Correlation Between Adolescent Mental Health and Sleep Quality: A Study in Indonesian Rural Areas During the COVID-19 Pandemic

Introduction

Adolescence is a critical stage of growth and development spanning from 10 and 19 years of age, between childhood and adulthood.¹ According to the World Health Organization (WHO), one in seven adolescents (14%) has mental health problems. Mental health issues among adolescents may affect maturity, disrupt physical health, and limit the chances of living a natural adult life.²

The coronavirus disease 2019 (COVID-19) pandemic was a major source of stress and mental health issues. Although the social constraints which accompanied the pandemic impacted people of all ages, it was more pronounced in adolescents since this period required emotional support and social growth from peers.³

Covid-19 survivors experienced multiple stressors and traumatic events, such as having family members become infected and/or die, as well as witnessing the painful symptoms and/or death of other patients.⁴ Additionally, the lockdown measures implemented during this period resulted in the closure of schools, confining children and adolescents to their homes for an extended period, as well as limiting students to online lessons. School closure during the pandemic affected several activities, including sleep. Consequently, a large proportion of adolescents and young adults experienced greater flexibility in their sleep schedules. Factors such as later school start times, reduced commute time, and fewer extracurricular activities, allowed for changes in sleep routine. Studies have shown a high prevalence of sleep problems and decreased quality among adolescents. According to a previous study, there was an association between Covid-19 related worries and difficulties in falling asleep, maintaining sleep, and delayed sleep/wake patterns. These sleep disturbances are often accompanied by increased levels of anxiety and depressive symptoms since the beginning of the pandemic.⁵ Sleep difficulties may develop as a result of isolation and shielding, which may lead to inactive habits, increased food intake, and weight gain. Additionally, being confined to one’s house causes significant lifestyle changes due to the absence of key zeitgebers, which might help one maintain a pattern and sleep/wake cycle. The limitations caused irregular sleep patterns, extended screen time, restricted access to outdoor activities, and fewer peer connections. Stress levels may rise as a result of potential changes in family finances, health issues, and future uncertainties, which may result in sleep problems.⁶

Sleep is one of the most important factors that influence adolescent mental health.⁷ According to a previous study, adequate sleep is part of good quality of life.⁴ Lack of sleep has been related to several mental health disorders and may affect a person’s capacity to control emotions along with a negative impact on daytime activities.⁸ One key aspect of sleep that affects emotions is the rapid eye movement (REM) sleep phase. In this phase, activation of the prefrontal hyper limbic and dorsolateral, as well as the prefrontal medial cortex occur, which underscores the importance of sleep in facing emotional events.⁹

Although there have been extensive studies on the correlation between sleep quality and mental health problems during the COVID-19 pandemic, the majority were focused on urban areas. Adolescents in urban areas are more at risk of developing behavioral disorders as well as emotional and mental problems.¹⁰ In rural areas, neighborhoods have a more peaceful atmosphere, making the population less emotional.¹⁰ However, only a small number of studies have examined how well teenagers sleeping in rural regions during the Covid-19 pandemic slept and whether they experienced any mental health issues.

Based on this background, this study’s goal is to examine the relationship between sleep quality and mental health in adolescents who were living in rural areas during the COVID-19 pandemic. The study was conducted in the Indonesian village of Sagaracipta, Ciparay, in the Bandung region.

Materials and Methods

Study Design

This study was performed in February 2023, with a cross-sectional design on school-age adolescents in the Sagaracipta village, Bandung region.

Participants

The subjects in this study were aged 12–15 years and the inclusion criteria were adolescents attending high school in Sagaracipta Village. Meanwhile, the exclusion criteria were those with physical disabilities or chronic diseases, taking medications for sleep disorders, smoking, and drinking alcohol.

Data Collection

Data collection was carried out after obtaining authorization from the Ethics Research Committee, Faculty of Medicine, Padjadjaran University with the number 142/UN6.KEP/EC/2023. The review adhered to the values set forth in the Helsinki Declaration. Before starting the study, the participant’s informed consent and the approval of their parents or legal guardians were also required. The Pittsburgh Sleep Quality Index (PSQI) and Strength and Difficulty Questionnaire (SDQ) were used to assess sleep quality and investigate mental health, respectively. Both instruments were considered self-reported questionnaires. The PSQI included 19 items that represented seven aspects of sleep, including subjective quality, latency, length, habitual efficiency, disruption, use of medicine, and daytime dysfunction, to evaluate whether the sleep quality was good (score < 5) or poor (score of >5). According to a previous report, The PSQI-Indonesian version had a Cronbach’s alpha of 0.72.¹¹

The SDQ questionnaire consisted of 25 questions used to evaluate four sub-scales of difficulty namely emotion, conduct, hyperactivity, and relationships with peers, as well as the pro-social sub-scale of strength. Each response was scored on a 3-point Likert scale (0 for “not true”, 1 for “partly true”, or 2 for “very true”); the score varied from 0 to 10 for each of the five subscales. The sum of all subscales, with the exception of prosocial behaviors, was used to determine the overall problems score, which ranges from 0 to 40. The overall result was classified as either normal, borderline, or abnormal. A higher score indicated behavioral issues that were more severe. The reliability of the SDQ-Indonesian version questionnaire had a Cronbach’s value of 0.773.¹²

According to previous studies, the link between sleep quality and mental health was 0.42. Consequently, it was estimated that the minimal sample size required based on calculation with a 5% level of significance was 59 adolescents. Purposive sampling was used to select the study site, while the subjects were recruited using total sampling.

Data Analysis

To describe sociodemographic factors, mental health issues, and sleep quality, descriptive statistics were used. Frequencies and percentages were used to present the data. The Spearman Rank correlation was used to examine the connection between sleep quality and mental health issues. The confidence range used was 95%, while p< 0.05 was assumed statistically significant.

Results

A total of 109 subjects were analyzed in this study with 72 being females (66.1%), the average age was 15 years old, 79 were living with both parents (72.5%), and 106 were attending school from home during the pandemic period (97.2%), as shown in Table 1.

Table 1 Characteristic of Subject (n = 109)

Figure 1 shows that 24, 18, 5, 15, and 26 adolescent subjects had abnormal values on the subscale of emotional, conduct, hyperactivity, problems with peers, and total difficulty with proportions of 22%, 16.5%, 4.6%, 13.8%, and 23.9% respectively. However, based on the results, there were no abnormal subjects on the pro-social subscale.

Figure 1 Distribution of mental emotional problems in adolescents.

About 77 subjects (70.6%) had poor sleep quality, while 32 (29.4%) had good quality. The results displayed no significant difference in demographic factors among the study population as shown in Table 2.

Table 2 Differences in Sleep Quality Based on Demographic Status

Furthermore, the link between sleep quality and mental health among adolescents was analyzed using the Spearman rank correlation. The results showed significant differences (p<0.05) between sleep quality and the emotional sub-scale (r = 0.247), behavioral (r =0.258), hyperactivity (r = 0.221), and total difficulty (r 0.310), with a moderate correlation as depicted in Table 3.

Table 3 Correlation of Mental Health and Sleep Quality in Adolescents

Discussion

Adolescence is a time when emotional and mental health issues can arise due to several predisposing factors, including poor sleep quality, lifestyle, environmental influence, and other medical conditions.¹³ Furthermore, adolescents exposed to crises, such as the COVID-19 pandemic tend to experience higher stress. According to a previous study conducted in Spain using the SDQ questionnaire, behavioral issues and general difficulties increased during the COVID-19 pandemic.¹³ In the United Kingdom, another study reported a rise in mental health problems among adolescents compared to the period before the pandemic.¹⁴

Several factors are associated with the decrease in sleep quality during the pandemic, like changes in daily activity schedules as well as circadian cycles due to lack of exposure to sunlight, as well as stress.¹⁵ A pre-pandemic study even indicated poor sleep quality among 54% of teens.¹⁶ However, numerous studies have discovered that adolescents’ sleep quality improved during the COVID pandemic compared to prior. According to a study conducted in Brazil using the PSQI questionnaire, 68% of the respondents reported having poor sleep quality.¹⁷ The latest results showed that 48% of subjects had poor sleep quality, with 85.6% reporting poor sleep quality based on the PSQI.¹⁸

Based on the results, 58 adolescents (37%) slept for 5–6 hours, with 20 (13%), 41 (26%), and 37 (24%) sleeping for 5 hours, 6-7 hours, and more than 7 hours respectively. Meanwhile, to perform at their best, teens should get 8 to 10 hours of sleep per night, according to the National Sleep Foundation.¹⁹ This showed that most participants in this study did not fulfill the existing sleep duration recommendations. Teens who get more sleep have better moods and experience fewer signs of depression.²⁰ In general, shorter sleep durations were associated with worse emotional regulation, while better emotional responses were obtained in children with regular sleep.²¹

The results revealed a link between sleep quality and adolescent mental health problems on the subscales of emotional, conduct, hyperactivity, and total difficulty problems. Emotional problems were found to be related to internal dimensions, such as depression and anxiety, while conduct problems were associated with external aspects, including quarreling with friends, lying, stealing, and other behavioral issues. Hyperactive problems indicated issues with focus, acting before thinking, and not being able to remain silent for a long period. Meanwhile, overall difficulty scores showed disturbances in the respondents’ general emotional and mental problems in both internal and external issues.²² According to reports, sleep problems are linked to emotional and behavioral disorders in children.²³ A Norwegian study discovered a significant association between poor sleep quality and emotional, conduct, hyperactivity, and inattentive problems.²⁴ Decreased sleep quality was associated with a person’s ability to regulate their emotions. Children with good sleep quality were found to have a better mood and control over their emotions compared to those with poor sleep quality.²⁵ Furthermore, imaging studies in individuals with sleep deprivation reported 60% and three times the activation of the amygdala, indicating a decrease in cognitive control in the emotional area of the brain.²⁶ Other studies also found that adolescents who lack sleep often take risky actions, regardless of the negative consequences.The influence of this effect can be moderated by the involvement of the striatum, which encompasses the caudate, putamen, and nucleus accumbens. As components of the basal ganglia, these structures play a crucial role in regulating motivation. Behavioral problems such as oppositional and aggressive behavior are often associated with sleep disorders in children. Children of school age who added an average of 30 minutes to their sleep showed improvements in emotional instability and impulsive behavior.^27–29 Sleep disruptions can give rise to symptoms that resemble those of attention deficit hyperactivity disorder (ADHD). This effect was circular, with about 34% of ADHD teenagers having significant sleep difficulties.³⁰ The study also found a correlation between sleep disorders and hyperactivity in adolescents.

Previous studies discovered that teenagers living in urban areas had more emotional and psychological problems than those in rural areas. Factors such as population density, pollution, lifestyle, and stress all contributed to this disparity.³¹ The results of this study showed that the COVID-19 pandemic not only affected the emotional and mental problems of adolescents living in urban areas but also those living in rural areas. A study conducted in Bangladesh found emotional problems among adolescents in rural areas but also highlighted the issue of limited access to mental health services.³² The prevalence of emotional and mental problems was higher in rural areas, primarily due to the low educational levels of their parents.³³

Based on the results, there was a decrease in sleep quality associated with the emergence of emotional and mental problems among adolescents living in rural areas during the pandemic. The study had the limitation of not describing the dynamics of mental health among adolescents as well as the quality of their sleep before and during the pandemic. This was because there were no previous data for comparison between the two periods.

Conclusion

There was a correlation between mental health problems and sleep quality among adolescents living in rural areas during the COVID-19 pandemic. Therefore, adequate sleep should be maintained to achieve optimum mental health. Adolescents having emotional and mental issues need further evaluation by health professionals.

As a recommendation, future studies should consider examining adolescents’ health problems and sleep quality after the pandemic period.