The mediating role of anxiety in poor sleep quality and passive coping among adolescents

doi:10.21203/rs.3.rs-4954919/v1

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Research Article

The mediating role of anxiety in poor sleep quality and passive coping among adolescents

https://doi.org/10.21203/rs.3.rs-4954919/v1

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Background

The increasing prevalence of poor sleep quality in children and adolescents highlights the essential role of quality sleep in promoting growth and development. Coping styles are associated with cognitive and behavioral adaptations to stress. However, their connection to sleep quality remains unclear.

Methods

In the summer of 2023, a cross-sectional survey was carried out among middle school students in Henan Province, China. The students were randomly chosen from five cities within the province, each representing varying economic levels, using a stratified random sampling approach. The questionnaire comprised inquiries regarding participants’ demographic details, along with assessments of sleep quality, anxiety levels, and coping styles. The Pittsburgh Sleep Quality Index (PSQI) was employed to gauge the sleep quality of middle school students. The Self-Rating Anxiety Scale (SAS) was used to evaluate the anxiety levels of participants. Additionally, coping styles were assessed using the Simplified Coping Style Questionnaire (SCSQ). The correlation coefficients among these three variables were calculated. The significance of the mediation effect was obtained using a bootstrap approach with SPSS PROCESS macro.

Results

This study included 592 middle school students, 76 (12.8%) had a poor sleep quality, while 23.0% showed signs of anxiety. Additionally, 54.6% of students employed passive coping styles in their daily lives. Spearman correlations analysis showed that poor sleep quality was positively correlated with anxiety (r = 0.583, P < 0.01) and passive coping (r = 0.175, P < 0.01). Anxiety was positively correlated with passive coping (r = 0.206, P < 0.01). We validated the significance of the indirect effect of sleep quality mediated through anxiety(95% bootstrap CI = 0.048, 0.112). The percentage of indirect effect was calculated to be 84.4%. The mediating role of anxiety in passive coping and poor sleep quality was established and was fully mediated.

Conclusions

The mediating effect of anxiety on passive coping and poor sleep quality was confirmed and found to be fully mediated. Passive coping style is associated with inadequate sleep quality and the occurrence of anxiety symptoms. Assessing the correlation between sleep quality and coping style among middle school students is crucial for developing effective health promotion strategies to improve students’ health.

mediating role

passive coping

sleep quality

adolescents

Sleep is a fundamental necessity for humans and serves as a crucial health indicator[1]. Sufficient and high-quality sleep is essential for the physical, mental, and emotional development of young individuals[2]. Adolescents, undergoing the transition from childhood to adulthood, are in a critical stage of robust physical and mental maturation. This special period of acquiring knowledge and skills is marked by social vulnerability and health fragility. Studies indicated that adolescence was a high-risk period for the emergence and sharp escalation of mental disorders, including sleep disturbances[3]. With escalating societal expectations and academic pressures, teenagers commonly experience sleep issues[4]. These problems not only disrupt daily life but also hinder learning and development[5]. In addition, insufficient sleep among students is associated with a higher prevalence of poor vision[6], and is a major cause of overweight and obesity[7] among secondary school students, as well as sleep may be a potential risk factor for hypertension later in life in children, aged 2-9.9 years[8]. Overall, the sleep quality in children and adolescents is a public health concern that requires attention to enhance their health.

Sleep quality could be influenced by various factors, with coping style emerging as a key factor[9]. Students who adopt immature and passive coping strategies tend to encounter more sleep-related issues[10]. Coping is the strategies individuals choose to deal with challenging or distressing situations, ultimately affecting their mental health and psychosocial outcomes[11]. The primary goal of coping is to adapt to the consequences of stressful event by assessing their severity and modifying somatic or emotional responses[12]. Coping contains two aspects as the active coping and passive coping. Passive coping entails avoiding the positive confrontation of stressful events, leading to negative emotions and behaviors such as problem avoidance, self-blame, and unhealthy habits like smoking, drinking[13], substance abuse, and excessive internet addiction[14]. Prolonged passive coping tendencies could evolve into a passive approach towards life events, triggering psychological and physiological changes in response to adverse circumstances, ultimately impacting the sleep duration and efficiency of teenagers [9, 15].

Poor sleep quality are closely associated with emotional and behavioral challenges[16, 17]. Epidemiological studies indicated that sleep disorders, especially insomnia, affect about 50% of people with anxiety disorders, and sleep deprivation can potentially trigger or further worsen anxiety disorders [18]. Approximately 20% of school-age children experience sleep disorders that can impair attention, cognition, memory, alertness, and language skills, leading to learning and behavioral difficulties and affecting parent-child relationships[19]. Furthermore, individuals experiencing chronic sleep disturbances are often accompanied by severe anxiety symptoms [20]. Moreover, short-term sleep disorders could impair attention and memory, while long-term sleep disorders would lead to a decline in immune function and trigger various physiological responses[21]. Among these, frequent mood swings exert the most significant impact on sleep quality[2]. This could be due to the heightened anxiety levels in individual, which can increase brain nerve excitability, making it more difficult to fall asleep. Meanwhile, early sleep issues may signal the emergence of behavioral or emotional challenges, particularly in children and adolescents[11].

Anxiety is an emotional state characterized by feeling of tension, worried thoughts, and physical changes like elevated blood pressure. Long-term anxiety would progress into anxiety disorders. Anxiety disorders represent the most prevalent type of mental health condition, with their global prevalence on the rise[22]. If left untreated, anxiety disorders can evolve into chronic conditions, leading to academic failure, unemployment and even premature mortality, seriously affecting both individuals and society[23]. Anxiety, being a negative emotional state, could detrimentally affect the quality of sleep[24]. Studies indicated that anxiety was a common issue among Chinese students and had been a persistent concern. A study conducted by Chen et al involving 63,205 secondary school students from Western China middle school, revealed one-fourth of the secondary school students in Western China suffered from depressive and anxiety symptoms, impacting their enjoyment of life, relaxation, and sleep[25]. In a survey by Gao et al involving 1,892 students from 15 Chinese universities, anxiety emerged as the most prevalent and severe psychological challenge among Chinese college students, especially affecting female students [26]. Additionally, a study by Liu et al highlighted a heightened level of anxiety among middle school students in rural China, emphasizing the significance of addressing anxiety issues in children and adolescents[27]. This may be due to the fact that higher anxiety levels in an individual can lead to increased brain nerve excitability, making it more challenging to fall asleep. This suggests that anxiety might act as a mediator in the relationship between coping styles and sleep quality. Therefore, it suggests to us that anxiety may play a mediating role in the effect of coping style on sleep quality.

In our study, we examined the present status of sleep quality among junior middle school students, explored the association between passive coping strategies and sleep quality, and performed a mediation analysis to investigate the mediating role of anxiety between passive coping and sleep disturbances. Middle school students are in an important transitional phase from childhood to adulthood, engaging in education and acquiring diverse knowledge and skills. Therefore, this research contributes to a deeper comprehension of the mechanisms underlying sleep disorders in middle school students, which is highly valuable for enhancing their sleep quality.

Participants

From July to August 2023, we selected five cities in Henan province based on their economic levels, arranged from high to low as Zhengzhou, Luoyang, Zhoukou, Pingdingshan and Sanmenxia. Employing convenience sampling, a field survey was conducted where all respondents were requested to complete the questionnaire on the spot. The investigators conducted real-time checks to ensure the completeness of the questionnaires. Subsequently, after excluding any invalid responses, a total of 636 questionnaires were collected, out of which 592 were deemed valid, resulting in an effective rate of 93.1%. The research conducted at Zhengzhou University was approved by the Science Ethics Committee, and written informed consent was obtained from each participant before commencing any study-related investigations.

Measures

Basic information

Participants' demographic information, such as age, gender, urban or rural residence, and city of domicile, was collected through a self-administered questionnaire.

Measurement of sleep quality

Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI)[28]. The PSQI is a valuable tool for evaluating sleep quality in individuals with sleep and mental health conditions, as well as in the general population, and is particularly useful for screening insomnia. Comprising eighteen items, the PSQI covers seven dimensions: sleep quality, sleep onset latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Each dimension is scored from 0 to 3 points, and the sum of all dimension scores yields the total PSQI score. A higher total score indicates poorer sleep quality, with a score exceeding 7 indicative of a poor sleep quality.

Measures of anxiety

Anxiety levels was measured using Zung's Self-Rating Anxiety Scale (SAS)[12], a commonly utilized normative scale for screening anxiety disorders. The SAS comprises 20 items, with each item rated on a 4-point scale ranging from 1 to 4. The standard score is calculated as the raw score multiplied by 1.25, and a standard score of 50 is considered the reference value. In this study, anxiety was deemed to be present if the standard score exceeded 50.

Measurement of coping tendency

Simplified Coping Style Questionnaire (SCSQ) was used to assess the coping tendency of the participants[29]. The SCSQ comprises 20 items rated on a 4-point scale ranging from 0 to 3, encompassing both active and passive coping styles. Active coping styles are represented by items 1–12, while passive coping styles are indicated by items 13–20. For this study, the passive coping style section, consisting of entries 13–20, was utilized.

Statistical analysis

The descriptive analyses of the demographic characteristics and correlation analyses of the three variables were calculated. A mediation analysis was carried out with passive coping style as the independent variable, sleep disturbance as the dependent variable, and anxiety as the mediator. The mediation model was analyzed using Model 4 in the PROCESS macro, with control variables such as age, gender, and urban/rural status included as covariates[30]. To assess the mediation effects effectively, 95% confidence intervals were calculated, with a bootstrap sample size of 5000. If the confidence interval encompasses zero, it indicates a lack of significant mediating (indirect) effect at the 5% significance level. All analyses were performed using SPSS 27.0 for Windows.

Demographic characteristics

Table 1 presents the detailed demographics of the participants in this study. A total of 592 middle school students were enrolled, with 253 males (42.7%) and 339 females (57.3%). Among them, 354 were from urban area (59.8%) and 238 were from rural areas (40.2%). The students were from five regions including Zhengzhou, Luoyang, Zhoukou, Pingdingshan and Sanmenxia in Henan province. The prevalence of poor sleep quality varied among these cities (p < 0.05). Students in Luoyang City had the highest prevalence of poor sleep quality (16.7%), while those in Zhoukou City had the lowest prevalenc (5.5%). Gender, grade, city residence, and living arrangements with parents did not exhibit significant differences in the prevalence of poor sleep quality.

Table 1

Comparison of the difference in the prevalence of poor sleep quality
Variables	Number of people participate	Prevalence of poor sleep quality (%)	χ2	P-value
Gender			3.451	0.063
Male	253	25 (9.9)
Female	339	51 (15.0)
Residence			1.302	0.254
City	354	50 (14.1)
Country	238	26 (10.9)
Living area			9.930	0.042
Zhengzhou	62	6 (9.7)
Luoyang	162	27 (16.7)
Zhoukou	128	7 (5.5)
Pingdingshan	150	23 (15.3)
Sanmenxia	90	13 (14.4)
Grade			6.656	0.084
Preincubation	43	6(14.0)
First	246	22(8.9)
Second	71	9(16.8)
Third	232	39(12.8)
Live with parents			0.764	0.382
Yes	502	67(13.3)
No	90	9(11.8)

Sleep quality, anxiety and coping style among participants.

The descriptive statistics of sleep quality, anxiety levels, and coping style scores among the students were shown in Table 2. According to the cross-sectional survey results, the average score on the PSQI was 4 (2,6). Specifically, the prevalence of poor sleep quality, defined by a PSQI total score greater than 7, was found to be 12.80%. this prevalence aligns closely with findings from previous studies[31], indicating consistency in the assessment of poor sleep quality among middle school students. The average score of SAS was 40 (33.75, 48.75), with a detection rate of anxiety defined by a SAS total score over 50 at 23.0%. Within this group, 16.20% exhibited mild anxiety, 4.40% showed moderate anxiety, and 2.40% experienced severe anxiety. These findings provide insights into the prevalence and severity of anxiety among the

surveyed population.

Table 2

Descriptive statistics of sleep quality, anxiety, and coping style scores of students
Items	M (P25, P75)	Level	Proportion(%)
PSQI	4(2,6)	Sleep well	60.0
		Average sleep quality	27.2
		Poor sleep quality	12.8
SAS	40(33.75, 48.75)	Normal	77.0
		Mild anxiety	16.2
		Moderate anxiety	4.4
		Severe anxiety	2.4
SCSQ	-0.136(-0.726,0.726)	Active	45.4
SCSQ	-0.136(-0.726,0.726)	Passive	54.6
Note. PSQI: Pittsburgh Sleep Quality Index;SAS: Self-Rating Anxiety Scale༛SCSQ༚Simplified Coping Style Questionnaire

Coping styles were categorized into active and passive coping styles. The distribution of coping styles showed an average score of -0.136 (-0.726,0.726). Among these students, 54.6% predominantly utilized passive coping styles in their daily lives, with an average score of 8 (5.25, 12). Conversely, 45.4% employed active coping styles, with an average score of 20 (14, 24) (Table 3). This breakdown illustrates the prevalent coping strategies adopted by the participants surveyed.

Preliminary correlation analyses among sleep quality, coping style and anxiety.

From all the participants in our study, the following observations were noted. The scores on the PSQI ranged from 0 to 16, with a mean score of 4(2,6). Scores on the SAS ranged from 25 to 90, with a mean score of 40(33.75, 48.75). Scores on the SCSQ ranged from − 3.32 to 3.39, with a mean score of -0.136(-0.726,0.726). Additionally, the mean score for passive coping was 8 (5.25, 12), while active coping had a mean score of 20 (14, 24). Spearman correlations revealed significant associations among these variables. The results showed that poor sleep quality was positively correlated with anxiety (r = 0.583, P < 0.01) and passive coping (r = 0.175, P < 0.01). Anxiety was positively correlated with passive coping (r = 0.206, P < 0.01). Meanwhile, active coping scores showed negative correlations with poor sleep quality (r=-0.296, P<0.01)and anxiety (r=-0.402, P<0.01). These findings are summarized in Table 3.

Table 3

Correlations between sleep quality, anxiety and coping style
Variables	M (P25, P75)	1	2	3	4
1 Sleep Quality	4(2,6)	-
2 Anxiety	40 (33.75, 48.75)	0.583**	-
3 Active coping	20(14,24)	-0.296**	-0.402**	-
4 Passive coping	8(5.25,12)	0.173**	0.206**	0.264**	-
**P<0.01

Mediation analyses between passive coping and sleep quality.

Based on the correlation analyses, we proceeded with mediation analyses to further examine the direct relationships among coping style, anxiety, and sleep quality in secondary school students. Specifically, we focused on the passive coping component of the SCSQ. Upon adjusting for socioeconomic variables (gender, urban-rural, and region of living), we assessed the significance of direct, indirect, and overall effects within the mediation model. In Model 1, passive coping exhibited a statistically significant associated with sleep quality after accounting for demographic variables (β = 0.163, p < 0.01). In Model 2, while controlling for demographic variables, passive coping showed a significant relationship with anxiety (β = 0.242, p < 0.01). Subsequently, in Model 3, after adjusting for demographic variables, both passive coping and anxiety were included in the mediation analysis. Here, passive coping did not demonstrate a significant direct relationship with sleep quality (β = 0.025, p > 0.05), whereas anxiety showed a significant effect on sleep quality (β = 0.568, p < 0.01) (Table 4).

Table 4

Mediating effect of anxiety between Passive coping and Poor Sleep Quality
Model	Model 1		Model 2		Model 3
Dependent variable	poor sleep quality		anxiety		poor sleep quality
	b	t	b	t	b	t
Gender	0.107	2.653**	0.053	1.327	0.077	2.300*
Residence	0.094	2.326**	0.123	3.072**	0.024	0.721
Living area	0.108	2.670**	0.087	2.177*	0.059	1.741
Passive coping	0.163	4.040**	0.242	6.078**	0.025	0.738
Anxiety					0.568	16.410**
R²	0.054		0.078		0.352
Adjusted R²	0.048		0.072		0.346
F	8.389**		12.421**		63.638**
P<0.05 *P<0.01

Furthermore, employing the non-parametric bootstrapping method, we validated the significance of the indirect effect of poor sleep quality mediated through anxiety(95% bootstrap CI = 0.048, 0.112). This indirect effect was confirmed, highlighting anxiety played a significant mediating role within the model. The confidence interval for the direct effect test yielded (-0.024, 0.052), indicating that the direct effect was not statistically established. The percentage of the total effect attributable to the indirect pathway was calculated to be 84.4%༈Table 5). These findings suggest that anxiety likely mediates the relationship between passive coping and poor sleep quality, representing a fully mediated pathway. Figure 1 illustrated the mediation model, along with standardized path coefficients for clarity.

Table 5

Mediating model examination by bootstrap
	Effect	SE	LLCL	ULCL
	0.094	0.023	0.048	0.139
Direct effect	0.015	0.020	-0.024	0.053
Indirect effect	0.079	0.016	0.048	0.112

In all, our research revealed that 12.80% of participants experienced poor sleep quality, while 23.0% showed signs of anxiety. Additionally, 54.6% of students employed passive coping styles in their daily lives. Spearman correlation analyses demonstrated that poor sleep quality positively correlated with both anxiety and passive coping. Moreover, anxiety showed a positive correlation with passive coping behaviors. Further mediation analyses indicated a significant association between passive coping and poor sleep quality. Importantly, anxiety emerged as a significant mediator in this relationship, with the indirect effect explaining 84.4% of the total effect. These findings suggest that anxiety fully mediates the association between passive coping and poor sleep quality.

The prevalence of poor sleep quality among middle school students in this study was 12.8%, which was significantly different from the results in India (2.5%)[32] and Turkey (36.4%)[33]. Compared to other regions in China, our results were lower than those reported by Ren et al (26.7%)[34], but similar to findings by Yang et al (10.8%)[31]. These variations may be due to selection of respondents or demographic characteristics. Our study found no significant differences in the prevalence of poor sleep quality in gender, residence or grade. However, there were differences in residential areas, potentially influenced by economic conditions and other contextual factors.

The results of the correlation analysis revealed several significant relationships. Firstly, passive coping was found to have a significantly positive correlation with anxiety and PSQI scores. This suggests that individuals who employ passive coping styles are more likely to experience heightened anxiety levels and poorer sleep quality. Moreover, there is also a significant positive correlation between anxiety and PSQI. This finding aligns with previous research[35, 36], which has consistently shown that higher anxiety levels are associated with lower sleep quality. This relationship underscores the impact of anxiety on sleep disturbances. Research has also highlighted that individuals suffering from insomniacs often resort to passive and immature coping strategies[34]. Interestingly, while the number of life events experienced by insomniacs may not increase compared to those with good sleep, the frequency of negative events they encounter does significantly rise. This suggests that passive coping styles can intensify negative emotional experiences, subsequently affecting sleep quality. Overall, these findings emphasize the detrimental effects of passive coping on both anxiety levels and sleep quality, illustrating the interconnectedness of psychological coping mechanisms and sleep outcomes.

Regression analysis was conducted with coping style as the independent variable and both sleep quality and anxiety as dependent variables. The results revealed that higher scores in passive coping were associated with increased anxiety levels and poorer sleep quality, consistent with previous findings[37]. Furthermore, a mediation model was established with passive coping style as the independent variable, anxiety as the mediating variable, and sleep quality as the dependent variable. According to this model, passive coping styles positively predicted both anxiety and sleep quality. Importantly, anxiety was found to fully mediate the relationship between passive coping and sleep quality. These findings suggest that students who frequently employ passive coping mechanisms are more likely to experience heightened anxiety levels, which in turn adversely affects their sleep quality and may lead to poor sleep quality. Addressing students' coping styles is crucial not only for enhancing their sleep quality but also for reducing anxiety-related issues.

Sleep disorders not only disrupt sleep itself, but are also associated with a variety of psychiatric disorders. Maintaining adequate sleep duration promotes positive emotions, while improving sleep quality reduces the risk of emotional disorders[19, 38–40]. Insomnia and sleep deprivation are prevalent among children and are associated with symptoms of mental health and immunity disorders[41, 42]. Children with early sleep disturbances and more severe anxiety symptoms are at higher risk of suicidal behaviors later in life [35]. Adolescents transitioning into adulthood may carry sleep-related challenges with long-term implications. Therefore, integrating sleep-related issues into anxiety prevention and intervention strategies holds significant public health implications[43, 44]. Our results suggest actionable insights for interventions aimed at improving coping strategies and ultimately enhancing psychological and sleep health among students.

Currently, mental health services in China are insufficient[45]. Adolescents are a pivotal demographic within the student population, with families and schools serving as crucial sources of psychological support[46]. They play significant roles in adolescents' lives. It is essential for schools and families to actively monitor students' academic progress, foster a supportive academic environment, and employ educational interventions to mitigate or prevent stressful events, and help students reduce the frequency of passive coping styles, so as to achieve the goal of improving sleep quality. Although short-term educational interventions have been found to improve sleep knowledge, but fall short in improving sleep quality[47]. Research indicates that physical exercise can mitigate passive coping styles[48], thereby improving sleep and reducing fatigue[49]. Maintaining a regular circadian rhythm and promoting a healthy lifestyle are also effective strategies for enhancing sleep quality[50]. Moreover, increasing breakfast frequency indirectly influences sleep duration and mood-related symptoms, thereby contributing to improved sleep quality[51].

In summary, our findings indicate that passive coping styles might elevate anxiety levels, consequently heightening the likelihood of poor sleep quality. These insights have enhanced our understanding of how passive coping styles contribute to poor sleep quality, and provided theoretical foundations and intervention strategies for preventing poor sleep quality in middle school students. Our research also has some limitations. As this is a cross-sectional study, it limits its ability to establish a causal relationship. Future work should further confirm the association through cohort long-term follow-up studies and involving more participants.

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki. All study participants signed informed consent forms. Clinical trial number: not applicable.

Consent for publication

Not applicable

Availability of data and materials

All data generated or used during the study are shown to be available through the corresponding author.

Competing interests

The authors declare that they have no competing interests.

Funding

This study sponsored by Natural Science Foundation of Henan（222300420305）, and there are no financial conflicts of interest.

Authors' contributions

Yongjuan Xin, Shuxin Zhao and Changfu Hao conceived, designed, and coordinated the study, and approved final version to be submitted. Shuxin Zhao collected and analyzed the data and wrote the manuscript. Chunguang Mu, Yanna Shang and Wenjie Yang helped with the collection and analysis of the data. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

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The mediating role of anxiety in poor sleep quality and passive coping among adolescents

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