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\begin{document}

\title{Sleep disorders in primary care: A Descriptive Study}



\author[1]{RAZİYE GÜMÜŞTAKIM}%
\author[2]{Duygu AYHAN BASER}%
\author[3]{MURAT CEVİK}%
\author[4]{PINAR BİLGİLİ}%
\author[5]{MEHMET ALİ ÇELİK}%
\author[6]{TAYYAR GÜNGÖR}%
\author[7]{HANDAN KARAHAN SARPER}%
\affil[1]{Kahramanmaras Sutcu Imam University - Avsar Campus}%
\affil[2]{Hacettepe University Faculty of Medicine}%
\affil[3]{Güdül Family Health Center, Güdül ANKARA}%
\affil[4]{Antalya 19 Güzeloba Family Health Center}%
\affil[5]{Gaziantep Sahinbey Family Health Center}%
\affil[6]{Bursa Sırameşeler Family Health Center}%
\affil[7]{İstanbul Ümraniye Family Health Center}%


\vspace{-1em}



  
  \date{May 20, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
ABSTRACT Purpose In our study, we aimed to evaluate the sleep disorders,
sleep quality of the patients who applied to family health centers, to
determine the situations that might be related with insomnia and to
determine the insomnia rates of the general population in primary care.
Methods This study is a descriptive research and conducted in Ankara
G\selectlanguage{ngerman}üdül, Antalya De\selectlanguage{polish}ğ\selectlanguage{english}irmen\selectlanguage{ngerman}özü, Bursa S\selectlanguage{polish}ı\selectlanguage{english}rame\selectlanguage{polish}ş\selectlanguage{english}eler, Gaziantep Family Health
Center policlinics. The study population consisted of all patients over
18 years of age who were admitted to the family health centers for any
reason. A 10-question questionnaire, Berlin questionnaire, Pittsburgh
sleep quality index and insomnia severity scales were collected by the
researchers from October to December 2017 using face-to-face interview
method. Results 299 people participated in study and 54.5\% of them were
women. According to the results of Pittsburgh Sleep Quality Scale, it
was found that 27.1\% of the participants' sleep quality was good and
72.9\% of them were poor; according to the Berlin sleep questionnaire,
27.4\% had high OSAS risk and 72.2\% had a low OSAS risk. According to
total Insomnia Severity Index, 27.1\% had insomnia lower threshold,
15.4\% had moderate insomnia, 3.7\% severe insomnia was detected.
Conclusions In this context, it will be very effective in terms of the
quality of life of patients in order to determine the conditions that
disrupt sleep hygiene and to perform the necessary interventions which
can be intervened in the primary health care institutions and the other
patients to be delivered to the related upper levels.%
\end{abstract}%



\sloppy


\textbf{}

WHAT'S KNOWN?

Sleep disorders are common disorders in the community, which effect both
physical and mental health, closely related to work and social life,
which can cause loss of work and work force, can lead to
life-threatening serious complications and work accidents.

WHAT'S NEW?

Despite the high prevalence of sleep disorders and their significant
consequences, sleep complaints are generally not addressed by primary
care physicians. According to the results of the study we conducted to
determine the sleep quality, insomnia, OSAS risks and related factors of
the patients who applied to family physicians, 72.9\% of the patients
who applied to family medicine had poor sleep quality, 27.4\% had high
OSAS risk and 46\% had 2 were found to have insomnia.

\par\null

\textbf{INTRODUCTION}

Sleep disorders are common disorders in the community, which effect both
physical and mental health, closely related to work and social life,
which can cause loss of work and work force, can lead to
life-threatening serious complications and work accidents. Sleep
disorders are important because of effects on the lives of people as
well as the impact of health spending. In a study to evaluate sleep
disorders in primary care; a questionnaire was applied to 35327 adults
in ten countries from four continents and it was determined that one out
of four people in the world had sleep disturbances and 95\% of the
population had insomnia in some part of their lives and less than one
third of these people applied for help to the health institution
{[}1{]}. Although it is very common in the community, as stated in the
study, most of the patients with sleep disorders do not apply to health
institutions or physicians. This situation delay the diagnosis of these
diseases. The diagnosis, treatment and follow-up of the common diseases
in the community is made by family physicians who evaluate the patients
on the basis of biopsychosocial approach, thus increasing the rate of
diagnosis and treatment of these patients and decreasing the problems
caused by sleep disorders throughout the society. In a study conducted
on patients who applied to primary health care facilities due to sleep
problems, it was stated that physicians and patients also wanted sleep
disorders to be addressed in primary health care {[}2{]}. In our study,
we aimed to evaluate the sleep disorders, sleep quality of the patients
who applied to family health centers, to determine the situations that
might be related with insomnia and to determine the insomnia rates of
the general population in primary care.

\textbf{MATERIAL METHOD}

\textbf{Type of Research}

This research is a descriptive epidemiologic research.

\textbf{Place of Research}

The research was conducted in Ankara G\selectlanguage{ngerman}üdül, Antalya De\selectlanguage{polish}ğ\selectlanguage{english}irmen\selectlanguage{ngerman}özü, Bursa
S\selectlanguage{polish}ı\selectlanguage{english}rame\selectlanguage{polish}ş\selectlanguage{english}eler, Gaziantep Family Health Center policlinics.

\textbf{Universe of Research}

The study population consisted of all patients over 18 years of age who
were admitted to the family health centers for any reason and agreed to
participate in the study.

\textbf{Sample Selection}

With the method of sample calculation, considering the family physicians
applied to 10 patients per day by taking the questionnaires and scales
into consideration, the universe size was calculated as 2400 with a 5\%
margin of error and 95\% confidence interval and the sample size was 332
persons; 315 volunteers were included in the study. However, 16 patients
with incomplete forms were excluded from the study and the study was
completed with 299 patients. In case of voluntary participation of the
patients in the study, an informed consent was signed for their consent.

\textbf{Permissions}

Ethical approval was obtained from Kahramanmara\selectlanguage{polish}ş \selectlanguage{english}S\selectlanguage{ngerman}ütçü \selectlanguage{polish}İ\selectlanguage{english}mam University
Medical Faculty Clinical Research Ethics Committee with the decision
number 2017 / 14-09 and the study was conducted in accordance with the
Declaration of Helsinki Declaration.

\textbf{Data Collection Tools}

A 10-question questionnaire including sociodemographic characteristics
and Pitsburgh sleep quality scale, Berlin questionnaire and insomnia
severity scale were used to collect data.

Pitsburgh sleep quality scale: Scale was developed from Buysse et al.
{[}3{]} and adapted to Turkish by A\selectlanguage{polish}ğ\selectlanguage{english}arg\selectlanguage{ngerman}ün et al. {[}4{]}. The scale is a
self-report scale of 19 items that evaluates sleep quality and
impairment in the past month. It consists of 24 questions, 19 questions
self-report, 5 questions are questions to be answered by spouse or
roommate. The 18 questions of the scale consist of 7 components. Each
component is rated at 0-3 points. The total score of the 7 components
gives the total score of the scale. The total score ranges from 0 to 21.
If the total score is greater than 5, it indicates ``poor sleep quality.

\textbf{The Berlin Questionnaire:} The Berlin Questionnaire is a scale
consisting of three categories that measure the risk of sleep apnea. It
consists of a 10-question questionnaire including information on the
patient's body mass, snoring characteristics, sleep status and blood
pressure. Each category is evaluated in its own way, and if 2 or more
categories are positive, the risk of obstructive sleep apnea syndrome
(OSAS) is considered high according to the Berlin Questionnaire
{[}5,6{]}.

\textbf{Insomnia Severity Scale:} It has been developed to evaluate the
severity of insomnia and has a high reliability and reliability. Scale
items consisting of seven questions are scored between 0-4. The scores
that can be taken from the scale vary between 0-28 {[}7{]}.

\textbf{Data Collection}

A 10-question questionnaire, Berlin questionnaire, Pittsburgh sleep
quality index and insomnia severity scales were collected by the
researchers from October to December 2017 using face-to-face interview
method.

\textbf{Analysis of Data}

For the analysis of sociodemographic data, whether the data is normal or
not is determined by Shapiro Wilk test, if the data provides parametric
conditions (data obtained by invertal, ratio scale, normal distribution,
W) for two groups (independent, conjugate) t test, F test (ANOVA) for
more than two groups. While ANOVA was used for comparisons with more
than two groups, Tekey, Scheffe, Tamhane OVs T2 tests were used to
determine which group was different from others. If no or all of the
assumptions were provided, Mann Whitney for two independent groups,
Wilcoxon test for two dependent groups, Kruskal Wallis for more than two
independent groups, Friedman test for more than two dependent groups.
Chi square test was used to evaluate the qualitative data. The error
level was 0.05.

\textbf{RESULTS}

A total of 299 people participated in our study and 54.5\% (163) of them
were women. The mean age of the participants was 42,70 ± 16,53 (min: 17;
max: 91). The majority of the respondents (66.9\%) were married, 38.1\%
(114) were university graduates, 30.1\% (80) were civil servants, and
66.6\% (199) were more than military wages. 66.2\% (198) have no chronic
disease. The sociodemographic characteristics of the participants are
given in Table 1.

\textbf{Table I. Sociodemographic characteristics of participants}

The average Pittsburgh Sleep Quality Scale of the participants was 7.55
± 4.41 (min: 0; max: 20). According to the results of Pittsburgh Sleep
Quality Scale, it was found that 27.1\% (81) of the participants' sleep
quality was good and 72.9\% (218) of them were poor.

The average Berlin sleep questionnaire was 2.62 ± 1.92 (min: 0; max: 7).
According to the Berlin sleep questionnaire, 27.4\% (82) had high OSAS
risk and 72.2\% (216) had a low OSAS risk.

Total Insomnia Severity Index of participants was 8.29 ± 6.44 (min: 0;
max: 27). 46.2\% of the participants (138) had insomnia. Of these,
27.1\% (n = 81) had insomnia lower threshold, 15.4\% (n = 46) had
moderate clinical insomnia (insomnia), 3.7\% (n = 11) severe clinical
insomnia (insomnia) was detected.

When the demographic characteristics were compared according to the
results of Pittsburgh Sleep Quality Scale, it was determined that the
quality of sleep was significantly better in males (p: 0.001), in
non-chronic patients (p: 0.043) and in smokers (p: 0.002). Table 2 shows
the comparison of demographic characteristics according to the results
of Pittsburgh Sleep Quality Scale.

\textbf{Table II. Comparison of demographic characteristics according to
Pittsburgh Sleep Quality Scale results}

According to the results of the Berlin sleep questionnaire, the
demographic characteristics were compared with age (p: 0,000), in
singles (p: 0,013), in primary school graduates (p: 0,000), in the
winners above the minimum wage (p: 0,003), in those with chronic disease
(p: 0,000) and high OSAS risk was detected in alcohol users (p: 0.020).
Table 3 shows the comparison of demographic characteristics according to
the results of the Berlin sleep questionnaire.

\textbf{Table III. Comparison of demographic characteristics according
to the Berlin sleep questionnaire}

When the demographic characteristics were compared according to the
Insomnia Severity Index (p: 0.002), in males (p: 0.0000), in those with
higher education (p: 0.038), in patients with chronic disease (p: 0.000)
and in alcohol users (p: 0.005) increased frequency of life. A
comparison of the demographic characteristics according to the Insomnia
Severity Index is given in Table 4.

\textbf{Table IV. Comparison of demographic characteristics according to
Insomnia Severity Index}

According to the Pittsburgh Sleep Quality Scale, those with good sleep
quality experienced less insomnia compared to the Insomnia Severity
Index (p: 0,000), while they had a lower OSAS risk compared to the
Berlin sleep questionnaire (p: 0,001). A comparison of the Pittsburgh
Sleep Quality Scale and the Insomnia Severity Index and the Berlin sleep
questionnaire is given in Table 5.

\textbf{Table V. Comparison of Pittsburgh Sleep Quality Scale with
Insomnia Severity Index and Berlin sleep questionnaire}

In our study, the correlation between the Pittsburgh Sleep Quality
Scale, Insomnia Severity Index and the scores of the Berlin sleep
questionnaire were also examined. According to this, the scores of the
Sleep-Sleep Index scores of those with high scores and the scores of the
Berlin Sleep Questionnaire were found to be low.

\textbf{DISCUSSION}

Despite the high prevalence of sleep disorders and their significant
consequences, sleep complaints are generally not addressed by primary
care physicians. According to the results of the study we conducted to
determine the sleep quality, insomnia, OSAS risks and related factors of
the patients who applied to family physicians, 72.9\% of the patients
who applied to family medicine had poor sleep quality, 27.4\% had high
OSAS risk and 46\% had 2 were found to have insomnia. In a large-scale
study of 9284 people in Germany, the rate of patients with poor sleep
quality was found to be 36\%, which is very low compared to our study
{[}7{]}. In the general population, symptoms of insomnia are present in
up to 33\% of individuals, OSA has a prevalence of about 5\% (though
26\% to 32\% have symptoms suggesting they are at risk for OSA). In the
study conducted in 2011, high OSAS risk was found in 33\% of the
participants and our study was higher than the results {[}8{]}. Again
according to this study, insomnia was assessed with the Sleeping
Questionnaire (CSHQ) questionnaire and found to be 30\%. In terms of
insomnia, our results are higher than the results of this study. In
another study conducted by Logue et al. in 2014 by primary care
patients, 78\% poor sleep quality and 59\% higher OSAS risk were found,
especially when OSAS risk was very high compared to our values, sleep
quality was higher than our study, but it was observed to be similar
{[}9{]}.~ In another study conducted in primary care, similar rates were
achieved in our study (71\%) {[}10{]}.

In another study conducted in Ankara, insomnia assessment was evaluated
in 79 (32.2\%) of the participants under-threshold insomnia, 43 (17.6\%)
of the patients with clinical insomnia, 12 (4.9\%) with severe clinical
insomnia, 88 (35.9\%) and insomnia was insignificant {[}11{]}.

In our study, according to the results of the Pittsburgh Sleep Quality
Scale, sleep quality was significantly better in men compared to the
demographic characteristics of sleep quality, non-chronically ill and
those who smoked. According to the Insomnia Violence Index, it was
determined that the frequency of insomnia was higher among the elderly,
the males, the students with the higher education level and those with
chronic diseases and those using alcohol.

In the literature search, it has been observed that studies related to
sleep quality and sleeplessness in our country are generally performed
in individuals with chronic diseases, occupation in occupation and
students. In most of these studies, sleep quality decreases with age
increase; it was stated that this situation is due to reasons such as
difficulty in falling asleep and sustaining with age. In our study, it
was found that sleep quality did not change with age but insomnia status
increased with age. A study in Spain found that sleep quality worsened
with age {[}11{]}, in accordance with our study no correlation was found
between age and sleep quality in two studies {[}7,13{]}. Ohayon et al.
,Aslan et al and Farazdaq et al was concluded that insomnia increases
with age and that was support our study {[}14-16{]}. In studies
conducted on healthy adults, sleep quality is generally not changed
according to gender, but in some studies it is stated that women sleep
quality is worse. In our study, we found that men 's sleep quality was
better, but they were more likely to have insomnia. In the study of Hinz
et al. and Madrid-Valero, it was concluded that the sleep quality of
women was worse in parallel with our study {[}7,12{]}. In a study
conducted in primary care and insomnia severity index, no difference was
found between sexes in terms of insomnia {[}17{]}. In international
studies, it was concluded that insomnia affects female gender more
{[}14,15{]}. In the study made by Aslan et al., it was concluded that
insomnia is seen more in female gender {[}16{]}. In a prospective cohort
study no difference was found between the genders {[}13{]}. It is known
that sleepers suffer from sleep problems and sleep quality is worse. In
our study, it was found that sleep quality of the patients who had
smoked but who had previously smoked before, had better sleep quality
and generally had less insomnia compared to those who did not use
non-smokers. Aslan et al. also found smoking as a risk factor for
insomnia {[}16{]}. In a study conducted in the family medicine clinic of
a university in Malaysia, it was found that insomnia was associated with
smoking {[}14{]}.

The effect of alcohol on sleep quality is the suppression of the central
nervous system and easing the transition to sleep, but it is known that
sleep quality disrupts the activity of REM sleep. In our study, the
effect of alcohol use on sleep quality was not found to be statistically
significant. The relationship between sleep and chronic disease is
mutual; impaired sleep quality increases the risk of cardiovascular,
metabolic (diabetes, obesity, thyroid diseases), rheumatic diseases, or
the frequency of current symptoms. Similarly, having chronic illness
affects both the quality of the sleep and the duration of sleep due to
both the disease and the drugs used. In our study, it was determined
that people with chronic diseases had higher incidence of insomnia in
accordance in a study Aslan et al {[}16{]}. In addition, according to
the Pittsburgh Sleep Quality Scale, we found that people with good sleep
quality had less insomnia than the Insomnia Severity Index.

When the demographic characteristics were compared according to the
results of the Berlin sleep questionnaire, the risk of OSAS was found to
be high in the elderly, in singles, in primary school graduates, in
winners above the minimum wage, in those with chronic diseases and in
alcohol users.

In addition, according to the Pittsburgh Sleep Quality Scale, it was
determined that those with good sleep quality and those with less
insomnia to the Insomnia Severity Index had a lower OSAS risk than the
Berlin sleep questionnaire. In studies, age, gender, obesity, neck
circumference, upper airway resistance, smoking and alcohol are the main
factors affecting obstructive sleep symptoms. In our study, findings
consistent with literature data were found.

When the contribution of our study to the literature was evaluated as
patient profile, the study of the patients of the family physicians who
have the richest patient group and the fact that the patients coming to
the family health center constitute the most appropriate group in terms
of generalizability, increase the interpretability of the results over
the general population when evaluating the results of the study. In our
study, it was thought that 2/3 of the patients had poor sleep quality
and that half of them had insomnia.

In this context, it will be very effective in terms of the quality of
life of patients in order to determine the conditions that disrupt sleep
hygiene and to perform the necessary interventions in the interventions
which can be intervened in the primary health care institutions and the
other patients to be delivered to the related upper levels. The fact
that sleep disorders are not taken seriously and the hospital is not
applied to this reason causes the frequency of these diseases to
continue to increase. In this context, family physicians play a vital
role in recognizing OSAS and sleep disorders and increasing the
awareness of patients on this issue.

\textbf{Compliance with Ethical Standard}

\textbf{Disclosure of potential conflicts of interest}

Raziye \selectlanguage{polish}Ş\selectlanguage{english}ule G\selectlanguage{ngerman}ÜMÜ\selectlanguage{polish}Ş\selectlanguage{english}TAKIM declares that she has no conflict of interest
concerning the research, authorship, or publication of this article.
Duygu AYHAN BASER declares that she has no conflict of interest
concerning the research, authorship, or publication of this article.
Murat CEVIK declares that she has no conflict of interest concerning the
research, authorship, or publication of this article. P\selectlanguage{polish}ı\selectlanguage{english}nar Bilgili
declares that she has no conflict of interest concerning the research,
authorship, or publication of this article. Mehmet Ali \selectlanguage{ngerman}Çelik declares
that she has no conflict of interest concerning the research,
authorship, or publication of this article. Tayyar Güngör declares that
she has no conflict of interest concerning the research, authorship, or
publication of this article. Selda Handan Karahan Saper declares that
she has no conflict of interest concerning the research, authorship, or
publication of this article.

\textbf{Research involving Human Participants and/or Animals}

Research involve only human participants.

\textbf{Ethical approval:} All procedures performed in studies involving
human participants were in accordance with

the ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki

declaration and its later amendments or comparable ethical standards.

\textbf{Informed consent}

Informed consent was obtained from all individual participants included
in the study

\textbf{Funding}

This study received no funding

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\textbf{Hosted file}

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