Social Media Use and Sleep Quality Among Secondary School Students in Aseer Region: A Cross-Sectional Study

Introduction

Sleep is recognized as a key component and determinant of physical and mental well-being. It plays an important role in metabolic regulation, emotional regulation, immune system function, brain recovery processes, learning and performance.^1,2 Inadequate sleep duration or quality is associated with increased risk of detrimental physical and mental health effects such as diabetes, hypertension, coronary heart diseases, cancer, neuropsychiatric problems, and strokes.^3,4 Despite this, it is generally overlooked in public health education and health awareness messages.²

While the sleep process starts maturing during the adolescence period, recently, sleep researchers and clinical professionals have expressed a growing concern that problematic sleep among young people is reaching epidemic levels. They further labelled this phenomenon as insufficient sleep syndrome considering it as a hidden health crisis. Accordingly, insufficient sleep among adolescents is currently recognized as a serious public health concern.^5,6 Sleep problems among young people have serious implications on adolescents’ physical and mental health, it can lead to obesity, impair concentration, cognition and academic performance. Sleep deprivation can interfere with adolescent safety increasing the risk of accidents and injuries safety.^7–9

Over the past few decades, a major change in lifestyle has taken place due to the incorporation of electronic media device use into people’s daily life. Adolescents and children nowadays are faced with major technological challenges where electronic media have become a core part of their lives. They use their smartphones and electronic devices, with their countless applications, for multiples purposes, including communication, including via social media, information retrieval, education, and entertainment.^10,11 In Saudi Arabia, almost 99% of adults own smartphones. Even children are growing up in environments surrounded by electronic media devices.¹²

The impact of screen time on adolescents’ health and well-being is receiving significant attention where child and adolescent health academies and researchers are calling for research evidence to support practices and policies. Nevertheless, they debate about the need to avoid studying associations between generic terms such as “screen time” as a generic exposure and poor well-being. They recommend to better investigate the impact of different types of technology on different areas of child and adolescent’s well-being.¹³

Communication through social media could be regarded as a double blade weapon where it enforces social connections, builds and maintains relationships with no location barrier. It can be used for work, educational and health purposes.^14,15 Moreover, social media platforms are people resort for self-expression.^16,17 Yet, several potential negative physical and mental health consequences had been found to be associated with social media use, implicating a rising public health concern.¹⁸ Improper use of electronic devices could lead to higher body mass index, neck or shoulder pain, symptoms of unclear vision and eye strain.^19,20 Also, mis and overuse of smartphones and social media can result social media addiction and fatigue, loneliness, poor work performance, psychological distress, depression, anxiety, stress, disruption of interpersonal relationships, poor work efficiency and causes sleep disturbance.^21–27

Recent studies revealed association between excessive use of social media and problematic sleep.^13,22 Limitless use of social media may also affect users’ sleep quality and quantity either through prolonging time to sleep or decreasing sleep duration with the adverse consequences of poor sleep.²⁸ Smartphone use was considered as an important factor disturbing sleep quality of young people.²⁹ The blue light emitted from the smartphone screens interferes with melatonin release and regulation of the circadian rhythm affecting sleep quality.³⁰ Also, the electromagnetic field associated with smart phones affect brain activity disturbing sleep pattern.^31,32. Yang et al³² in their systematic review and meta-analysis reported an increased risk of poor sleep quality among smartphone addicts.

Moreover, previous research revealed the association between poor sleep quality and adverse mental health consequences with each having substantive impacts on both individuals and community health.^33–35 A systematic review reported association between poor sleep quality and poor mental health outcomes among young people who excessively use social media.³⁶ Nevertheless, sleep problems and mental health difficulties are also interlinked where mental health problems are assumed to lead to sleep problems also the reverse could also be true.^37,38 Poor sleep quality and insomnia were found to be associated with depression, anxiety,³⁹ post-traumatic stress,⁴⁰ eating disorders⁴¹ and suicidal ideation especially among youth.⁴²

As in the different regions of the World, use of social media has become an essential part for everyone daily life even in Saudi Arabia (SA hereafter). It is now widely used for different purposes such as communication, education, and daily work.⁴³ Supportive research evidence is continuously needed to understand the pattern of use and the effect of excessive use of electronic devices and social media, on health and well-being of young adults who represent Saudi future adults. Hypothesizing that excessive use of social media among Saudi young people could be associated with disturbance in their sleep quality. The present study aims to investigate the pattern of social media use and the association between the use of different social media platforms and sleep quality among secondary school students in Aseer region in SA.

Subjects and Methods

Study Design, Setting and Population

From March 12 to March 17, 2023, a cross-sectional survey was carried out in public high schools in Aseer region of SA. The study included male and female public secondary school students.

Tools for Data Collection

Students who and their parents agreed to join the study were asked to fill a structured self-administered interview questionnaire. The questionnaire consisted of three sections. The first section included personal and demographic data such as age, gender, nationality, academic year, academic performance, physical exercise frequency, social media platforms used and duration of use. The second section included The Pittsburgh Sleep Quality Index (PSQI) which is a self-report questionnaire that evaluates the quality of sleep over the last of a month.⁴⁴ The questionnaire consists of 19 self-reported items belongs to one of seven subcategories: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. The seven components are further combined to give an overall single global PSQI score. The global PSQI score ranges from 0 to 21 with lower scores denoting better sleep quality. The reliability of the scale was evaluated by Cronbach’s alpha test yielding a value of (0.7). The total global PSQI score was further categorized at cut off point of 7 where those who had global score of 7 points or less were considered to have good sleep quality (good sleepers) while others with global score of more than 7 points were considered to have moderate to poor sleep quality (poor sleepers). The third section included the validated Arabic version of the Depression, Anxiety Stress Scale-21 (DASS-21). This is a set of three self-report scales designed to measure the emotional states of depression, anxiety and stress.⁴⁵ Scoring of the three scales finally categorizes participants on a spectrum from normal to severe for each of depression, anxiety and stress states.

The content validity of the questionnaire items was assessed by 3 staff members at Faculty of Medicine, King Khaled University. They also examined the tool for clarity, significance, comprehensiveness, wording, and understanding. Their suggestions and recommendations were taken into consideration. A pilot test of the tool was conducted on a group of 30 secondary school students to examine clarity of the questions as well as to estimate the required time of the interview. Those who participated in the pilot test were excluded from the main study sample.

Study Sample and Sampling Techniques

The sample size was calculated using the Epi-info software based on the assumption of a precision of 5%, a confidence interval of 95%, and an average sleep disorder of 37.7%⁴⁶ among social media users and design effect 2. The minimum sample size was calculated to be 722. The final number of students who participated in the study was 961 students. The Ministry of Education in the Aseer Region provided a list of public secondary schools in the cities of Abha and Khamis Mushait, along with their addresses. Using a stratified random sample method, four secondary schools for boys and four secondary schools for girls were chosen. Using the simple random sample method, students from the chosen public schools were asked to participate in the study with the aid of a students’ guide.

Ethical Considerations

After receiving the approval of the King Khalid University Research Ethics Committee (HAPO-06-B-001) with approval number ECM#2022-1901, the researchers asked the approval of the Ministry of Education to conduct the study and collect the required data from public secondary schools in the cities of Abha and Khamis Mushait. Public secondary schools were chosen based on the aforementioned sampling strategy. To collect the required data, the researchers paid a firsthand visit to the chosen public secondary schools presenting the Ministry of Education’s letter of approval. After approval of the school administration researchers asked to send parents notification concerning the informed consent to get parental consent for interviewing their children after explaining the purpose of the study and the nature of the data to be collected. Following the parental consent, students were asked to participate in the study during their free time. Students whom their parents accepted to participate in the study were asked to fill in the study questionnaire.

Data Analysis

Statistical analysis was performed using the Statistical Package for Social Science (SPSS version 24.0). Categorical variables and were presented as frequencies and percentages while mean and standard deviation were used for quantitative variables. For bivariate analysis, qualitative variables were correlated using Pearson’s chi-squared test. While Independent t-test was used to compare means between two groups. For logistic regression analysis, variables with significance ≤ 0.2 in the univariate analysis and showing no collinearity with other variables were used in the logistic regression model. For all the statistical tests used, the results were considered significant if the p-value was lower than 0.05.

Results

A total of 961 secondary school students were included. Students’ ages ranged from 15 to 20 years with a mean age of 16.7 ± 2.1 years old. More than half of the students (570; 59.3%) were females and most of them (853; 88.8%) were Saudi. A total of 309 (32.2%) were in their first year, 346 (36%) were in the second year and 306 (31.8%) were third-year students. Most of them (821;85.4%) earned excellent in their academic grades. Above one-quarter of the students (281;29.2%) never practiced any sports. More than one-third of them (350; 37.5%) practiced sports 1–2 times/week while 142 (14.8%) practiced sports five times or more per week (Table 1).

Table 1 Personal Characteristics of Secondary School Students, Aseer Region, Saudi Arabia

The use of social media platforms by secondary school students in Aseer region is shown in Table 2. As for the frequently used social media platforms, the most reported platforms used were Tiktok (769; 80%), Snapchat (749; 77.9%), Instagram (613; 63.8%) and YouTube (565; 58.8%). Regarding the single most frequently used social media platform, Tiktok (36.5%), snapchat (29.4%), Instagram (16.5%), and YouTube (5.9%) were cited most. Concerning the duration of use, 389 (40.5%) used social media platforms for 5 hours or more daily. Only (28; 2.9%) use social media platforms for less than 1 hour.

Table 2 Social Media Platform Used by Secondary School Students, Aseer Region, Saudi Arabia

The PSQI components among the study participants using are illustrated in Table 3. Sleep latency (time to fall asleep), was the worst sleep component among the studied students where 419 (43.6%) showed very bad to fairly bad sleep latency. As for subjective sleep quality, it was very bad to fairly bad among 237 (24.7%) of the students. Exactly 131 (13.6%) of the students slept 5 hours or less. Regarding sleep efficiency, 131 (13.6%) scored less than 75% while 254 (26.5%) had high to very high levels of sleep disturbance. Use of sleep medications was reported among 209 (21.7%) of the sampled students and 172 (17.9%) had fairly high to very high daytime dysfunction. Concerning the PSQI score, it ranged from 0 to 16 with mean score of 6.6 ± 3.2 out of 21 points (31.4%). Based on this score, 333 (34.7%) were classified as poor sleepers while 628 (65.3%) had good sleep quality Figure 1.

Table 3 Distribution of Pittsburgh Sleep Quality Index (PSQI) Components Among Secondary School Students, Aseer Region, Saudi Arabia

Figure 1 Sleep hygiene (based on PSQI) among high school students, Aseer region, Saudi Arabia.

Association of students’ characteristics and their sleep quality are depicted in Table 4. None of the personal characteristics (age, gender, nationality, academic years, academic performance or sports practice) of students were significantly associated with students’ sleep quality. On the other hand, Table 5 demonstrates the pattern of social media use and students’ sleep quality. Among the frequently used platforms only Tiktok and Snapchat use were significantly associated with higher rates of poor sleep quality versus other platforms (36.4% vs 27.6%, p = 0.022 and 37.1% vs 25.9%, p = 0.003, respectively). However, investigating the students’ reported single platform preference and usage, only Tiktok users had higher poor sleep quality compared to other platforms (39.6% vs 31.8%, p=0.014). Regarding the number of platforms used, poor sleepers showed significantly higher mean number of platforms used compared to good sleepers (4.3 ± 1.6 vs 3.9 ± 1.6, p = 0.011). As for the duration spent on social media, 45% of students who spent 5 hours or more on social media were poor sleepers in comparison to 31.5% among 2 to less than 5 hours users and 11.7% of less than 2 hours users (p < 0.001).

Table 4 Secondary School Students’ Sleep Quality and Their Personal and Mental Health Characteristics Associated with Their Sleep Quality, Saudi Arabia

Table 5 Sleep Quality and Social Media Platform Used Among the Study Participants

In the multivariate analysis (Table 6), TikTok use (OR 1.33, 95% CI 1.01–1.77), time spent on social media (OR 1.26, 95% CI 1.16–1.37), having depressive symptoms (moderate to extremely severe) (OR 1.69, 95% CI 1.19–2.40) were the only significant predictors of poor sleep among the studied sample. Keeping other predictors constant, participants using TikTok mostly were showed 33% more risk to have a poor sleep than those who did not. Similarly, participants with moderate to extremely severe depressive symptoms had 69% more chance of being poor sleepers than those with no or mild symptoms. Regarding hours spent on social media, for each 1-hour increase in duration spent on social media, there is about a 26% increase in the odds of having poor sleep.

Table 6 Multivariate Logistic Regression Analysis Showing Predictors of Sleep Disturbance Among the Study Participants

Discussion

The present investigated the association between social media use and sleep quality among secondary school adolescent students in Aseer Region, SA. Findings of the current study showed that all students were social media users. This is in line with findings from a similar study conducted in SA.⁴⁶ Such finding indicate that similar to other countries, social media use is an integral part of adolescent daily lives in SA.

Poor sleep quality among the study participants represented 34.7%. This rate is consistent with the figure reported in a similar study conducted SA examining sleep quality among Saudi adolescents.⁴⁷ While all participants were social media users, 34.7% of them were poor sleepers with the subsequent hazards of disturbed sleep. High rates of sleep disturbance among frequent social media users were previously cited in national and international literature.^12,48–53 The study conducted in USA⁵² was a longitudinal one revealing stronger evidence.

Also another study conducted in SA suggested that smartphone addiction is negatively associated with sleep quality.¹² While we did not assess addiction in our current study, however, we reported significant association between poor sleep quality and prolonged use of social media (5 hours/day).

However, a recent study contradicted the association between social media use and sleep disturbance, yet their conclusion was based only on short use duration where they did not infer their conclusions on long use.⁵⁴ Similar contradiction was revealed in another cross-sectional study conducted in SA.⁴⁷ However, such contradiction may be attributed to the difference in the assessment tools used in those studies. In addition, our findings are derived from a cross-sectional study which fails to prove temporal association or causality. In other words, our design could not determine whether social media use contributed to sleep disturbance or sleep disturbance contributes to increased social media use, or both. Longitudinal and long-term studies on different populations are needed to alleviate this conflict.

The association between social media use and sleep disturbances can be explained by several assumptions. Researchers suggested that social media use is a form of unstructured activity with no clear beginning or an end. Thus, it is more likely to be prolonged.¹⁸ Moreover, use of social media is an entertaining effortless activity, which may alter sleep duration and quality.⁴⁶ Staying up late at night on social media (posting pictures or watching videos) may delay or reduce sleep. The content may prolong the arousal such as exciting or provoking contents videos may disturb person’s sleep. Also engaging in discussions at bedtime may delay sleep and shorten its duration.⁴⁸ Furthermore, the blue light from using screens can prevent the body’s usual sleep rhythms, with experienced difficulty to fall asleep and stay asleep.⁵⁵ This is in line with our finding that poor sleepers use a higher mean number of platforms than good sleepers where different platforms allow for different activities (texting, posting, studying, discussing, reading, watching) that may delay students’ sleep. Also, the afore-mentioned research findings could explain how longer duration of social media use was among the independent predictors of poor sleep.

Regarding the most used social media platform and their association with sleep disturbance Tiktok and Snapchat were the most frequent platforms used. TikTok and Snapchat are the most popular short-video platforms ranked 4^th and 5^th most used globally.⁵⁶ They are more preferred among adolescents.⁵⁷ Tiktok is different from other social media platforms like Facebook, Twitter, Instagram, which mainly focus on images and text. TikTok enables users to browse, watch and produce short video contents.^58,59 Social media companies provide their service aiming to prolong users stay as long as possible.⁵⁹ Both platforms were associated with poor sleep among students. Such association could be interpreted by the content and structure of the platform that prolong individual use of it. A similar study conducted in the United States reported that Snapchat was the only platform associated with sleep disturbance.⁶⁰ In our study this could be attributed to them being the most commonly used platforms in SA which are used for long times consequently affecting sleep quality. Further research is needed to understand why TikTok and Snapchat are the most used platforms.

Poor sleep quality showed no association with gender of the participants. However, similar studies conducted in SA revealed that females were more to be social media users.^12,61 This might be explained by the type of the platforms assessed in previous studies or the method of assessment. On the other hand, our finding might suggest that with increasing use of social media males tend to use social media equally as females. Furtherly, it is to be considered in social media hazards awareness activities both males and females should be targeted.

According to the current study, logistic regression results revealed that depressive state was found to be independently associated with poor sleep. Generally, both sleep and mental health are regarded as global public health challenges where both problems are considered interlinked.^33,37 Previous studies suggested that the association between mental health problems and sleep is bidirectional.^37,38,62 Thus, such bidirectional causal relation assume that poor sleep could have led to the depressive state among participants leading to more problematic sleep, such interpretation implies the complicated negative effects of prolonged use of social media on individual sleep quality and mental health. Future in-depth research is called for to investigate such interplay between social media use, poor sleep and depressive state.

Study Limitations

Despite the useful findings obtained through our study, some limitations still exist. The cross-sectional design fails to prove the temporal or the causal association between sleep quality and social media use. Longitudinal studies or studies with multiple follow-ups are needed to obtain more solid evidence. Conducting the study over a short timeframe limits its ability to capture seasonal or long-term trends, accordingly, the results’ generalizability and reliability. Also, the results are confined to public school attendants only. Also, students’ responses were mainly subjective and purpose and the pattern of their use of social media plat form, especially at night, were not assessed.

Conclusion

The most frequent and preferred social media platforms used by participants were Tiktok and Snapchat. More than one-third of them were poor sleepers with Tiktok use, extended duration of use and depressive state of participants were significantly associated with poor sleep quality. Those factors interplay together to disturb their sleep where Tiktok, as a preferred platform, with appealing structure and content attracts adolescents to use them for prolonged duration affecting their physiological sleep process. Our findings reveal an urgent call for awareness as well as social and behavioral communication change strategies and activities among secondary school students and their parents. Stakeholders including ministry of education, ministry of health, health educators, school administration and teachers should co-operate to adopt strategies and activities focusing on sleep hygiene and consequences of poor sleep, and the negative impact of limitless and inappropriate use of smart phones and social media to prevent hazards of poor sleep and social media addiction. Also, further in-depth studies are needed to understand why adolescents prefer certain platforms over others, and why sleep disturbance was associated with certain social media platforms than others investigating their content and structure. Longitudinal studies are needed to assess causality and temporal relationship between social media and problematic sleep.