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Abstract

Objectives:

We aimed to investigate the prevalence of snoring and associated factors among adolescents aged 10 to 19 years in Eastern Sudan.

Methods:

A community-based cross-sectional study was conducted at Gadarif, Eastern Sudan. A questionnaire was used to collect sociodemographic information.

Results:

Among the 384 participants, 32 (8.2%) were found to snore. These adolescents rated the frequency of their snoring as daily (34.4%), 4 times per week (21.9%), 1 to 3 times per week (25.0%), or 1 to 2 times per month (18.8%). A higher body mass index (unadjusted odds ratio = 1.12; 95% confidence interval = 1.05-1.19) was associated with snoring. In contrast, age, sex, and parental level of education were not found to be associated with snoring.

Conclusion:

One in 10 adolescents in Eastern Sudan snore. Launching programs that help individuals achieve a healthy BMI during adolescence is crucial for maintaining health.

Keywords

prevalence age snoring adolescent body mass index sudan

Introduction

Globally, snoring is a common sleep health problem among all age groups, including adolescents.^1
-4 It is considered a major public health problem in children and adolescents for several reasons.^2,5 For example, snoring during childhood and adolescence can negatively impact mental health and cognitive development in the long term,² and snoring during adolescence and young adulthood may have metabolic consequences (eg, development of dyslipidemia and metabolic syndrome).⁵ Given the potential negative effects of snoring during childhood and adolescence, early identification and management of snoring among children and adolescents are recommended to improve their quality of life and academic performance^2,4,6 and avoid any long-term negative consequences.

Globally, including in Sudan,^3,7 relatively more attention has been paid to snoring and its complications in adults than to snoring in adolescents. To address this gap, research should be conducted to assess the prevalence of snoring and associated factors among children and adolescents, especially at the community level. Applying a proactive and preventive approach could reduce the development of snoring and its complications, as well as improve the management of diseases associated with snoring, such as obesity,² metabolic syndrome,⁵ and hypertension.³ Utilizing a preventive approach may be particularly vital in African countries, such as Sudan, where resources are limited and poorly managed.

The prevalence of snoring among children and adolescents has been shown to vary in studies conducted in different countries, including African countries.^1,4,8,9 For example, in a study conducted in Nigeria with 909 children and adolescents (aged 3-16 years), it was revealed that one-third (34.2%) of the participants were snorers.⁴ Several risk factors are reportedly associated with snoring among children and adolescents, including male sex,¹ increasing age,⁹ low paternal educational level,¹⁰ adolescent smoking,¹¹ maternal smoking,¹² overweight, and obesity.^1,9,10

While few studies have addressed the epidemiology of snoring among adults in Sudan,^3,13 no such studies have been conducted on adolescents in Sudan. Moreover, most of the public health issues associated with snoring, such as metabolic syndrome,¹⁴ hypertension,¹⁵ poor mental health,¹⁶ and poor academic performance,¹⁷ have been reported to occur among Sudanese children and adolescents. Thus, this study aimed to investigate the prevalence of snoring and associated factors among adolescents aged 10 to 19 years in Eastern Sudan.

Materials and Methods

Study Setting and Design

This community-based cross-sectional study was conducted with 384 adolescents in the city of Gadarif. Gadarif State has a vast amount of land suitable for agriculture and is home to Sudan’s most significant projects for rain-fed agriculture. According to the 2008 census, the population of Gadarif State was 1,400,000.^18,19 There are 11 localities in Gadarif State, and the Gadarif locality, where the city of Gadarif is located, is the most populous. The population of Gadarif State comprises ethnic groups representing various tribes, making it a multiethnic society.²⁰ More details about the study area can be found in our previous publications.²¹ This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) system (Additional File 1).¹⁸

Sampling Technique

The Gadarif locality was selected from the 11 localities due to its multiethnic population, which represents the entire population of Gadarif State. Gadarif is divided into 4 zones (Mouraba), comprising 13 blocks (Hay). The population of each block was obtained from the local authorities. The desired sample size was calculated to be 384 adolescents, including both males and females. The number of adolescents included in a block depended on the total estimated number of adolescents in that specific block, that is, the probability was proportional to the size. Therefore, blocks with larger populations made greater contributions to the sample. A simple random technique, known as the lottery method, was used to select households for inclusion from a list of households within a block. If there were no adolescents in the selected household, if a household refused to participate in the study, or if a household met one of the exclusion criteria of this study, the next household was approached as a replacement.

Inclusion and Exclusion Criteria

To be included in this study, an individual must be a healthy adolescent aged 10 to 19 years and reside in the study area, specifically the city of Gadarif. Individuals aged less than 10 years or more than 19 years, those who did not consent to participate in the study, and those who were sick, pregnant, or lactating were excluded from participation in the present study.

Sample Size Calculation

OpenEpi Menu software was used to compute the desired sample size (n = 384).²¹ Based on the prevalence (34.2%) of snoring reported among adolescents in a similar African context (in Nigeria), we assumed that 50.0% of the participating adolescents would report that they snored. Then, based on a previous study,¹ we assumed that 30.0% of the adolescents who reported that they snored would be female and that 20.0% of those who reported that they did not snore would be female. The calculated sample size (n = 384) was chosen to detect a difference of 5% at α = 0.05, with a power of 80%.

Study Variables and Measures

The questionnaire was designed from previous similar studies.^1,4,12 The questionnaire was designed to collect data on sociodemographic characteristics, such as age (in years), sex (male or female), parental educational levels (<secondary or ≥secondary), mother’s occupational status (housewife or employed), father’s occupational status (skilled worker or laborer), cigarette smoking, and family member smoking. Anthropometric measurements, including weight and height, were also taken and later used to calculate the body mass index (BMI). The investigators trained 5 medical officers to collect the data.

The medical officers approached the selected adolescents after they and their guardians agreed to participate and signed an informed consent form. The selected adolescents were informed about the study’s aims and provided with all necessary information, including details on their voluntary participation in the study and their right to withdraw at any time without providing a reason. Preventive measures were taken to ensure the participants’ privacy, confidentiality, and safety; personal identifiers were excluded during data collection.

Weight and Height Measurements

Each participant’s weight was measured in kilograms (kg) to the nearest 100 g using well-calibrated scales that were adjusted to zero before each measurement. Participants were in a standing position, made minimal movement, and had their hands by their sides. Shoes and excess clothing were removed. Height was measured to the nearest 0.1 cm with the participant standing upright against a wall with their feet together. Height measurements were later converted into meters (m). Each participant’s BMI was computed by dividing their weight in kg by the square of their height in m².²² To have an accurate estimate of the influence of a 1-unit increase in BMI on snoring among adolescents, BMI was analyzed as a continuous variable rather than a categorical one, similar to the approach taken in a recent study.²³

Snoring Measurement

The severity and frequency of snoring were measured using a self-reporting methodology. Participants were asked to report on their snoring over the past 30 days. They were asked to specify (a) whether they snored or someone told them they snored (yes or no), (b) the inensity of the snoring sound, if any (quiet, normal, moderate, loud, or very loud); and (c) the frequency of snoring (every day, four times per week, 1-3 times per week, or 1-2 times per month). Self-reporting is commonly used in the diagnosis of snoring in adolescents in different countries.^1,6,24

Statistical Analysis

The data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) software for Windows (version 22.0; SPSS Inc., New York, NY). Continuous data, such as age and BMI, were evaluated for normality using the Shapiro–Wilk test and found to be non-normally distributed, expressed as median (interquartile range [IQR]) values. Initially, a univariate analysis was performed with snoring as the dependent variable and sociodemographic characteristics (eg, age, sex, BMI, parental education and occupation, and smoking habit) as independent variables. Initially, we planned to analyze variables with a P-value of less than .20 to build a multivariable logistic regression model that adjusted for covariates; however, the results showed that BMI was the only significant variable, and no other variables had a P-value of less than .20. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and a P-value of less than .05 was considered statistically significant.

Results

General Characteristics

Of the 384 enrolled adolescents, 177 (46.1%) were male and 207 (53.9%) were female. The median (IQR) age and BMI were 14.1 (12.1-16.2) years and 16.9 (15.3-20.0) kg/m², respectively. In terms of their parents’ educational level, more than half of the participants (n = 264, 68.8%) had mothers with an educational level of at least secondary level, and most of the participants (n = 287, 74.7%) had fathers with an educational level of at least secondary level. Only 69 (18.0%) of the participants had mothers who were employed. Less than one-third (n = 109, 28.4%) had family members who smoked.

Prevalence and Characteristics of Snoring

Among the 384 participants, 32 (8.2%) reported that they snored. The median (IQR) BMI of the snorers was 18.9 (16.8-24.5) kg/m², and that of the non-snorers was 16.8 (15.2-19.7) kg/m² (Table 1). Five participants (1.3%) were smokers. The participants who reported that they snored (n = 32) rated their intensity of snoring as follows: very quiet (n = 6, 18.8%), normal (n = 12, 37.5%), moderate (n = 5, 15.6%), loud (n = 5, 15.6%), or very loud (n = 4, 12.5%). They rated the frequency of their snoring as follows: daily (n = 11, 34.4%), 4 times per week (n = 7, 21.9%), 1 to 3 times per week (n = 8, 25.0%), or 1 to 2 times per month (n = 6, 18.8%; Table 2).

Table 1.

The Characteristics of the Studied Adolescents and Univariate Analysis of Snoring in Eastern Sudan (n = 384), 2023.

Variable		Total (n = 384)	Adolescents with snoring (32/384 = 8.3%)	Adolescents without snoring (352/384 = 91.7%)	Unadjusted odds ratio (95% confidence interval)	P-value
	Median (interquartile range)
Age, years		14.1 (12.1-16.2)	15.4 (13.6-16.5)	14.1 (12.2-16.3)	0.96 (0.84-1.11)	.598
Body mass index, kg/m²		16.9 (15.3-20.0)	18.9 (16.8-24.5)	16.8 (15.2-19.7)	1.12 (1.05-1.19)	.001
	Frequency (percentage)
Gender	Female	207 (53.9)	16 (50.0)	191 (54.5)	Reference
Gender	Male	177 (46.1)	16 (50.0)	161 (45.7)	1.19 (0.58-2.45)	.644
Mother’s education level	≥Secondary	264 (68.8)	8 (25.0)	240 (68.2)	Reference
Mother’s education level	<Secondary	120 (31.2)	24 (75.0)	112 (31.8)	0.71 (0.31-1.64)	.427
Father’s education level	≥Secondary	287 (74.7)	25 (78.1)	262 (74.4)	Reference
Father’s education level	<Secondary	97 (25.3)	7 (21.9)	90 (25.6)	0.82 (0.34-1.95)	.646
Mother’s occupation	Employed	69 (18.0)	8 (25.0)	61 (17.3)	Reference
Mother’s occupation	Housewife	315 (82.0)	24 (75.0)	291 (82.7)	0.63 (0.27-1.47)	.283
Father’s occupation	Skilled	152 (39.6)	13 (40.6)	139 (39.5)	Reference
Father’s occupation	Laborer	232 (60.4)	19 (59.4)	213 (60.5)	0.95 (0.46-1.99)	.900
Family member smoker	No	275 (71.6)	23 (71.9)	252 (71.6)	Reference
Family member smoker	Yes	109 (28.4)	9 (28.1)	100 (28.4)	0.99 (0.44-2.21)	.973

Table 2.

Pattern of Snoring Among the Snoring Adolescents in Eastern Sudan (n = 32), 2023.

Variable		Frequency	Percentage
Prevalence of snoring among the total studied adolescents (n = 384)		32	8.2
Intensity of snoring	Very quiet	6	18.8
	Normal	12	37.5
	Moderate	5	15.6
	Loud	5	15.6
	Very loud	4	12.5
Frequency of snoring	Daily	11	34.4
	4 times per week	7	21.9
	1 to 3 times per week	8	25.0
	1 to 2 times per month	6	18.8

Factors Associated with Snoring

The logistic regression results showed that a higher BMI (unadjusted OR = 1.12, 95% CI = 1.05-1.19) was associated with snoring; age, sex, parental level of education, parental occupation, and family member smoking were not associated with snoring (Table 1).

Discussion

The main findings of this study were that 8.3% of the participating adolescents reported snoring, and a high BMI was the primary factor associated with snoring. The prevalence (8.3%) of snoring among the participants in this study is comparable to that found in other study; a study conducted in China with 3047 children and adolescents aged 6 to 12 years showed a prevalence of 10.9% of habitual snorers (defined as at least 6 nights a week).⁸

The prevalence (8.3%) of snoring found in this study is higher than that reported in studies conducted in Turkey (4.0%) with 1030 adolescents aged 12 to 17 years¹² and in Italy (5.6%) with 2209 adolescents aged 10 to 15 years.⁹ In contrast, the prevalence (8.3%) of snoring found in this study is lower than that previously reported in studies conducted in Nigeria (34.2%),⁴ Korea (22.8%),¹ and Chile (43.5%).

In this study, approximately half of the snoring adolescents described the intensity of their snoring as moderate to very loud, and one-third reported experiencing daily snoring. These findings are comparable to those of previous studies.^8,24,25 For example, in Singh et al’s study conducted in India with participants aged 17 to 25 years, among the 97 participants who snored, 16 (16.49%) described the intensity as loud (more than talking). The remaining 81 (83.50%) were non-loud (not more than talking), and 19 (19.58%) stated that the frequency was ≥3 to 4 times per week, while 78 (80.41%) stated that the frequency was ≤1 to 2 times per week.²⁶ The high-intensity and high-frequency snoring reported in this study could be associated with adverse health problems, including depression and poor academic performance.⁶

The results of this study showed that a 1-unit increase in BMI was associated with a 1.12-fold increase in the risk of developing snoring in adolescents; in other words, each unit increase in BMI increased the odds of being at high risk for snoring by 12% among adolescents. Similarly, other studies have shown a positive association between adolescent snoring and high BMI/obesity.^1,8
-10 Yang et al¹ included 12 672 students (10th-12th grades) in a study conducted in Korea and found a 2.2-fold higher association between obesity and self-reported snoring (OR = 2.18, 95% CI = 1.94-2.46). In China, a study that included 3047 children and adolescents aged 6 to 12 years who were followed up for 4 to 6 years showed that a high BMI was a significant risk factor for both persistent and incident habitual snoring during follow-up.⁸ Another study conducted in China, which included 20 152 children aged 5 to 12 years, revealed that obese and overweight children had a 1.50-times and 1.35-times greater risk of developing habitual snoring, respectively.¹⁰ In Italy, a cross-sectional study of 2209 adolescents aged 10 to 15 years reported that adolescents with a BMI greater than the 90th percentile were significantly more likely to be snorers.⁹ It is worth mentioning that a cross-sectional study that included 921 adolescents aged 10 to 15 years was recently conducted in Khartoum, Central Sudan, and a higher prevalence of short sleep duration was found among overweight and obese adolescents.²⁶

This study found no association between the participants’ snoring and the studied sociodemographic characteristics (eg, age, sex, parental educational level and occupation, and smoking). In contrast, other studies have reported associations between adolescent snoring and male sex,^1,8 increasing age,⁹ low paternal education level,¹⁰ adolescent smoking,¹¹ and maternal smoking.¹² The lack of association between snoring and parental educational level and occupation could be attributed to the low quality of education provided to parents, especially girls, and its limited impact on improving socioeconomic status. In this study, only 18.0% of the adolescents’ mothers were employed, and we have previously reported on the low maternal employment rate in Eastern Sudan.²⁷ It is worth noting that Li et al¹⁰ reported that children and adolescents from families with a low socioeconomic status and low paternal educational levels were 1.5 times and 1.4 times more likely to develop habitual snoring, respectively.

The variation in the intensity and frequency of snoring observed in different studies, as well as cultural differences (eg, in smoking behavior), could explain the contradiction between snoring and the studied health problems. For instance, in this study, only 5 adolescents (1.3%) reported that they smoked, whereas in another study, about one-quarter of Chinese adolescents reported smoking, which was associated with snoring.¹¹

Our results should be cautiously compared with those of other studies. First, while we used the WHO age range (10-19 years), others used different age groups (ie, early adolescent, late adolescent, both adolescent and children, or adolescent and younger adults).^1,5,8,10 Second, different methods have been used to diagnose snoring and identify its features (eg, the intensity and frequency) among adolescents, such as self-reporting and/or witness reporting. Therefore, there is a need to create a standardized questionnaire for assessing snoring among adolescents. Given the inter- and intra-country variation in the prevalence of snoring and its associated factors, there is also a need to explore the local epidemiology of snoring among children and adolescents and devise tailored solutions based on the local context.

The results of this study have implications for improving adolescent health, as the identified factor (BMI) is a modifiable one. The adolescents who were found to snore were advised to undergo further evaluation at the nearest healthcare facility, as it has been shown that persistent snoring later in life is particularly common among obese children and adolescents.⁸ It has also been shown that treatable causes of snoring in adolescents can be identified during further evaluation, including respiratory problems (eg, chronic/allergic rhinitis and asthma), adenotonsillar hypertrophy, and chronic otitis media.^9,10,12

The present results provide further support for implementing routine health screening, including screening for snoring and sleep-disordered breathing in overweight and obese children and adolescents. Furthermore, the results of this study will be communicated to policymakers, enabling them to create or update policies related to adolescent health; thus, the findings of this study will have implications at the policy level.

Strengths and Limitations of the Study

This study has several strengths. First, to the best of our knowledge, this study is the first to address the prevalence of snoring and its associated factors among adolescents in Eastern Sudan. Second, the present results add to the limited existing data on snoring in Sudan.^3,13 Third, the practical recommendations proposed above can be implemented to improve adolescent health.

This study also has some limitations that must be acknowledged and overcome in future studies. While this cross-sectional study provided valuable information, conducting longitudinal studies will provide greater clarity on the associations between snoring and various variables in adolescents, as well as their patterns. This study was conducted in Eastern Sudan; thus, the results cannot be generalized and applied to all adolescents across Sudan. Moreover, unlike in other studies.^9,12 Importantly, the quality of sleep was not assessed, and the definition of snoring sound intensity was subjectively and self-reported, without a clear definition or objective assessment. The participants did not undergo a clinical examination; however, some causes of snoring, such as tonsil enlargement and issues with nasal and pharyngeal patency, can be identified during a clinical examination. However, the adolescents found to snore were advised to undergo further evaluation at the nearest healthcare facility. No data on dietary patterns and lifestyle practices were collected in the current study, which may influence snoring and BMI.

Conclusion

In this study conducted in Eastern Sudan, approximately 1 in 10 adolescents were found to snore. Launching programs that help individuals achieve a healthy BMI during adolescence is crucial in maintaining health during adolescence and adulthood. Involving all potential stakeholders at an early stage is essential for the sustainability of such programs.

Supplemental Material

sj-docx-1-gph-10.1177_30502225251364962 – Supplemental material for Prevalence of Snoring and Associated Factors Among Adolescents in Eastern Sudan: A Community-Based Cross-Sectional Study

Supplemental material, sj-docx-1-gph-10.1177_30502225251364962 for Prevalence of Snoring and Associated Factors Among Adolescents in Eastern Sudan: A Community-Based Cross-Sectional Study by Hiba Elhag, Saeed M. Omar, Hatim Y. Alharbi, Ahmed A. Hassan and Ishag Adam in Sage Open Pediatrics

Footnotes

Acknowledgements

We thank the adolescents who participated in this study, their guardians, and the local community for their cooperation.

ORCID iD

Hiba Elhag

Ethical Considerations and Consent to Participants

This study was conducted according to the Declaration of Helsinki and using good clinical research practices. This study was approved by the research ethical committee of the Faculty of Medicine, University of Gadarif, Gadarif, Sudan (Ref. #2023, 14). All the adolescents and their guardians signed a written informed consent form. The authors took measures to ensure the privacy, confidentiality, and safety of the participants; for example, personal identifiers were excluded during data collection. All methods and procedures used in this study were performed in accordance with appropriate guidelines and regulations.

Author Contributions

HE and IA conceptualized the study, supervised the work, guided the analysis, and critically reviewed the manuscript; SMO, HYA, AAH, and IA prepared the analysis plan, performed the data analysis, and wrote the first draft of the paper; and supervised the data collection. All authors reviewed and approved the final manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data are available from the corresponding author upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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