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

Dear editor

We thank Dr. Imran Rauf for his insightful comments and interest in our study “Sleep Patterns and Disruptions Among Adults in Tunisia: An Online Cross-Sectional Survey”. We would like to address the concerns expressed and offer further context for our research.

Factors Associated with Poor Sleep Quality

Dr Rauf correctly highlighted further factors that could impact sleep quality, such as mental health challenges faced by healthcare workers during the COVID-19 outbreak and Ramadan intermittent fasting. In our study, we did not find any independent association between previous COVID-19 infection and sleep-wake disorders.¹ However, we agree that subjects with a history of COVID-19 are likely at high risk for long-lasting sleep disturbances as was suggested by several previous studies.² Furthermore, CircsCOVID, a large prospective multicentric study from the United Kingdom, showed that sleep disturbances following hospital admission for COVID-19 were associated with dyspnoea, anxiety and muscle weakness.² This suggests that targeting sleep disturbance may help improve long COVID-19 conditions. As a result, we concur with Dr Rauf’s perspective on the need for further research to better understand the connection between sleep disturbances and COVID-19. Several environmental and cultural factors might also impact sleep-wake patterns in Tunisian adults. One significant cultural factor is the practice of intermittent fasting during Ramadan, which was linked to disturbed sleep and vigilance due to associated lifestyle changes. A meta-analysis by Faris reported that during Ramadan, total sleep time is reduced by an average of one hour, while the Epworth Sleepiness Scale shows no significant change.³ As Ramadan is a special context, it requires dedicated studies with an appropriate methodology.

Mood Disorders and Sleep Disturbances

Sleep disturbances and mood disorders are closely linked and improving sleep quality may positively affect mood issues even though the underlying mechanisms of this association remain unclear. As shown in our study, Tunisia currently faces an increased prevalence of sleep disturbances. Unfortunately, most general practitioners lack the proper training for sleep disturbance screening and management. As a result, most people with sleep disturbance seek assistance from a limited number of overcrowded tertiary hospitals. From this perspective, it would be interesting to develop integrated public health intervention models that include all issues and involve primary care physicians. The implementation of the World Health Organization’s Mental Health Gap Action Programme (mhGAP) in Tunisia, launched in 2016, aims to bring about a substantial and positive shift in how primary care physicians view and manage mental health.⁴ As suggested by Dr Rauf, it might be a good idea to adopt the same strategy for sleep health by adding modules on sleep disorders into mhGAP. This could improve the management of sleep-related problems by primary care doctors in Tunisia.

Objective Measures of Sleep Quality

Our study used validated Arabic versions of several self-reported questionnaires with acceptable reliability. Further validation of these questionnaires in the Tunisian context would be valuable. Our results provide a good foundation to highlight global trends and significant associations in sleep health among Tunisian adults. We acknowledge, however, that including objective measures of sleep such as actigraphy, as suggested, or at best polysomnography would enhance the accuracy of our results. Unfortunately, we could only use free instruments, because of the lack of funding.

Overall, we fully agree with Dr Rauf that further studies with a longitudinal design, objective measures of sleep quality and the inclusion of specific environmental and cultural factors are required to draw more reliable conclusions.