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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Sleep Hygiene Intervention and its Effectiveness in Reduction of Insomnia and Obesity among Undergraduate Medical Students
Correspondence Address :
Dr. E Suganya,
Assistant Professor, Department of Community Medicine, Sri Venkateshwaraa
Medical College Hospital and Research Centre, Puducherry-605102, India.
E-mail: drsuganyae@gmail.com
Introduction: Adequate amount and quality of sleep is the basic need for any human. Children and adolescents requires at least eight to nine hours of sleep per night. Insomnia results in both mental and physical health consequences, diminished productivity, accident proneness, increased medical utilisation and elevated risk of psychiatric disorders. Sleep hygiene intervention is a behavioral intervention to improve sleep quality.
Aim: To determine the effectiveness of sleep hygiene intervention programme in reduction of insomnia and obesity among undergraduate medical students.
Materials and Methods: This interventional study was conducted at Tagore Medical College and Hospital, Chennai, India, January 2019 to May 2019, among 602 undergraduate medical students. Study was conducted in two phases, in phase 1, participants were surveyed for Insomnia Severity Index (ISI) scoring and BMI. Those with ISI scores between 8-21 and BMI ≥30 kg/m2 were eligible for phase 2. In phase 2 using, stratified random sampling total 100 subjects, 50 each for control and intervention group were selected. Periodical sleep hygiene intervention was given for intervention group, insisting to follow 10 simple non pharmacological behavioral measures. Follow-up assessment of weight (kg) and ISI scoring was done. Paired t-test, repeated measures Analysis of Variance (ANOVA) and Bonferine Post-hoc test was done to identify the statistical significance using Statistical Package for Social Sciences (SPSS) version 20.0.
Results: Among the 100 participants in phase II, 29 were female in both control and intervention group. The prevalence of Subthreshold insomnia 289 (48%) was higher. Over 4 month period comparison, intervention group had better reduction in weight {(62.48±10.62 kg to 51.48±6.88 kg) vs (61.58±10.35 kg to 62.48±10.66 kg)} and insomnia severity (13.70±3.62 to 10.34±2.43) vs (12.56±3.78 to 13.50±3.63) than control group.
Conclusion: Simple non pharmacological intervention seems to have greater benefits in improving sleep hygiene and reducing obesity.
Behavior change, Quality of sleep, Sleep pattern, Weight
Sleep is one of the basic physiological need of every human being, though the circadian rhythm of the sleep is being controlled by the pacemaker in brain lots of other external factors which are modifiable, are considered to be the major influencing parameter (1),(2). Adequate sleep is important to carry out even the routine activity in a most efficient way, children and adolescents requires at least eight to nine hours of sleep per night (3),(5),(6). In spite of the fact that there is a high prevalence of Insomnia which is associated with significant morbidity, it remains unrecognised and untreated, partly due to several barriers to assessment (7). Insomnia results in both mental and physical health consequences, diminished productivity, accident proneness, increased medical utilisation, and elevated risk of psychiatric disorders (8),(9),(10),(11). Various research studies have also proved that insufficient sleep is independently associated with a higher risk of obesity (12),(13).
There are various validated scales for identification of participants with insomnia and most of them are in the form of patient self-reported questionnaire (14). The commonly used instruments for screening the people for Insomnia are Insomnia Severity Index (ISI), which is a subjective self reporting 7 item questionnaire to determine the severity of Insomnia. It’s a 5 item liker questionnaire with a maximum of 28 score (11),(15), the Pittsburgh Sleep Quality Index, a scale designed for measuring quality of sleep among clinical population over a month interval. It is a 19 item questionnaire a score of more than 5 indicates poor sleep quality (16) and the Athens Insomnia Scale, scale which was designed based on International Classification of Diseases-10 (ICD-10) criteria, for sleep difficulty quantification (15),(17).
In order to help the people with mild to moderate level of Insomnia, a practice developed in late 1970s pertaining to behavioral and environmental measure is termed sleep hygiene (7). Various published articles have proved positive outcomes of sleep quality with the help of, proper sleep hygiene (18),(19),(20). Studies have also suggested that interventional measure to improve sleep quality is the need of hour and its effectiveness should also be assessed (9),(21).
The novelty of the study is that, the behavioral measures were developed for the study purpose after expert validation. Medical undergraduates who are often at risk of insomnia were planned to be assessed. Hence, the study was planned to assess the prevalence of insomnia using ISI scale and to identify if non pharmacological behavioral intervention could improve sleep hygiene and has some effect on obesity reduction. The objective of present study was to determine the effectiveness of sleep hygiene intervention programmed in reduction of insomnia and obesity among undergraduate medical students.
This interventional study was conducted among medical undergraduates of Tagore Medical College Hospital, Chennai, Tamil Nadu, India, from January 2019 to May 2019. The Institutional Ethical clearance was obtained (Ethical clearance number: ECR/1122/TMCH/INST/TN/RR-20).
Inclusion criteria: All the MBBS students (first year to final year), during the specified study period willing to participate in both the phases of study were considered eligible for phase I. Those students who have obtained ISI score between 8-21 and having Body mass Index (BMI) ≥30 kg/m2 (22) were considered eligible for phase II.
Exclusion criteria: Those students who were not able to participate even after three attempts or not attended any one or more of the intervention session were excluded, however in the present study no such participants were there, hence all of them were included.
Phases
The study was conducted in 2 phases.
Phase I: A total of 602 students were involved for Phase I. In phase I, level of insomnia and obesity was assessed by using Insomnia Severity Index (ISI) scale and calculation of Body Mass Index (BMI) respectively (11),(15),(21).
The effectiveness of the program was assessed by measuring the ISI score and weight periodically.
Phase II: In the phase II, the effectiveness of sleep hygiene intervention program was planned by assigning them in two groups namely intervention and control group. Gender and academic year was used (i.e equal number of male to female and academic year was considered to be assigned in control and intervention group) in assigning them into two groups by stratified random sampling method (Table/Fig 1).
Total 100 participants were divided equally in each group:
• Intervention group (50)
• Control group (50)
Procedure
A total of 602 participants were eligible for Phase I, hence all of them were included. In the Phase I, Insomnia Severity Index (ISI) scale was used to assess the level of insomnia. ISI scoring (11),(15):
• Absence of insomnia: 0-7
• Subthreshold insomnia: 8-14
• Moderate insomnia: 15-21
• Severe insomnia: 22-28
Students with severe insomnia were referred to Psychiatrist for further evaluation and medical intervention.
Height (cms) and Weight (Kg) was measured to calculate the Body Mass Index (BMI). Those with ISI score of 8 to 21 and BMI ≥30 were considered eligible for phase II. Out of 602 participants, 433 became eligible based on ISI grading and 318 became eligible criteria for selection of participants for Phase II:
• ISI score between 8-21
• BMI ≥30 kg/m2
Out of this, 318 participants, 100 participants were selected for phase II (remaining 218 were excluded for the convenience of the author to impart a proper intervention for a smaller group, however all of them were given health education program regarding the same).
Intervention group received direct face to face, health education (15 minutes/session) through behavioral change communication 4 times i.e, immediately following the allocation of the participants in the intervention group, at day 1 and at the end of 1, 2 and 4 months following the allocation; they were also followed-up through telephonic conversation twice weekly regarding adherence and challenges in following the suggested intervention and necessary guidance was given. The sleep hygiene intervention had 10 simple steps to be followed, developed by the author after extensive literature review and expert validation (Table/Fig 2) (23),(24),(25),(26). Control group received no such intervention. The participants under both intervention and control group were assessed for insomnia and weight (kg) at day 1 and at end of 4 months in both the group apart from the weight (kg) that was measured at the end of 1 month and 2 month also in the intervention group.
The sleep hygiene intervention program was considered effective in reducing Insomnia, if the ISI score decreases from the baseline, similarly its considered effective in reducing the obesity if there is more decrease in weight in intervention group than the control group (9).
Statistical Analysis
The statistical tests like frequency, paired t-test, repeated measures Analysis of Variance (ANOVA) and Bonferine Post-hoc test was done to identify the statistical significance using Statistical Package for Social Sciences (SPSS) version 20.0.
Among the initial 602 participants screened for insomnia using ISI, most of them were classified under sub-threshold insomnia 289 (48%) followed by 151 (25%), 144 (24%) and 18 (3%) of them under no clinical significant, moderate and severe clinical significant insomnia respectively.
Among the 100 participants (50 each) allotted in control and interventional group, more number of participants were female (29 in each group) and aged between 20-22 (26 in each group) years having a BMI range of 35-35.99 (kg/m2) (Table/Fig 3).
The severity of insomnia decreased in intervention group based on the mean ISI score of the participants which was 13.70±3.62 on day 1 compared to 10.34±2.43 at the end of 4 months and this declined insomnia severity over a time period was found to be statistically significant (p-value=0.0001). In contrast to the pattern of change in insomnia severity level among the intervention group, the control group had higher ISI score of 13.70±3.63 at 4 month compared to 12.56±3.78 at day 1, indicating unfavorable outcome, this difference was also found to be statistically significant (p-value=0.001) (Table/Fig 4).
There was a weight reduction observed in the intervention group having a change in mean weight from 62.48±10.62 kg on day 1 to 51.48±6.88 kg at the end of 4 months and this reducing pattern of weight change over a period of time was found to be statistically significant (p-value=0.0001). In contrast to the pattern of weight change among the participants of intervention group, the control group had weight gain over a period of 4 months depicting from the mean weight change of 62.48±10.66 kg at the end of 4 months from 61.58±10.35 on day 1, however this difference was not found to be statistically significant (p-value=0.6669) (Table/Fig 5).
Thus by using the repeated measures ANOVA with Greenhouse-Geisser correction, the mean scores of weight (kg) were statistically significantly different (df:1.242,60.881, f-value=67.812, p-value=0.0001).
The results of Bonferroni post hoc test done to discover which specific means differed are as follows. It was noted that, there was a significant difference in weight (kg) between day 1 with 1 month, 2 month and 4 month after intervention (p-value <0.001) (Table/Fig 6).
Post-hoc tests using the Bonferroni correction revealed that sleep hygiene intervention elicited reduction in weight (kg) in the intervention group from day 1 to 1 month postintervention (53.88±6.66 kg vs 53.51±6.61 kg respectively), between day 1 to 2 month postintervention (53.88±6.66 kg vs 52.97±6.69 kg respectively), between day 1 to 4 month postintervention (53.88±6.66 kg vs 51.94±6.88 kg respectively) also between the three postintervention period at 1 month, 2 month and 4 month (53.51±6.61 kg vs 52.97±6.69 kg vs 51.94±6.88 kg respectively) and this reduction in weight over time were also found to be statistically significant (p-value <0.005) (Table/Fig 7).
The present study has identified alarming prevalence of Insomnia as identified by insomnia severity index scoring system, those scored ≥8 were considered to have insomnia and it was 74.9 %. In another study conducted by Zhang C et al., it was found to be 36.1% and Dragioti E et al., in their study reported that prevalence of Insomnia having ISI score of ≥8 was 64.3% this difference could be due to different geographic setting and also the study participants (27),(28).
Tan E et al., developed a sleep hygiene Intervention program named F.E.R.R.E.T (an acronym for the categories of Food, Emotions, Routine, Restrict, Environment and Timing) which included three sleep hygiene specific rules to be followed for attaining proper sleep hygiene among children and adolescent in their study (25). In the present study we have adopted a ten simple steps to be followed which was provided to the participants in the form of behavior change communication.
The present study reported that there was a reduction in obesity among the intervention group compared to control group, having a mean weight change from 62.48±10.62 kg on day 1 to 51.48±6.88 kg at the end of 4 months. Similar to the present study findings, Tan E et al., also reported reduction in weight following Sleep hygiene intervention programmed compared from baseline to 20 weeks postintervention (25).
Christine S et al., conducted a text message intervention program to promote sleep hygiene which showed improvement in sleep quality however it was not statistically significant (26). The present study also have the component of intervening mobile phone and other electronic gadgets while going to bed, however was not individually assessed.
Based on the study findings of Brown FC et al., varying sleep schedule, environmental noise, worrying while falling asleep lead to poor sleep quality. In our present study, all these parameters were considered while developing the ten simple steps of sleep hygiene intervention program and the effectiveness was assessed by reduction in ISI score from base line to postintervention status, which was found statistically significant, thus indirectly incoherence with the Brown FC et al., study findings (27).
Zhou ES et al., in their study, reported that there was a significant reduction in mean ISI score from baseline to 12 weeks following interventional measure to promote sleep hygiene from 17.1 to 11.2 (p-value=0.0001) (28). This was similar to the present study findings which also reported the reduction of ISI score from 13.7 on Day 1 to 10.4 at the end of 4 months and this difference was found to be statistically significant (p-value=0.0001).
Limitation(s)
In the present study, there was only subjective measurement of insomnia level. Separate behavioral factor influence in level of insomnia was not assessed. Control group was not assessed with same frequency as intervention group.
Simple non pharmacological intervention seem to have greater benefits in improving sleep hygiene and reducing obesity, was evident by reduction in severity of Insomnia level and weight over a period of time. Hence, such behavior change communication based sleep hygiene intervention programmed should be provided on regular basis to achieve maximum benefit. This 10 step intervention can be tried among school children to know the benefits among them and to reduce the level of obesity in school children, which is almost a threat to their health in future.
DOI: 10.7860/JCDR/2022/55304.16727
Date of Submission: Jan 29, 2022
Date of Peer Review: Mar 01, 2022
Date of Acceptance: May 12, 2022
Date of Publishing: Aug 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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