Abstract

Adverse effects on the physical and mental health of adolescents associated with excessive smartphone use have been reported. This paper aims to assess adolescent smartphone addiction and related factors in a region in Northeastern Brazil. This cross-sectional study was carried out in six State-run Professional Education Schools in Fortaleza, Ceará, Brazil, from September to October 2019 with 286 adolescents aged 15-19 years who completed five data collection instruments. Bivariate and multivariate analyses were performed to assess factors related to the outcome using SPSS version 23.0. Smartphone addiction prevalence rate was 70,3% and was associated with being underage (OR=0,583; p=0,001), fewer sleep hours (OR=0,715; p=0,020), longer use on weekends (OR=1,115; p=0,015), cervical pain (OR=2,206; p=0,020), and suspected common mental disorder (OR=1,272; p=0,000). A high smartphone addiction level was observed among adolescents in the sample and was related to multiple factors. Attention should be drawn to the importance of educational campaigns to guide adolescents, parents, educators, and health professionals about the risks of excessive smartphone use to the health of adolescents.

Key words:
Addiction medicine; Smartphone; Risk factors; Adolescents

Introduction

The last decades have endured a social transition that has changed society’s way of thinking, communicating, relating, and working through digital transformation. Technology allows different people to communicate at the same time, connected in a single network but physically distant. The smartphone is among the technological devices most widely used to access the internet¹1 Spizzirri RCP, Wagner A, Mosmann CP, Armani AB. Adolescência conectada: mapeando o uso da internet em. Psicol Argumento 2012; 30(69):327-335..

The number of smartphone users is growing exponentially globally, regardless of age²2 Xie Y, Szeto G, Dai J. Prevalence and risk factors associated with musculoskeletal complaints among users of mobile handheld devices: a systematic review. Appl Ergon 2017;59:132-142.. Data point to a 54% increase in smartphone use as the primary internet access by the population, according to a survey in 21 emerging countries³3 Pew Research Center. Smartphone ownership and internet usage continues to climb in emerging economies. Pew Research Center [Internet]. 2016 Feb 22. [cited 2020 Apr 26];1-5. Available from: http://www.pewglobal.org/2016/02/22/smartphone-ownership-and-internet-usage-continues-to-climb-in-emerging-economies/
http://www.pewglobal.org/2016/02/22/smar... . In this scenario, Brazil ranks second globally concerning the daily internet connection time, at nine hours⁴4 We are social. Global Digital Report 2019 - We Are Social [Internet]. 2019 [cited 2020 Apr 26]. p. 1-11. Available from: https://wearesocial.com/global-digital-report-2019
https://wearesocial.com/global-digital-r... . Another survey directed at children and adolescents informs that 86% access the internet through this device⁵5 Brazilian Internet Steering Committee. Pesquisa sobre o uso da internet por crianças e adolescentes no brasil. [Internet]. Núcleo de Informação e Coordenação do Ponto BR, editor. Pesquisa sobre o uso da internet por crianças e adolescentes no Brasil: TIC kids online Brasil 2018 / Survey on internet use by children in Brazil: ICT kids online Brazil 2018. São Paulo; 2019. 352 p..

Such growth is associated with several resources such as communication and entertainment, which are compressed on the same device⁶6 Cha SS, Seo BK. Smartphone use and smartphone addiction in middle school students in Korea: Prevalence, social networking service, and game use. Heal Psychol Open 2018; 5(1):1-25.. Easy access has advantages such as increased productivity, instant dissemination of information, and greater pleasure in using social networks. Studies show that people use smartphones excessively, highlighting adolescents as a risk group regarding prolonged use⁷7 Elhai JD, Dvorak RD, Levine JC, Hall BJ. Problematic smartphone use: A conceptual overview and systematic review of relations with anxiety and depression psychopathology. J Affect Disord 2017; 207:251-259..

This device is convenient to its users. However, its prolonged use causes problems that compromise health conditions⁸8 Derevensky JL, Hayman V, Lynette Gilbeau. Behavioral Addictions: Excessive Gambling, Gaming, Internet, and Smartphone Use Among Children and Adolescents. Pediatr Clin North Am 2019; 66(6):1163-1182.. The literature describes smartphone addiction as a behavioral disorder characterized by impulsiveness and uncontrollable use as a constant display of notifications, games, and applications, compared to other behavioral dependencies. While there is no specific classification within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), this behavior adversely affects adolescent biopsychosocial aspects⁹9 Gutiérrez JDS, de Fonseca FR, Rubio G. Cell-phone addiction: A review. Front Psychiatry 2016; 7(175):1-15..

Adolescents are strongly tied to their smartphones and say they cannot live without their devices. These digital natives often use them addictively, following fashioned use of applications and searching for relationships and emotional support. They commonly express their thoughts in a virtual recreation environment, looking for instant reactions and feedbacks¹⁰10 Csibi S, Griffiths MD, Cook B, Demetrovics Z, Szabo A. The Psychometric Properties of the Smartphone Application-Based Addiction Scale (SABAS). Int J Ment Health Addict 2018; 16(2):393-403..

Given the scenario presented, the need to foster data related to the excessive use of the smartphone and its consequences to direct actions and fill gaps is highlighted, as previously warned by the WHO¹¹11 World Health Organization (WHO). Public health implications of excessive use of the internet, computers, smartphones and similar electronic devices: meeting report, Main Meeting Hall, Foundation for Promotion of Cancer Research, National Cancer Research Centre, Tokyo, Japan, 27-29 August 2014. [Internet]. 2015[cited 2021 Mar 9]. Available from: https://apps.who.int/iris/bitstream/handle/10665/184264/9789241509367_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... . Thus, this study aimed to assess smartphone addiction and related factors in adolescents from the Brazilian Northeast.

Methods

This is a quantitative, cross-sectional, and analytical study nested in a research project entitled Study of postural and painful changes in the cervical region associated with the use of smartphones in adolescents, developed at State Professional Education Schools (EEEPs) at the high school level, in Fortaleza, Ceará, Brazil. Recruitment and data collection were carried out in August and September 2019.

Fortaleza, capital of Ceará, is the fifth-most populous Brazilian city, with a population of 2,643,247 inhabitants. Its municipal HDI is 0.754 and that of Education 0.692, ranking 17^th in the HDI ranking of the country’s metropolises¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Panorama população. Fortaleza, Ceará [Internet]. 2010 [acessado 2020 abr 26]. Disponível em: https://cidades.ibge.gov.br/brasil/ce/fortaleza/panorama
https://cidades.ibge.gov.br/brasil/ce/fo... . Since 1997, it has been administratively divided into seven Regional Executive Secretariats (SER) and currently houses 119 neighborhoods in five districts¹³13 Prefeitura de Fortaleza. A cidade [Internet]. 2014 [acessado 2020 abr 26]. p. 289. Disponível em: www.fortaleza.ce.gov.br/a-cidade
www.fortaleza.ce.gov.br/a-cidade... .

In 2008, EEEPs were established in Ceará to integrate high school and full-time professional education. For the study, the selection was made by conglomerate in two stages. Six schools were selected by draw in the first stage, one in each SER, except for the SER Centro, which does not have one. In the second stage, one class per grade (first to third) was selected, morning or afternoon shifts, totaling three classes per EEEP. At least 13 adolescents were recruited per class in each.

Two hundred ninety-one adolescents (15-19 years) were selected, attending the first to third high school grades, enrolled in the 2019 academic year in the selected EEEPs, with a smartphone, composing a probabilistic sample. Five students were excluded from this total because they did complete one of the collection instruments or due to the lack of anthropometric data and were considered sample losses. As a result, the final sample included 286 adolescents, equally distributed among grades (96 from the first grade, 95 from the second grade, and 95 from the third grade of high school).

We excluded those who did not attend classes on the days of data collection, had a self-reported diagnosis of scoliosis, fracture or degenerative injuries in the cervical spine, recent traumatic injuries, and people with physical disabilities due to factors related to postural and painful spine changes, pregnant women due to physiological changes, and people with visual, hearing, and cognitive impairments due to the lack of adaptability of the collection instruments for this population and their self-completion.

The number of participants was estimated by sample calculation, considering a finite population (n=224,153) of adolescents (15-19 years) from Fortaleza¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Panorama população. Fortaleza, Ceará [Internet]. 2010 [acessado 2020 abr 26]. Disponível em: https://cidades.ibge.gov.br/brasil/ce/fortaleza/panorama
https://cidades.ibge.gov.br/brasil/ce/fo... , 18% prevalence of cervical pain in users of mobile devices²2 Xie Y, Szeto G, Dai J. Prevalence and risk factors associated with musculoskeletal complaints among users of mobile handheld devices: a systematic review. Appl Ergon 2017;59:132-142., sampling precision of 5%, 95% confidence interval, and 10% increase for sample loss. The series and age range listed for this study were based on the recommendations of the National School Health Survey (PENSE)¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Brasília: IBGE; 2016. 132p.. The school has an essential influence on the upbringing of adolescents in the cognitive, social, and emotional development stage; therefore, it is a favorable environment for monitoring risk factors and protecting the population¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Brasília: IBGE; 2016. 132p..

After authorization from the school directors, the recruitment of participants started by public call for an explanatory lecture addressed to parents/guardians and adolescents. Then, consent was requested by signing the informed consent and assent forms (ICF). Data were collected in two stages. In the first stage, they answered five self-applicable data collection instruments, in the school’s classroom, at a specific time set by the director to ensure non-interference in school activities.

The collection instruments applied were: 1) Sociodemographic and health conditions questionnaire; 2) International Physical Activity Questionnaire short version (IPAQ); 3) Nordic Musculoskeletal Symptoms Questionnaire (NMQ), 4) Self-Report Questionnaire (SRQ-20); and 5) Smartphone Addiction Inventory (SPAI-BR).

The researchers developed the sociodemographic and health conditions questionnaire, which collected sociodemographic data (age, gender, ethnicity, living with, social class, maternal and paternal schooling) and health history (sleep characteristics and self-assessed health).

The IPAQ short version, validated in Brazil for use in adolescents, adults, and older adults, consists of eight open-ended questions that estimate the weekly time spent in different physical activity dimensions (walking and moderate/vigorous-intensity physical efforts) and sedentary behavior (sitting position)¹⁵15 Pinto Guedes D, Correa Lopes C, Pinto Guedes JER. Reprodutibilidade e validade do questionário internacional de atividade física em adolescentes. Rev Bras Med do Esporte 2005;11(2):151-158.. Two categories were used in this study to classify the physical activity level: non-sedentary (very active, active, irregularly active) and sedentary¹⁶16 Ceschini FL, Figueira Júnior A. Nível de atividade física de adolescentes durante o ensino médio. Rev Bras Cien Saude 2006; 3(7):32-38..

The Nordic Musculoskeletal Symptoms Questionnaire, validated¹⁷17 Pinheiro FA, Tróccoli BT, Carvalho CV. Validação do Questionário Nórdico de Sintomas Osteomusculares como medida de morbidade. Rev Saude Publica 2002; 36(3):307-312. and cross-culturally adapted¹⁸18 Barros ENC, Alexandre NMC. Cross-cultural adaptation of the Nordic musculoskeletal questionnaire. Int Nurs Rev 2003;50(2):101-108. to Portuguese, measures reported musculoskeletal pain/symptoms (yes/no) in nine anatomical regions (cervical, shoulders, chest, elbows, wrists/hands, lumbar region, hips/thighs, knees, and ankles/feet) in the last seven days.

The SRQ-20, validated for Portuguese, is an instrument that identifies psychosomatic symptoms for the screening of Common Mental Disorder (CMD). It is recognized by the World Health Organization and validated in Brazil¹⁹19 Mari JJ, Williams P. A Validity Study of a Psychiatric Screening Questionnaire. Br J Psychiatry 1986; 148:23-27.. It consists of twenty questions in four groups of symptoms referred in the last thirty days with yes/no answers. In this study, we employed the sum of the answers marked as “yes” (numerical variable), and a cut-off point ≥ 8 points for suspected CMD (categorical variable) was used, with a sensitivity of 86.3% and specificity of 89.3%²⁰20 Moraes RSM, Silva DAS, Oliveira WF, Peres MA. Iniquidades sociais na prevalência de desordens mentais comuns em adultos: Estudo de base populacional no Sul do Brasil. Rev Bras Epidemiol 2017; 20(1):43-56..

The SPAI-BR is an instrument with 26 items, divided into four subscales, with a yes/no answer to assess smartphone addiction. The cut-off point adopted for smartphone addiction was seven points, which has a sensitivity of 90.54% and specificity of 59.93% for validation and adaptation to Portuguese²¹21 Khoury JM, Freitas AAC, Roque MAV, Albuquerque MR, Neves MDCL, Garcia FD. Assessment of the accuracy of a new tool for the screening of smartphone addiction. PLoS One 2017;12(5):1-13.. Two questions were added at the end of the instrument about smartphone use hours on weekdays and weekends.

We performed the anthropometric assessment (weight and height) to calculate the BMI (Kg/cm²) in the second stage. Weight was measured using an Omron portable digital scale, with a capacity of up to 150 kg, calibrated and positioned on a firm surface. Height was gauged with a duly calibrated compact Macrosul portable stadiometer. BMI was classified in the presence or absence of overweight as per the table proposed by the World Health Organization²²22 Brasil. Ministério de Saúde (MS). Saúde IMC [Internet]. 2017 [acessado 2020 abr 20]. Brasília: MS. Disponível em: https://www.saude.gov.br/artigos/804-imc/40510-imc-em-criancas-e-adolescentes
https://www.saude.gov.br/artigos/804-imc... .

The data were analyzed using descriptive and inferential statistics using SPSS Statistics IBM® version 23.0. The univariate analysis calculated the absolute (n) and relative (%) values of the categorical variables and the means ± standard deviations (SD) of the numerical variables. Pearson’s chi-square was applied to analyze factors related to smartphone addiction, followed by calculation of the crude ORs and respective 95% confidence intervals, and Student’s t-test, after normality test. Then, a multivariate logistic regression was performed by the stepwise backward method, selecting the variables with a level of significance of up to 20% in the bivariate analysis (p<0.020), allowing the selection of relevant variables for the model and controlling for confounding variables, as proposed by Hosmer and Lemeshow²³23 Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med 2008; 3:1-8.. Variables with a 5% significance level (p<0.05) remained in the final model, calculating the adjusted ORs and their 95% confidence intervals.

The study was approved by the Human Research Ethics Committee of the University of Fortaleza (COÉTICA/UNIFOR) under Opinion N° 3.341.394, as per Resolution N° 466/12 of the National Health Council. Parents/guardians and adolescents consented to their participation by signing the consent terms.

Results

Regarding socioeconomic variables, there was a higher proportion of adolescents aged 16 (n=90; 31.5%), male (n=152; 53.1%), from social class D (n=150; 52.4 %) and with parents with high school education (n=142; 49.6% for the mother and n=127; 44.4% for the father). Concerning health conditions, they slept on average 6.8 (±1.1) daily hours, 40.2% (n=115) were sedentary, 47.6% (n=136) complained of cervical pain, and 23.1% (n=66) were overweight. Of the total, 70.3% (n=201) were smartphone addicts and used it for 5.8 hours (±3.5) and for 8.8 hours (±5.0) on weekdays and weekends, respectively (Table 1).

In the bivariate analysis, smartphone addiction was related to complaints of pain in the cervical (OR=2.960; p=0.000), upper back (OR=1.950; p=0.010) and wrist (OR=1.956; p=0.029) regions, age (16.1 ± 0.9; p=0.008), sleep hours (6.6 ± 1.1; p=0.001), weekend use time (9.4 ± 5.3; p=0.000) and suspected CMD (8.7 ± 4.5; p=0.000) (Tables 2 and 3). In the multivariate analysis, smartphone addiction was associated with complaints of cervical pain (OR=2.206; p=0.020), younger age (OR=0.583; p=0.001), fewer sleep hours (OR=0.715; p=0.020), more use time on weekends (OR=1.115; p=0.015) and suspected CMD (OR=1.272; p=0.000) (Table 4).

Discussion

This study investigated an emerging theme, focused on the epidemiological and health promotion fields, which involves smartphone addiction by adolescents and the associated factors. This particular population is strongly attracted by technology, staying for long hours connected to the internet and social networks, among other virtual environments¹¹11 World Health Organization (WHO). Public health implications of excessive use of the internet, computers, smartphones and similar electronic devices: meeting report, Main Meeting Hall, Foundation for Promotion of Cancer Research, National Cancer Research Centre, Tokyo, Japan, 27-29 August 2014. [Internet]. 2015[cited 2021 Mar 9]. Available from: https://apps.who.int/iris/bitstream/handle/10665/184264/9789241509367_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... . The smartphone is one of the primary means of accessing the internet⁵5 Brazilian Internet Steering Committee. Pesquisa sobre o uso da internet por crianças e adolescentes no brasil. [Internet]. Núcleo de Informação e Coordenação do Ponto BR, editor. Pesquisa sobre o uso da internet por crianças e adolescentes no Brasil: TIC kids online Brasil 2018 / Survey on internet use by children in Brazil: ICT kids online Brazil 2018. São Paulo; 2019. 352 p. among the current mobile devices.

As a result, there is growing concern about understanding the behavior and addiction of the internet, video games, and smartphones. Internet use and the interaction with online content/activities are historically considered global addictions. Given this scenario, with the possibility of connecting and offering applications, the emergence of the smartphone becomes a potentially addictive device⁹9 Gutiérrez JDS, de Fonseca FR, Rubio G. Cell-phone addiction: A review. Front Psychiatry 2016; 7(175):1-15..

Concerned about these issues, the WHO declared that the excessive and problematic use of electronic devices, including the smartphone, is a global public health problem and encouraged research to provide scientific evidence on the factors involved in this behavior and possible harm to users’ health¹¹11 World Health Organization (WHO). Public health implications of excessive use of the internet, computers, smartphones and similar electronic devices: meeting report, Main Meeting Hall, Foundation for Promotion of Cancer Research, National Cancer Research Centre, Tokyo, Japan, 27-29 August 2014. [Internet]. 2015[cited 2021 Mar 9]. Available from: https://apps.who.int/iris/bitstream/handle/10665/184264/9789241509367_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... .

The problematic use of the smartphone can be investigated by specific instruments that analyze the dependence/addiction and measure this device’s use time. Both variables were investigated in this study, and it was found that 70.3% of the sample was dependent on the smartphone, and the use times were 5h 48 minutes on weekdays and 8h 48 minutes on weekends. Also, adolescents with smartphone addiction had more time on weekends than those not addicted.

The prevalence found was higher than others reported with adolescents in different countries, 55% in Taiwan²⁴24 Liu CH, Lin SH, Pan YC, Lin YH. Smartphone gaming and frequent use pattern associated with smartphone addiction. Med 2016 1; 95(28):1-4., 50.6% in Turkey²⁵25 Firat S, Gül H, Sertçelik M, Gül A, Gürel Y, Kiliç BG. The relationship between problematic smartphone use and psychiatric symptoms among adolescents who applied to psychiatry clinics. Psychiatry Res 2018; 270:97-103., 30.9% in South Korea⁶6 Cha SS, Seo BK. Smartphone use and smartphone addiction in middle school students in Korea: Prevalence, social networking service, and game use. Heal Psychol Open 2018; 5(1):1-25., and 16.9% in Switzerland²⁶26 Haug S, Paz Castro R, Kwon M, Filler A, Kowatsch T, Schaub MP. Smartphone use and smartphone addiction among young people in Switzerland. J Behav Addict 2015; 4(4):299-307.. In Brazil, a previous study for adaptation and validation of the Smartphone Addiction Inventory pointed to a prevalence of 35% in a young population (18-25 years)²¹21 Khoury JM, Freitas AAC, Roque MAV, Albuquerque MR, Neves MDCL, Garcia FD. Assessment of the accuracy of a new tool for the screening of smartphone addiction. PLoS One 2017;12(5):1-13.. This high value can be justified by the increased access of Brazilian adolescents to the internet and its resources, primarily through their smartphones⁵5 Brazilian Internet Steering Committee. Pesquisa sobre o uso da internet por crianças e adolescentes no brasil. [Internet]. Núcleo de Informação e Coordenação do Ponto BR, editor. Pesquisa sobre o uso da internet por crianças e adolescentes no Brasil: TIC kids online Brasil 2018 / Survey on internet use by children in Brazil: ICT kids online Brazil 2018. São Paulo; 2019. 352 p.^,1414 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Brasília: IBGE; 2016. 132p.. Furthermore, the risk of bias is mitigated, using an instrument cross-culturally adapted to the Portuguese language.

Adolescent’s smartphone use time should also be monitored due to its direct relationship with the addiction to this device²⁷27 Dewi RK, Efendi F, Has EMM, Gunawan J. Adolescents' smartphone use at night, sleep disturbance and depressive symptoms. Int J Adolesc Med Health 2018; 33(2):1-8.. Previous studies in Korea⁶6 Cha SS, Seo BK. Smartphone use and smartphone addiction in middle school students in Korea: Prevalence, social networking service, and game use. Heal Psychol Open 2018; 5(1):1-25. and Switzerland²⁶26 Haug S, Paz Castro R, Kwon M, Filler A, Kowatsch T, Schaub MP. Smartphone use and smartphone addiction among young people in Switzerland. J Behav Addict 2015; 4(4):299-307. have shown use times similar to those found in our study, with 5.2 hours and 5.6 hours, respectively. Unlike previous data, a lower use time was found in a study carried out in the United Kingdom, with 3.1 hours/day²⁸28 Hussain Z, Griffiths MD, Sheffield D. An investigation into problematic smartphone use: The role of narcissism, anxiety, and personality factors. J Behav Addict 2017;6(3):378-386..

This study found that smartphone addiction was associated with age. In line with age, a survey in Switzerland found that smartphone addiction was more prevalent in younger adolescents (15-16 years) than young adults (19 years and older)²⁶26 Haug S, Paz Castro R, Kwon M, Filler A, Kowatsch T, Schaub MP. Smartphone use and smartphone addiction among young people in Switzerland. J Behav Addict 2015; 4(4):299-307.. This generation is known to face different stressors more than any previous generation. Besides the physiological changes inherent to adolescence, there is pressure to expose own daily life in the virtual environment, requiring more time online. The excessive use of smartphones and online games aims to minimize stressors, such as school demands, future uncertainties, family and social pressures, leading this population to addictive behaviors⁸8 Derevensky JL, Hayman V, Lynette Gilbeau. Behavioral Addictions: Excessive Gambling, Gaming, Internet, and Smartphone Use Among Children and Adolescents. Pediatr Clin North Am 2019; 66(6):1163-1182..

Other factors were also associated with smartphone addiction, such as less sleep, cervical pain, and common mental disorder. Concerning the physical and mental health aspects, a review study listed the multiple health problems from the excessive use of the smartphone, such as depression, anxiety, impulsivity, sedentary behavior, sleep disorder, contracture in the muscles, and pain in the cervical and lumbar spine⁸8 Derevensky JL, Hayman V, Lynette Gilbeau. Behavioral Addictions: Excessive Gambling, Gaming, Internet, and Smartphone Use Among Children and Adolescents. Pediatr Clin North Am 2019; 66(6):1163-1182..

Several studies address the association between smartphone addiction and sleep quality. Studies in Switzerland²⁹29 Schweizer A, Berchtold A, Barrense-Dias Y, Akre C, Suris JC. Adolescents with a smartphone sleep less than their peers. Eur J Pediatr 2017;176(1):131-136. and Brazil³⁰30 Caumo GH, Spritzer D, Carissimi A, Tonon AC. Exposure to electronic devices and sleep quality in adolescents: A matter of type, duration, and timing. Sleep Heal 2020; 2020; 6(2):172-178. found that smartphone users sleep less, especially on weekdays, and report more sleep problems. Another study in Indonesia revealed that the excessive use of the smartphone at night could lead to sleep disorders and contribute to the onset of depression²⁷27 Dewi RK, Efendi F, Has EMM, Gunawan J. Adolescents' smartphone use at night, sleep disturbance and depressive symptoms. Int J Adolesc Med Health 2018; 33(2):1-8.. The impacts of the excessive use of this device on the quality of sleep and its duration are of concern since sleep restriction can cause physical and mental disorders, and conscious and monitored use is essential.

Among the physical repercussions related to the outcome, the adolescents in the sample reported pain in the cervical region. A similar complaint was reported by Taiwanese adolescents who reported musculoskeletal discomfort in the cervical and thoracic spine when using the smartphone for more than three daily hours³¹31 Yang SY, Chen M De, Huang YC, Lin CY, Chang JH. Association between smartphone use and musculoskeletal discomfort in adolescent students. J Community Health 2016; 42(3):423-430.. Another research carried out in Lebanon found a relationship between musculoskeletal pain in the cervical and pain in the back region using smartphones or tablets due to excessive flexion after 5-7 hours on these devices³²32 Fares J, Fares MY, Fares Y. Musculoskeletal neck pain in children and adolescents: Risk factors. Surg Neurol Int 2017; 8(72):1-5.. In China, in adolescents with a mean age of 18 years, the region of the body with the most significant pain was the cervical region after prolonged use of the smartphone³³33 Namwongsa S, Puntumetakul R, Neubert MS, Boucaut R. Factors associated with neck disorders among university student smartphone users. Work 2018; 61(3):367-378..

Regarding the mental health aspect, 52.4% of the sample had suspected CMD, which was related to the outcome of smartphone addiction. Previous research carried out in Hungary³⁴34 Körmendi A. Smartphone usage among adolescents. Psychiatr Hung 2015; 30(3):297-302. and Turkey²⁵25 Firat S, Gül H, Sertçelik M, Gül A, Gürel Y, Kiliç BG. The relationship between problematic smartphone use and psychiatric symptoms among adolescents who applied to psychiatry clinics. Psychiatry Res 2018; 270:97-103. concluded that the smartphone’s time is directly related to impulsivity, anxiety, depression, interpersonal sensitivity, and hostility symptoms. Convergingly, two other cross-sectional studies in Japan³⁵35 Nishida T, Tamura H, Sakakibara H. The association of smartphone use and depression in Japanese adolescents. Psychiatry Res 2019; 273:523-527. and Korea³⁶36 Kim H, Cho M-K, Ko H, Yoo JE, Song Y-M. Association between Smartphone Usage and Mental Health in South Korean Adolescents: The 2017 Korea Youth Risk Behavior Web-Based Survey. Korean J Fam Med 2020; 41(2):98-104. attest that the longer the use, the greater the risk of depressive symptoms and suicidal thoughts.

The findings alert to the importance of monitoring the excessive smartphone use by adolescents and the possible harm to mental and physical health. There is a need to implement health prevention/care programs aimed at these issues with the involvement of the family, educational environments, and the health system. The Brazilian Society of Pediatrics reinforces awareness of the laws in force in the country and the implementation of public policies, culminating in health education campaigns and support materials for the comprehensive protection and prevention of the risks of using the internet and social networks, games, and other applications³⁷37 Sociedade Brasileira de Pediatria (SBP). Saúde de Crianças e Adolescentes na Era Digital. Manual de Orientação. Nº 1. 2016 Out.[cited 20 Apr 2020]. 1-13 p. Available from: https://www.sbp.com.br/fileadmin/user_upload/2016/11/19166d-MOrient-Saude-Crian-e-Adolesc.pdf
https://www.sbp.com.br/fileadmin/user_up... .

Some sample limitations are recognized in this study, such as the non-inclusion of private schools hindering analyses involving socioeconomic factors and the delimitation of the age group (15-19 years). While these limitations potentially affect generalizations of the results, the research findings will contribute to discussing the topic.

Conclusion

This study aimed to assess smartphone addiction and associated factors in adolescents and found a high prevalence among adolescents in the sample and its relationship with multiple factors, such as age, use time, and impairment of physical health conditions, evidenced by the complaint of cervical pain and harm to mental health with fewer sleep hours and evidence of a common mental disorder.

The results can be elucidated by the peculiarities inherent to adolescence, such as the study routine and the need to use the internet for research purposes and its use for leisure moments such as watching movies, games, and relating to other people. Thus, the studied population can develop this behavioral disorder due to these particularities.

Therefore, given the results, the importance of education and health promotion campaigns in various socio-educational settings and the media is highlighted to sensitize adolescents, parents, educators, and health professionals regarding the risks of smartphone addiction to physical health mental and raise awareness of the proper use of this device.

Acknowledgments

We are grateful to the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and the Universidade de Fortaleza (UNIFOR) for the Edson Queiroz Foundation for the scientific initiation grants.

References

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History