Association between social media addiction and sleep quality among undergraduate nursing students: a cross-sectional study

: Objectives: To examine the association between social media addiction and sleep quality among undergraduate nursing students. Methods: This research is an analytical observational study with a cross-sectional approach. The sampling technique was purposive sampling of 150 nursing students at a private university in Malang, Indonesia. Respondents filled out a questionnaire about self-identity, a sleep quality questionnaire from the Pittsburgh Sleep Quality Index (PSQI), and social media addiction from Social Media Addiction Scale (SMAS). This was a bivariate analysis which was conducted using the Pearson Product Moment Correlation test. Results: The results of this study reported that most nursing students were addicted to social media (76%). As for the parameter of the quality variable, most respondents had poor sleep quality, which were about 106 people (70.3%). The result of the Pearson Product Moment Correlation test obtained a P value of 0.000. The Pearson correlation coefficient was 0.358. Social media addiction (adjusted odds ratio [OR] 4.80, 95% confidence interval [CI] = 2.08–11.02), gender (adjusted OR 3.79, 95% CI = 1.58–9.12), and using social media for a long time (adjusted OR 4.21, 95% CI = 1.97–10.48) were associated with sleep quality. Conclusions : We found that there is an association between social media addiction and sleep quality among nursing students. Furthermore, we might be educating nursing students to manage their time to improve their quality of sleep to avoid any health problems.


Introduction
The dynamics of life in Indonesia is currently experiencing very rapid development.Cultural acculturation with the existence of information technology is one of the phenomena driving these changes. 1 According to Jones (2007) and Xanidis and Brignell, 2 usage of internet use is an inseparable part of activities in daily life, especially among young adults.Today's modern society is almost impossible not to be exposed to media exposure; whether we realize it or not, all content is present as a part of human life.Along with the development of this modern era, the presence of the media is increasingly diverse and growing bigger. 3he age group of 19-34 years accounts for 49.52% of the phenomenon of social media use among internet users; nevertheless, the greatest age group accounts for 75.50% of all users.The number of Facebook users began to compete with Instagram users, followed by YouTube, Twitter, and LinkedIn. 4Although Facebook is still popular among young adults, teenagers are starting to switch to Instagram. 5The results of a survey conducted by the Ministry of Communication and Information Technology of the Republic of Indonesia 6 showed the five most frequently used social media platforms in Indonesia: Facebook (50.7%),Instagram (17.8%),YouTube (15.1%),Twitter (1.7%), and LinkedIn (0.4%).
A previous study by Pane et al. 7 reported that 85 nursing students in level III which were as many as 54 people (63.5%) who were students used social media moderately and as many as 31 people (36.5%) who were students used social media more than normal.Furthermore, in a previous study by Stiawan et al., 8 the number of respondents were 128 nursing students: 41 students (32%) used social media moderately, as many as 87 students (68%) used social media at a normal rate, and as many as 117 students (91.4%) used social media more than normal, with the average use time being 11-20 min; 57 people (44.5%) had used social media for an average of 11-20 min.Besides that, a study by Hartinah et al. 9 as many as 240 respondents showed that the level of symptoms of social media addiction in nursing students was dominated by moderate levels of 173 students (72.1%).
The use of social media greatly affects a person's mental health.A research study by Bashir and Bhat 10 stated that several mental health problems were related to the use of social media such as anxiety, stress, depression, and loneliness.A previous study by Nurlina et al. 11 showed that nursing students had moderate levels of anxiety, which was the result of using social media excessively.A research study by Al Aziz 12 shows that the higher the intensity of the use of social media, the higher the level of depression of a person.Symptoms of depression result in loss of interest and reduced energy, which resulted in tiredness, pessimism, and disturbed sleep patterns in students.During the recovery period, fear of COVID-19 was predicted by a shift in problematic internet use, according to a regression analysis. 13he use of social media can also cause dependence/addiction and adversely affect sleep quality. 14ecent research conducted by the Great British Sleep Survey shows that women are 3 times more likely to suffer from sleeplessness or insomnia than men.The results of survey for cases of insomnia from various countries show that approximately 30%-45% of adults experienced symptoms of insomnia such as difficulty falling asleep, difficulty managing sleep, waking up too early, and poor sleep quality. 15leep is a condition in which individual perceptions and reactions to the environment have decreased. 16leep is an activity that must be fulfilled as it is the state of the body at which the brain rests. 17To restore biochemistry in the body, sleep is necessary. 18A good number of hours of sleep as recommended by the American National Sleep Foundation are 7-9 h for adults. 19oor sleep quality can result in disturbed physiological and psychological health. 20Physiologically, poor sleep quality can cause a person's level of health to decline and experience fatigue easily.Psychologically, poor sleep quality causes unstable emotions, reduced self-confidence, excessive impulsivity, and carelessness. 21Poor sleep quality can be caused by social activities as young adults are highly active and spend more time and energy in social activities.In addition to this, electronic devices also affect sleep quality, which includes accessing the internet and using electronic equipment (TV, gadgets, and computers).Syamsoedin et al. and Wicaksono et al. 22,23 said in their research "Analysis of dominant factors related to sleep quality in nursing students at Airlangga University" that stress can affect a person's sleep quality.The results of this study showed a significant factor between stress and sleep quality (P = 0.024) and tiredness and sleep quality (P = 0.001).
According to the National Sleep Foundation in America, more than a third (36%) of young adults aged 18-29 years report experiencing difficulty in getting up in the morning.Nearly a quarter of young adults (22%) are often late for class or work because it is difficult for them to get up.About 40% of young adults complain of drowsiness when working at least 2 d a week or more. 19he lack of sleep has an impact on memory and concentration of a person.In this condition, lack of sleep is often found in school children and students; in this case, the group that has a high risk of developing sleep disorders is students. 24n general, internet usage by students has reached a critical point, which is >5 h a day on average, and most of their time is spent on chat applications on social media. 25Students are one of the groups that have quite dense activities, as students must wake up early morning to prepare for lectures.Both adolescents and young adults find it difficult to fall asleep, sleep late at night, and wake up early in the morning because of the burden of tasks they do until they stay up late. 26Therefore, this study aims to identify the association between social media addiction and sleep quality among undergraduate nursing students in Malang City, Indonesia.

Study design
The research design used in this research is a nonexperimental research study, which is an analytical observational study with a cross-sectional approach.This research was conducted from August to December, 2020.

Setting and sample
In this study, the sample used was nursing students at a private university in the city of Malang.Through purposive sampling, 150 nursing students were selected as respondents.Respondents recruited had to meet the inclusion criteria, which are as follows: (1) nursing students with active college status, (2) students who use social media, and (3) students who are willing to be respondents.

Data collection
Data were collected by using a questionnaire which was filled out by the respondent through the Google form, taking up approximately 15 min to complete each form.Indonesian language version was used in the measures.Then, the researcher would check the completeness of the data collected from the respondents.The questionnaires used are given in the following sections.

The Pittsburgh Sleep Quality Index (PSQI)
The PSQI questionnaire was used to measure sleep quality, which was adopted from the study by Buysse et al. 27 This questionnaire consists of questions about sleep latency, sleep duration, sleep efficiency, and drug use, along with 10 closed-ended questions.The scores of these components are added to make up one global score, which ranges from 0 to 21.The number of scores is adjusted according to the assessment criteria: good sleep quality is characterized if the score is <5 and poor sleep quality is characterized if the score is ≥5.The reliability of the PDSI is 0.889.

Social Media Addiction Scale (SMAS)
This questionnaire was used to measure the use of social media, which was adopted from the study by Ünal and Deniz 28 .It is a scale that consists of 41 items and 4 factors (occupation, mood modification, relapse, and conflict).It is represented on a 5-point Likert scale with "Always," "Often," "Sometimes," "Seldom," and "Never."Thus, respondents with a total score of <123 are categorized as not dependent on social media use, while >123 of them are categorized as dependent on social media use.Cronbach's α value of the SMAS is 0.789.

Data analysis
The Pearson Product Moment Correlation test was used to examine the correlation between social media addiction and sleep quality among undergraduate nursing students.The significance level was set at P < 0.05.

Ethical clearance
Ethical clearance was obtained from the Ethical Review Board (ERB) Committee of the Faculty of Medicine, University of Muhammadiyah Malang, Indonesia (No:E.5.a/023/KEPK-UMM/III/2021).

Sociodemographic characteristics of the participants
The minimum age of the respondent is 19 years, and the maximum age of the respondent is 25 years.The mean value of the age was 20.97 years, with a standard deviation of 2.54 years.This shows that the respondents are still in the productive age range.The data showed that most respondents were females with a total of 123 people (82%), the year with a huge number of enrollments was in 2017, where as many as 52 people (35%) enrolled.The social media platform most used by students is WhatsApp, which was chosen by 44 respondents (29%), and Twitter is reportedly used rarely by the students.The results of this study through data on the duration of using social media in students with a category of addicted level of 114 (76%).As for quality of sleep, 104 people (70.7%) reported poor sleep quality.Full data of sociodemographic characteristics of the respondents are shown in Table 1.

Relationship between social media addiction and sleep quality
Table 2 shows the results of students who have poor sleep quality; it represents students who are addicted social media (79.8%) than those who are not.
coefficient was 0.358.These data illustrate that addiction of students on social media will affect the sleep quality.

Logistic regression analysis of factors related to sleep quality
Table 3 shows the analysis results using multivariate logistic regression with the backward Euler method.
The final results showed that the variables which significantly related to the incidence of sleep quality were gender, social media addiction, and using social media for a long time.The value of Nagelkerke R

Discussion
The results of the analysis showed that majority of nursing students were addicted to social media.This phenomenon is currently a trend among the public, especially among students.The visible phenomenon is, whenever and wherever students are never separated from social media, both in their daily activities on campus, and outside campus. 29ccording to Kandell, college students are a group that appears to be more vulnerable in using internet than any other community group.Students appear to be more vulnerable as they are in the phase of reaching adulthood, namely the transition period from late adolescence to young adulthood, and experience psychological dynamics.This shows that currently with the emergence of Web 4.0 Technology, if social media applications are widely used, the risk of addiction from excessive use of social media would also get higher. 30he analysis results of respondent data indicate that the social media platform that is most widely used is WhatsApp, this shows that through communication with WhatsApp there will be a lot of information obtained such as academic information, lecture information or information about administration on campus, even now information through social media is received more quickly.publication rather than announcements through The results of the Pearson Product Moment Correlation test obtained a P value of <0.05.This means that there is a relationship between social media addiction and sleep quality in nursing students.The Pearson correlation campus print media.This is what makes students happy to use social media because it is more convenient and easier to get information through social media as compared with other platforms.The more information that is sought, the higher the use of the internet and social media interactions among students. 25he use of WhatsApp is the most dominant one as this is equipped with photo, video, and voice messages along with features including sharing documents, contacts, location, etc., which makes it easier for someone to communicate with family and friends and obtain information, as well as receive subject matter expertise by teachers through chat groups.In addition, WhatsApp has no advertisements or pop-ups like other social media; this proves to be more effective as WhatsApp directly connects users with its phone contacts and conveys information related to the user. 31his dependence on social media can lead to negative impacts that will be experienced because social media makes a person indifferent to his responsibilities as a student, which has an impact on delays in collecting school assignments, learning time is reduced, and achievement has decreased drastically because teenagers are busy in spending their studying time in accessing social media. 32he results of statistical tests show that social media addiction, gender, and using social media for a long time affect the sleep quality of nursing students.The use of social media results in melatonin imbalance, causing unfulfilled sleep.Melatonin is a hormone formed by the pineal gland and retina which is responsible for falling asleep and restoring physical energy during sleep.The production of melatonin can be stimulated by darkness and silence; melatonin production is inhibited by bright light and devices with electromagnetic fields.Melatonin in the body depends on the amount of light that the eyes receive; a lot of light will slow down the process of forming melatonin in the body; in other words, lack of light will rapidly increase the amount of melatonin, causing drowsiness in people. 33rom the results of research on students from the 2017-2019 batches who lack sleep fulfilment due to frequent use of social media for a long time.Most students admitted that they spent a lot of time using social media to complete their college assignments; Most of them admitted to using smartphones to access social media at that time.In this case, accessing social media for too long makes students addicted it, leading to a decline in sleep quality.As a result, the students have difficulty in sleeping and reduce their sleep time.On average, most teens claim to sleep <7 h.According to Haswita, 34 students aged 18-40 years should sleep for 8.5 h.Students should have adequate sleep time so that it does not interfere with their college activities.
Poor sleep quality can also make a person use social media more as it is difficult for the person to initiate and maintain sleep. 35The incidence of insomnia is then assumed by researchers as an indicator of poor sleep quality.Based on the frequency and duration of using social media, which gradually becomes frequent and long, the habit of carrying a gadget when going to bed can interfere with melatonin regulation, which is one of the hormones that triggers feelings of depression.If melatonin regulation is disturbed, sleep is also disturbed.So, the quality of sleep decreases as well. 36he limitation of the present study was the small sample size as a result having low generalizability of the study  findings, and the impacts of COVID-19 pandemic not included in this study.

Conclusions
Most nursing students were addicted to the social media.Most respondents had poor sleep quality due to social media addiction.Social media addiction, gender, and using social media for a long time affected the sleep quality of nursing students.Students who are addicted to social media tend to experience poor sleep quality four times more as compared with those who are not addicted to social media.Furthermore, we might be educating the nursing student to manage their time to improve their quality of sleep to avoid any health problems.

Table 2 .
Relationship between social media addiction and sleep quality.

Table 3 .
Logistic regression analysis of factors related to sleep quality of nursing student.