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Demographic, Lifestyle and Environmental Factors Associated with Sleep and Loneliness Problems among Adolescents: A Two-Part Approach Applied to Pooled Cross-Sectional Data

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Title: Demographic, Lifestyle and Environmental Factors Associated with Sleep and Loneliness Problems among Adolescents: A Two-Part Approach Applied to Pooled Cross-Sectional Data
Language: English
Authors: Yong Kang Cheah (ORCID 0000-0002-6793-7055), Chee Cheong Kee, Kuang Kuay Lim, Lay Kim Tan
Source: Psychology in the Schools. 2025 62(9):3090-3104.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 15
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Life Style, Sleep, Psychological Patterns, Drinking, Physical Activities, Adolescents, Scores, Gender Differences, Family Structure, Drug Use, At Risk Persons, Parent Child Relationship, Food, Hunger, Truancy, Aggression, Violence, Bullying, Health Behavior, Instructional Program Divisions, Foreign Countries
Geographic Terms: Malaysia
DOI: 10.1002/pits.23524
ISSN: 0033-3085
1520-6807
Abstract: This study examines the influences of demographic, lifestyle and environmental factors on sleep and loneliness problems (SLP) among adolescents in Malaysia. SLP was formed based on the magnitudes of adolescent sleep deprivation and loneliness. Its scores were derived from five responses to two questions related to sleep deprivation and loneliness. The minimum and maximum scores were 0 and 8, respectively. Data were obtained from two cross-sectional surveys. Lognormal hurdle models were utilized. Females, high grade levels and having divorced/widowed parents were associated with severe SLP. Positive relationships existed between SLP and being physically active, alcohol consumption, and use of illicit drugs. Adolescents at high risk of SLP were more likely to have inadequate intake of fruit and vegetable, and consume fast food. Going hungry, truancy, and poor parental connectedness and bonding were risk factors for SLP. Adolescents tended to experience serious SLP if they were physically attacked, involved in physical fights and bullied. Non-Malays and soft drink consumers were less likely to encounter SLP but had higher scores of SLP than others. School authorities are advised to ensure food security, encourage students to maintain a healthy lifestyle, monitor students' attendance records, address disciplinary problems and detect criminal elements among students.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1479957
Database: ERIC
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  Value: <anid>AN0187257399;pis01sep.25;2025Aug14.01:14;v2.2.500</anid> <title id="AN0187257399-1">Demographic, Lifestyle and Environmental Factors Associated With Sleep and Loneliness Problems Among Adolescents: A Two‐Part Approach Applied to Pooled Cross‐Sectional Data </title> <p>This study examines the influences of demographic, lifestyle and environmental factors on sleep and loneliness problems (SLP) among adolescents in Malaysia. SLP was formed based on the magnitudes of adolescent sleep deprivation and loneliness. Its scores were derived from five responses to two questions related to sleep deprivation and loneliness. The minimum and maximum scores were 0 and 8, respectively. Data were obtained from two cross‐sectional surveys. Lognormal hurdle models were utilized. Females, high grade levels and having divorced/widowed parents were associated with severe SLP. Positive relationships existed between SLP and being physically active, alcohol consumption, and use of illicit drugs. Adolescents at high risk of SLP were more likely to have inadequate intake of fruit and vegetable, and consume fast food. Going hungry, truancy, and poor parental connectedness and bonding were risk factors for SLP. Adolescents tended to experience serious SLP if they were physically attacked, involved in physical fights and bullied. Non‐Malays and soft drink consumers were less likely to encounter SLP but had higher scores of SLP than others. School authorities are advised to ensure food security, encourage students to maintain a healthy lifestyle, monitor students' attendance records, address disciplinary problems and detect criminal elements among students.</p> <p>Summary: Gender, grade levels, ethnicity and parental marital status significantly predict SLP.Adolescents who are physically active, consume alcohol and use illicit drugs tend to experience SLP and have high scores of SLP.Adolescents with severe SLP are more likely to have inadequate intake of fruit and vegetable, consume fast food, go hungry, play truant, be without parental connectedness and bonding, be physically attacked, be involved in physical fights, and be bullied.</p> <p>Keywords: adolescents; demographic factors; lifestyle; loneliness; sleep deprivation</p> <hd id="AN0187257399-2">Introduction</hd> <p>Loneliness is referred to the feeling of chronic stress that arises from insufficiency of quality and quantity of social relationships (Tandon et al. [<reflink idref="bib37" id="ref1">37</reflink>]). It is prevalent in the adolescent population and has received extensive attention as a serious public health issue across the globe (Rodriguez et al. [<reflink idref="bib32" id="ref2">32</reflink>]). Owing to the dramatic changes in biology, psychology and development, adolescents are prone to loneliness, which is seen as a consistent risk factor for various negative health behaviours, such as use of illicit drugs, alcohol drinking, unprotected sexual activity, and smoking (Peltzer and Pengpid [<reflink idref="bib28" id="ref3">28</reflink>]; Igami et al. [<reflink idref="bib16" id="ref4">16</reflink>]). Loneliness is also highly correlated with poor physical health, suicidal behaviours and social withdrawal (Igami et al. [<reflink idref="bib16" id="ref5">16</reflink>]). Numerous studies have shown strong relationships between loneliness and social anxiety, low self‐esteem, depression, and somatic symptoms (Stickley et al. [<reflink idref="bib36" id="ref6">36</reflink>]; Peltzer and Pengpid [<reflink idref="bib28" id="ref7">28</reflink>]; Rodriguez et al. [<reflink idref="bib32" id="ref8">32</reflink>]).</p> <p>Another major public health concern by psychologists and health professionals is sleep deprivation. It is well evident that sleep is essential for health and plays an important role in adolescent development. Inadequate sleep can reduce learning capabilities, memory skills and academic performance (Bartel et al. [<reflink idref="bib3" id="ref9">3</reflink>]). Sleep deprivation is also associated with poor mental health and weak social functioning. Adolescents who do not have enough sleep are more likely to suffer from depression and anxiety compared to those with adequate sleep (Gangwisch et al. [<reflink idref="bib12" id="ref10">12</reflink>]). There is also evidence suggesting that insufficient sleep may elevate the risk of psychotic disorders and bipolar (Morales‐Muñoz and Gregory [<reflink idref="bib26" id="ref11">26</reflink>]). In the studies by Bartel et al. ([<reflink idref="bib3" id="ref12">3</reflink>]) and Liew and Aung ([<reflink idref="bib21" id="ref13">21</reflink>]), sleep deprivation was associated with cardiovascular, respiratory and neurological disorders, as well as various social problems, such as crime and delinquency.</p> <p>Concerted efforts to lower the prevalence of loneliness and sleep deprivation among adolescents should be made in light of its identifiable determining factors. Numerous studies found significant relationships between gender and loneliness, and sleep problems, with males being less likely to feel lonely and experience sleep inadequacy than females (Zhou et al. [<reflink idref="bib43" id="ref14">43</reflink>]; Lewien et al. [<reflink idref="bib20" id="ref15">20</reflink>]; Moksnes et al. [<reflink idref="bib25" id="ref16">25</reflink>]; Rodriguez et al. [<reflink idref="bib32" id="ref17">32</reflink>]; Semenza et al. [<reflink idref="bib34" id="ref18">34</reflink>]). Adolescents of higher grade levels had a higher tendency to encounter sleep disturbance compared to those of lower grade levels (Guo et al. [<reflink idref="bib14" id="ref19">14</reflink>]; Bartel et al. [<reflink idref="bib3" id="ref20">3</reflink>]; Choi et al. [<reflink idref="bib9" id="ref21">9</reflink>]; Glasbeek et al. [<reflink idref="bib13" id="ref22">13</reflink>]). Research focusing on the influences of lifestyle factors observed alcohol consumption, soft drink intake and use of illicit drugs to be positively associated with the odds of loneliness and sleep disorders (Malone et al. [<reflink idref="bib22" id="ref23">22</reflink>]; Kwon et al. [<reflink idref="bib19" id="ref24">19</reflink>]; Seidu [<reflink idref="bib33" id="ref25">33</reflink>]). Adolescents with parental connectedness and bonding were less likely to suffer from loneliness when compared with those without (Seidu [<reflink idref="bib33" id="ref26">33</reflink>]). Being hungry, physically attacked, involved in physical fights and bullied were associated with increased likelihood of loneliness (Amu et al. [<reflink idref="bib1" id="ref27">1</reflink>]; Bayat et al. [<reflink idref="bib5" id="ref28">5</reflink>]; Pengpid and Peltzer [<reflink idref="bib29" id="ref29">29</reflink>]).</p> <p>While loneliness and sleep deprivation tend to occur simultaneously, many studies examined them separately. As found in a meta‐analysis of 84 published articles, sleep deprivation is highly correlated with loneliness, and their correlations are bidirectional (Hom et al. [<reflink idref="bib15" id="ref30">15</reflink>]). Individuals with severe sleep deprivation often have greater loneliness perceptions compared to their peers who did not encounter sleep disorders. Similar findings were evidenced by Guo et al. ([<reflink idref="bib14" id="ref31">14</reflink>]) and Wang et al. ([<reflink idref="bib39" id="ref32">39</reflink>]), who found a positive relationship between loneliness and sleep disturbance. Eccles et al. ([<reflink idref="bib11" id="ref33">11</reflink>]) also observed loneliness to be closely associated with various sleep problems. It appears, therefore, that gaining a deep understanding of factors influencing the magnitude of the co‐occurrence of loneliness and sleep deprivation is of interest.</p> <p>Our current knowledge of adolescent loneliness and sleep deprivation is comprehensive, but it depends mainly on studies conducted within the samples from Western, African, and large Asian countries (Guo et al. [<reflink idref="bib14" id="ref34">14</reflink>]; Malone et al. [<reflink idref="bib22" id="ref35">22</reflink>]; Amu et al. [<reflink idref="bib1" id="ref36">1</reflink>]; Bayat et al. [<reflink idref="bib5" id="ref37">5</reflink>]; Kwon et al. [<reflink idref="bib19" id="ref38">19</reflink>]; Pengpid and Peltzer [<reflink idref="bib29" id="ref39">29</reflink>]). Less is known about loneliness and sleep deprivation in the Malaysian adolescent population. Even though the prevalence of loneliness and sleep deprivation among Malaysian adolescents is not very high, it shows a rising trend, and this needs urgent attention. In particular, the prevalence of loneliness increased from 8.1% in 2012% to 9.3% in 2017, and the prevalence of sleep deprivation surged from 5.4% in 2012% to 7.1% in 2017 (Institute for Public Health [<reflink idref="bib17" id="ref40">17</reflink>], [<reflink idref="bib18" id="ref41">18</reflink>]). The potential reason explaining these increases is the rise in the depression incidence. As the reports of the Ministry of Health Malaysia show, the prevalence of adolescent depression increased from 17.7% in 2012% to 18.3% in 2017 (Institute for Public Health [<reflink idref="bib17" id="ref42">17</reflink>], [<reflink idref="bib18" id="ref43">18</reflink>]). Several empirical studies conducted a meta‐analysis and found that depression was highly correlated with loneliness and sleep deprivation in adolescents (O'Callaghan et al. [<reflink idref="bib27" id="ref44">27</reflink>]; Dunn and Sicouri [<reflink idref="bib10" id="ref45">10</reflink>]).</p> <p>The objective of the present study is to examine demographic, lifestyle and environmental factors associated with sleep deprivation and loneliness in the school‐going adolescent population. Numerous contributions are generated. Firstly, the present study is perhaps the first known comprehensive study to focus on adolescents in Malaysia. It is of the utmost importance to obtain an in‐depth understanding of the factors that may elevate the risk of adolescent loneliness and sleep deprivation in Malaysia, where loneliness and sleep issues are becoming an alarming problem, so that more effective protective policies can be formulated.</p> <p>Secondly, loneliness and sleep deprivation are rarely observed in isolation as they are highly correlated with each other. Hence, the present study develops a new variable, which is named as sleep and loneliness problems (SLP), based on the seriousness of sleep deprivation and loneliness. This variable is important in the sense that it can denote the magnitudes of the co‐occurrence of sleep deprivation and loneliness. Therefore, which cohorts of the adolescent population are likely or unlikely to experience severe loneliness and sleep deprivation can be well‐identified. Furthermore, this variable may also provide an appropriate basis for comparison and identifying the changes in loneliness and sleep deprivation condition among adolescents over time if longitudinal data are available.</p> <p>Lastly, the present study uses a lognormal hurdle model, that is, a two‐part approach, to examine factors affecting the likelihood and scores of SLP. The lognormal hurdle model is more informative than logistic regression and ordered logit models as it allows separate mechanisms to estimate probabilities and levels. Not only the tendency to encounter SLP can be identified, but also the magnitudes. Additionally, the present study uses pooled cross‐sectional data for comprehensive analyses. Data pooling can increase sample sizes and allow for temporal variations in SLP.</p> <hd id="AN0187257399-3">Methods</hd> <p></p> <hd id="AN0187257399-4">Data</hd> <p>The present study was conducted using secondary data from the National Health and Morbidity Survey (NHMS) 2012 and 2017 that focused on three major scopes, that is, adolescent health risk behaviours, nutrition, and mental health (Institute for Public Health [<reflink idref="bib17" id="ref46">17</reflink>], [<reflink idref="bib18" id="ref47">18</reflink>]). The rationale of using pooled cross‐sectional data was that a larger sample size could enhance the accuracy of statistical analyses. Furthermore, pooled cross‐sectional data allowed for the inclusion of a temporal variable. The NHMS 2012 and 2017 were nationally representative school‐going adolescent health surveys conducted by the Ministry of Health Malaysia. The survey periods of NHMS 2012 and 2017 were from 23 February to 26 April 2012 and from 26 March to 3 May 2017, respectively. The NHMS 2022 is the latest survey, but it was not publicly available at the time this study was carried out. The primary objective of NHMS 2012 and 2017 was to gather details of school‐going adolescents' protective factors and health risk behaviours, which included alcohol use, dietary behaviours, drug use, mental health problems and use of tobacco. The target population was secondary school students aged between 13 and 17 years in Malaysia. The sample sizes of NHMS 2012 and 2017 were determined based on a single proportion formula for estimation of prevalence. The response rates of NHMS 2012 and 2017 were 88.7% (<emph>n</emph> = 25507) and 89.2% (<emph>n</emph> = 27497), respectively. However, not all the surveyed respondents were included in the analyses as some reported incomplete information. Specifically, the NHMS 2012 and 2017 comprised 267 and 53 incomplete responses, correspondingly. Respondents with missing data were omitted from the analysis. Since the samples only consist of a small proportion of incomplete responses, deletion of observations is acceptable and may not introduce bias (Wooldridge [<reflink idref="bib41" id="ref48">41</reflink>]).</p> <p>Two‐stage stratified sampling was used to collect nationally representative data. First, secondary schools in all the states in Malaysia were selected randomly based on the probability that was proportionate to the school sizes. Next, classes within the selected schools were chosen using systematic random sampling. All students in the selected classes were eligible respondents. Validated self‐administrated questionnaires were prepared in the Malay and English languages. To minimize social desirability bias, respondents' answer sheets remained anonymous. Data collection training and pilot studies were conducted before the survey to reduce non‐sampling error. The Ministry of Education gave the permission to conduct the survey. School teachers took the responsibilities to distribute the parental consent forms a week before the survey. Students were not allowed to be involved in the survey if they did not obtain written consent from their parents or guardians.</p> <hd id="AN0187257399-5">Dependent Variables</hd> <p>The dependent variable of the present study was measured by the scores of SLP. It was formed based on two questions related to loneliness and sleep deprivation asked in the questionnaire: (i) "During the past 12 months, how often have you felt lonely?", and (ii) "During the past 12 months, how often have you been so worried about something that you could not sleep at night?". The plausible answers for each of these questions were "never", "rarely", "sometimes", "most of the time" and "always". They were given the values of 0 (never), 1 (rarely), 2 (sometimes), 3 (most of the time) and 4 (always). The scores of SLP were equal to the summation of these values. Since there were only two questions, 8 was the maximum score (the most severe SLP) and 0 was the minimum score (absence of SLP). Therefore, the dependent variable had non‐negative integer values with a limited range. To ensure that the combination of scores from these two questions aligned conceptually with the dependent variable, we performed a Pearson chi‐squared test of independence between sleep deprivation and loneliness. We found that these two variables were significantly correlated to each other in the datasets. This finding is consistent with the empirical evidence of previous studies that showed sleep problems to be highly associated with loneliness (Hom et al. [<reflink idref="bib15" id="ref49">15</reflink>]). Therefore, we assumed that the analysis of SLP could achieve the objective of the present study. In addition to SLP scores, a binary variable for co‐occurrence of both loneliness and sleep deprivation (1 = having both loneliness and sleep deprivation, 0 = none) was formed to measure respondents with both conditions at any given scores of SLP. Respondents who answered "rarely", "sometimes", "most of the time" or "always" to both questions related to loneliness and sleep deprivation were considered having both loneliness and sleep deprivation. Non‐co‐occurrence referred to those who answered "never" to either question.</p> <hd id="AN0187257399-6">Independent Variables</hd> <p>In light of the findings pertaining to loneliness and sleep deprivation from prior studies, and the availability of data, the selected independent variables comprised demographic (gender, grade levels, ethnicity and parental marital status), lifestyle (physical activity, smoking, alcohol consumption, use of illicit drugs, fruit and vegetable [FV] intake, soft drink consumption and fast‐food consumption), and environmental factors (going hungry, truancy, parental connectedness, parental bonding, physical attacks, physical fights and being bullied) (Peltzer and Pengpid [<reflink idref="bib28" id="ref50">28</reflink>]; Amu et al. [<reflink idref="bib1" id="ref51">1</reflink>]; Seidu [<reflink idref="bib33" id="ref52">33</reflink>]; Pengpid and Peltzer [<reflink idref="bib29" id="ref53">29</reflink>]; Pengpid and Peltzer [<reflink idref="bib30" id="ref54">30</reflink>]).</p> <p>Respondents' grade levels were categorised based on the local educational system: Form 1 (Grade 7), Form 2 (Grade 8), Form 3 (Grade 9), Form 4 (Grade 10) and Form 5 (Grade 11). Respondents' age was not included because it was highly correlated with grade levels. Respondents' ethnic groups consisted of Malay, Chinese, Indian, Sabah and Sarawak natives, and other ethnicities. Physical activity referred to the days of being physically active for at least 60 min in the past 7 days. It was categorised into three categories: 0–1 day, 2–4 days and ≥ 5 days. The respondents who reported smoking cigarettes, consuming alcohol and using illicit drugs in the past 30 days were categorised as smokers, alcohol drinkers and illicit drug users, respectively. These variables were formatted as binary variables because large proportions of respondents did not smoke, consume alcohol and use illicit drugs. Adequate FV consumption referred to intake of FV of at least five times per day in the past 30 days. The respondents were asked: "During the past 30 days, how many times per day did you usually drink carbonated soft drinks?". Respondents' responses were grouped into three categories: 0 time, 1–2 times and ≥ 3 times. The respondents also reported their fast‐food consumption behaviours when asked: "During the past 7 days, how many days did you eat food from a fast‐food restaurant?". Based on respondents' answers, three categories were formed: 0 day, 1–3 days and ≥ 4 days.</p> <p>In terms of going hungry, the respondents answered "never", "sometimes" or "always" to the following question: "During the past 30 days, how often did you go hungry due to inadequate food at home?". Truancy was defined as missing classes without permission. It was measured based on the days that the respondents missed classes in the past 30 days. Respondents' responses were broken down into four categories: 0 day, 1–2 days, 3–5 days and ≥ 6 days. The respondents with parental connectedness were those having parents who always understood their worries and problems in the past 1 month. Parental bonding referred to "parents who always knew what their children were doing during their free time in the past 1 month". In addition, the respondents were asked to report the frequencies of being physically attacked and involved in physical fights in the past 12 months. Their responses were grouped into four categories: 0 time, 1–3 times, 4–7 times and ≥ 8 times. Also, the respondents declared the days that they were bullied during the past 30 days. Four categories were formed: 0 day, 1–5 days, 6–19 days and ≥ 20 days. To examine temporal variations in the scores of SLP, the year of survey (2017 vs. 2012) was used as a variable. It was interesting to explore whether adolescents in 2017 were more or less likely to encounter SLP compared to those in 2012.</p> <hd id="AN0187257399-7">Statistical Analysis</hd> <p>The data of 25240 and 27444 respondents from the NHMS 2012 and 2017, respectively, were derived and analysed. Before estimating the multivariable regression models, the present study used one‐way analysis of variance (ANOVA) to explore whether there were demographic, lifestyle and environmental differences in the mean of SLP scores. Since not every respondent experienced loneliness and sleep deprivation, the dependent variable contained a large number of zeros. To deal with this kind of limited dependent variable, a lognormal hurdle model was utilised to estimate the results (Wooldridge [<reflink idref="bib40" id="ref55">40</reflink>]). Different from the ordered logistic regression which only estimated the odds of having different ordinal categories of outcomes, a lognormal hurdle model allowed for separate mechanisms for analysing the probabilities and levels of SLP. In the first part of this model, a probit regression was used to identify whether the respondents experienced SLP (yes vs. no). Then, an ordinary least square (OLS) was used to estimate the scores of SLP. Only the respondents with non‐zero values of SLP were analysed in the second part. Logarithmic transformation was performed for OLS analysis. Standardised coefficients were estimated to identify the most important variable.</p> <p>In addition, the present study used a probit model to examine the effects of demographic, lifestyle and environmental factors on the probability of co‐occurrence of both loneliness and sleep deprivation, so that which groups of individuals were likely to experience both problems simultaneously could be identified. One of the assumptions of probit was that errors followed a normal distribution. The data used in the present study was assumed to be normally distributed because they had a large sample size. According to the central limit theorem, as the sample size increased, the distribution of data approximately normally distributed (Wooldridge [<reflink idref="bib40" id="ref56">40</reflink>]). Therefore, the present study assumed normally distributed errors. There were mental health‐related studies using probit to examine depression, anxiety and suicidal behaviours (Cheah et al. [<reflink idref="bib7" id="ref57">7</reflink>]; Cheah et al. [<reflink idref="bib8" id="ref58">8</reflink>]).</p> <p>The present study developed three lognormal hurdle models to identify whether demographic, lifestyle and environmental variables contributed significantly to estimating SLP. This identification was important as it could determine the best model for the data. Model 1 consisted of demographic variables only. Lifestyle variables were added to Model 2, and Model 3 used all the independent variables, including environmental and temporal variables. These three models were then compared based on their log likelihood, pseudo‐R‐squared, adjusted R‐squared and Akaike's information criterion (AIC). Additionally, variance inflation factor (VIF) of each independent variable was calculated to ensure no multicollinearity issues. The significance level was fixed at 0.05. Stata statistical software was used to perform the statistical analysis (StataCorp [<reflink idref="bib35" id="ref59">35</reflink>]).</p> <hd id="AN0187257399-8">Results</hd> <p>The respondents were evenly distributed across grade levels (Table 1). The majority of the respondents were females (51.2%), were Malays (67.6%), lived with married parents (86.9%), spent at least 2 days on physical activity (58.8%), were non‐smokers (89.7%), did not consume alcohol (91.7%) and did not use illicit drugs (98.3%). More than half of the respondents did not consume adequate FV (79.1%), did not consume soft drink (67.9%), ate fast food 1–3 days per week (50.6%), sometimes went hungry (51.5%), did not play truant (70.9%), did not connect with their parents (67.2%), did not bond with their parents (56.3%), and did not engage in physical fights (74.9%). Only small proportions of respondents were physically attacked at least 8 times per year (2.5%) and bullied at least 20 days per month (1.5%). Slightly more than half of the respondents were surveyed in 2017 (52.1%).</p> <p>1 Table Summary statistics of the independent variables and the results of one‐way ANOVA tests for differences in SLP scores (n = 52684).</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th>Variables</th><th>Frequency</th><th>Percent</th><th>Mean</th><th>SD</th><th><italic>p</italic> value<ext-link href="#" /></th></tr></thead><tbody valign="top"><tr><td>Demographic</td><td /><td /><td /><td /><td /></tr><tr><td>Gender</td><td /><td /><td /><td /><td /></tr><tr><td>Male</td><td>25700</td><td>48.78</td><td>1.86</td><td>1.61</td><td>< 0.001</td></tr><tr><td>Female</td><td>26984</td><td>51.22</td><td>2.33</td><td>1.66</td><td /></tr><tr><td>Grade levels</td><td /><td /><td /><td /><td /></tr><tr><td>Form 1</td><td>11072</td><td>21.02</td><td>1.87</td><td>1.64</td><td>< 0.001</td></tr><tr><td>Form 2</td><td>10783</td><td>20.47</td><td>1.99</td><td>1.61</td><td /></tr><tr><td>Form 3</td><td>11406</td><td>21.65</td><td>2.09</td><td>1.64</td><td /></tr><tr><td>Form 4</td><td>9900</td><td>18.96</td><td>2.26</td><td>1.65</td><td /></tr><tr><td>Form 5</td><td>9433</td><td>17.90</td><td>2.35</td><td>1.67</td><td /></tr><tr><td>Ethnicity</td><td /><td /><td /><td /><td /></tr><tr><td>Malay</td><td>35623</td><td>67.62</td><td>2.07</td><td>1.60</td><td>< 0.001</td></tr><tr><td>Chinese</td><td>8563</td><td>16.25</td><td>2.00</td><td>1.70</td><td /></tr><tr><td>Indian</td><td>2850</td><td>5.41</td><td>2.39</td><td>1.93</td><td /></tr><tr><td>Sabah & Sarawak</td><td>4691</td><td>8.90</td><td>2.36</td><td>1.70</td><td /></tr><tr><td>Others</td><td>957</td><td>1.82</td><td>2.24</td><td>1.77</td><td /></tr><tr><td>Marital status</td><td /><td /><td /><td /><td /></tr><tr><td>Married</td><td>45799</td><td>86.93</td><td>2.06</td><td>1.63</td><td>< 0.001</td></tr><tr><td>Divorced/widowed</td><td>6885</td><td>13.07</td><td>2.38</td><td>1.78</td><td /></tr><tr><td>Lifestyle</td><td /><td /><td /><td /><td /></tr><tr><td>Physical activity</td><td /><td /><td /><td /><td /></tr><tr><td>0–1 day</td><td>21705</td><td>41.20</td><td>2.09</td><td>1.67</td><td>0.441</td></tr><tr><td>2–4 days</td><td>19183</td><td>36.41</td><td>2.11</td><td>1.63</td><td /></tr><tr><td>≥ 5 days</td><td>11796</td><td>22.39</td><td>2.10</td><td>1.66</td><td /></tr><tr><td>Smoking</td><td /><td /><td /><td /><td /></tr><tr><td>Smokers</td><td>5407</td><td>10.26</td><td>2.24</td><td>1.75</td><td>< 0.001</td></tr><tr><td>Non‐smokers</td><td>47277</td><td>89.74</td><td>2.09</td><td>1.64</td><td /></tr><tr><td>Alcohol</td><td /><td /><td /><td /><td /></tr><tr><td>Drinkers</td><td>4361</td><td>8.28</td><td>2.53</td><td>1.85</td><td>< 0.001</td></tr><tr><td>Non‐drinkers</td><td>48323</td><td>91.72</td><td>2.06</td><td>1.63</td><td /></tr><tr><td>Illicit drugs</td><td /><td /><td /><td /><td /></tr><tr><td>Users</td><td>884</td><td>1.68</td><td>2.98</td><td>2.05</td><td>< 0.001</td></tr><tr><td>Non‐users</td><td>51800</td><td>98.32</td><td>2.09</td><td>1.64</td><td /></tr><tr><td>Fruit & vegetable</td><td /><td /><td /><td /><td /></tr><tr><td>Adequate</td><td>11014</td><td>20.92</td><td>2.09</td><td>1.70</td><td>0.291</td></tr><tr><td>Inadequate</td><td>41640</td><td>79.08</td><td>2.11</td><td>1.64</td><td /></tr><tr><td>Soft drink</td><td /><td /><td /><td /><td /></tr><tr><td>0 time</td><td>35765</td><td>67.89</td><td>2.06</td><td>1.61</td><td>< 0.001</td></tr><tr><td>1–2 times</td><td>12744</td><td>24.19</td><td>2.15</td><td>1.68</td><td /></tr><tr><td>≥ 3 times</td><td>4175</td><td>7.92</td><td>2.33</td><td>1.87</td><td /></tr><tr><td>Fast food</td><td /><td /><td /><td /><td /></tr><tr><td>0 day</td><td>24057</td><td>45.66</td><td>2.00</td><td>1.63</td><td>< 0.001</td></tr><tr><td>1–3 days</td><td>26630</td><td>50.55</td><td>2.16</td><td>1.64</td><td /></tr><tr><td>≥ 4 days</td><td>1997</td><td>3.79</td><td>2.62</td><td>1.97</td><td /></tr><tr><td>Environmental</td><td /><td /><td /><td /><td /></tr><tr><td>Going hungry</td><td /><td /><td /><td /><td /></tr><tr><td>Never</td><td>23300</td><td>44.23</td><td>1.77</td><td>1.59</td><td>< 0.001</td></tr><tr><td>Sometimes</td><td>27138</td><td>51.51</td><td>2.33</td><td>1.62</td><td /></tr><tr><td>Always</td><td>2246</td><td>4.26</td><td>2.83</td><td>1.98</td><td /></tr><tr><td>Truancy</td><td /><td /><td /><td /><td /></tr><tr><td>0 day</td><td>37375</td><td>70.94</td><td>2.02</td><td>1.63</td><td>< 0.001</td></tr><tr><td>1–2 days</td><td>11200</td><td>21.26</td><td>2.25</td><td>1.65</td><td /></tr><tr><td>3–5 days</td><td>2790</td><td>5.30</td><td>2.40</td><td>1.77</td><td /></tr><tr><td>≥ 6 days</td><td>1319</td><td>2.50</td><td>2.61</td><td>1.92</td><td /></tr><tr><td>Connectedness</td><td /><td /><td /><td /><td /></tr><tr><td>Yes</td><td>17290</td><td>32.82</td><td>1.94</td><td>1.60</td><td>< 0.001</td></tr><tr><td>No</td><td>35394</td><td>67.18</td><td>2.18</td><td>1.68</td><td /></tr><tr><td>Bonding</td><td /><td /><td /><td /><td /></tr><tr><td>Yes</td><td>23031</td><td>43.72</td><td>1.95</td><td>1.60</td><td>< 0.001</td></tr><tr><td>No</td><td>29653</td><td>56.28</td><td>2.22</td><td>1.68</td><td /></tr><tr><td>Physically attacked</td><td /><td /><td /><td /><td /></tr><tr><td>0 time</td><td>39195</td><td>74.40</td><td>1.97</td><td>1.60</td><td>< 0.001</td></tr><tr><td>1–3 times</td><td>10079</td><td>19.13</td><td>2.41</td><td>1.68</td><td /></tr><tr><td>4–7 times</td><td>2076</td><td>3.94</td><td>2.69</td><td>1.84</td><td /></tr><tr><td>≥ 8 times</td><td>1334</td><td>2.53</td><td>2.90</td><td>2.01</td><td /></tr><tr><td>Physical fights</td><td /><td /><td /><td /><td /></tr><tr><td>0 time</td><td>39458</td><td>74.90</td><td>1.98</td><td>1.60</td><td>< 0.001</td></tr><tr><td>1–3 times</td><td>10423</td><td>19.78</td><td>2.37</td><td>1.69</td><td /></tr><tr><td>4–7 times</td><td>1746</td><td>3.31</td><td>2.70</td><td>1.89</td><td /></tr><tr><td>≥ 8 times</td><td>1057</td><td>2.01</td><td>2.95</td><td>2.14</td><td /></tr><tr><td>Being bullied</td><td /><td /><td /><td /><td /></tr><tr><td>0 day</td><td>44152</td><td>83.81</td><td>1.98</td><td>1.59</td><td>< 0.001</td></tr><tr><td>1–5 days</td><td>6502</td><td>12.34</td><td>2.66</td><td>1.75</td><td /></tr><tr><td>6–19 days</td><td>1239</td><td>2.35</td><td>3.03</td><td>1.88</td><td /></tr><tr><td>≥ 20 days</td><td>791</td><td>1.50</td><td>3.23</td><td>2.09</td><td /></tr><tr><td>Year of survey</td><td /><td /><td /><td /><td /></tr><tr><td>2017</td><td>27444</td><td>52.09</td><td>2.12</td><td>1.69</td><td>0.020</td></tr><tr><td>2012</td><td>25240</td><td>47.91</td><td>2.09</td><td>1.61</td><td /></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note:</emph> Mean refers to average scores of SLP. SD refers to standard deviation. The significance level is <emph>p</emph> < 0.05.</p> <p>2 # p‐values in one‐way ANOVA.</p> <p> <emph>Source:</emph> NHMS 2012 & 2017.</p> <p>The average scores of SLP increased with grade levels (1.87–2.35). SLP scores were higher among females (2.33), those with divorced/widowed parents (2.38), those who smoked (2.24), alcohol drinkers (2.53), illicit drug users (2.98), frequent soft drink consumers ( ≥ 3 times) (2.33) and frequent fast‐food consumers ( ≥ 4 days) (2.62) than others. Always going hungry (2.83), high truancy levels ( ≥ 6 days) (2.61), being frequently physically attacked ( ≥ 8 times) (2.90), frequent involvement in physical fights ( ≥ 8 times) (2.95) and being frequently bullied (3.23) were associated with higher scores of SLP. Parental connectedness (1.94) and bonding (1.95) were correlated with lower scores of SLP.</p> <p>Of all the regression models, Model 3 had the highest pseudo‐R‐squared (0.078), adjusted R‐squared (0.090), log likelihood (−57854.572), as well as the lowest AIC (115861.100) (Table 2). Moreover, multicollinearities were not an issue as its maximum VIF was low (1.620). Collectively, Model 3 was the best model that explained SLP, and this also indicated that demographic, lifestyle and environmental variables were well‐fitted to the model.</p> <p>2 Table Estimated results for the lognormal hurdle models (n = 52684).</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th>Variables</th><th>Model 1</th><th /><th /><th>Model 2</th><th /><th /><th>Model 3</th><th /><th /></tr><tr valign="bottom"><th>First</th><th>Second</th><th>Beta</th><th>First</th><th>Second</th><th>Beta</th><th>First</th><th>Second</th><th>Beta</th></tr></thead><tbody valign="top"><tr><td>Constant</td><td>—</td><td>0.867<ext-link href="*" /></td><td>0.363<ext-link href="*" /></td><td>—</td><td>0.804<ext-link href="*" /></td><td>0.300<ext-link href="*" /></td><td>—</td><td>0.675<ext-link href="*" /></td><td>0.171<ext-link href="*" /></td></tr><tr><td /><td /><td>(0.010)</td><td>(0.010)</td><td /><td>(0.011)</td><td>(0.011)</td><td /><td>(0.012)</td><td>(0.012)</td></tr><tr><td>Gender</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Male</td><td>−0.082<ext-link href="*" /></td><td>−0.127<ext-link href="*" /></td><td>−0.063<ext-link href="*" /></td><td>−0.088<ext-link href="*" /></td><td>−0.149<ext-link href="*" /></td><td>−0.074<ext-link href="*" /></td><td>−0.104<ext-link href="*" /></td><td>−0.175<ext-link href="*" /></td><td>−0.087<ext-link href="*" /></td></tr><tr><td /><td>(0.003)</td><td>(0.005)</td><td>(0.003)</td><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td></tr><tr><td>Female</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Grade levels</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Form 1</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Form 2</td><td>0.032<ext-link href="*" /></td><td>0.022<ext-link href="*" /></td><td>0.009<ext-link href="*" /></td><td>0.031<ext-link href="*" /></td><td>0.024<ext-link href="*" /></td><td>0.009<ext-link href="*" /></td><td>0.037<ext-link href="*" /></td><td>0.036<ext-link href="*" /></td><td>0.014<ext-link href="*" /></td></tr><tr><td /><td>(0.005)</td><td>(0.009)</td><td>(0.003)</td><td>(0.005)</td><td>(0.009)</td><td>(0.003)</td><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td></tr><tr><td>Form 3</td><td>0.052<ext-link href="*" /></td><td>0.044<ext-link href="*" /></td><td>0.018<ext-link href="*" /></td><td>0.052<ext-link href="*" /></td><td>0.051<ext-link href="*" /></td><td>0.021<ext-link href="*" /></td><td>0.068<ext-link href="*" /></td><td>0.082<ext-link href="*" /></td><td>0.034<ext-link href="*" /></td></tr><tr><td /><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td></tr><tr><td>Form 4</td><td>0.092<ext-link href="*" /></td><td>0.078<ext-link href="*" /></td><td>0.031<ext-link href="*" /></td><td>0.090<ext-link href="*" /></td><td>0.083<ext-link href="*" /></td><td>0.033<ext-link href="*" /></td><td>0.107<ext-link href="*" /></td><td>0.117<ext-link href="*" /></td><td>0.046<ext-link href="*" /></td></tr><tr><td /><td>(0.005)</td><td>(0.009)</td><td>(0.003)</td><td>(0.005)</td><td>(0.009)</td><td>(0.003)</td><td>(0.005)</td><td>(0.009)</td><td>(0.003)</td></tr><tr><td>Form 5</td><td>0.102<ext-link href="*" /></td><td>0.103<ext-link href="*" /></td><td>0.039<ext-link href="*" /></td><td>0.100<ext-link href="*" /></td><td>0.113<ext-link href="*" /></td><td>0.043<ext-link href="*" /></td><td>0.122<ext-link href="*" /></td><td>0.157<ext-link href="*" /></td><td>0.060<ext-link href="*" /></td></tr><tr><td /><td>(0.006)</td><td>(0.009)</td><td>(0.003)</td><td>(0.006)</td><td>(0.009)</td><td>(0.003)</td><td>(0.006)</td><td>(0.009)</td><td>(0.003)</td></tr><tr><td>Ethnicity</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Malay</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Chinese</td><td>−0.046<ext-link href="*" /></td><td>0.021<ext-link href="*" /></td><td>0.008<ext-link href="*" /></td><td>−0.055<ext-link href="*" /></td><td>0.010</td><td>0.004</td><td>−0.041<ext-link href="*" /></td><td>0.021<ext-link href="*" /></td><td>0.008<ext-link href="*" /></td></tr><tr><td /><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td></tr><tr><td>Indian</td><td>−0.031<ext-link href="*" /></td><td>0.176<ext-link href="*" /></td><td>0.040<ext-link href="*" /></td><td>−0.037<ext-link href="*" /></td><td>0.152<ext-link href="*" /></td><td>0.034<ext-link href="*" /></td><td>−0.038<ext-link href="*" /></td><td>0.139<ext-link href="*" /></td><td>0.031<ext-link href="*" /></td></tr><tr><td /><td>(0.007)</td><td>(0.012)</td><td>(0.003)</td><td>(0.007)</td><td>(0.012)</td><td>(0.003)</td><td>(0.007)</td><td>(0.012)</td><td>(0.003)</td></tr><tr><td>Sabah & Sarawak</td><td>0.034<ext-link href="*" /></td><td>0.086<ext-link href="*" /></td><td>0.025<ext-link href="*" /></td><td>0.027<ext-link href="*" /></td><td>0.056<ext-link href="*" /></td><td>0.016<ext-link href="*" /></td><td>0.028<ext-link href="*" /></td><td>0.061<ext-link href="*" /></td><td>0.017<ext-link href="*" /></td></tr><tr><td /><td>(0.006)</td><td>(0.009)</td><td>(0.003)</td><td>(0.006)</td><td>(0.010)</td><td>(0.003)</td><td>(0.006)</td><td>(0.009)</td><td>(0.003)</td></tr><tr><td>Others</td><td>−0.011</td><td>0.075<ext-link href="*" /></td><td>0.010<ext-link href="*" /></td><td>−0.016</td><td>0.055<ext-link href="*" /></td><td>0.007<ext-link href="*" /></td><td>−0.019</td><td>0.046<ext-link href="*" /></td><td>0.006<ext-link href="*" /></td></tr><tr><td /><td>(0.013)</td><td>(0.021)</td><td>(0.003)</td><td>(0.013)</td><td>(0.021)</td><td>(0.003)</td><td>(0.013)</td><td>(0.021)</td><td>(0.003)</td></tr><tr><td>Marital status</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Married</td><td>−0.034<ext-link href="*" /></td><td>−0.088<ext-link href="*" /></td><td>−0.030<ext-link href="*" /></td><td>−0.029<ext-link href="*" /></td><td>−0.074<ext-link href="*" /></td><td>−0.025<ext-link href="*" /></td><td>−0.015<ext-link href="*" /></td><td>−0.053<ext-link href="*" /></td><td>−0.018<ext-link href="*" /></td></tr><tr><td /><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td><td>(0.005)</td><td>(0.008)</td><td>(0.003)</td></tr><tr><td>Divorced/widowed</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Physical activity</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>0–1 day</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>2–4 days</td><td /><td /><td /><td>0.015<ext-link href="*" /></td><td>0.005</td><td>0.002</td><td>0.017<ext-link href="*" /></td><td>0.009</td><td>0.004</td></tr><tr><td /><td /><td /><td /><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td></tr><tr><td>≥ 5 days</td><td /><td /><td /><td>0.013<ext-link href="*" /></td><td>0.021<ext-link href="*" /></td><td>0.009<ext-link href="*" /></td><td>0.015<ext-link href="*" /></td><td>0.024<ext-link href="*" /></td><td>0.010<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td>(0.004)</td><td>(0.007)</td><td>(0.003)</td><td>(0.004)</td><td>(0.007)</td><td>(0.003)</td></tr><tr><td>Smoking</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Smokers</td><td>—</td><td>—</td><td>—</td><td>0.022<ext-link href="*" /></td><td>0.035<ext-link href="*" /></td><td>0.011<ext-link href="*" /></td><td>−0.008</td><td>−0.010</td><td>−0.003</td></tr><tr><td /><td /><td /><td /><td>(0.006)</td><td>(0.010)</td><td>(0.003)</td><td>(0.006)</td><td>(0.010)</td><td>(0.003)</td></tr><tr><td>Non‐smokers</td><td /><td /><td /><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Alcohol</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Drinkers</td><td>—</td><td>—</td><td>—</td><td>0.063<ext-link href="*" /></td><td>0.090<ext-link href="*" /></td><td>0.025<ext-link href="*" /></td><td>0.041<ext-link href="*" /></td><td>0.055<ext-link href="*" /></td><td>0.015<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td>(0.007)</td><td>(0.011)</td><td>(0.003)</td><td>(0.007)</td><td>(0.011)</td><td>(0.003)</td></tr><tr><td>Non‐drinkers</td><td /><td /><td /><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Illicit drugs</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Users</td><td>—</td><td>—</td><td>—</td><td>0.068<ext-link href="*" /></td><td>0.189<ext-link href="*" /></td><td>0.024<ext-link href="*" /></td><td>0.005</td><td>0.066<ext-link href="*" /></td><td>0.008<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td>(0.016)</td><td>(0.023)</td><td>(0.003)</td><td>(0.016)</td><td>(0.023)</td><td>(0.003)</td></tr><tr><td>Non‐users</td><td /><td /><td /><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Fruit & vegetable</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Adequate</td><td>—</td><td>—</td><td>—</td><td>−0.025<ext-link href="*" /></td><td>0.007</td><td>0.003</td><td>−0.019<ext-link href="*" /></td><td>0.011</td><td>0.004</td></tr><tr><td /><td /><td /><td /><td>(0.004)</td><td>(0.007)</td><td>(0.003)</td><td>(0.004)</td><td>(0.007)</td><td>(0.003)</td></tr><tr><td>Inadequate</td><td /><td /><td /><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Soft drink</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>0 time</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–2 times</td><td /><td /><td /><td>−0.001</td><td>0.040<ext-link href="*" /></td><td>0.017<ext-link href="*" /></td><td>−0.014<ext-link href="*" /></td><td>0.020<ext-link href="*" /></td><td>0.009<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td>(0.004)</td><td>(0.007)</td><td>(0.003)</td><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td></tr><tr><td>≥ 3 times</td><td /><td /><td /><td>−0.003</td><td>0.088<ext-link href="*" /></td><td>0.024<ext-link href="*" /></td><td>−0.022<ext-link href="*" /></td><td>0.046<ext-link href="*" /></td><td>0.012<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td>(0.007)</td><td>(0.011)</td><td>(0.003)</td><td>(0.007)</td><td>(0.011)</td><td>(0.003)</td></tr><tr><td>Fast food</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>0 day</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–3 days</td><td /><td /><td /><td>0.024<ext-link href="*" /></td><td>0.031<ext-link href="*" /></td><td>0.015<ext-link href="*" /></td><td>0.016<ext-link href="*" /></td><td>0.018<ext-link href="*" /></td><td>0.009<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td><td>(0.003)</td><td>(0.005)</td><td>(0.003)</td></tr><tr><td>≥ 4 days</td><td /><td /><td /><td>0.029<ext-link href="*" /></td><td>0.169<ext-link href="*" /></td><td>0.032<ext-link href="*" /></td><td>0.007</td><td>0.117<ext-link href="*" /></td><td>0.022<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td>(0.010)</td><td>(0.015)</td><td>(0.003)</td><td>(0.010)</td><td>(0.015)</td><td>(0.003)</td></tr><tr><td>Going hungry</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Never</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Sometimes</td><td /><td /><td /><td /><td /><td /><td>0.106<ext-link href="*" /></td><td>0.112<ext-link href="*" /></td><td>0.056<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.003)</td><td>(0.006)</td><td>(0.003)</td></tr><tr><td>Always</td><td /><td /><td /><td /><td /><td /><td>0.089<ext-link href="*" /></td><td>0.221<ext-link href="*" /></td><td>0.045<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.009)</td><td>(0.014)</td><td>(0.003)</td></tr><tr><td>Truancy</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>0 day</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–2 days</td><td /><td /><td /><td /><td /><td /><td>0.025<ext-link href="*" /></td><td>0.015<ext-link href="*" /></td><td>0.006<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.004)</td><td>(0.007)</td><td>(0.003)</td></tr><tr><td>3–5 days</td><td /><td /><td /><td /><td /><td /><td>0.015<ext-link href="*" /></td><td>0.061<ext-link href="*" /></td><td>0.014<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.008)</td><td>(0.012)</td><td>(0.003)</td></tr><tr><td>≥ 6 days</td><td /><td /><td /><td /><td /><td /><td>0.024<ext-link href="*" /></td><td>0.074<ext-link href="*" /></td><td>0.012<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.012)</td><td>(0.017)</td><td>(0.003)</td></tr><tr><td>Connectedness</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Yes</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>−0.019<ext-link href="*" /></td><td>−0.034<ext-link href="*" /></td><td>−0.016<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td></tr><tr><td>No</td><td /><td /><td /><td /><td /><td /><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Bonding</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Yes</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>−0.021<ext-link href="*" /></td><td>−0.043<ext-link href="*" /></td><td>−0.022<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.004)</td><td>(0.006)</td><td>(0.003)</td></tr><tr><td>No</td><td /><td /><td /><td /><td /><td /><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Physically attacked</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>0 time</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–3 times</td><td /><td /><td /><td /><td /><td /><td>0.053<ext-link href="*" /></td><td>0.061<ext-link href="*" /></td><td>0.024<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.005)</td><td>(0.007)</td><td>(0.003)</td></tr><tr><td>4–7 times</td><td /><td /><td /><td /><td /><td /><td>0.061<ext-link href="*" /></td><td>0.102<ext-link href="*" /></td><td>0.020<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.010)</td><td>(0.014)</td><td>(0.003)</td></tr><tr><td>≥ 8 times</td><td /><td /><td /><td /><td /><td /><td>0.073<ext-link href="*" /></td><td>0.127<ext-link href="*" /></td><td>0.020<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.013)</td><td>(0.019)</td><td>(0.003)</td></tr><tr><td>Physical fights</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>0 time</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–3 times</td><td /><td /><td /><td /><td /><td /><td>0.048<ext-link href="*" /></td><td>0.046<ext-link href="*" /></td><td>0.018<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.005)</td><td>(0.007)</td><td>(0.003)</td></tr><tr><td>4–7 times</td><td /><td /><td /><td /><td /><td /><td>0.050<ext-link href="*" /></td><td>0.090<ext-link href="*" /></td><td>0.016<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.011)</td><td>(0.016)</td><td>(0.003)</td></tr><tr><td>≥ 8 times</td><td /><td /><td /><td /><td /><td /><td>0.033<ext-link href="*" /></td><td>0.149<ext-link href="*" /></td><td>0.021<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.014)</td><td>(0.022)</td><td>(0.003)</td></tr><tr><td>Being bullied</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>0 day</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–5 days</td><td /><td /><td /><td /><td /><td /><td>0.088<ext-link href="*" /></td><td>0.136<ext-link href="*" /></td><td>0.045<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.006)</td><td>(0.008)</td><td>(0.003)</td></tr><tr><td>6–19 days</td><td /><td /><td /><td /><td /><td /><td>0.131<ext-link href="*" /></td><td>0.199<ext-link href="*" /></td><td>0.030<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.014)</td><td>(0.017)</td><td>(0.003)</td></tr><tr><td>≥ 20 days</td><td /><td /><td /><td /><td /><td /><td>0.103<ext-link href="*" /></td><td>0.272<ext-link href="*" /></td><td>0.033<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.017)</td><td>(0.022)</td><td>(0.003)</td></tr><tr><td>Year of survey</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>2017</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>−0.001</td><td>0.010<ext-link href="*" /></td><td>0.005<ext-link href="*" /></td></tr><tr><td /><td /><td /><td /><td /><td /><td /><td>(0.003)</td><td>(0.005)</td><td>(0.003)</td></tr><tr><td>2012</td><td /><td /><td /><td /><td /><td /><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Pseudo R<sup>2</sup></td><td>0.025</td><td>—</td><td>—</td><td>0.030</td><td>—</td><td>—</td><td>0.078</td><td>—</td><td>—</td></tr><tr><td>Adjusted R<sup>2</sup></td><td>—</td><td>0.027</td><td>—</td><td>—</td><td>0.041</td><td>—</td><td>—</td><td>0.090</td><td>—</td></tr><tr><td>Log likelihood</td><td>−60699.570</td><td>−60200.658</td><td align="center">−57854.572</td></tr><tr><td>AIC</td><td>121443.100</td><td>120485.300</td><td align="center">115861.100</td></tr><tr><td>Maximum VIF</td><td>1.590</td><td>1.600</td><td align="center">1.620</td></tr></tbody></table> </ephtml> </p> <ulist> <item>3 <emph>Note:</emph> For the first part, marginal effects from probit regressions are presented. For the second, estimates from OLS regressions are presented. Beta refers to standardised coefficient. Robust standard errors in parentheses. Ref refers to reference group. AIC refers to Akaike's information criterion. VIF refers to variance inflation factors.</item> <item>4 * <emph>p</emph> < 0.05.</item> </ulist> <p> <emph>Source:</emph> NHMS 2012 & 2017.</p> <p>Males were 10.4% less likely to experience SLP and also had 17.5% lower scores of SLP than females. Compared to Form 1 respondents, the probabilities of having SLP were higher among Form 2 (3.7%), 3 (6.8%), 4 (10.7%) and 5 (12.2%) respondents. These respondents also had 3.6–15.7% higher SLP scores. When compared with Malays, Chinese and Indians had 4.1% and 3.8% lower probabilities of facing SLP, respectively, whereas Sabah and Sarawak natives had 2.8% higher probabilities. Chinese, Indians, Sabah and Sarawak natives, and those of other ethnic groups had 2.1%, 13.9%, 6.1% and 4.6% higher scores of SLP, respectively, compared to Malays. Respondents with married parents were 1.5% less likely to experience SLP and had 5.3% lower scores of SLP than those with divorced/widowed parents.</p> <p>Respondents who spent at least 5 days on physical activity were 1.5% more likely to experience SLP than those spent less than 2 days. These respondents also had 2.4% higher scores of SLP. Alcohol drinkers and illicit drug users had 5.5% and 6.6% higher scores of SLP, respectively, compared to non‐alcohol drinkers and non‐illicit drug users. Respondents who regularly consumed soft drink ( ≥ 3 times) and ate adequate FV were 2.2% and 1.9% less likely to encounter SLP, respectively, than those who did not. However, frequent soft drink consumption ( ≥ 3 times) was associated with increased scores of SLP (4.6%). The probability and scores of SLP increased by 1.6% and 1.8%, respectively, if the respondents consumed 1–3 days of fast food per week.</p> <p>Sometimes and always going hungry were positively correlated with the probabilities (8.9–10.6%) and scores of SLP (11.2–22.1%). Positive relationships between the frequency of truancy and the probabilities (1.5–2.5%), and scores of SLP (1.5–7.4%) were also observed. Respondents with parental connectedness and bonding were 1.9% and 2.1% less likely to experience SLP, respectively, than those without. These respondents also had 3.4–4.3% lower scores of SLP. Respondents who were physically attacked 1–3, 4–7 and ≥ 8 times in the past 12 months were 5.3%, 6.1% and 7.3% more likely to encounter SLP, respectively, than those without suffering from physical attack. The probabilities of SLP increased by 3.3–5% if the respondents were involved in physical fights. So did the scores of SLP, which increased by 4.6–14.9%. Being bullied was associated with increased probabilities (8.8%–13.1%) and scores of SLP (13.6–27.2%). Respondents in 2017 had 1% higher scores of SLP than those in 2012. Gender was the most important variable as it had the largest standardised coefficient. Grade levels and going hungry were the second and third most important variables, respectively.</p> <p>Males were 16.5% less likely to experience both sleep deprivation and loneliness than females (Table 3). The probability of encountering both sleep deprivation and loneliness was 21% higher among respondents in Form 5. Compared to Malays, Chinese and Indian were 3.4% and 4.2% less likely to encounter both sleep deprivation and loneliness, respectively, whereas Sabah and Sarawak natives were 5.3% more likely. Having married parents reduced the probability of experiencing both sleep deprivation and loneliness by 1.4%. Respondents who spent ≥ 5 days on physical activity were 3% more likely to experience both sleep deprivation and loneliness than those who spent only 0–1 day. Alcohol drinkers had a 4.6% higher probability of experiencing both sleep deprivation and loneliness than non‐drinkers. Respondents who regularly consumed fast food ( ≥ 4 days) and always went hungry were 5.4% and 13.9% more likely to encounter both sleep deprivation and loneliness, respectively, than those who did not.</p> <p>3 Table Factors associated with co‐occurrence of both loneliness and sleep deprivation (n = 52684).</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th>Variables</th><th>Coefficients</th><th>Marginal effects</th></tr></thead><tbody valign="top"><tr><td>Constant</td><td>−0.493<ext-link href="*" /></td><td>—</td></tr><tr><td /><td>(0.026)</td><td /></tr><tr><td>Gender</td><td /><td /></tr><tr><td>Male</td><td>−0.415<ext-link href="*" /></td><td>−0.165<ext-link href="*" /></td></tr><tr><td /><td>(0.012)</td><td>(0.005)</td></tr><tr><td>Female</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Grade levels</td><td /><td /></tr><tr><td>Form 1</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Form 2</td><td>0.147<ext-link href="*" /></td><td>0.058<ext-link href="*" /></td></tr><tr><td /><td>(0.018)</td><td>(0.007)</td></tr><tr><td>Form 3</td><td>0.287<ext-link href="*" /></td><td>0.114<ext-link href="*" /></td></tr><tr><td /><td>(0.017)</td><td>(0.007)</td></tr><tr><td>Form 4</td><td>0.431<ext-link href="*" /></td><td>0.172<ext-link href="*" /></td></tr><tr><td /><td>(0.018)</td><td>(0.007)</td></tr><tr><td>Form 5</td><td>0.527<ext-link href="*" /></td><td>0.210<ext-link href="*" /></td></tr><tr><td /><td>(0.019)</td><td>(0.007)</td></tr><tr><td>Ethnicity</td><td /><td /></tr><tr><td>Malay</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Chinese</td><td>−0.086<ext-link href="*" /></td><td>−0.034<ext-link href="*" /></td></tr><tr><td /><td>(0.017)</td><td>(0.007)</td></tr><tr><td>Indian</td><td>−0.106<ext-link href="*" /></td><td>−0.042<ext-link href="*" /></td></tr><tr><td /><td>(0.026)</td><td>(0.010)</td></tr><tr><td>Sabah & Sarawak</td><td>0.133<ext-link href="*" /></td><td>0.053<ext-link href="*" /></td></tr><tr><td /><td>(0.021)</td><td>(0.008)</td></tr><tr><td>Others</td><td>−0.026</td><td>−0.011</td></tr><tr><td /><td>(0.042)</td><td>(0.017)</td></tr><tr><td>Marital status</td><td /><td /></tr><tr><td>Married</td><td>−0.035<ext-link href="*" /></td><td>−0.014<ext-link href="*" /></td></tr><tr><td /><td>(0.017)</td><td>(0.007)</td></tr><tr><td>Divorced/widowed</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Physical activity</td><td /><td /></tr><tr><td>0–1 day</td><td>Ref.</td><td>Ref.</td></tr><tr><td>2–4 days</td><td>0.067<ext-link href="*" /></td><td>0.027<ext-link href="*" /></td></tr><tr><td /><td>(0.013)</td><td>(0.005)</td></tr><tr><td>≥ 5 days</td><td>0.075<ext-link href="*" /></td><td>0.030<ext-link href="*" /></td></tr><tr><td /><td>(0.015)</td><td>(0.006)</td></tr><tr><td>Smoking</td><td /><td /></tr><tr><td>Smokers</td><td>−0.045</td><td>−0.018</td></tr><tr><td /><td>(0.021)</td><td>(0.008)</td></tr><tr><td>Non‐smokers</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Alcohol</td><td /><td /></tr><tr><td>Drinkers</td><td>0.116<ext-link href="*" /></td><td>0.046<ext-link href="*" /></td></tr><tr><td /><td>(0.023)</td><td>(0.009)</td></tr><tr><td>Non‐drinkers</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Illicit drugs</td><td /><td /></tr><tr><td>Users</td><td>−0.042</td><td>−0.017</td></tr><tr><td /><td>(0.049)</td><td>(0.020)</td></tr><tr><td>Non‐users</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Fruit & vegetable</td><td /><td /></tr><tr><td>Adequate</td><td>−0.016</td><td>−0.006</td></tr><tr><td /><td>(0.014)</td><td>(0.006)</td></tr><tr><td>Inadequate</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Soft drink</td><td /><td /></tr><tr><td>0 time</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–2 times</td><td>−0.023</td><td>−0.009</td></tr><tr><td /><td>(0.014)</td><td>(0.005)</td></tr><tr><td>≥ 3 times</td><td>−0.015</td><td>−0.006</td></tr><tr><td /><td>(0.022)</td><td>(0.009)</td></tr><tr><td>Fast food</td><td /><td /></tr><tr><td>0 day</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–3 days</td><td>0.085<ext-link href="*" /></td><td>0.034<ext-link href="*" /></td></tr><tr><td /><td>(0.012)</td><td>(0.005)</td></tr><tr><td>≥ 4 days</td><td>0.135<ext-link href="*" /></td><td>0.054<ext-link href="*" /></td></tr><tr><td /><td>(0.031)</td><td>(0.013)</td></tr><tr><td>Going hungry</td><td /><td /></tr><tr><td>Never</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Sometimes</td><td>0.378<ext-link href="*" /></td><td>0.151<ext-link href="*" /></td></tr><tr><td /><td>(0.012)</td><td>(0.005)</td></tr><tr><td>Always</td><td>0.350<ext-link href="*" /></td><td>0.139<ext-link href="*" /></td></tr><tr><td /><td>(0.029)</td><td>(0.012)</td></tr><tr><td>Truancy</td><td /><td /></tr><tr><td>0 day</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–2 days</td><td>0.052<ext-link href="*" /></td><td>0.021<ext-link href="*" /></td></tr><tr><td /><td>(0.014)</td><td>(0.006)</td></tr><tr><td>3–5 days</td><td>0.095<ext-link href="*" /></td><td>0.038<ext-link href="*" /></td></tr><tr><td /><td>(0.026)</td><td>(0.010)</td></tr><tr><td>≥ 6 days</td><td>0.050</td><td>0.020</td></tr><tr><td /><td>(0.037)</td><td>(0.015)</td></tr><tr><td>Connectedness</td><td /><td /></tr><tr><td>Yes</td><td>−0.052<ext-link href="*" /></td><td>−0.021<ext-link href="*" /></td></tr><tr><td /><td>(0.013)</td><td>(0.005)</td></tr><tr><td>No</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Bonding</td><td /><td /></tr><tr><td>Yes</td><td>−0.090<ext-link href="*" /></td><td>−0.036<ext-link href="*" /></td></tr><tr><td /><td>(0.012)</td><td>(0.005)</td></tr><tr><td>No</td><td>Ref.</td><td>Ref.</td></tr><tr><td>Physically attacked</td><td /><td /></tr><tr><td>0 time</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–3 times</td><td>0.194<ext-link href="*" /></td><td>0.077<ext-link href="*" /></td></tr><tr><td /><td>(0.016)</td><td>(0.006)</td></tr><tr><td>4–7 times</td><td>0.247<ext-link href="*" /></td><td>0.098<ext-link href="*" /></td></tr><tr><td /><td>(0.031)</td><td>(0.012)</td></tr><tr><td>≥ 8 times</td><td>0.243<ext-link href="*" /></td><td>0.097<ext-link href="*" /></td></tr><tr><td /><td>(0.039)</td><td>(0.016)</td></tr><tr><td>Physical fights</td><td /><td /></tr><tr><td>0 time</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–3 times</td><td>0.157<ext-link href="*" /></td><td>0.063<ext-link href="*" /></td></tr><tr><td /><td>(0.016)</td><td>(0.006)</td></tr><tr><td>4–7 times</td><td>0.156<ext-link href="*" /></td><td>0.062<ext-link href="*" /></td></tr><tr><td /><td>(0.034)</td><td>(0.014)</td></tr><tr><td>≥ 8 times</td><td>0.127<ext-link href="*" /></td><td>0.050<ext-link href="*" /></td></tr><tr><td /><td>(0.044)</td><td>(0.018)</td></tr><tr><td>Being bullied</td><td /><td /></tr><tr><td>0 day</td><td>Ref.</td><td>Ref.</td></tr><tr><td>1–5 days</td><td>0.321<ext-link href="*" /></td><td>0.128<ext-link href="*" /></td></tr><tr><td /><td>(0.018)</td><td>(0.007)</td></tr><tr><td>6–19 days</td><td>0.348<ext-link href="*" /></td><td>0.139<ext-link href="*" /></td></tr><tr><td /><td>(0.039)</td><td>(0.016)</td></tr><tr><td>≥ 20 days</td><td>0.346<ext-link href="*" /></td><td>0.138<ext-link href="*" /></td></tr><tr><td /><td>(0.049)</td><td>(0.019)</td></tr><tr><td>Year of survey</td><td /><td /></tr><tr><td>2017</td><td>0.024<ext-link href="*" /></td><td>0.010<ext-link href="*" /></td></tr><tr><td /><td>(0.012)</td><td>(0.005)</td></tr><tr><td>2012</td><td>Ref.</td><td>Ref.</td></tr></tbody></table> </ephtml> </p> <ulist> <item>5 <emph>Note:</emph> Robust standard errors in parentheses. Ref refers to reference group.</item> <item>6 * <emph>p</emph> < 0.05.</item> </ulist> <p> <emph>Source:</emph> NHMS 2012 & 2017.</p> <p>Frequent truancy (3–5 days) was associated with a 3.8% higher probability of experiencing both sleep deprivation and loneliness. The probability of experiencing both sleep deprivation and loneliness reduced by 2.1% and 3.6% if respondents had parental connectedness and bonding, correspondingly. Being physically attacked ( ≥ 8 times) and involvement in physical fights ( ≥ 8 times) increased the probability of experiencing both sleep deprivation and loneliness by 9.7% and 5%, respectively. Being bullied was positively associated with the probability of experiencing both sleep deprivation and loneliness (12.8–13.9%). Respondents in 2017 were 1% more likely to experience both sleep deprivation and loneliness compared to those in 2012.</p> <hd id="AN0187257399-9">Discussion</hd> <p>The rise in the prevalence of sleep deprivation and loneliness among adolescents is an alarming public health problem across the globe that needs concerted planning efforts. Despite the continuous monitoring of this issue, many adolescents still suffer from sleep deprivation and loneliness. The present study is perhaps the first to use two‐part models to examine the associations between the magnitudes of co‐occurrence of sleep deprivation and loneliness, and demographic, lifestyle and environmental factors within two large nationally representative samples of school‐going adolescents in Malaysia. Collectively, the present study's findings showed that gender, grade levels, ethnicity, marital status, physical activity, alcohol drinking, use of illicit drugs, FV intake, consumption of soft drink and fast food, going hungry, truancy, parental connectedness and bonding, being physically attacked and bullied, and involvement in physical fights were independently associated with the probabilities and scores of SLP.</p> <p>Findings from the present study support gender differences in loneliness and sleep deprivation. The associations between being females and increased likelihood and scores of SLP as well as an elevated probability of co‐occurrence of loneliness and sleep deprivation are consistent with the findings of previous studies (Zhou et al. [<reflink idref="bib43" id="ref60">43</reflink>]; Pinto et al. [<reflink idref="bib31" id="ref61">31</reflink>]; Moksnes et al. [<reflink idref="bib25" id="ref62">25</reflink>]; Rodriguez et al. [<reflink idref="bib32" id="ref63">32</reflink>]). For instance, Glasbeek et al. ([<reflink idref="bib13" id="ref64">13</reflink>]) and Pengpid and Peltzer ([<reflink idref="bib29" id="ref65">29</reflink>]) found that female adolescents were more susceptible to loneliness and tended to face more serious sleep problems than males. This may be attributable to the fact that males have better capabilities of coping with stress than females because their thoughts are less likely to be influenced by emotions (Pengpid and Peltzer [<reflink idref="bib30" id="ref66">30</reflink>]). The mediational roles of cognitive and emotional arousal may exist in the association between the female gender and sleep reduction (Glasbeek et al. [<reflink idref="bib13" id="ref67">13</reflink>]).</p> <p>In the present study, older adolescents were not only more likely to experience SLP and co‐occurrence of loneliness and sleep deprivation but also had higher scores of SLP when compared with their younger counterparts. These results are consistent with the previous studies' findings, indicating that adolescents' age and grade levels are important determinants of loneliness and sleep problems (Choi et al. [<reflink idref="bib9" id="ref68">9</reflink>]; Lewien et al. [<reflink idref="bib20" id="ref69">20</reflink>]; Pengpid and Peltzer [<reflink idref="bib29" id="ref70">29</reflink>]; Pengpid and Peltzer [<reflink idref="bib30" id="ref71">30</reflink>]; Glasbeek et al. [<reflink idref="bib13" id="ref72">13</reflink>]). Changes in individual thought due to increases in autonomy and pubertal development, as well as increased dependence on peers may be the potential reasons for age differences in SLP as have been noted by previous studies (Pengpid and Peltzer [<reflink idref="bib30" id="ref73">30</reflink>]; Glasbeek et al. [<reflink idref="bib13" id="ref74">13</reflink>]). Based on our findings, school teachers are strongly suggested to provide students of higher age groups with psychological support and professional counselling services if the students shows symptoms of loneliness and sleep deprivation.</p> <p>The present study contributed to the limited findings related to ethnic variations in adolescent loneliness and sleep deprivation, and observed that Malays were more likely than Chinese and Indians to encounter SLP and co‐occurrence of loneliness and sleep deprivation but had lower scores of SLP compared to Sabah and Sarawak natives, and those of other ethnic groups. The reason for these ethnic variations is unclear and has to be sought in qualitative research. It was noteworthy that the relationships between ethnicity and loneliness, and sleep problems were also evidenced in previous studies that focused on White, Black and Hispanic (Malone et al. [<reflink idref="bib22" id="ref75">22</reflink>]; Kwon et al. [<reflink idref="bib19" id="ref76">19</reflink>]; Semenza et al. [<reflink idref="bib34" id="ref77">34</reflink>]). If data allow, a forthcoming longitudinal study can be conducted to supplement a better understanding of the mediational roles of culture and religion in the effects of ethnicity on sleep and loneliness. Nevertheless, findings from the present study imply that policymakers should take account of the influences of the ethnic factor on loneliness and sleep deprivation when designing intervention strategies.</p> <p>A previous study conducted in the Netherlands demonstrated that significant relationships existed between parental marital status and loneliness, with having divorced parents to be associated with increased odds of loneliness (Bayat et al. [<reflink idref="bib5" id="ref78">5</reflink>]). This finding is supported by the evidence of the present study, which showed positive relationships between having divorced or widowed parents and SLP, and co‐occurrence of loneliness and sleep deprivation. Additionally, Stickley and colleagues devoted their attention to adolescents in Czech, Russian and US adolescents, and also found that adolescents who did not live with their biological parents were more likely to suffer from loneliness compared to those staying with because of poor family cohesion (Stickley et al. [<reflink idref="bib36" id="ref79">36</reflink>]).</p> <p>Alcohol consumption and use of illicit drugs were associated with increased likelihood and scores of SLP but only alcohol use was correlated with a higher risk of co‐occurrence of loneliness and sleep deprivation. These findings are in line with the past findings observed in the USA and Southeast Asian countries, which showed adolescents with alcohol drinking and illicit drug use behaviours to be more likely to encounter loneliness and sleep deprivation than those without (Peltzer and Pengpid [<reflink idref="bib28" id="ref80">28</reflink>]; Kwon et al. [<reflink idref="bib19" id="ref81">19</reflink>]). In today's fast‐paced society, adolescents are likely to use illicit drugs and alcohol as a method to reduce their loneliness‐related stress (Peltzer and Pengpid [<reflink idref="bib28" id="ref82">28</reflink>]; Kwon et al. [<reflink idref="bib19" id="ref83">19</reflink>]). Alcohol can also impair social relations, human body and daily life, thereby leading to sleep deprivation and loneliness (Kwon et al. [<reflink idref="bib19" id="ref84">19</reflink>]; Antunes et al. [<reflink idref="bib2" id="ref85">2</reflink>]).</p> <p>Physically active respondents, especially those who spent at least 5 days per week on physical activity, not only had a higher tendency to encounter SLP and co‐occurrence of loneliness and sleep deprivation but also experienced more serious SLP compared to their inactive peers. This is perhaps because regular exercise may cause sleep disturbance due to release of endorphin hormone (Basso and Suzuki [<reflink idref="bib4" id="ref86">4</reflink>]). Also, owing to time constraints, frequent participation in physical activity may reduce time spent on social activities. These unintended effects of exercise may result in different degrees of loneliness and sleep deprivation. Although being physically active is positively associated with loneliness and sleep deprivation, it has large beneficial effects on physical and mental health outcomes. Therefore, public health interventions aimed at lowering the prevalence of adolescent loneliness and sleep deprivation should not ignore the importance of physical activity. The present study urges that parents and school teachers should work together to oversee adolescents' lifestyle behaviours.</p> <p>There appeared to be limited prior findings that showed relationships between dietary behaviours and loneliness, and sleep deprivations. Therefore, the present study filled this gap by focusing on consumption of FV, soft drink and fast food. Overall, adolescents who consumed adequate FV were less likely to face SLP than those who did not, and those who occasionally (1–3 days per week) or often ( ≥ 4 days per week) consumed fast food were more likely to experience SLP and co‐occurrence of loneliness and sleep deprivation, and also had severer SLP compared to non‐fast‐food consumers. These findings lead to a conclusion that healthy eating may safeguard adolescents from having sleep problems and loneliness. This is simply because a healthy diet can reduce inflammation and consequently improves mental health (Tuck et al. [<reflink idref="bib38" id="ref87">38</reflink>]). Somewhat similar findings were observed by Pengpid and Peltzer ([<reflink idref="bib29" id="ref88">29</reflink>]) and Wang et al. ([<reflink idref="bib39" id="ref89">39</reflink>]), who focused on other Southeast Asian countries.</p> <p>The opposite effects of the frequency of soft drink consumption on the probabilities and scores of SLP found in the present study indicated that occasional (1–2 times per month) and regular ( ≥ 3 times per month) soft drink consumers exhibited a lower likelihood of experiencing SLP than non‐soft drink consumers but, conditional on having SLP, they suffered from more serious SLP. While a small amount of soft drink intake may boost mood (Mantantzis et al. [<reflink idref="bib23" id="ref90">23</reflink>]), moderate or high consumption of soft drink may result in mental disorders (Chaput et al. [<reflink idref="bib6" id="ref91">6</reflink>]), and shorter sleep duration due to its stimulating properties, such as caffeine (Zhang et al. [<reflink idref="bib42" id="ref92">42</reflink>]). Considering the present study's findings, intervention strategies that promote healthy eating based on adolescent dietary lifestyles should be undertaken together with the efforts to alleviate further increases in the prevalence of sleep disorders and loneliness among adolescents. School teachers must take the responsibilities to educate students about the benefits of FV as well as the disadvantages of fast food and soft drink.</p> <p>In line with the past studies, the present study found that sometimes and always going hungry were positively associated with the likelihood and levels of SLP, as well as the probability of co‐occurrence of loneliness and sleep deprivation (Amu et la., 2020; Seidu [<reflink idref="bib33" id="ref93">33</reflink>]; Pengpid and Peltzer [<reflink idref="bib29" id="ref94">29</reflink>]; Marthoenis et al. [<reflink idref="bib24" id="ref95">24</reflink>]). This is mainly because adolescents who often or occasionally go hungry are usually from low‐income family backgrounds and thus have poor social skills and low self‐esteem (Amu et al. [<reflink idref="bib1" id="ref96">1</reflink>]; Seidu [<reflink idref="bib33" id="ref97">33</reflink>]). In addition, the present study found truancy to be correlated with SLP, with adolescents who missed a few or many days of classes scoring higher SLP points and exhibiting a higher risk of co‐occurrence of loneliness and sleep deprivation than those who did not miss any classes. Future studies are thereby suggested to identify the actual reasons for the effects of truancy on loneliness and sleep deprivation. In terms of policy implication, school teachers should focus exclusively on monitoring their students' attendance records as truancy could be the signs of sleep problems and loneliness.</p> <p>Multiple studies conducted across the world demonstrated that parental factors were important predictors of adolescent mental health. For instance, Antunes et al. ([<reflink idref="bib2" id="ref98">2</reflink>]) found that the likelihood of experiencing loneliness was lower among adolescents with understanding parents than those without because family support could improve children's self‐confidence and promote good mental health. In another study, Guo et al. ([<reflink idref="bib14" id="ref99">14</reflink>]) observed a good family relationship to be a protective factor for adolescent sleep disturbance. The present study expanded those findings by confirming that parental connectedness and bonding reduced the likelihood and scores of SLP as well as the tendency to experience co‐occurrence of loneliness and sleep deprivation. As such, school authorities should make a concerted effort to encourage parents to allocate more time to their children, especially in light of the fact that the time spent by parents in monitoring adolescents typically reduce as adolescents grow older.</p> <p>The present study's findings that adolescents who were physically attacked, involved in physical fights and bullied had higher probabilities of SLP and co‐occurrence of loneliness and sleep deprivation than those who were not are in agreement with the findings from numerous previous studies (Stickley et al. [<reflink idref="bib36" id="ref100">36</reflink>]; Peltzer and Pengpid [<reflink idref="bib28" id="ref101">28</reflink>]; Amu et al. [<reflink idref="bib1" id="ref102">1</reflink>]; Seidu [<reflink idref="bib33" id="ref103">33</reflink>]; Bayat et al. [<reflink idref="bib5" id="ref104">5</reflink>]; Pengpid and Peltzer [<reflink idref="bib29" id="ref105">29</reflink>]; Pengpid and Peltzer [<reflink idref="bib30" id="ref106">30</reflink>]; Antunes et al. [<reflink idref="bib2" id="ref107">2</reflink>]). The present study also found that the SLP scores constantly increased with the frequencies of being physically attacked, participating in physical fights and being bullied. This phenomenon suggests that environment factors, which are denoted by physical attacks, physical fights and bully victimization, may result in loneliness and sleep deprivation. One of the plausible explanations is that adolescents who are bullied and physically attacked by their peers tend to have poor mental health and trouble making new friends because of low self‐esteem and being worried about future victimization (Stickley et al. [<reflink idref="bib36" id="ref108">36</reflink>]; Amu et al. [<reflink idref="bib1" id="ref109">1</reflink>]). Furthermore, adolescents who indulge in fighting tend to be isolated and rejected by their peers (Amu et al. [<reflink idref="bib1" id="ref110">1</reflink>]). Since physical attacks, physical fights and bully victimization can be modified via appropriate intervention, they should be an important target for future policies. For instance, the school authorities and police can cooperate in addressing disciplinary problems and detect criminal elements, such as physical violence and bullying among school children. This can be facilitated through the appointment of police‐school liaison officers at the secondary schools with serious disciplinary issues.</p> <p>Temporal variations in SLP were evidenced in the present study. Compared to adolescents in 2012, those in 2017 were more likely to encounter co‐occurrence of loneliness and sleep deprivation, and had higher SLP scores. While a comprehensive assessment of sleep and loneliness related policies does not fall within the scope of the present study, we assume that certain intervention measures that have been implemented by the Malaysian government to prevent adolescents from developing loneliness and sleep problems need to be improved. Discussion of these measures can be a direction for future research that focuses on analysing the cost‐effectiveness of policies.</p> <p>The novelty of the population, use of pooled cross‐sectional data with a large sample size, development of a variable that measures the degrees of sleep and loneliness, as well as utilisation of a strong analytical approach to examine the probabilities and scores of SLP were the main strengths of the present study. Nevertheless, the present study's findings have to be interpreted by considering their limitations. Firstly, owing to cross‐sectional data, the causal relationships between variables were unable to be identified. Secondly, the population of interest of the present study was school‐going adolescents. Therefore, the differences in SLP between school‐going and out‐of‐school adolescents could not be explored. Thirdly, two questions related to sleep deprivation and loneliness may be insufficient to evaluate SLP. Fourthly, the present study did not examine the effect of the number of siblings on SLP. Fifthly, given that the data were collected several years ago, they may not reflect the current scenario in Malaysia. Lastly, due to self‐reported data, social desirability bias and recall bias may exist.</p> <hd id="AN0187257399-10">Conclusion</hd> <p>The findings from the present study demonstrated that adolescents were more likely to experience SLP and had higher SLP scores if they were females, were in higher grade levels, had divorced or widowed parents, were physically active, consumed alcohol, used illicit drugs, did not consume adequate FV, consumed fast food, went hungry, played truant, did not have parental connectedness and bonding, were physically attacked, were involved in physical fights, and were bullied. These findings are useful in the sense that they can help in formulating effective approaches directed toward reducing the prevalence of adolescent sleep deprivation and loneliness. They emphasize the fundamental requirements for public health and school interventions in the adolescent population. With the availability of data, a future longitudinal study is warranted to shed light on the effects of SLP on poor academic performance and chronic diseases.</p> <hd id="AN0187257399-11">Author Contributions</hd> <p> <bold>Yong Kang Cheah:</bold> conceptualization, visualization, methodology, validation, formal analysis, investigation, writing – original draft, writing – review and editing. <bold>Chee Cheong Kee:</bold> methodology, writing – review and editing. <bold>Kuang Kuay Lim:</bold> methodology, writing – review and editing. <bold>Lay Kim Tan:</bold> writing – review and editing.</p> <hd id="AN0187257399-12">Acknowledgments</hd> <p>The authors would like to thank the Director General of Health, Malaysia for his permission to use the data from the National Health and Morbidity Survey (NHMS) 2012 and NHMS 2017, and to publish this paper.</p> <hd id="AN0187257399-13">Ethics Statement</hd> <p>Both the NHMS 2012 (NMRR‐11‐974‐10401) and NHMS 2017 (NMRR‐16‐698‐30042) were approved by the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia.</p> <hd id="AN0187257399-14">Conflicts of Interest</hd> <p>The authors declare no conflicts of interest.</p> <hd id="AN0187257399-15">Data Availability Statement</hd> <p>The data that support the findings of this study are available from the Ministry of Health Malaysia but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Demographic, Lifestyle and Environmental Factors Associated with Sleep and Loneliness Problems among Adolescents: A Two-Part Approach Applied to Pooled Cross-Sectional Data
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Yong+Kang+Cheah%22">Yong Kang Cheah</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-6793-7055">0000-0002-6793-7055</externalLink>)<br /><searchLink fieldCode="AR" term="%22Chee+Cheong+Kee%22">Chee Cheong Kee</searchLink><br /><searchLink fieldCode="AR" term="%22Kuang+Kuay+Lim%22">Kuang Kuay Lim</searchLink><br /><searchLink fieldCode="AR" term="%22Lay+Kim+Tan%22">Lay Kim Tan</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Psychology+in+the+Schools%22"><i>Psychology in the Schools</i></searchLink>. 2025 62(9):3090-3104.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 15
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Life+Style%22">Life Style</searchLink><br /><searchLink fieldCode="DE" term="%22Sleep%22">Sleep</searchLink><br /><searchLink fieldCode="DE" term="%22Psychological+Patterns%22">Psychological Patterns</searchLink><br /><searchLink fieldCode="DE" term="%22Drinking%22">Drinking</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Activities%22">Physical Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Scores%22">Scores</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Family+Structure%22">Family Structure</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Use%22">Drug Use</searchLink><br /><searchLink fieldCode="DE" term="%22At+Risk+Persons%22">At Risk Persons</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Child+Relationship%22">Parent Child Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Food%22">Food</searchLink><br /><searchLink fieldCode="DE" term="%22Hunger%22">Hunger</searchLink><br /><searchLink fieldCode="DE" term="%22Truancy%22">Truancy</searchLink><br /><searchLink fieldCode="DE" term="%22Aggression%22">Aggression</searchLink><br /><searchLink fieldCode="DE" term="%22Violence%22">Violence</searchLink><br /><searchLink fieldCode="DE" term="%22Bullying%22">Bullying</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Program+Divisions%22">Instructional Program Divisions</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Malaysia%22">Malaysia</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1002/pits.23524
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0033-3085<br />1520-6807
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: This study examines the influences of demographic, lifestyle and environmental factors on sleep and loneliness problems (SLP) among adolescents in Malaysia. SLP was formed based on the magnitudes of adolescent sleep deprivation and loneliness. Its scores were derived from five responses to two questions related to sleep deprivation and loneliness. The minimum and maximum scores were 0 and 8, respectively. Data were obtained from two cross-sectional surveys. Lognormal hurdle models were utilized. Females, high grade levels and having divorced/widowed parents were associated with severe SLP. Positive relationships existed between SLP and being physically active, alcohol consumption, and use of illicit drugs. Adolescents at high risk of SLP were more likely to have inadequate intake of fruit and vegetable, and consume fast food. Going hungry, truancy, and poor parental connectedness and bonding were risk factors for SLP. Adolescents tended to experience serious SLP if they were physically attacked, involved in physical fights and bullied. Non-Malays and soft drink consumers were less likely to encounter SLP but had higher scores of SLP than others. School authorities are advised to ensure food security, encourage students to maintain a healthy lifestyle, monitor students' attendance records, address disciplinary problems and detect criminal elements among students.
– Name: AbstractInfo
  Label: Abstractor
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1479957
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RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1002/pits.23524
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 15
        StartPage: 3090
    Subjects:
      – SubjectFull: Life Style
        Type: general
      – SubjectFull: Sleep
        Type: general
      – SubjectFull: Psychological Patterns
        Type: general
      – SubjectFull: Drinking
        Type: general
      – SubjectFull: Physical Activities
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Scores
        Type: general
      – SubjectFull: Gender Differences
        Type: general
      – SubjectFull: Family Structure
        Type: general
      – SubjectFull: Drug Use
        Type: general
      – SubjectFull: At Risk Persons
        Type: general
      – SubjectFull: Parent Child Relationship
        Type: general
      – SubjectFull: Food
        Type: general
      – SubjectFull: Hunger
        Type: general
      – SubjectFull: Truancy
        Type: general
      – SubjectFull: Aggression
        Type: general
      – SubjectFull: Violence
        Type: general
      – SubjectFull: Bullying
        Type: general
      – SubjectFull: Health Behavior
        Type: general
      – SubjectFull: Instructional Program Divisions
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      – SubjectFull: Foreign Countries
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      – SubjectFull: Malaysia
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    Titles:
      – TitleFull: Demographic, Lifestyle and Environmental Factors Associated with Sleep and Loneliness Problems among Adolescents: A Two-Part Approach Applied to Pooled Cross-Sectional Data
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            NameFull: Chee Cheong Kee
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            NameFull: Kuang Kuay Lim
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            NameFull: Lay Kim Tan
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          Dates:
            – D: 01
              M: 09
              Type: published
              Y: 2025
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            – TitleFull: Psychology in the Schools
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