Sleep Habits and Disturbances Among Tunisian Adults: A Cross-Sectional Online Survey [Letter]

Dear editor

We were intrigued by the recent findings of Msaad et al which offer useful insights into the sleep patterns and disruptions experienced by Tunisian adults. The study revealed that over half of the participants experienced poor sleep quality, with 53.8% having a PSQI > 5.¹ We commend the authors for their efforts in drawing attention to this crucial public health matter. Below, we present our comments on their research, aimed at deepening our comprehension of sleep habits within the same population and proposing potential solutions to alleviate this health concern.

Poor sleep quality in Tunisia results from various factors, some not considered in this study. Omrane et al found in a single centre study that Tunisian healthcare workers treating COVID-19 patients experience elevated anxiety and depression, both predictors of poor sleep.² Despite the stagnation of COVID-19 associated mortality in Tunisia due to effective preventative measures, it highlights the significant mental health burden that healthcare professionals face and the need for prompt psychological support.² Additionally, Bouattour et al reported that COVID-19 patients face long-term sleep disturbances, depression, and chronic pain post-recovery.³ Cultural and environmental impacts on sleep, such as the intermittent fasting during Ramadan observance, alters eating and sleep patterns. Msaad et al observed delayed average bedtimes during Ramadan, leading to daytime drowsiness and reduced productivity, indicating sleep pattern disruptions.⁴ Overall, we recommend a wider study of the determinants of sleep health that could contribute to poor sleep quality and insomnia, across various contexts. This could help with the development of targeted and effective strategies for different subsets of adults from Tunisia, to address the specific underlying causes of sleep disturbances.

The present study recommends sleep education, awareness, and optimal management of significant mood symptoms.¹ For brevity, we suggest one potential strategy. As the study highlights the link between severe depression, impaired well-being, and sleep disturbances,¹ we propose developing integrated public health intervention models addressing all issues. For instance, adapting the World Health Organization’s Mental Health Gap Action Programme (mhGAP) Intervention Guide to include sleep disorder modules and subsequently re-piloting training, could enhance Tunisian primary care physicians’ abilities to offer evidence-based interventions to improve adult sleep quality. Extensive use of the mhGAP has been observed in low- and middle-income countries (LMICs) to enhance non-specialists’ mental health capacity.⁵ Spagnolo et al discusses this approach in the Tunisian context, noting the need to address contextual barriers for successful implementation, but recognizing the program’s many positive effects on developing competencies and skills.⁵

While validated self-reporting tools such as PSQI, ISI, ESS, PHQ-9, and WHO-5 were used in this study,¹ incorporating non-intrusive objective measures like actigraphy could reduce human recall errors. To clarify, long-term, home-based actigraphy monitoring could provide a more detailed assessment of sleep quality and disturbances. Combining this with a longitudinal study design could help establish temporal relationships and causality, offering deeper insights into sleep pattern dynamics over time.