The Journal of School Nursing2022, Vol. 38(2) 173–183© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520921920journals.sagepub.com/home/jsn
The purpose of the study is to identify the relationships between allergic disease, suicidal ideation, and plans among Korean adolescents. Additionally, we examined the mediating role of short sleep duration. We analyzed nationally representative cross-sectional data from the 12th to 14th Korea Youth Risk Behavior Web-Based Survey; the final sample included 164,725 middle school–aged and high school–aged adolescents (mean age = 15.17 years, standard deviation = .13; 51.1% male). Allergic disease was a statistically significant risk factor for suicidal ideation (crude odds ratio [COR] = 1.284, 95% confidence interval [CI] = [1.246, 1.323]) and suicide plans (COR = 1.165, 95% CI = [1.108, 1.224]). Short sleep duration was a statistically significant mediator (p < .001). We advised school nurses to assess warning signs of poor sleep—including irritability, depression, sleep problems, poor concentration, and poor academic achievement—and that programs be created to improve sleep and mental health in adolescents with allergic disease.
short sleep duration, allergic disease, suicidal plans, adolescents, mediation, school nursing
About 67% of middle school–aged and high school–aged adolescents have one allergic disease and about 33% have two or more (Sterner et al., 2019). Allergic disease is commonly related to genetic determinants and environmental factors (Barnes, 2000; von Mutius, 2000). The most prevalent allergic diseases among Korean adolescents in 2017 were asthma (8.8%), allergic rhinitis (35.8%), and atopic dermatitis (25.1%). These allergies have rapidly increased in Korea in step with their rates in developed Western countries (Oh & An, 2019).
Asthma symptoms such as wheezing and dyspnea worsen at the end of the night or early in the morning, interfering with the ongoing sleep process and reducing sleep quality and duration (Bhattacharjee et al., 2018; Perikleous et al., 2018; Ramirez et al., 2019). Additionally, inflammatory mediators in allergic rhinitis, such as histamine and certain cytokines, can act directly on the central nervous system by altering sleep rhythm, resulting in sleep disruption (Loekmanwidjaja et al., 2018; Zhou et al., 2015). Meanwhile, atopic dermatitis is an inflammatory skin disease that involves severe pruritus; the itching can last all night, frequently disrupting sleep. Silverberg et al. (2015) noted that about 60% of adolescents with atopic dermatitis experience sleep disturbances. Furthermore, as allergic diseases occur mainly in childhood and involve chronic progression, middle school–aged and high school–aged adolescents experience negative impacts on overall quality of life including physiological and psychological health in the form of sleep disorders and suicidality (Littlewood et al., 2019; Steinberg et al., 2015).
Lack of sleep time is a risk factor for middle school–aged and high school–aged adolescents’ physical and psychological growth and development (Verkooijen et al., 2018). Despite the fact that sufficient sleep time is an essential element of mental health in adolescents, short sleep duration is widespread in this population; accordingly, it has been receiving much attention as a social health issue (Owens & Adolescent Sleep Working Group, 2014). Notably, East Asian adolescents, including Koreans, spend significantly less time sleeping, in part due to Korea’s unusually competitive academic system (J. E. Lee et al., 2017).
Inadequate sleep duration has been reported to be strongly associated with behavioral and psychosocial problems and health risk behaviors, including suicidality, in middle school–aged and high school–aged adolescents (Verkooijen et al., 2018). It is important to note that short sleep duration is related to self-harm and depression symptoms in adolescents (Yeo et al., 2019). Furthermore, short sleep duration has been related to mental health and an increased risk of anxiety disorders in youth aged 11–17years (Roberts & Duong, 2017). Middle school–aged and high school–aged U.S. adolescents are now more likely to have shorter sleep times than they were a few decades ago (Keyes et al., 2015). About 66% of middle and high school students in China are facing consequences of sleep deficiency (Wang et al., 2018), and about 26% of Canadian adolescents were short sleepers (Chaput & Janssen, 2016).
Whitmore and Smith (2019) emphasize that school-aged adolescents’ lack of sleep time requires attention because it is a serious risk factor for suicidal ideation and plans. It is crucial to note that Korean adolescents who sleep 6 r or less are about 1.3 times more likely to demonstrate suicidal ideation compared to adolescents in the 8 hr more sleep duration (Park & Kim, 2017).
Globally, 17% of middle school–aged and high school–aged adolescents engage in suicidal ideation and plans (Uddin et al., 2019). Despite the decrease in suicide rates over the past two decades, suicidal ideation and attempts remain common among school-aged adolescents (Siu, 2019). To be sure, such a suicidal tendency is a severe public health problem, given its serious impact on affected individuals and their families (Muhammad et al., 2018). To prevent death by suicide, it is important to detect the indicators of suicidal thoughts (Lewis et al., 2014). As school-aged adolescents are more emotionally unstable and impulsive than adults, they tend to conceal their health and emotional states and attempt suicide unexpectedly; this makes it difficult to detect their suicide plans (De Los Reyes et al., 2015). With the difficulty in detection together with the fact that suicidal ideation climaxes during adolescence emphasizes the importance of identifying the influencing factors of suicidal ideation and plans among school-aged adolescents (Ordaz et al., 2018).
Adolescents with allergic disease have been reported to demonstrate greater perceived stress, greater perceived sleep problems, and more severe depression than their counterparts without allergic disease (Bedolla-Barajas et al., 2018; Muhammad et al., 2018; Shin et al., 2018). Moreover, short sleep duration in adolescents has been reported to affect suicidal ideation and plans (Whitmore & Smith, 2019). However, research linking allergic disease, short sleep duration, and suicidal ideation and plans in adolescents is scarce. Indeed, few studies examine the mediating effect of short sleep duration on these associations in representative samples of South Korean middle school–aged and high school–aged adolescents.
In an effort to address this gap, the purpose of this study is to (1) identify the prevalence of allergic disease among Korean adolescents in relation to demographic characteristics and short sleep duration, (2) identify suicidal ideation and plans in relation to demographic characteristics and short sleep duration, (3) examine the associations between allergic disease and suicidal ideation and plans, and (4) investigate the mediating effect of short sleep duration on the relationships between allergic disease and suicidal ideation and plans.
We obtained secondary cross-sectional data from the 2016–2018 National Korea Youth Risk Behavior Web-Based Survey (KYRBWS) conducted by the Korea Centers for Disease Control and Prevention (KCDC) in South Korea. This survey was approved by the Institutional Review Board (IRB) of the KCDC; Y. Kim et al., 2016). The KYRBWS includes health behaviors related to smoking, drinking, physical activity, diet, mental health, sexual behavior, allergic disease, substance use, and sleep (S. Y. Kim et al., 2019). Adolescents who gave informed consent by the way of an online form were protected by ensuring anonymous and voluntary participation. Informed consent from their parents was exempted. It used the stratified and multistage cluster sampling designed to explore the health behaviors of middle school–aged and high school students aged 12–18 years in South Korea. The IRB of Chung-Ang University (IRB No. 1041078-201908-HRSB-227-01) exempted this study from the requirement for ethical approval because it conducted a secondary analysis of a government-approved statistical survey.
Annually, 400 student participants were selected from middle schools, high schools, and vocational high schools, with regional groups (big city, medium-sized city, and rural area) used as stratification variables. After the survey, sampling weights were represented by consideration of the response and sampling rates, and these sampling weights were applied to the analysis to estimate the parameters.
Finally, this study involved an analysis of the data derived from 164,725 middle school–aged and high school–aged adolescents in the 12th–14th KYRBWS. The 12th KYRBWS was conducted in 2016 (N = 65,528, 87.6% response rate), the 13th KYRBWS in 2017 (N = 62,276, 87.6% response rate), and the 14th KYRBWS in 2018 (N = 60,040, 87.8% response rate; Ministry of Education, Ministry of Health and Welfare, & Korea Centers for Disease Control, 2017, 2018, 2019).
Demographic characteristics. These included age, gender, school type, city type, economic level, academic performance, perceived depression, and whether the respondents had ever had alcohol, smoked cigarettes, or used drugs. School type was classified as “middle school (aged 12–15 years),” “general high school (aged 15–18 years),” or “vocational high school.” City type was categorized as “large,” “medium,” or “small.” Economic level was identified as “very high,” “high,” “average,” “low,” or “very low.” Academic performance was classified as “very high,” “high,” “moderate,” “low,” or “very low.” All responses for perceived depression and ever having had alcohol, smoked cigarettes, or used drugs were dichotomized into “yes” or “no.”
Allergic disease. In the KYRBWS, respondents were asked “Have you ever been diagnosed with asthma, allergic rhinitis, or atopic dermatitis by a doctor?” All responses were categorized as “yes” or “no.” Those who responded “yes” were classified as having an allergic disease, while those who responded “no” were classified as not having an allergic disease.
Short sleep duration. Short sleep duration was estimated using the following question: “During the last 7 days, what time did you go to bed and wake up on weekdays?” Sleep duration was calculated from the difference between these two reported times, and fewer than 6 hr per day was considered short sleep duration, following previous studies linking insufficient sleep with health problems among adolescents (Calamaro et al., 2010; Roberts & Duong, 2017; Winsler et al., 2015). Short sleep duration was classified as “yes (less than 6 hr).” The opposite was classified as “no (more than 6 hr).”
Suicidal ideation and plans. Suicidal ideation and plans were assessed by the following questions: “During the last 12 months, have you seriously considered suicide?” and “During the last 12 months, have you made specific plans to commit suicide?” The response options were “yes” or “no.”
We analyzed a complex sample design of the crosssectional survey data using the IBM SPSS statistics Version 25.0 (SPSS Inc., Chicago, IL, USA) that provided sampling weights and nationally representative estimates. Descriptive statistics were used to present continuous variables as mean and standard error and categorical variables as percentages and standard error. For categorical variables, χ2 tests were employed to analyze differences in allergic disease and suicidal ideation and plans by demographic characteristics. To compare continuous variables, an independent t test was used.
We used a multivariate logistic regression model to identify these associations. The model was adjusted for age, gender, school type, city type, economic level, academic performance, perceived depression, and ever having had alcohol, smoked cigarettes, or used drugs. It represents multivariate adjusted odds ratios and 95% confidence intervals (CIs). A p value < .05 was considered statistically significant.
The mediational role of short sleep duration in the association between allergic disease and suicidal ideation and plans was identified in accordance with Baron and Kenny’s (1986) model. Suicidal ideation and plans were the dependent variable, allergic disease was the independent variable, and short sleep duration was the mediating variable. The indirect role of short sleep duration in these associations was statistically examined by the Sobel (1982) test. The indicator of the mediation effect size was measured by the ratio of indirect to total effect using Alwin and Hauser’s (1975) method.
Table 1 presents the sample characteristics and differences in prevalence of allergic disease in relation to demographic characteristics and short sleep duration among Korean adolescents. There were significant differences in allergic disease by demographic characteristics. Specifically, the characteristics associated with having allergic disease were older age, female gender, attending a general high school, living in a large- or medium-sized city, having a high or low economic level, having very high or high academic performance, enduring perceived depression, and alcohol consumption. Korean adolescents with allergic disease reported sleeping an average of 6.24 hr (standard deviation = .005) a night, and about 25.8% of Korean adolescents with allergic disease reported short sleep duration (fewer than 6 hr; Table 1).
The differences in suicidal ideation and plans for suicide in relation to demographic characteristics and short sleep duration among Korean adolescents are depicted in Table 2. The results showed significant differences; specifically, the characteristics associated with a greater probability of having suicidal ideation over the last 12 months were female gender; being in middle school; having a low or very low economic level; having low or very low academic performance; perceived depression; and alcohol, cigarette, or drug consumption. Additionally, the characteristics associated with a higher likelihood of having suicidal plans over the last 12 months were female gender; being in middle school; having a very high, low, or very low economic level; having low or very low academic performance; perceived depression; alcohol, cigarette, or drugs consumption; and short sleep duration. About 33.1% or 33.4% of Korean adolescents who experienced suicidal ideation or plans reported short sleep duration (fewer than 6 hr; Table 2).
Table 3 depicts the relationships between allergic disease and suicidal ideation and plans among Korean adolescents. Allergic disease was a statistically significant risk factor for suicidal ideation (crude odds ratio [COR] = 1.284, 95% CI = [1.246, 1.323]) and suicidal plans (COR = 1.165, 95% CI = [1.108, 1.224]; Table 3).
Table 4 presents the mediating effect of short sleep duration on the relationships between allergic disease and suicidal ideation and plans among Korean adolescents. The results of the multivariate logistic regression analyses are depicted. The Sobel test revealed that the mediational role of short sleep duration in these relationships was statistically significant (all p < .001). Table 4 also presents the ratios of indirect to total effects—a marker of mediation effect size proposed by Alwin and Hauser (1975); in this case, it indicates the mediating effect size of short sleep duration in these relationships. The effect size of allergic disease mediated by short sleep duration was 6.14% for suicidal ideation and 10.13% for suicidal plans (Table 4).
We identified the relationships between allergic disease and suicidal ideation and plans among Korean adolescents, focusing on the mediating role of short sleep duration. Ultimately, we found that 6 hr of sleep or more was associated with decreased reports of suicidal ideation and plans.
This study indicated that middle school–aged and high school–aged Korean adolescents with allergic disease are at higher risk of short sleep duration than those without allergic disease. This finding is similar to previous studies in which adolescents with asthma had a higher risk of disturbed sleep owing to nocturnal asthma symptoms (Lawless et al., 2018). The results of this study, suicidal ideation, and plans for suicide were more likely in school-aged Korean adolescents with short sleep duration. In a recent study, sleep time and suicide plans showed a linear dose–response relationship: a 1-hr increase in sleep time decreased the risk of suicide plans by 11% (Chiu et al., 2018). Although sleep disturbance might be a particular risk factor for adolescent suicide, such problems are easily assessed across health care settings and amenable to treatment (Kearns et al., 2018). In this context, discovering the factors associated with depression and suicidal ideation, including sleep disturbance and poor sleep quality, might inspire interventions that prevent suicide attempts among school-aged adolescents with allergic disease.
The prevalence of allergic disease has increased in recent years in the Asia-Pacific region including Korea (Han & Chung, 2018), with Korea home to the highest adolescents’ suicide rates among the Organization for Economic Cooperation and Development countries (Roh et al., 2018). It is important to note that Korean adolescents demonstrate higher the suicide rates than Western youth, perhaps as a result of Korean youth being subject to high levels of stress—especially in relation to studying—as well as high rates of sleep deficiency and low rates of leisure (S. Lee & Shin, 2017). Therefore, it may have clinical implications for school nurses who care for South Korean adolescents.
The relation between youth suicide and sleep remains a globally significant topic: increasing adolescent suicidal risk rates around the world coincide with global trends in sleep–wake regulation (Goldstein & Franzen, 2019). It is important to establish that Korean adolescents who sleep less than 6 hr a night are 2 times more likely to attempt suicide (S. Y. Kim et al., 2017), while U.S. adolescents who sleep less than 7 hr a night are 1.68 times more likely to attempt suicide (Zhang et al., 2017). The findings of this study indicate a difference in Korean Youth when compared to similar studies related to youth suicide and sleep (Porras-Segovia et al., 2019), and therefore, it is necessary to pay attention to the ways in which this relationship changes across contexts. Further comparative research on the topic are sure to prove valuable.
An important aspect this study revealed is that a lack of sleep can harm the development and growth of school-aged Korean adolescents with allergic disease by increasing neurocognitive ailments and suicidality. Owing to circadian fluctuations of inflammatory mediators, adolescents often experience worsening symptoms and outcomes leading to insufficient sleep time during the night (Jasiak-Panek et al., 2019). In particular, since a greater ability to maintain consistent sleep patterns is related to higher sleep quality, it is important to establish consistent sleep habits among adolescents with allergies (Lawless et al., 2018).
More specifically, the mediational analysis showed that middle school–aged and high school–aged Korean adolescents with allergic disease may be indirectly at risk of suicidal ideation and plans for suicide through short sleep duration. This finding demonstrates the need for further research on how to best monitor and assess adolescent sleep conditions in order to decrease suicidal ideation and plans in school-aged adolescents. Our findings also suggest the need to enhance the consciousness of parents, school nurses, and school nurse educators about the importance of sleep time and quality with regard to suicidal ideation and plans in school-aged adolescents.
As reported by the American Academy of Sleep Medicine, for teenagers aged 13–18 years to be in optimal health, they should routinely sleep for 8–10 hr a night (Paruthi et al., 2016)—youth who do not sleep for this duration have an elevated risk of chronic illness, including diabetes and obesity, as well as developmental problems and inferior academic performance (Owens & Adolescent Sleep Working Group, 2014). In addition, Wheaton (2016) notes that short sleep duration is linked to risky health behaviors among high school students.
To ensure that school-aged adolescents get adequate sleep, school nurses need to be aware of the clinical markers of short sleep duration such as irritability, tiredness when arriving at school, low motivation to engage in class, poor academic achievement, and absence from school (Berger et al., 2018). Moreover, we recommend that parents encourage the establishment of good sleep habits including a consistent sleep schedule. School-aged adolescents with strict bedtimes have been found to be more likely to get sufficient sleep (Short et al., 2013). In addition, although the use of electronic devices is unavoidable, Bartel et al. (2015) highlight that adolescent sleep duration is negatively associated with light exposure and technology use. Therefore, parents should limit adolescents’ indiscriminate use of electronic devices at bedtime, especially among allergic schoolaged adolescents.
Furthermore, short sleep duration is associated with increased consumption of energy drinks (Sampasa-Kanyinga et al., 2018). Adolescents who cannot sleep well because of allergy-related symptoms may seek more sugar and caffeine to remain awake longer, thereby perpetuating a vicious cycle. Franckle et al. (2015) highlight that tailored education programs and parent supervision are required to encourage good sleep and healthy diets in middle school–aged and high school–aged adolescents with allergic disease.
Regarding the size of the mediating effects, short sleep duration played the greatest mediating role in the association between allergic disease and suicide plans. This can be explained by Wong et al.’s (2016) study, in which they noted that, among adolescents, insomnia, including difficulty falling asleep and early morning awakening, has a greater effect on suicide plans than on suicidal ideation or attempts. However, it is necessary for further studies to explore this mediating effect size by considering confounding factors. Other research has shown that in adolescents, frequent nighttime awakening is connected with suicidal ideation or planned suicide (Lopes et al., 2016). These problematic sleep patterns impair school-aged adolescents’ emotional control, thereby adversely influencing neurocognitive and emotional development and multiplying the risk of mental illness including anxiety, depression, and suicide (Fishbein et al., 2018; Palmer et al., 2018).
To prevent suicidal ideation and planning, it is recommended to carefully consider and monitor the sleep characteristics of school-aged adolescents with allergic disease. Accordingly, it is vital for parents and school nurses and educators to cooperate with each other in supervising sleep behaviors and habits to prevent suicidal ideation and plans in allergic school-aged adolescents. We also need to carefully monitor students for symptoms of intense distress, including nonsuicidal self-injury behavior, depression, and agitation, which often emerge as warning signs before a suicide attempt (Kleiman et al., 2019). It is also necessary to establish guidelines for ensuring good sleep quality and preventing suicide among middle school–aged and high school–aged adolescents with allergic disease.
The results of this study show evidence about the relationships between short sleep duration, allergic disease, and suicidal ideation and plans among Korean adolescents that may prove helpful for school nurses who play a crucial role in monitoring and intervening in student suicide (Jakobsson et al., 2019). More specifically, we advise that school nurses monitor and assess students with allergic disease for symptoms of poor sleep such as daytime somnolence, poor concentration, troubled cognitive ability, and fatigue (Noh et al., 2020). School nurses should also ask students about their sleep patterns when they demonstrate trouble with their academics or when they are absent from school (Brew et al., 2019).
And school nurses carefully need to assess their responses to allergic medication and treatments because of a significant association between sleep disorders and several markers of allergic disease severity or lack control of symptoms (Loekmanwidjaja et al., 2018). Furthermore, school nurses play an important role in providing comprehensive and tailored health education in schools (Holmes et al., 2016). Collaboration between school nurses and administrators, students, and parents in health promotion programs focused on sleep could have efficient and cost-effective outcomes (Wernette & Emory, 2017). For this reason, informing parents and adolescents simultaneously using evidence-based knowledge may enhance understanding about the importance of healthy sleep and encourage better patterns (Fuligni et al., 2015).
This study has a few limitations. First, because of the crosssectional design, causal relationships between variables cannot be inferred. Second, respondents were asked only about whether they had been diagnosed with an allergic disease, ignoring the aspects of severity and onset time. Finally, our measures were based on self-reports, and the selfadministered online survey, including the scale for measuring sleep time, had low internal consistency. Despite these limitations, this study is noteworthy in that it examines a chain of relationships in a mediational model between allergic disease, short sleep duration, and suicidal ideation and plans using a large nationally representative sample.
It is important to know that middle and high school students with allergic disease are more likely to experience short sleep duration, causing sleep deprivation that can be linked to the possibility of suicidal ideation and planning. Thus, this may have important implications for school nurses who care for adolescents with allergic disease to assess the symptoms and responses of poor sleep and lack control of symptoms related to allergic medication and treatments.
The abstract was presented at the conference of 23rd East Asian Forum of Nursing Scholars in Chiang Mai, Thailand, on January 10–11, 2020.
Yeji Seo conceptualized the manuscript as well as prepared the draft. Ji-Su Kim contributed to the acquisition, analysis, and interpretation of data as well as to the revisions of the manuscript. Both authors gave final approval on the manuscript and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Yeji Seo https://orcid.org/0000-0002-8447-2157
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Ji-Su Kim is an associate professor at Department of Nursing, Chung-Ang University, Seoul, Republic of Korea.
Yeji Seo is a doctoral student at Department of Nursing, Graduate School, Chung-Ang University, Seoul, Republic of Korea.
1 Department of Nursing, Graduate School, Chung-Ang University, Seoul, Republic of Korea
Corresponding Author:Yeji Seo, Department of Nursing, Graduate School, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, 06974, Seoul, Republic of Korea.Email: yejihj23@cau.ac.kr
