Journal of Sleep Disorders: Treatment and CareISSN: 2325-9639

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Research Article, J Sleep Disord Treat Care Vol: 6 Issue: 1

Study on the Evaluation of Average Daytime Sleepiness among Female College Students using ESS Questionnaire

Bano R* and Awad WM
Department of clinical Nutrition, College of Applied Medical Sciences, UOH, Hail, Saudi Arabia
Corresponding author : Rafia Bano
Department of Clinical Nutrition, College of Applied Medical Sciences University of Hail, 2440, Saudi Arabia
Tel: 00966-536662964
Received: January 03, 2017 Accepted: January 19, 2017 Published: January 26, 2017
Citation: Bano R, Awad WM (2017) Study on the Evaluation of Average Daytime Sleepiness among Female College Students using ESS Questionnaire. J Sleep Disor: Treat Care 6:1. doi: 10.4172/2325-9639.1000187


The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. Two hundred adults answered the ESS, They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. The highest mean was found for the question number 7 i.e. the highest chance of dozing was sitting quietly after a lunch without alcohol, followed by question one i.e. sitting and reading. Results show that category of daytime sleepiness was significantly correlated with Body Mass Index (BMI) and anxiety score.

Keywords: Sleepiness questionnaire; Sleep propensity; Insomnia; Obstructive sleep apnea syndrome


Sleepiness questionnaire; Sleep propensity; Insomnia; Obstructive sleep apnea syndrome


Sleep is a normal recurring state that manifests as loss of responsiveness to the external environment. Sleep had been seen as a passive state that ensues in the absence of wakefulness. However, it is now known to be an active physiologic state involving dynamic changes in neural, metabolic, and cardio respiratory function.


Sleep is a normal recurring state that manifests as loss of responsiveness to the external environment. Sleep had been seen as a passive state that ensues in the absence of wakefulness. However, it is now known to be an active physiologic state involving dynamic changes in neural, metabolic, and cardio respiratory function. Sleep disorders encompass a wide range of conditions that have been most recently categorized in the International Classification of Sleep Disorders, Second Edition (ICSD-2) [1]. The ICSD-2 lists more than 80 distinct sleep disorders sorted into 8 categories, including the insomnias, sleep-related breathing disorders and hypersomnias of central origin, circadian rhythm sleep disorders, parasomnias, and sleep-related movement disorders.

Excessive Daytime Sleepiness

Excessive daytime sleepiness refers to the inability to stay alert during the major awake period of the day, resulting in falling asleep at inappropriate times. Excessive daytime sleepiness is more likely to occur in monotonous situations when alerting stimuli are absent, and it is associated with increased risk of accidents, such as when operating motor vehicles or other machinery. The severity of sleepiness can be quantified subjectively using scales such as the Epworth Sleepiness Scale (Table 1) or can be measured objectively in the sleep laboratory using the multiple sleep latency test (MSLT) or maintenance of wakefulness test (MWT) [2]. The MSLT measures the physiologic tendency to fall asleep in quiet situations, and the MWT measures the ability to stay awake in quiet situations.
Table 1: Epworth sleepiness scale* *A score of ≥ 10 indicates sleepiness
Excessive daytime sleepiness (EDS) is a public health concern. It can be caused by disorders such as obstructive sleep apnea (OSA), narcolepsy, and idiopathic hypersomnia [1-4]. A previous study showed that the prevalence of EDS was 2.5% in the Japanese general population [5], and another study showed an EDS prevalence of 8.7% in the general population of the United States [6]. Thus, EDS is common worldwide. People who suffer from EDS sleep a lot during the daytime and usually have cognitive and memory problems. In addition, EDS might be associated with impaired health-related quality of life (HRQOL) in patients with OSA [7] and narcolepsy [8-11]. However, there is a lack of data on the relationship between HRQOL and EDS. Briones et al. [12] found that EDS had an important impact on general health and functional status, which they interpreted as reflecting HRQOL, as measured by the Medical Outcomes Study Short Form 36 [12]. Similar results were also obtained in another study [13].
The Epworth Sleepiness Scale (ESS) is a widely used subjective method for assessing EDS in English-speaking countries. Compared with objective methods such as the Multiple Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT), the ESS is simpler, cheaper, and less time-consuming [14]. Furthermore, it attempts to measure the general level of daytime sleepiness over a recent period, rather than providing information on an individual’s sleepiness at a particular time only [1]. The ESS is an eight-item, selfadministered questionnaire that contains eight situations commonly encountered in daily life. The subject is instructed to answer how likely it is that he/she would fall asleep in those different situations, by giving a score from 0 to 3. Thus, the total score of the ESS ranges from 0 to 24. The higher the score, the greater the possibility the individual will fall asleep during the daytime.
The English version of the ESS has been demonstrated to have high reliability and consistency [15]. Different versions of the ESS have also been developed in non-English speaking countries [16-20]. The Korean version has good internal consistency (Cronbach’s α coefficient=0.90) and test-retest reliability (r=0.78–0.93) [19]. In the Japanese version of the ESS, the response rate is usually quite high with the percentage of missing values ranging from 0.7% to 1.1%, and the Cronbach’s α coefficient is 0.85. The test-retest reliability of the Japanese version is also quite high (r=0.78) [20]. The ESS has been used extensively in sleep-disordered and medical populations [21-24]. However, seldom have studies focused on a Mandarin version of the ESS, and few studies have used the ESS to assess the general population.

Sleep Disorders Manifesting with Excessive Daytime Sleepiness

Lifestyle and Behavioral Modifications
Behavioral modifications in sleep disorders that cause excessive daytime sleepiness include diet and exercise to promote weight loss, and positional therapy (not sleeping on the back) for OSA. Positional therapy has modest benefits in sleep quality, excessive daytime sleepiness, and AHI in positional OSA (defined as a supine AHI at least twice that of the lateral AHI). In narcolepsy, scheduled naps, which are typically refreshing, can help to sustain alertness and reduce the need for stimulant drugs. Planned sleep schedules are also an important part of treating circadian rhythm sleep disorders.
In this study, we aimed to (1) assess the prevalence of subjective EDS among the Saudi general population by using the ESS; and (2) assess the relationship between ESS scores and general health.


Study design and sample
From October 2016 to November 2016, a population-based sample of 200 individuals aged 18 to 80 years was selected randomly hail city of Saudi Arabia using a multiple-stage sampling method with stratification. We obtained the basic demographic information of residents from self administered questionnaire. Residents who were suffering from psychiatric illnesses or other disabilities were excluded from the study. Respondents completed the questionnaires by themselves. All gave written informed consent before participation. The study was approved by the Department of Clinical Nutrition, University of Hail, Saudi Arabia.
We gathered socio demographic information, including region of residence, gender, age, height, weight, educational level, and data on the prevalence of chronic diseases, including hypertension, diabetes, liver diseases, renal diseases, chronic bronchitis, and rheumatoid arthritis.
The Arabic version of the ESS was used to evaluate EDS. It is an eight-item, self-administered questionnaire, with a total score ranging between 0 and 24. A score was greater than 10 indicates subjective EDS [1,21]. The English ESS was translated into Arabic. After completion the Arabic version of the ESS was translated back into English. Disagreements were discussed among experts on epidemiology and public health, and then we developed a revised version.

Statistical Analysis

Statistical Package for Social sciences (SPSS) 17.0 was used to analyze survey data. Data were analyzed using frequencies and percentages for categorical variables and central tendency and dispersion measures (SD) for quantitative variables. The correlations between various parameters were determined by Chi square and Pearson's correlation. Differences in ESS scores between the diagnostic groups were tested by one-way ANOVA. P-value less than 0.05 were considered statistically significant.


Table 2 shows the mean score for the questions of Epworth sleepiness scale questionnaire. The highest mean was found for the question number 7, i.e., the highest chance of dozing was sitting quietly after a lunch without alcohol, followed by question one i.e. sitting and reading.
Table 2: Mean scores for individual questions of the ESS questionnaire.
Table 3 shows the frequency distribution of the different categories of the sleepiness. It was found that the highest percentage (51%) participants have score 9 and above showing a high degree of sleepiness in the day time.
Table 3: Frequency distribution of categories of sleepiness.
Figures 1 and 2 shows Categories of sleepiness among the study population and the total excessive daytime sleep score. It was noticed that the highest number of participants scored 8, followed by 5, 10, 12 and 13.
Figure 1: Categories of sleepiness among the study population.
Figure 2: Total excessive daytime sleep score.
Table 4 shows the means of different study variables according to day time sleepiness score. On applying analysis of variance it was found that the daytime sleepiness was significantly correlated with total mean score, total anxiety score, weight and height of the subjects, where all P values being less than 0.05.
Table 4: ANOVA for the different study variables and daytime sleepiness score.
Tables 5 and 6 shows the correlation between category of daytime sleepiness and BMI and anxiety score respectively. Chi square test shows that the correlation was statistically significant for both tables.
Table 5: Chi square test for BMI and category of sleepiness.
Table 6: Chi square for category of sleepiness and anxiety score.
Table 7 the mean score of daytime sleepiness according to the prevalence of chronic diseases. It was observed from the results that the highest mean score was found for the patients of hypertension, followed by vitamin D deficiency, and those subjects having more than one illness.
Table 7: Mean excessive daytime sleep score according to the chronic diseases.


Sleep is one of our basic needs. It is important for our physical, intellectual and emotional health [25] . Previous study by Trocker et al. to evaluate health related variables on academic performance found that sleep had the largest effect on semester GPA compared to the other health related variables such as exercise, nutrition intake, mental health, stress and time management [26]. Americans report getting 8 hours or more of sleep per night [27] . If a person reduces the amount of sleep by only one hour in a night, it still has a significant impact on next day functioning. Response time, ability to focus, and performance at a job or school can all be adversely affected. These results provide evidence that a questionnaire based scale as brief and as simple as the ESS can give valid measurements of sleep propensity in adults. ESS scores significantly distinguished groups of patients who are known from other investigations to have differences in their levels of sleepiness,. The high ESS scores of EDS were the clinical features of sleep apnea. In this study, the ESS was correlated with anxiety score and BMI. Apart from sleeping about 1-2 h less per day by waking up earlier in the morning in summer than in winter, most aspects of the sleep habits of such students do not change significantly over a year [28]. The availability of a simple, self-reported measure of sleepiness across different times of the day should help define these characteristics in a variety of populations [29]. A few students have taken medication at that time. The findings by the other authors revealed that EDS was more prevalent in women than in men and that destitute nocturnal sleep, an irregular sleep-wake schedule, and depression were the risk factors of EDS for both sexes, and being married works as a protective factor against EDS for men alone [30]. It could also lead to inaccurate inferences with consequential outcomes. High scores on sleepiness in inappropriate situations could be an indication of further complication during pregnancy. Sleepiness in pregnant women can be related to preterm labor [31] and gestational diabetes mellitus [32]. Conversely, the relationships between these clinical characteristics and the factors of ESS are still to be explored . The ESS assumes that subjects can remember whether or not and under what circumstances they have dozed off during the day as part of their "usual way of life in recent times".
The present results suggest that most patients can give meaningful self reports about this aspect of their behavior and that their ESS scores provide a measurement of their general level of daytime sleepiness, from low to very high levels. This has not been achieved previously by any other published questionnaire.


The college years are a time of critical transition from adolescence to adulthood. For many individuals, this transition is associated with inadequate sleep and daytime sleepiness. Many factors contribute to this, including the students’ own circadian physiology. Class times are often scheduled without consideration of young adults’ circadian patterns. Inadequate sleep hygiene is common, as students often use technology and substances that compromise sleep quality and quantity. This chronic sleep deprivation may impair academic performance, mood regulation, and driving safety. Students who attain sufficient sleep may still struggle with sleepiness due to sleep disorders.
The ESS is appropriate to measure DS. This study is required in the area of test-retest reliability. In addition, it provides information on sleepiness at multiple times across the day. In summary, the ESS requires high chance of dozing quality to assess its measurement properties. High scores on sleepiness in inappropriate situations indicate complications in future. Sleep disorders are common and have a limited range of symptoms. A practical approach to diagnosis is to consider the various diagnoses from these 3 main symptom categories: insomnia, excessive daytime sleepiness, and abnormal movements in sleep. Insomnia is often multi factorial, with specific therapy directed to the identifiable cause. RLS is common cause of sleep disturbance and should be excluded in all patients presenting with sleep-related complaints based on the clinical diagnostic criteria. Chronic partial sleep deprivation and OSA are the most commonly encountered causes of excessive daytime sleepiness in practice. Sleep studies are indicated in the diagnosis of certain conditions, such as suspected sleep-related breathing disorders, narcolepsy, injurious parasomnias, and sleep-related epilepsy. Many sleep disorders are multi factorial and respond best to a holistic approach, which includes lifestyle modifications, behavioral changes, pharmacotherapy, timed bright light therapy, positive airway pressure therapy, and surgery.
Further research is needed to not only determine how to best educate students about the importance of sleep and the consequences of sleep deprivation, but also how to translate this knowledge into practice. Electronic or web-based interventions may be economically feasible and attractive to an electronically savvy demographic. Universities and colleges need to understand, acknowledge, and publicize that policies and class schedules may have substantial impacts on the sleep, learning, and health of their students. Investigation of new approaches to promote good sleep and sleep habits could have significant public health impact and should be prioritized.

Limitations of the ESS

Because ESS item-scores are based on subjective reports, they can be influenced by the same sources of bias and inaccuracy as any other such reports. The ESS should not be used in isolation in circumstances where the scores could determine outcomes with potential legal implications, such as granting or withholding a driver’s license. Confirmatory evidence of excessive daytime sleepiness or an increased risk of a drowsy road-crash should be sought from other sources too.
The ESS does not usually enable accurate predictions to be made of a person’s level of drowsiness, and hence their crash-risk, when driving a vehicle at some particular time. However, there may be an exception to this among people with very high ESS scores (>15), whose ASP is very high under most circumstances.
The ESS does not distinguish which factors, or which sleep disorders, have caused any particular level of ASP. The ESS is not a diagnostic tool by itself. Nor does it assess other aspects of a person’s sleep habits, for which other methods are available.
The ESS is not suitable for use among people with serious cognitive impairment. Nor is it suitable for measuring rapid changes in sleep propensity over periods of hours, e.g. to demonstrate the short-term sedative effects of a drug, or to assess the circadian rhythm of sleep propensity.


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