Anxiety-induced sleep disturbances among in-school adolescents in the United Arab Emirates: Prevalence and associated factors

Supa Pengpid; Karl Peltzer

doi:10.4103/shb.shb_120_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 5 | Issue : 1 | Page : 18-23

Anxiety-induced sleep disturbances among in-school adolescents in the United Arab Emirates: Prevalence and associated factors

Supa Pengpid¹, Karl Peltzer²
¹ ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand; Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa
² Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa; Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan

Date of Submission	17-Oct-2021
Date of Decision	25-Dec-2021
Date of Acceptance	20-Jan-2022
Date of Web Publication	25-Feb-2022

Correspondence Address:
Karl Peltzer
Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/shb.shb_120_21

Abstract

Introduction: The goal of the study was to estimate the prevalence of anxiety-induced sleep disturbance (AISD) and assess its relationship with psychosocial distress, socio-environmental variables, and health risk indicators among adolescent schoolchildren in the United Arab Emirates (UAE). Methods: Cross-sectional data from the 2016 UAE “Global School-Based Student Health Survey” (n = 5849) were analyzed. The nationally representative sample of all students in grades 8–12 in the UAE was selected through a two-stage cluster sampling procedure. Schools were included with probability proportional to enrollment size, and classes were randomly selected, with all students present in selected classes being eligible to participate. Results: The overall prevalence of AISD was 16.2%, 11.9% had AISD among males, and 20.5% had AISD among females. In adjusted logistic regression analysis, older age (16 years or older), lower economic status (hunger), loneliness, frequent bullying victimization (10–30 days), frequently physically attacked (≥6 times), parental emotional neglect, parents never check homework, parental disrespect of privacy, passive smoking on all past 7 days, sedentary behavior (>8 h/day) during leisure time, and multiple (≥4 times) injuries were positively and being male was negatively associated with AISD. Conclusion: Almost one in six participants reported AISD, and several factors associated with AISD were identified.

Keywords: Adolescents, anxiety, protective factors, risk behavior, sleep disturbance, United Arab Emirates

How to cite this article:
Pengpid S, Peltzer K. Anxiety-induced sleep disturbances among in-school adolescents in the United Arab Emirates: Prevalence and associated factors. Asian J Soc Health Behav 2022;5:18-23

How to cite this URL:
Pengpid S, Peltzer K. Anxiety-induced sleep disturbances among in-school adolescents in the United Arab Emirates: Prevalence and associated factors. Asian J Soc Health Behav [serial online] 2022 [cited 2023 Sep 23];5:18-23. Available from: http://www.healthandbehavior.com/text.asp?2022/5/1/18/338373

Introduction

Mental disorders constitute a major burden among adolescents,^[1] including 6.5% of any anxiety disorder globally.^[2] “Generalised anxiety disorder in a child or adolescent is excessive worry and tension about everyday events that the child or adolescent cannot control and that is expressed on most days for at least 6 months, to the extent that there is distress or difficulty in performing day-to-day tasks.”^[3] During adolescence, sleep problems may increase due to various stressors, such as substance use, emotional problems, and worries, contributing negatively to physical and mental health.^[4],[5] “During adolescence, worry becomes more prominent with the development of abstract thinking and the cognitive ability to foresee multiple negative outcomes.”^[6] Worry or anxiety-induced sleep disturbance (AISD) could be conceptualized as one of the psychological distress, including “symptoms of depression, anxiety, stress, and somatic complaints.”^[7]

In a large multicountry adolescent school survey,^[8] 7.8% of the students reported AISD “worried about something that you could not sleep at night in the past 12 months”, with 17.9% in Qatar and 18.9% in Kuwait, as examples of countries in the Middle East. In two small local school surveys in the United Arab Emirates (UAE), high proportions of depressive symptoms (17.2%)^[9] and anxiety disorders (28%)^[10] have been reported. National studies on AISD among adolescents are needed to inform school health policies, which, to our knowledge, are lacking in the UAE.

Factors associated with AISD among adolescents many include psychosocial distress^[11] (loneliness,^[12] social isolation,^[13] and aggression^[12],[13]), socio-environmental factors^[11] (hunger,^[14] and low support^{[13],[14],[15],[16]}), health risk behaviors^[11] (substance use,^{[14],[17],[18]} internet addiction,^[19] injury,^[20] and poor diet and sedentary behavior^{[8],[20],[21],[22]}), and respiratory symptoms.^[23] The present analysis aimed at estimating the national prevalence of AISD and assessed its relationship with psychosocial distress, socio-environmental variables, and health risk indicators among adolescent schoolchildren in the UAE.

Methods

Study population and sampling

Cross-sectional secondary data from the “2016 UAE Global School-Based Student Health Survey (GSHS)” were analyzed;^[24] the overall response rate was 80%.^[24] The 2016 UAE GSHS dataset is publicly available from the World Health Organization Noncommunicable Disease (NCD) Microdata Repository.^[24] “A two-stage cluster sampling design was used to generate a national representative country sample.”^[24] “Schools were selected with a probability proportional to the sample size, and school classes of students in grades 8–12 within schools were randomly selected.”^[24] “All students in the selected classes were eligible to take part in the survey regardless of their age.”^[24] Data were collected with a self-administered instrument translated into Arabic, and pilot tested in the field and fine-tuned for use in the survey.^[25] Test and retest reliability has been proven for the US Youth Risk Behavior Survey instrument, which is similar to the GSHS instrument,^[26] and for the GSHS instrument, the test–retest reliability found that “the average agreement between test and retest was 77%, and the average Cohen's kappa was 0.47.”^[27] The UAE Ministry of Health provided ethics approval and written informed consent was obtained from parents and students.^[24]

Measures

AISD was measured with the item “During the past 12 months, how often have you been so worried about something that you could not sleep at night?” and defined as “mostly or always,” as in previous research.^[8] “Emotional neglect was defined as never parental, or guardian understanding of your problems and worries? AND never parents or guardians really know what you were doing with your free time when you were not at school or work?”^[28] Cronbach's alpha for the emotional neglect index was 0.7 in this study. Further items of the questionnaire are indicated in [Supplementary File 1].

Ethical consideration

As the study was secondary data analysis from the “2016 UAE Global School-Based Student Health Survey (GSHS). So further ethical code was not acquired.

Statistical analysis

Statistical procedures were conducted with “STATA software version 15.0 (Stata Corporation, College Station, Texas, USA).” Sampling design and weighting of the data were taken into account in all analyses with Taylor linearization methods. Associations between psychosocial distress, socio-environmental variables, health-risk indicators, and AISD were tested with univariate and multivariable logistic regression; variables significant in univariate analysis were included in the multivariable model. Missing values were excluded from the analysis, and P < 0.05 was accepted as significant.

Results

Sample and anxiety-induced sleep disturbance characteristics

In all, 5849 school adolescents (median age: 15 and interquartile range: 2 years) participated, 50.3% were female, and 9.0% reported experiencing frequent hunger (or low economic status). Almost one in six students (16.2%) reported AISD, 20.5% AISD among females, and 11.9% AISD among males. Further sample details are described in [Table 1] and [Table 2].

Table 1: Sample characteristics by anxiety-induced sleep disturbance among adolescents in the United Arab Emirates, 2016: Demographic and psychosocial distress factors

Click here to view

Table 2: Sample characteristics by anxiety-induced sleep disturbance among adolescents in United Arab Emirates, 2016: Social–environmental factors and health risk behavior

Click here to view

Associations with anxiety-induced sleep disturbance

In adjusted logistic regression analysis, older age (16 years or older) (adjusted odds ratio [AOR]: 1.70, 95% confidence interval [CI]: 1.26–2.31), lower economic status (feeling hungry) (AOR: 1.62, 95% CI: 1.22–2.14), loneliness (AOR: 4.78, 95% CI: 3.77–6.06), frequent bullying victimization (10–30 days) (AOR: 3.09, 95% CI: 1.83–5.21), frequently physically attacked (≥6 times) (AOR: 1.81, 95% CI: 1.11–2.97), parental emotional neglect (AOR: 1.98, 95% CI: 1.43–2.75), parents never check homework (AOR: 1.24, 95% CI: 1.02–1.52), parental disrespect of privacy (AOR: 1.69, 95% CI: 1.21–2.37), exposure to secondary smoke (AOR: 1.54, 95% CI: 1.11–2.13), sedentary behavior (>8 h/day) during leisure time (AOR: 1.65, 95% CI: 1.18–2.30), and multiple (≥4 times) serious injuries (AOR: 2.49, 95% CI: 1.28–3.68) were positively and being male (AOR: 0.37, 95% CI: 0.28–0.48) was negatively associated with AISD. Moreover, in univariate analysis, school truancy, having no close friends, frequent involvement in physical fights, and soft-drink and fast-food consumption were associated with AISD [Table 3].

Table 3: Associations with anxiety-induced sleep disturbance estimated by univariate and multivariable logistic regression

Click here to view

Discussion

The proportion of AISD (16.2%) found in this investigation among adolescents in the UAE was similar to Kuwait (18.9%) and Qatar (17.9%) but much higher than globally (7.8%).^[8] Findings seem to confirm the high prevalence of mental problems (depressive symptoms 17.2% and anxiety disorders 28%^[9],[10]) among adolescents in the UAE, emphasizing the need for mental health promotion in this school population.

In agreement with former research,^[20] female sex was associated with AISD. Al-Yateem et al.^[10] propose that several contextual factors may be contributing to higher anxiety symptoms in girls than in boys in the UAE, including being raised to a great extent by a maid^[29] and strict traditional rules placing “extra pressure on girls and women, and limiting their life choices (e.g., study, career, and travel).” Furthermore, sex-specific coping styles to respond to stressors may make girls more vulnerable to AISD.^[13],[30] Consistent with a study in Tanzania,^[14] AISD increased with age. Compared to younger adolescents, older adolescents engaged more likely in tobacco use, truancy, sedentary behavior, passive smoking, parental emotional neglect, and were more lonely (analysis not shown) in this study, contributing to an increase of AISD among older adolescents.^[5]

In line with previous results,^[12] loneliness increased the odds of AISD. Social skills programs to address loneliness may be indicated to reduce AISD.^[12],[31] Furthermore, being physically attacked and bullying victimization was associated with AISD, which is consistent with previous studies.^[12],[13] The worry of being attacked or bullied may negatively impact on the sleep of adolescents.^[12],[32] Consistent with other studies,^{[13],[14],[15],[16]} the association between low parental support and AISD emphasizes the importance of parental support programs.

In line with previous research,^{[8],[14],[18],[20],[21],[22]} various health risk behaviors (sedentary, injury, and substance use) were associated with AISD in this study. The link between high sedentary behavior and sleep disturbance has been shown in a systematic review,^[33] which may increase with longer screen time.^[34] Several possible mechanisms, such as increased inflammatory processes, have been described to explain the association between sedentary behavior and AISD.^[8],[35] Students with AISD may accumulate sleep debt over time, making them more vulnerable to sustain injuries.^[36],[37]

Limitations

Limitations were that only in-school participants were included in the sample, the self-report of the data, and the cross-sectional nature of the study design. Furthermore, the GSHS instrument assesses AISD only with one item, and future studies should include more comprehensive scales.

Conclusion

The study found that more than one in five students reported AISD in the UAE. Several risk factors for AISD were detected, including older age, lower economic status, having sustained a serious injury in the past year, and loneliness, and in unadjusted analysis, ever cannabis use, school truancy, having no close friends, and multiple sexual partners. Health-care providers may want to address psychosocial distress and social-environmental factors in order to reduce and prevent AISD in this adolescent population.

Acknowledgments

“The data source, the World Health Organization NCD Microdata Repository (URL: https://extranet.who.int/ncdsmicrodata/index.php/catalog), is hereby acknowledged.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	World Health Organization (WHO). Adolescent Mental Health; 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health. [Last accessed on 2020 Jan 02].
2.	Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry 2015;56:345-65.
3.	Gale CK, Millichamp J. Generalised anxiety disorder in children and adolescents. BMJ Clin Evid 2016;2016:1002.
4.	Owens JA, Weiss MR. Insufficient sleep in adolescents: Causes and consequences. Minerva Pediatr 2017;69:326-36.
5.	Stores G. Aspects of sleep disorders in children and adolescents. Dialogues Clin Neurosci 2009;11:81-90.
6.	Vasey MW, Daleiden EL. Worry in children. In: Davey GC, Tallis F, editors. Worrying: Perspectives on Theory, Assessment and Treatment. Oxford: Wiley; 1994. p. 185-207.
7.	Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003;60:184-9.
8.	Vancampfort D, Van Damme T, Stubbs B, Smith L, Firth J, Hallgren M, et al. Sedentary behavior and anxiety-induced sleep disturbance among 181,093 adolescents from 67 countries: A global perspective. Sleep Med 2019;58:19-26.
9.	Shah SM, Al Dhaheri F, Albanna A, Al Jaberi N, Al Eissaee S, Alshehhi NA, et al. Self-esteem and other risk factors for depressive symptoms among adolescents in United Arab Emirates. PLoS One 2020;15:e0227483.
10.	Al-Yateem N, Bani Issa W, Rossiter RC, Al-Shujairi A, Radwan H, Awad M, et al. Anxiety related disorders in adolescents in the United Arab Emirates: A population based cross-sectional study. BMC Pediatr 2020;20:245.
11.	Khan MM, Rahman MM, Islam MR, Karim M, Hasan M, Jesmin SS. Suicidal behavior among school-going adolescents in Bangladesh: Findings of the global school-based student health survey. Soc Psychiatry Psychiatr Epidemiol 2020;55:1491-502.
12.	Wang Q, Liu Y, Mati K. Bully victimization is a correlate of sleep loss over worry (SLOW) among adolescents in four South-East Asian countries. Sleep Med 2020;69:179-88.
13.	Siziya S, Mazaba ML. Prevalence and correlates for psychosocial distress among in-school adolescents in Zambia. Front Public Health 2015;3:180.
14.	Mills GC, Alperin JB, Trimmer KB. Studies on variant glucose-6-phosphate dehydrogenases: G6PD fort worth. Biochem Med 1975;13:264-75.
15.	Beattie TS, Prakash R, Mazzuca A, Kelly L, Javalkar P, Raghavendra T, et al. Prevalence and correlates of psychological distress among 13-14year old adolescent girls in North Karnataka, South India: A cross-sectional study. BMC Public Health 2019;19:48.
16.	Lee H, Lee EY, Greene B, Shin YJ. Psychological distress among adolescents in laos, Mongolia, Nepal, and Sri Lanka. Asian Nurs Res (Korean Soc Nurs Sci) 2019;13:147-53.
17.	Pengpid S, Peltzer K. Early substance use initiation and psychological distress among adolescents in five ASEAN countries: A cross-sectional study. Psychol Res Behav Manag 2019;12:1003-8.
18.	Kwon M, Park E, Dickerson SS. Adolescent substance use and its association to sleep disturbances: A systematic review. Sleep Health 2019;5:382-94.
19.	Alimoradi Z, Lin CY, Broström A, Bülow PH, Bajalan Z, Griffiths MD, et al. Internet addiction and sleep problems: A systematic review and meta-analysis. Sleep Med Rev 2019;47:51-61.
20.	Pengpid S, Peltzer K. Leisure-time sedentary behavior is associated with psychological distress and substance use among school-going adolescents in five southeast asian countries: A cross-sectional study. Int J Environ Res Public Health 2019;16:E2091.
21.	Khan A, Uddin R. Is consumption of fast-food and carbonated soft drink associated with anxiety-induced sleep disturbance among adolescents? A population-based study. Clin Nutr ESPEN 2020;36:162-5.
22.	Werneck AO, Vancampfort D, Oyeyemi AL, Stubbs B, Silva DR. Joint association of ultra-processed food and sedentary behavior with anxiety-induced sleep disturbance among Brazilian adolescents. J Affect Disord 2020;266:135-42.
23.	Camhi SL, Morgan WJ, Pernisco N, Quan SF. Factors affecting sleep disturbances in children and adolescents. Sleep Med 2000;1:117-23.
24.	World Health Organization (WHO). Global School-Based Student Health Survey, 2019 (GSHS). Available from: https://www.who.int/ncds/surveillance/gshs/en/. [Last accessed on 2020 Apr 10].
25.	World Health Organization (WHO) United Arab Emirates Global School-Based Student Health Survey 2005. Available from: https://www.who.int/ncds/surveillance/gshs/2005_United_Arab_Emirates_GSHS_Country_Report.pdf?ua=1. [Last accessed on 2021 Jul 10].
26.	Brener ND, Collins JL, Kann L, Warren CW, Williams BI. Reliability of the youth risk behavior survey questionnaire. Am J Epidemiol 1995;141:575-80.
27.	Becker AE, Roberts AL, Perloe A, Bainivualiku A, Richards LK, Gilman SE, et al. Youth health-risk behavior assessment in Fiji: The reliability of global school-based student health survey content adapted for ethnic Fijian girls. Ethn Health 2010;15:181-97.
28.	World Health Organization (WHO). Adverse Childhood Experiences International Questionnaire (ACE-IQ) Guidance for Analysing ACE-IQ; 2016. Available from: https://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/guidance_for_analysing.pdf?ua=1. [Last accessed on 2020 Apr 02].
29.	Al Mutawa M. What is the Real Cost when Domestic Help Raises our Children? The National; November 08, 2010. Available from: https://www.thenational.ae/what-is-the-real-cost-whendomestic-help-raises-our-children–1.530455. [Last accessed on 2021 Apr 01].
30.	Zhang M, Zhang J, Zhang F, Zhang L, Feng D. Prevalence of psychological distress and the effects of resilience and perceived social support among Chinese college students: Does gender make a difference? Psychiatry Res 2018;267:409-13.
31.	Chorney DB, Detweiler MF, Morris TL, Kuhn BR. The interplay of sleep disturbance, anxiety, and depression in children. J Pediatr Psychol 2008;33:339-48.
32.	Donoghue C, Meltzer LJ. Sleep it off: Bullying and sleep disturbances in adolescents. J Adolesc 2018;68:87-93.
33.	Yang Y, Shin JC, Li D, An R. Sedentary behavior and sleep problems: A systematic review and meta-analysis. Int J Behav Med 2017;24:481-92.
34.	Hale L, Guan S. Screen time and sleep among school-aged children and adolescents: A systematic literature review. Sleep Med Rev 2015;21:50-8.
35.	Edwards MK, Loprinzi PD. Experimentally increasing sedentary behavior results in increased anxiety in an active young adult population. J Affect Disord 2016;204:166-73.
36.	Lam LT, Yang L. Short duration of sleep and unintentional injuries among adolescents in China. Am J Epidemiol 2007;166:1053-8.
37.	Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on physiological rhythms. Rev Neurol 2003;159 Suppl 11:6S11-20.