual Relevance: The findings highlight the alarmingly high prevalence of sleep and anxiety disorders in a setting characterized by chronic instability and resource scarcity. The authors suggest these rates reflect the cumulative impact of conflict exposure, economic hardship, and disrupted services.
• Interconnectedness: The study establishes a significant bidirectional relationship between sleep disturbances and anxiety in this demographic, reinforcing the need for integrated interventions.
• Policy Implications: The authors argue for urgent, coordinated interventions involving policymakers, schools, and healthcare providers. Specific recommendations include integrating sleep hygiene education into school curricula, establishing school-based mental health screening, and developing national guidelines that address the social determinants of health (poverty and conflict) in Yemen.

Limitations
The authors acknowledge several limitations:

• Causality: The cross-sectional design precludes establishing causal relationships or temporal sequences between sleep and anxiety.
• Measurement Bias: Reliance on self-reported measures (PSQI and GAD-7) introduces potential recall and social desirability biases.
• Generalizability: The study was limited to Aden Governorate; findings may not represent other regions in Yemen.
• Unmeasured Confounders: Variables such as detailed trauma exposure, specific substance use patterns, and family conflict were not fully assessed.
• Objective Data: The lack of objective sleep measures (e.g., actigraphy) is noted, as the study relied on subjective assessment.