Motivational Interview Based Intervention Program on Smartphone Addiction and Sleep Quality

The Effect of Transtheoretic Model and Motivational Interview Based Intervention Program on Smartphone Addiction and Sleep Quality Levels in Nursing Students

Smartphones are the technological devices of our age that are constantly evolving and whose use is becoming more widespread day by day. Smartphones, which are preferred by almost everyone for reasons such as being easily portable, providing quick access to transactions, providing ease of use and sometimes as a status indicator, can pose a risk of addiction when used uncontrolled. Since young people are more intertwined with technology and use smartphones more, they are at greater risk of addiction and the problems that addiction can cause. Poor sleep quality is an important problem that can occur with smartphone addiction and negatively affects both daily life and the health of the individual. Smartphone addiction and the problems it causes are an important public health problem that threatens the whole society, especially young people. In solving this problem, it is among the duties of nurses to teach individuals healthy lifestyle behaviors instead of problematic behaviors. A road map is needed to facilitate the behavior change process. Transtheoretical Model (TTM) is widely used today to improve the behavior change process in the individual and to achieve the most effective health behavior change. TTM, which targets interventions appropriate to the individual's stage of change, is used as a guide that facilitates behavioral change. TTM is a model that contributes to change, accelerates it, and supports individuals considering change. In addition to TTM, another method that is more frequently used and contributes to change, especially in addicted individuals, is the "motivational interviewing" method. Motivational interviewing is very effective in gaining positive health behaviors and changing negative health behaviors and aims to reveal the individual's internal motivation. It is thought that the university years, which are an important period in terms of developing and maintaining health-protective and preventive behaviors, will both increase students' health responsibility and protect them from health-threatening behaviors with the healthy lifestyle behaviors acquired during this period. In line with all this information, this study was planned to determine the effect of the Transtheoretical model and motivational interview-based online intervention program on smartphone addiction and sleep quality levels in nursing students who are in the smartphone addiction risk group.

Smartphones are the technological devices of our age that are constantly developing and their use is becoming more widespread every day. Nowadays, many transactions from shopping to banking activities, playing mobile games and taking photos can be done easily with smart phones. Smart phones, which make positive contributions to daily life, attract great attention by individuals of all age groups, especially young people. According to Newzoo's report, the number of smartphone users, which was 3.5 billion in 2020, is expected to reach 4.1 billion in 2023 (Newzoo Global Mobile Market Report, 2020). Smartphones, which are preferred by almost everyone for reasons such as being easily portable, providing fast access in transactions, ease of use and sometimes a status indicator, can pose a risk for addiction when used uncontrolled. Smartphone addiction, although not yet clearly defined; It can manifest itself with symptoms such as constantly checking the phone, feeling restless when staying away, withdrawing, mood changes, not being able to control the duration of use, disruption in daily life due to problematic use, constant desire to use and pleasure from use (Li and Lin, 2019; Mohamed and Mostafa, 2020). According to the behavioral approach, if a person takes pleasure from a behavior or avoids negative emotions with this behavior, this situation turns into a habit in the individual (Oulasvirta et al., 2012). Uncontrollable and frequently repetitive habits carry a risk for addiction (Grant et al., 2010). Smartphone addiction, in addition to being a behavioral disorder, can cause many physical, social and psychological problems. Problematic use of the smartphone; decrease in sleep duration (Randler et al., 2016) and quality (Amez et al., 2020), height (AlAbdulwahab et al., 2017), wrist (Choi, 2018), thumb (Baabdullah et al., 2020) and shoulder pain (Xie et al., 2016), dry eye syndrome (Paek, 2017), and eye fatigue (Golebiowski et al., 2019), decreased physical activity (Haripriya et al., 2019), as well as depression (Alhassan et al., 2018), anxiety (Hawi & Samaha, 2017), social phobia, loneliness (Enez Darçın et al., 2016), and decreased academic performance (Baert et al., 2020) can bring along many psychological and social problems. It can be said that poor sleep quality is one of the primary problems that may occur in the problematic use of the smartphone, and it negatively affects both daily life and the health of the individual. Especially at night and in the pre-sleep period, the use of smartphones adversely affects sleep quality as it causes arousal due to the blue light it emits, shortens the sleep duration and disrupts the circadian rhythm (Jniene et al., 2019). Ishizawa et al. (2021) stated that exposure to blue light for 1 hour before sleep reduces the duration of deep sleep and causes poor sleep quality. Hughes and Burke (2018) stated in their study that leaving smartphones out of the bedroom improves sleep quality. It is stated that poor sleep quality negatively affects the individual physically and psychologically, causes performance losses and increases the risk of accidents (Watson et al., 2015). In studies conducted with students, it was stated that poor sleep quality negatively affects academic performance (El Hangouche et al., 2018), while good sleep quality increases academic performance (Adelantado-Renau et al., 2019). Woods and Scott (2016) stated in their study with adolescents that poor sleep quality is associated with low self-esteem, increased anxiety and depression levels. Nurses, who serve almost all of the society, have an important role in defining risky health behaviors and planning and implementing appropriate interventions for behavior change (Erol & Erdoğan, 2007). For this reason, nurses need to make an effort to find the most appropriate behavior change approaches for the individual. Today, the Transtheoretic Model (TTM) is widely used to improve the behavior change process in the individual and to achieve the most effective health behavior change (Taş et al., 2016). TTM, which aims at the initiative suitable for the change phase of the individual, is used as a guide that facilitates behavior change (Erol & Erdoğan, 2007). TTM is a cognitive-behavioral model that accepts that any behavioral change in an individual does not happen all at once, but that behavior change includes different stages and processes (Erol & Erdoğan, 2007). The model, which was first used in smoking cessation programs, was later used in many areas such as exercise, sun protection, reducing the amount of excess fat in the diet, weight control, condom use, supporting mammography screening, widespread drug use, coping with stress and quitting substance abuse. Traditional behavior change models have an understanding that does not take into account the change stage of the individual or accepts that all individuals have the same level of readiness for behavior change (Taş et al., 2016). it is stated that the initiatives applied without considering the individual's readiness level for behavior change develop resistance to behavior change (Taş et al., 2016). In TTM, behavior change; It is defined as a gradual, continuous and dynamic structure. Change in traditional behaviorist approaches; In this model, change focuses on helping individuals willingly make behavioral change and understanding the change process. In other words, it does not classify individuals only according to whether they can perform a certain behavior, but also according to the stages passed in the behavior change process (Güngörmüş, 2010; Sertel et al., 2016). While TTM creates a roadmap in change, there are also approaches that contribute to and accelerate this change and support the individual who thinks about change. One of these approaches, which is used more frequently in addicted individuals, is the "motivational interview" method. Motivational interviewing is very effective in gaining positive health behaviors and changing negative health behaviors and can be an effective communication technique for nurses in providing behavior change (Walters et al., 2012). Motivational interviewing as defined by Miller; "It is a client-centered interview form in which suggestions are made to provide behavior change by helping individuals discover and solve their problems" (Rollnick & Miller, 1995). In motivational interviewing, the expert is the consultant, but the consultant does not assume the role of the knower, is not ready before the client, does not impose his own thoughts, wherever the client is, the consultant is directed there (Rollnick & Miller, 1995). Solving problems in motivational interviewing is the client's job, not the counselor's. Direct persuasion, aggressive confrontation and discussion are the conceptual opposites of motivational interviewing (Ögel, 2009). Motivational interviewing is accompaniment and non-judgmental acceptance. In the interview, the energy of the client should be used and his desire for change should be revealed. motivational interview; It is a partnership-friendship relationship rather than an expert-recipient role. The counselor should respect the client's autonomy, freedom to make choices and bear the consequences (Miller & Moyers, 2007). Nurses, who have very important roles and duties in the provision of health services to the society, undertake important duties not only at the point of care for the sick individual, but also in the fight against situations that threaten public health. In particular, public health nurses interact not only with patients but also with the entire society they serve, as they work in primary health care institutions. Smartphone addiction and the problems it causes are an important public health problem that threatens the whole society and especially young individuals. In the solution of this problem, it is also among the duties of the public health nurse to provide the individual with healthy lifestyle behaviors instead of problematic behavior. As in all risky behaviors that threaten public health, the public health nurse provides consultancy services to the society as a requirement of education and consultancy in smart phone addiction and informs the society about the problems that may arise with the trainings it will organize. Based on this information, the reason for the selection of nursing students in the research universe; To raise awareness among students and contribute to public health, since nursing students are candidates to provide health services to the society, they are role models for the society with their healthy lifestyle behaviors, they interact with individuals from all parts of the society in business life, and there are institutions that provide service on addiction among their work areas. decided with consideration. Another important factor in the selection of the research population is that, considering smartphone addiction, especially young individuals are more at risk for addiction and the problems that may arise from addiction, as they are more intertwined with technology and use smartphones more (Augner & Hacker, 2012; Cocoradă et al., 2018). According to the data of the Turkish Statistical Institute (TUIK) for 2021, it is stated that the rate of smartphone usage is higher for people with a university level education (TUIK, 2021). In studies conducted in our country and abroad, approximately 50% of university students expressed themselves as smartphone addicts (Aljomaa et al., 2016; Ghosh et al., 2021). Considering that being away from family and being more active in social life increases the need for communication among university students, it can be said that they are at higher risk for smartphone addiction when it is considered that they are not under family supervision since most of them reside in dormitories or student houses. In studies evaluating the smart phone usage habits of university students; It has been concluded that they use it for 6 hours or more, the purpose of their use is communication and access to social media, they use it more intensively in the evening and late at night, and they always keep it with them in the pre-sleep period (Yang et al., 2019; Soft, 2019; Sohn et al., 2021). In studies examining the results of smartphone addiction in university students, results such as decrease in sleep quality, decrease in academic performance, depression, anxiety, muscle and joint pain were reached (Alhassan et al. 2018; Amez et al., 2020). It is thought that the university years, which are an important period for the development and maintenance of health protective and preventive behaviors, will both increase the health responsibility of the students and protect them from health-threatening behaviors with the healthy lifestyle behaviors to be gained in this period. It is seen that studies on smartphone addiction are generally descriptive studies aimed at determining the situation. Almost all of the intervention studies that could be reached were carried out in Far East countries and different intervention methods were used. In intervention studies aimed at preventing smartphone addiction; motivational interviewing (Setiawan et al., 2021), cognitive behavioral therapy (Khalily et al., 2021; Lu et al., 2020), laughter therapy (Choi et al., 2016), sand play therapy (Shin & Jang, 2016), literacy therapy (Baek and Ha, 2018), peer relations development program (Jo & Bang, 2022), music therapy (Bong et al., 2018), mind-bending meditation program (Yoo et al. 2019, Choi et al. 2020), mind-body exercise (Lu et al., 2020), journaling (Lee et al., 2016), and art therapy (Jang et. al. 2017; Bae & Won, 2019) have been reached. In line with all this information, our study was planned to determine the effect of TTM and motivational interview-based online intervention program on smartphone addiction and sleep quality levels in nursing students who are in the risk group for smartphone addiction.

The method of this research; It is a quasi-experimental study with pre-test and post-test, with intervention and control groups randomly selected.

Smartphone addiction scale will be applied to nursing department students. Those who score 31 or more on the scale for men and 33 or more for women will be considered at risk and will be invited to the study. Those who meet the participation criteria and volunteer to participate will be included in the study. Participants will be homogeneously and randomly distributed into intervention and control groups.

No intervention will be made to the intervention group. After evaluating the final data, if the motivational interview and training program is found to be effective, a motivational interview and training program will also be carried out to the control group participants.

It will be determined at which stage of change of the transtheoretic model the participants in the intervention group are. A varying number of motivational interviews will be held depending on the stage of change and a maximum of 6 motivational interviews. Those in the preparatory phase will be trained on smartphone addiction. Following completion of the motivational interviewing and training content, the study scales will be re-administered and the effectiveness of the motivational interviewing and training content will be evaluated by comparison with the baseline data.

The form, which was created to determine students' socio-demographic characteristics and smartphone usage habits, was prepared by the researcher in line with the literature review on the subject. The form consists of a total of 18 questions; There are 8 questions about the socio-demographic characteristics of the students, 8 questions evaluating smartphone usage characteristics, and 2 questions evaluating the individual's smartphone addiction and sleep quality by self-report.

The scale is a 6-point Likert type and consists of 10 items. The lowest score from the scale can be 10 and the highest score can be 60. Increasing the total score from the scale indicates that the risk for smartphone addiction increases. The cut-off score of the scale in the Korean sample was determined as 31 for men and 33 for women.

Pittsburgh Sleep Quality Index consists of 18 questions in which the individual evaluates himself. The scale consists of 7 components in total. These; subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping pills, and daytime sleep dysfunction. Each component is evaluated separately on a scale of 0-3 points. The total score that can be obtained from the Pittsburgh Sleep Quality Index varies between 0-21. A total score of 5 or less on the scale is interpreted as "good" sleep quality, and a score above 5 is interpreted as "bad" sleep quality.

The Stages of Change Classification Scale indicates the stages of change that individuals go through when they try to change their problematic behavior alone or with support. The stages of change that the individual goes through were developed based on the Transtheoretic Model. The scale guides the practices necessary for the individual to move on to the next stage of change. There is no scoring on the scale, and participants are divided into stages based on their answers to the questions. Not Considering Change Stage: It is the stage where behavior change is not considered. Consideration Stage: This is the stage where behavior change is considered within the next six months. Preparation Phase: This is the phase where behavioral change is considered within the next month. Action Phase: This is the phase where behavioral change begins to be implemented. Maintenance Phase: This is the phase that covers six months and indefinite period following the behavioral change.

he form, which was created to determine students' socio-demographic characteristics and smartphone usage habits, was prepared by the researcher in line with the literature review on the subject. The form consists of a total of 18 questions; There are 8 questions about the socio-demographic characteristics of the students, 8 questions evaluating smartphone usage characteristics, and 2 questions evaluating the individual's smartphone addiction and sleep quality by self-report.

Pittsburgh Sleep Quality Index consists of 18 questions in which the individual evaluates himself. The scale consists of 7 components in total. These; subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping pills, and daytime sleep dysfunction. Each component is evaluated separately on a scale of 0-3 points. The total score that can be obtained from the Pittsburgh Sleep Quality Index varies between 0-21. A total score of 5 or less on the scale is interpreted as "good" sleep quality, and a score above 5 is interpreted as "bad" sleep quality.

The Stages of Change Classification Scale indicates the stages of change that individuals go through when they try to change their problematic behavior alone or with support. The stages of change that the individual goes through were developed based on the Transtheoretic Model. The scale guides the practices necessary for the individual to move on to the next stage of change. There is no scoring on the scale, and participants are divided into stages based on their answers to the questions. Not Considering Change Stage: It is the stage where behavior change is not considered. Consideration Stage: This is the stage where behavior change is considered within the next six months. Preparation Phase: This is the phase where behavioral change is considered within the next month. Action Phase: This is the phase where behavioral change begins to be implemented. Maintenance Phase: This is the phase that covers six months and indefinite period following the behavioral change.

Inclusion Criteria: Aksaray University Faculty of Health Sciences, Nursing Department 1st, 2nd, 3rd and 4th year students Those who have been using smartphones for at least 1 year Those who score above the cut-off score on the Smartphone Addiction Scale-Short Form (31 for men, 33 for women) Those who do not have internet access problems Those who volunteer to participate in the study and have no problems communicating Exclusion Criteria: Having a chronic disease, diagnosed psychiatric health problem or sleep problem The individual does not want to continue working or does not attend a maximum of 2 motivational interview sessions. Having to take a break from education or terminate university education

Sociodemographic data of participants, Smartphone Addiction Scale Short Form results, Pittsburgh Sleep Quality Index results, Classification of Stages of Change Scale results

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