{'fraction_non_alphanumeric': 0.047050418452745456, 'fraction_numerical': 0.03582363747703613, 'mean_word_length': 4.895908543922984, 'pattern_counts': {'":': 0, '<': 16, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
RELATIONSHIP BETWEEN SLEEP, DIGITAL USAGE AND EMOTIONAL STATES IN THAI OCCUPATIONAL THERAPY STUDENTS

INTRODUCTION: Occupational imbalance of overloaded online education and sleep deprivation has been complained by Thai occupational therapy students (OTS) during the worldwide pandemic of coronavirus disease 2019 (COVID-19) e.g., feeling asleep in the classroom, inactive engagement in problem-based learning. METHODS: This cross-sectional study aims to survey the OTS (n = 52 out of 128) regarding many standardized tools: smartphone addiction, internet addiction, sleep quality, sleep hygiene, and emotional states. Data analysis includes Pearson’s and Spearman’s rank-order correlations, Chi-square tests, and calculation of point prevalence rates. RESULTS: A strong correlation of smartphone and internet addiction was found (r = 0.703, p < 0.001). Moderate correlations were addressed including sleep quality and smartphone addiction (r = 0.566), sleep quality and stress (r = 0.574), sleep quality depression (r = 0.554), and anxiety and smartphone addiction (r = 0.512). This study has reported point prevalence rates, such as 23.44% poor sleep quality, 17.96% smartphone addiction, and 7.81% anxiety. CONCLUSION: The unwell sleep OTS are gaining comorbidities of smartphone and internet addiction and negative emotional states than those well sleep OTS. A restoration of occupational balance will be required for those poor sleep quality and anxiety.


INTRODUCTION
Digital usage is studied for everyone in the 21st century; the numbers of smartphone users were reported at 5.22 billion people worldwide as well as 4.66 billion for internet users. [1] There were 90.66 million and 48.59 million Thais for smartphone and internet users, respectively. [1] International university students (n = 470) could not break a routine pattern of unhealthy lifestyle which was smartphone addiction or using the smartphone/tablet longer period of time than intended. They gained excessive use of the smartphone/tablet in classes, even controlled by their observed peers, resulting in poor academic performance over 2 years. [2] There were many smartphones and internet addiction studies in Thai university students [3][4][5]. Thai pharmacy students (N = 484) were surveyed and 39.1% out of 391 students were smartphone addiction. They preferred looking down at their smartphone/tablet screens rather than face-to-face communication which becomes negative emotional states of depression (p < 0.001) and stress (p < 0.002). [3] Thai Thammasat University students (n = 460) were smartphone addiction around 109 males and 156 females.
When compared to those students with no smartphone addiction, both genders with addictive smartphone scored higher depression and stress (p < 0.001). [4] Moreover, 45.8% out of 800 Thai university students at Chiang Mai who had engaged internet addiction; excessive levels of smartphone or tablet use including internet activities. They would be significantly scored low psychological well-being such as social relationship and meaningful life (p < 0.001). [5] Thai occupational therapy students (OTS) have activities including sleep quality and hygiene. [6] As seen those smartphone and internet addiction studied in Thai university student, however, no study was conducted in Thai Occupational Therapy Students (OTS) who would be trained for helping their clients with occupational participation after impairments of physical and mental health. Previously, there was significant correlation between quality of sleep and stress; internet addiction and stress in the Indian OTS study (n = 110). [7] Consequently, this OTS study suggests a prevention of smartphone and internet addiction is needed for enhancing occupational balance which is defined as individual experience of having right time use and amount of productive, leisure, and sleep activities. [8][9] Similarly, the Korean OTS study (n = 120) showed smartphone and internet addiction related negative relationships with interpersonal relationships, problem-solving skills, self-efficacy, participation in classes, and self-control learning. [10] The Spanish OTS study (n = 192) resulted a self-control on their internet use only 3.2% of samples and a moderate occupational imbalance (averaged 38.7 out of 65) meaning stress related too little spending on productive activities and too much internet activities without social engagement. [11] As seen those OTS studies were discussed in non-Thai cultural contexts and a number of lifestyle modification has been suggested [12][13][14][15], this study was firstly interested in

PARTICIPANTS AND PROCEDURE
This study was a cross-sectional descriptive study.

SAMPLE SIZE AND SUBJECT SELECTION
The sample size was calculated for 38.40, with the largest sample size required 40 students. [16] In order to minimize the risk of miscalculation, a replacement participant could be accepted in the event of a participant's withdrawal.
Inclusion criteria for subject selection included no history of psychiatric disorders and the daily use of smartphone as well as internet connection. Different age ranges between 18 and 23 years were excluded. All participants had the human rights for unwilling to participate, and request to be a withdrawal criterion halfway through the online survey.

INSTRUMENTS FOR DATA COLLECTION
The online survey consisted of five sections of the following The SAS-SV-TH [17] has been used to assess smartphone addiction behavior; a cut-off score above or equal to 31 and 33 for males and females, respectively. The SAS-SV-TH was composed of 10 items with scores ranging from 10 to 60; choices ranging from 1 (strongly disagree) to 6 (strongly agreed) for each question. The SAS-SV-TH had internal consistency of 0.94 for the total scale and validity with satisfactory at aged 18 to 23. [17] The IAT: Thai version [18] has been extenively tested for its psychometric properties; with 20 items to be rated ranging from 1(rarely) to 5(always). Total scores grater than 30 were considered internet addiction. Cronbach's alpha of 0.89 was previously tested at aged 18-25. [18] The T-PSQI [19] has been used to assess an overall sleep quality over one-month; consisted of 19 self-rated items.

STATISTICAL ANALYSIS
All obtained data were analyzed using the IBM Statistical [24]

PARTICIPANT CHARACTERISTICS
Fifty-two of OTS were recruited in this study (see Table 1).

SLEEP QUALITY AND HYGIENE
The T-PSQI averaged 6.10 ± 2.23 with its point prevalence rate of poor sleep quality 23.44% (n = 30). A moderate level practice of sleep hygiene behaviors has shown to be 3.51 ± 0.35 with its point prevalence rate of 32.81% (n = 42).
However, there was no significant correlation between sleep quality and sleep hygiene (r = -0.260, p = 0.063).   Table   2.

EMOTIONAL STATES
This study considered a cut-off scoring below 5, 4, and 8 for anxiety (n = 10), and 3.13% for mild to moderate stress (n = 4). Both depression and stress were strongly correlated (r = 0.702, p < 0.001) as shown in Table 2.

CORRELATION OF SMARTPHONE & INTERNET ADDICTION, SLEEP QUALITY, AND EMOTIONAL STATES
The results in Table 2 showed a moderate positive correlation between sleep quality and smartphone addiction (r = 0.566, p < 0.001). A weak positive correlation was found between sleep quality and internet addiction (r = 0.416, p < 0.05). Significant correlations of smartphone addiction and emotional states were found at depression (rs = 0.335, p < 0.05); anxiety (rs = 0.512, p < 0.001) and stress (rs = 0.411, p < 0.001). Moreover, internet addiction and emotional states were also found at depression (rs = 0.425, p < 0.001); anxiety (rs = 0.400, p < 0.001) and stress (rs = 0.445, p < 0.001). Significantly, a chi-square test found differences at 95% confidence interval; the unwell group (n = 30) seemed to get more problematic counts or comorbidities than the well sleep group (n = 22) as seen in Figure 1. Firstly, the mean + SD scores of self-report smartphone smartphone/tablet addiction, numbers of depression and stress were significantly counted more than those without smartphone/tablet addiction (p < 0.05). [3][4] However, Thai OTS might use smartphone to relieve anxiety because their anxiety scores was moderately correlated with smartphone addiction (r = 0.512, p < 0.001).
Implication for the further research of occupational participation suggests that time-use diary mixed in-depth interview can be used in order to determine whether Thai OTS are able to manage occupational balance or not. The OTS may be trained to prioritize doing self-care activities as the most importance as well as spending time with family and friends. [12] Using the Pomodoro techniques of 5-min breakout in every 25-min working is recommended. [13] As seen the OTS are easily distracted by digital stimuli [14], so that their emotional inhibition may not be created in the classrooms. Creative environment and meaningful activities may improve their concentration adapted to achieve the educational plan of digital usage. [15]

CONCLUSION
The main purpose of this study is achieved finding moderate correlations: smartphone addiction and anxiety, smartphone addiction and sleep quality, sleep quality and depression, and sleep quality and stress. Both smartphone and internet addiction are strongly correlated, and then both stress and depression are strongly correlated. This study raises awareness and engagement for a reduction of cognitive overload during the day, a prevention of smartphone/internet addiction, and a promotion of sleep quality related emotional states management in Thai OTS.

DECLARATION OF CONFLICT OF INTEREST
The authors decalre no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.