The association between smartphone use and sleep quality, psychological distress, and loneliness among health care students and workers in Saudi Arabia

Abdullah Muhammad Alzhrani; Khalid Talal Aboalshamat; Amal Mohammmad Badawoud; Ismail Mahmoud Abdouh; Hatim Matooq Badri; Baraa Sami Quronfulah; Mahmoud Abdulrahman Mahmoud; Mona Talal Rajeh

doi:10.1371/journal.pone.0280681

Peer Review History

Original SubmissionAugust 18, 2022
29 Nov 2022 Decision Letter - Yaser Mohammed Al-Worafi, Editor PONE-D-22-22716The association between smartphone use and sleep quality, psychological distress, and loneliness among health care students and workers in Saudi ArabiaPLOS ONE Dear colleagues, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 13 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study entitled "The association between smartphone use and sleep quality, psychological distress, and loneliness among health care students and workers in Saudi Arabia" has good sample size (n=773), a meaningful sample (i.e., healthcare students and workers), and appropriate statistical analyses. However, it should be improved with the following considerations. 1. Please elaborate more on the literature. The authors are encouraged in describing the generalized internet addiction and specific internet addiction in the Introduction. Moreover, the authors can indicate that some scholars consider smartphone addiction as generalized internet addiction because smartphone provides a variety of activities instead of specific activities (e.g., social media use and gaming). 2. The authors then should use some references to indicate that both generalized internet addiction and specific internet addiction have been found to be associated with sleep problems or psychological distress among students. This strengthen the rationale of studying the association between smartphone use and sleep quality/psychological distress. Ranjan LK, Gupta PR, Srivastava M, Gujar NM. Problematic internet use and its association with anxiety among undergraduate students. Asian J Soc Health Behav 2021;4:137-41 Oluwole LO, Obadeji A, Dada MU. Surfing over masked distress: Internet addiction and psychological well-being among a population of medical students. Asian J Soc Health Behav 2021;4:56-61 Kwok C, Leung PY, Poon KY, Fung XC. The effects of internet gaming and social media use on physical activity, sleep, quality of life, and academic performance among university students in Hong Kong: A preliminary study. Asian J Soc Health Behav 2021;4:36-44 Patel VK, Chaudhary P, Kumar P, Vasavada DA, Tiwari DS. A study of correlates of social networking site addiction among the undergraduate health professionals. Asian J Soc Health Behav 2021;4:30-5 3. It would be better to mention the association between sleep and psychological distress. 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 4. In Introduction, the authors have mentioned the impacts of COVID-19. They may want to elaborate this using some recent publications in the Sleep Epidemiology. 5. The SABAS has been recently validated in Malaysia student population. The authors may want to mention this to strengthen the rationale of using SABAS in the present study. Tung, S. E. H., Gan, W. Y., Chen, J.-S., Kamolthip, R., Pramukti, I., Nadhiroh, S. R., Chang, Y.-L., Lin, C.-C., Pakpour, A. H., Lin, C.-Y., Griffiths, M. D. (2022). Internet-related instruments (Bergen Social Media Addiction Scale, Smartphone Application-Based Addiction Scale, Internet Gaming Disorder Scale-Short Form, and Nomophobia Questionnaire) and their associations with distress among Malaysian university student. Healthcare, 10, 1448. 6. The statement "Moreover, females were found to be more dependent on their smartphones than males" can also be supported by a recent study. Xu P, Chen JS, Chang YL, et al. Gender Differences in the Associations Between Physical Activity, Smartphone Use, and Weight Stigma. Front Public Health. 2022;10:862829. Published 2022 Mar 29. doi:10.3389/fpubh.2022.862829 Reviewer #2: The first comment is you have not added line numbers for your document, it makes the comments to be addressed accurately. The figure 1 is not clear at all, also could not find figures 2 and 3. Table 1 does not present t-test or ANOVA as you claimed at the end of your methodology. You have presented interesting results, but you have no recommendation or suggestion. I think you should add a paragraph at least. I think you need to recheck carefully. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes: Nazdar Qudrat Abas ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0280681.r001
Revision 1
2 Jan 2023 Author Response Respond to reviewer We would like to thank the reviewers for their insightful comments, which we believe have overall improved the manuscript. In the below table, we have addressed each comment individually. To be organized, we used R1 and R2 to indicate the reviewer and a number for the comment (e.g. R1-1, R1-2 and so on) Reviewer#1 R1-1: The study entitled "The association between smartphone use and sleep quality, psychological distress, and loneliness among health care students and workers in Saudi Arabia" has good sample size (n=773), a meaningful sample (i.e., healthcare students and workers), and appropriate statistical analyses. However, it should be improved with the following considerations. Response: Thank you. Each comment was considered and has been addressed R1-2: 1. Please elaborate more on the literature. The authors are encouraged in describing the generalized internet addiction and specific internet addiction in the Introduction. Moreover, the authors can indicate that some scholars consider smartphone addiction as generalized internet addiction because smartphone provides a variety of activities instead of specific activities (e.g., social media use and gaming). Response: To address this comment additional information about generalized and specific smartphone/internet addition was added to the introduction along with appropriate references as follows: Change: …, including smartphone addiction, sleep disruption, loneliness, and distress, have been associated with smartphone use.[12–15] The use of smartphone relays on the availability of internet concoction since most of the smartphone application require internet connection. Therefore, some researchers consider smartphone addiction to be part of generalized internet addiction, when smartphones are overused to conduct a variety of activity, rather than specific internet addiction, when the internet is overused to conduct a particular activity such as social media use or gaming. [16,17] Both, specific and generalized internet addiction have been reported to be associated with poor sleep quality, psychological distress, and loneliness. [18–21] R1-3: The authors then should use some references to indicate that both generalized internet addiction and specific internet addiction have been found to be associated with sleep problems or psychological distress among students. This strengthen the rationale of studying the association between smartphone use and sleep quality/psychological distress. Ranjan LK, Gupta PR, Srivastava M, Gujar NM.Problematic internet use and its association with anxiety among undergraduate students. Asian J Soc Health Behav 2021;4:137-41 Oluwole LO, Obadeji A, Dada MU.Surfing over masked distress: Internet addiction and psychological well-being among a population of medical students. Asian J Soc Health Behav 2021;4:56-61 Kwok C, Leung PY, Poon KY, Fung XC. The effects of internet gaming and social media use on physical activity, sleep, quality of life, and academic performance among university students in Hong Kong: A preliminary study. Asian J Soc Health Behav 2021;4:36-44 Patel VK, Chaudhary P, Kumar P, Vasavada DA, Tiwari DS. A study of correlates of social networking site addiction among the undergraduate health professionals. Asian J Soc Health Behav 2021;4:30-5 Response: To address this comment additional information about generalized and specific smartphone/internet addition was added to the introduction along with the suggested relevant references as follows: Changes: “Smartphone addiction has been reported to be associated with poor sleep quality, psychological distress, and loneliness. [1–4] R1-4: It would be better to mention the association between sleep and psychological distress. 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 Response: We agree to this comment and text was edited Changes: “Poor sleep has been associated with adverse psychological and physical effects, such as depression, anxiety, heart disease, and psychological distress.[5,6] R1-5: In Introduction, the authors have mentioned the impacts of COVID-19. They may want to elaborate this using some recent publications in the Sleep Epidemiology. Response: We appreciate this comment. We have not mentioned the impacts of COVID-19 in this manuscript. Instead, we have gave an example of how smartphone-based applications can be useful in tracking COVID-19 cases and vaccination. We believe that there is no need to add more about COVID-19 impacts on sleep in the introduction because it is not the focus of this research. However, we think it is important to mention that COVID-19 may have an impact on our findings in the limitation section as follows. Changes: “As we are in COVID-19 aftermath, it is also possible that our findings are affected by the pandemic. Many studies reported association between COVID-19 and sleep and psychological problems [7,8].” R1-6: The SABAS has been recently validated in Malaysia student population. The authors may want to mention this to strengthen the rationale of using SABAS in the present study. Tung, S. E. H., Gan, W. Y., Chen, J.-S., Kamolthip, R., Pramukti, I., Nadhiroh, S. R., Chang, Y.-L., Lin, C.-C., Pakpour, A. H., Lin, C.-Y., Griffiths, M. D. (2022). Internet-related instruments (Bergen Social Media Addiction Scale, Smartphone Application-Based Addiction Scale, Internet Gaming Disorder Scale-Short Form, and Nomophobia Questionnaire) and their associations with distress among Malaysian university student. Healthcare, 10, 1448 Response: This study is relevant and has been added to the methods Changes: “achieved good Cronbach’s alpha scores of 0.81-0.88 in English,[9] [10]” R1-7: The statement "Moreover, females were found to be more dependent on their smartphones than males" can also be supported by a recent study. Xu P, Chen JS, Chang YL, et al. Gender Differences in the Associations Between Physical Activity, Smartphone Use, and Weight Stigma. Front Public Health. 2022;10:862829. Published 2022 Mar 29. doi:10.3389/fpubh.2022.862829 Response: The reference is relevant and has been cited Changes: Reference was added to text and reference list Reviewer#2 R2-1: Reviewer #2: The first comment is you have not added line numbers for your document, it makes the comments to be addressed accurately. I think you need to recheck carefully. Response: Due to journal submission process, line numbers was not added initially as it was not required. We apologize for any inconvenience. Changes: We added line number to the revised manuscript R2-2: The figure 1 is not clear at all, also could not find figures 2 and 3. Response: We now have submitted figures with higher quality. Figures 2 and 3 was not submitted due to error at our end. We apologize for that. We will make sure the complete files are submitted R2-3: Table 1 does not present t-test or ANOVA as you claimed at the end of your methodology. Response: The P-values in Table one are actually the findings of t-test and ANOVA or Mann-Whiteny and Kruskal-Wallis tests when indicated by Asterisk (). Changes: To make this clearer, we have added footnote to indicate which statistical test was used to obtain p-values (t-test, ANOVA, Whiteny and Kruskal-Wallis tests) R2-4: You have presented interesting results, but you have no recommendation or suggestion. I think you should add a paragraph at least. Response: We appreciate the reviewer comment, however, we would like to highlight that we have provided recommendation in the 6th paragraph in the discussion section, which mention the need to promote different strategies such as education, coping, psychological assessment to manage smartphone addiction. The following is the 6th paragraph in the discussion section “As indicated by the findings of this study and others, it is important to promote strategies to reduce smartphone dependency among health care students and workers. A meta-analysis by Malinauskas and Malinauskiene [52] concluded that cognitive behavioral therapy intervention is an effective method to reduce smartphone addiction. Another meta-analysis reported that increasing physical activity through exercise intervention could have positive effects on the management of smartphone addiction, especially when the smartphone user exercises on regular and continuous bases.[53] This is supported by this study, as we found that those who walk regularly had significantly lower addiction scores than those who do not walk or exercise. Educating smartphone addicts regarding coping strategies may also reduce addictive smartphone behavior.[50] It is also critical to manage withdrawal symptoms, such as negative feelings, impulsiveness, and anxiety, using psychological evaluations when necessary.[54] However, to further clarify this, we have amended the first sentence to be: Changes: “it is recommended to promote strategies…” Attachments Attachment Submitted filename: Respond to reviewer.docx* https://doi.org/10.1371/journal.pone.0280681.r002
6 Jan 2023 Decision Letter - Yaser Mohammed Al-Worafi, Editor The association between smartphone use and sleep quality, psychological distress, and loneliness among health care students and workers in Saudi Arabia PONE-D-22-22716R1 Dear Dr. Amal, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Yaser Mohammed Al-Worafi Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0280681.r003
Formally Accepted
18 Jan 2023 Acceptance Letter - Yaser Mohammed Al-Worafi, Editor PONE-D-22-22716R1 The association between smartphone use and sleep quality, psychological distress, and loneliness among health care students and workers in Saudi Arabia Dear Dr. Badawoud: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Yaser Mohammed Al-Worafi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0280681.r004

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