Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 11 Azyvati Karesna Putera, Salmon Charles P.T Siahaan
Medical Faculty of Ciputra University, Surabaya, Indonesia Correspondence email: akaresna@student.ciputra.ac.id
Rapid development changes the era and all walks of life. One of the results of this development is the internet. There is one that attracts a lot of fans of all ages caused of various types of internet launches which is online games. Online games are platform that provides entertainment and could play at any time as well as anywhere (1). The rapid development of technology is also marked by the presence of smartphones. With smartphones, people could easily access all information and also can be used as a tool to play online games practically.
Online games develop their concepts and types in terms. Now online games provide various features, one of which is the communication online feature that makes the interaction between online players. The online game was created to reduce stress, but over time can lead to dependency and thus pathological conditions (2,3). The game continues to develop over time and produces different various types. According to Hurst (2015), there are 12 types of online games such as:
1. Massively Multiple Online Role Playing Games (MMORPGs) 2. Simulation Games
3. Adventure
4. Real-Time Strategy 5. Puzzles Games 6. Action
7. Stealth Shooter 8. Combat
9. First Person Shooter 10. Sport
11. Role Playing 12. Education
The Relationship Between Online Games and Behavioral Changes in Pregnant Women At Surabaya in 2021
ABSTRACT
Online games are types of games that can be accessed by many people using a device connected to the internet. The various types of available games can easily attract the interest of all ages and people with certain health conditions such as pregnant women. Online games whose initial purpose for entertainment can have a negative impact both physically and mentally on users. Behavioral changes in pregnant women that are not appropriate can have a negative impact on the condition of the pregnant women and fetus. The purpose of the study was to explain the relationship between online games and behavioral changes in pregnant women. This research used an observational analysis type and prospective cohort design, the sampling random using a questionnaire conducted to pregnant women in the first & second trimesters at Puskesmas Made Surabaya from August to December 2021 which will be tested with the chi-square. There is a significant relationship between several variables. There is a positive relationship between playing duration and pathologic conditions with p=0.014 and depression with p = 0.036. There is a positive relationship between game types and pathologic conditions with p = 0.033 and knowledge improvement with p = 0.047. There is a relationship between online games and behavioral changes in pregnant women, both from the duration of playing or the type of game chosen.
Keywords: Pregnant women, online games, pathological play, depression, knowledge
INTRODUCTION
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 12 Online games are often considered to have bad influences on human beings, but also have good influences on other sides such as:
1. Add intelligence 2. Add concentration 3. Increase eye sharpness 4. Increase brain performance 5. Remove stress (4)
However, online games also have bad impacts such as:
1. Caused an addiction
2. Have a neglected activity in real life 3. Change eat and rest habit
4. Health problems, that are:
a. Eye Strain b. Hemorrhoid
c. Carpal Tunnel Syndrome d. Lower Metabolism (4).
All women will find physiological changes throughout their life cycle. Begins with fertilization by a sperm into an ovum which makes the pregnancy experience. That phase will through some steps number before ending by postpartum time (5–7). Pregnancy is a normal phenomenon that occurs in productive women. They will feel changes during each pregnancy such as physical and emotional psychological as specific reactions to their experienced or feel (6,8).
Besides physical things, the psychological aspect of pregnant women could influence pregnancy conditions. Maturation crises experienced by every pregnant women during pregnancy could cause stress. If this phase can be handled by the pregnant women, then the pregnant women is ready to take care and responsibility for her pregnancy. The personal concepts also changed to prepare for their role as a parent. However, if the phase not could be handled by pregnant women so could cause problem serious psychological problems such as stress, anxiety, and depression. Especially when first pregnancy, pregnant women often experienced worry about various kinds of changes that might occur to them, such as an appearance change or a self- confidence decrease after pregnancy (9).
There are changes in behavior in women who experience pregnancy based on the length of the pregnancy. Where in the first trimester, namely the adjustment period, pregnant women will begin to adapt to their role, change their self-concept, focus on themselves, have a commitment to give affection to other individuals. In the second trimester, which is the period of good health, the pregnant woman turns her attention to her pregnancy, is able to differentiate herself from the fetus she is carrying, and a sense of responsibility for mother and child appears. In the third trimester, women will begin to realistically accept their mother's role, prepare for pregnancy and parenting, and actively communicate with other mothers about their pregnancy.
Changes in the behavior of pregnant women must be precise, because if you experience failed it will have a bad impact. One of the bad effects is depression in pregnancy because it can affect the fetus in the womb such as increasing the risk for growth and development, so that babies can be born with deficiencies and low weight. Lifestyle, fulfillment of nutrition and activities of pregnant women with depression also affect this condition.
This study aims for knowing the influence between online games and behavioral changes in pregnant women physically and mentally based on the duration of playing or the type of chosen game.
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 13 METHOD
This research used an observational analysis type. This research uses a cohort prospective design. Cohort prospective design aims to use research data and analyze risk factors following the course of the disease forward based on time order. The samples were taken with a simple random sampling method consisting of 44 pregnant women in their first and second trimesters who played online games. The research instrument form as a questionnaire will be given to first and second trimesters of pregnant women who indicate play online games. The variables in this research were divided into independent and dependent. Independent variables of this research are knowledge, depression, and pathologic gaming. Dependent variables of this research are behavioral changes in the first and second trimesters of pregnant women.
The instrument used in this research uses 4 types of questionnaires which are demographics to determine the identity and status of pregnant women, the Internet Addiction Test (IAT) which has been modified for pathology games users by A. Rahmat (2014) using the Linkert scale, Depression anxiety stress scale 21 (DASS-21) which is based on Psychology Foundation of Australia research divided on 3 variable that is depression, stressed, and worry, also last descriptive questionnaire by Nisak (2015) for determining the effect of online games on knowledge improvement. The data will be processed using SPSS 25 to find the relationship between variables using chi-square test.
RESULTS AND DISCUSSION
Table 1 Distribution Frequency of Pregnant Women Who Play Online Games
Characteristics Frequency (n) Percetage (%)
Pregnancy Age <13 weeks 11 25
13-28 weeks 33 75
Duration Short 18 40.9
Long 26 59.1
Games Type Action 25 56.8
Education 19 43.2
Pathologic Pathologic 22 50.0
Nonpathologic 22 50.0
Depression Yes 23 52.3
No 21 47.7
Knowledge improvement Improve 30 68.2
Not Improve 14 31.8
Based on table 1, the characteristics of the pregnant women's pregnancy age are divided into 2 types such as first trimester (<13 weeks) and second trimester (14-16 weeks). Among 44 samples, there was a dominance in second trimester pregnancy which amounted to 33 respondents (75%), while in the first trimester only 11 respondents (25%). Based on gameplay duration of pregnant women characteristics obtained 18 respondents (40.9%) are pregnant women who played with a short duration and 26 respondents (59.1%) are pregnant women who played with longer durations. The characteristics of gameplay types are divided into actions and education which 25 respondents (56.8%) referring to action games and 19 respondents (43.2%) referring to educational games. There is a balanced amount of pathologic and nonpathological gaming experiences data that 22 respondents (50%) on pathologic gaming and 22 respondents
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 14 (50%) also on nonpathological gaming. Regarding depression characteristics, there is no domination of pregnant women who have depression experience, the result of pregnant women who were depressed obtained 23 respondents (52.3%) and 21 respondents (47.7%) with no depression experience. Knowledge improvement characteristics found domination in pregnant women who have knowledge improvement, yet 14 respondents (31.8%) did not have knowledge improvement.
Maternal gestational age was divided into 2 groups, namely the first trimester (<13 weeks) and the second trimester (14-16 weeks). Maternal gestational age who had entered the second trimester dominated the study subjects with findings of 33 data (75%) compared to 11 data (25%) in mothers with first trimester gestational age.
The duration of play is divided into 2 categories, namely short duration of play (<90 minutes) and long duration of play. (>90 minutes). The distribution of pregnant women who played with a fast duration amounted to 18 data (40.9%) and mothers who played with a long duration more with a total of 26 data (59.1%). Types of games are categorized into 2, where more pregnant women are interested in playing action games than education with the distribution of data on action games as much as 25 data (56.8%) and education as many as 19 data (43.2%).
Pathologic gaming experienced by pregnant women as samples is equally distributed with findings of pathologic gaming, namely 22 data (50%) and non-pathologic gaming, 22 data (50%).
Research shows that those who play video games excessively are likely to exhibit a number of addiction-like symptoms, including impairment of normal, social and occupational or educational functioning, tolerance, and withdrawal which may be considered moderately "pathological" and require clinical attention and intervention. Depression in pregnant women who played online games found that the difference was not too large between mothers who were depressed or not with the distribution of pregnant women who experienced depression as many as 23 data (52.3%) and those who did not experience depression 21 data (47.7%). Several studies have found a strong relationship between ED and depression. Pregnant women who play online games experience a significant increase in intelligence, where there is a large dominance in the distribution of data on mothers who experience an increase in knowledge. With findings on mothers who experienced an increase in knowledge as much as 30 data (68.2%) while those who did not experience an increase in knowledge were 14 data (31.8%).
Table 2 Relationship Results Data of Relationship Between Online Games and Pathologic Gaming Based on Short & Long Play Duration Trend
Variable Duration Total P OR (CI 95%)
Short Duration Long Duration
n % N %
Pathologic Yes 5 27.8 17 65.4 22
0,014 4,911 (1,325- 18,205)
No 13 72.2 9 34.6 22
Total 18 100 26 100 44
According to table 2 can be inferred those 18 pregnant women respondents played for a short duration, 5 pathologic gaming respondents (27.8%), and 13 non-pathologic gaming respondents (72.2%). Moreover, 26 respondents of pregnant women who played for a long duration have 17 pathologic gaming respondents (65.4%), and 9 non-pathologic gaming respondents (34.6%).
The chi-square test result obtained a p-value = 0.014 with an OR = 4.911 means that there is a significant relationship between play duration and pathologic gaming. Play duration has a risk of about 4,911 times to emergence of pathologic gaming conditions in pregnant women at
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 15 Surabaya. Meanwhile, the result indicates that playing duration can affect the emergence of the pathologic gaming condition, following previous research theory which mentions the length of playing online games times can affect human taking care of himself, also as long as playing duration can trigger bad behavior (Anjayani et al., 2020). Long physical exposure to light radiation can make eyes become tired and damage the nerves of the eye, furthermore can decrease sleep quality caused by addiction to online games (10).
Table 3 Relationship Result Data Between Online Games and Depression Based on Short & Long Play Duration Trend
Variable
Duration
Total P OR (CI 95%) Short Duration Long Duration
n % N %
Depression Yes 6 33.3 17 65.3 23 0.036 3,778 (1,061-
13,453)
No 12 66.6 9 34.6 21
Total 18 100 26 100 44
Table 3 shows 18 pregnant women respondents who played for a short duration 6 depressed respondents (33.3%) and 12 non-depressed respondents (66.6%). Moreover, 26 respondents of pregnant women who played for a long duration have 17 depressed respondents (65.3%), and 9 non-depressed respondents (34.6%). The chi-square test results obtained a p-value = 0.036 with OR = 3,778 means that there is a significant relationship between playing duration and the emergence of depression. Play duration has a risk of 3,778 times to the emergence of depression in pregnant women at Surabaya. The results can be interpreted that there is an influence between playing duration with the emergence of depression in pregnant women, these results are following significant positive relationship research between the level of play and a depressed condition, which as long as playing duration will higher the level emergence of depression (Zaelani et al., 2019). A study found the impact of high-intensity playing games on mood and psychic conditions, as well as the risk of 12,48 times more sadness experience and 2,56 times more sensitive (11).
Table 4 Relationship Result Data Between Online Games and Knowledge Improvement Based on Short
& Long Play Duration Trend
Variable
Duration
Total P OR (CI 95%) Short Duration Long Duration
N % n %
Knowledge Improvement
Yes 11 61.1 19 73 30 0.402 1,727 (0,478-
6.238)
No 7 38.9 7 37 14
Total 18 100 26 100 44
Table 4 shows that 18 pregnant women respondents who played for a short duration had 11 knowledge improvement respondents (61.1%) and 7 respondents (38.9%) who did not have knowledge improvement. Moreover, 26 respondents of pregnant women who played for a long duration hhad19 knowledge improvement respondents (73%), and 7 respondents (37%) did not have knowledge improvement. The chi-square test results obtained a p-value = 0.402 with OR = 1,727 means that there is no relationship which significant between playing duration and the emergence of knowledge improvement. Playing duration has a risk of 1,727 times to knowledge
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 16 improvement in pregnant women at Surabaya. The results can be interpreted that there is no relationship between playing duration and knowledge improvement in pregnant women. This result is opposite to previous research tests which state that there is a relationship between knowledge levels with short and long duration, also playing games with a short duration can have a positive impact on cognitive and intelligence, whereas playing with a long duration give a negative impact to cognitive and intelligence (12). Players with long duration trends will have decreased cognitive and attention function (13).
Table 5 Relationship Result Data Between Online Games and Pathologic Gaming Based on Played Game Types
Variable
Game Types
Total P OR (CI 95%) Action Education
N % N %
Pathologic Yes 16 64 6 31.6 22 0.033 0,260 (0,73-
0,921)
No 9 36 13 68.4 22
Total 25 100 19 100 44
Table 5 shows that 25 pregnant women respondents who play action games have 16 pathologic respondents (64%) and 9 non-pathologic respondents (36%). Moreover, 19 respondents of pregnant women who play education games have 6 pathologic respondents (31.6%) and 13 non-pathologic respondents (68.4%). The chi-square test results obtained a p- value = 0,033 with an OR = 0,260 means that there is a significant relationship between game types and the emergence of pathologic conditions. Game types have a risk of 1,727 times to pathologic conditions in pregnant women at Surabaya. The results can be interpreted that there is an influence of game types and the emergence of pathologic conditions in pregnant women. This result is following previous research which states that individuals who play a certain type of game show different clinical based on the group, also a specific type of game has different pathological conditions that arise (14). According to one research data mentions that games that tend to have violent content could trigger behavior aggressive toward an individual (15).
Table 6 Relationship Result Data Between Online Games and Depression Based on Played Game Types
Variable
Game Types
Total P OR (CI 95%) Action Education
N % N %
Depression Yes 15 60 8 42.1 23 0.239 0,485 (0,133-
1.630)
No 10 40 11 57.9 21
Total 25 100 19 100 44
Table 6 shows that 25 pregnant women respondents who played action games have 15 depressed respondents (60%) and 10 non-depressed respondents (40%). Moreover, 19 respondents of pregnant women who play education games have 8 depressed respondents (42.1%) and 11 non-depressed respondents (57.9%). The chi-square test results obtained a p- value = 0.239 with an OR = 0.485 means that there is no significant relationship between game types and the emergence of depression. Game types still have a risk of 0,239 times for depressed
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 17 pregnant women at Surabaya. According to the results can be interpreted that there are no influence game types to the emergence of depression in pregnant women. This result is following previous research conducted by Na et al. that there is no difference in psychological conditions in each group to different game types.
Table 7 Relationship Result Data Between Online Games and Knowledge Improvement Based on Played Game Types
Variable
Game Types
Total P OR (CI 95%) Action Education
N % N %
Knowledge Improvement
Yes 14 56 16 84.2 30
0.047 4.190 (0,969- 18,122)
No 11 44 3 15.8 14
Total 25 100 19 100 44
Table 7 shows that 25 pregnant women respondents who play action games have 14 knowledge improvement respondents (56%) and 11 respondents (44%) who did not have knowledge improvement. Moreover, 19 respondents of pregnant women who play education games have 16 knowledge improvement respondents (84.2%) and 3 respondents (15.8%) who did not have knowledge improvement. The chi-square test results obtained a p-value = 0,047 with an OR = of 4.190 with an OR = 0,260 means that there is a significant relationship between game types and knowledge improvement. Game types have a risk of 4,190 times on knowledge improvement of pregnant women at Surabaya. Based on data can be inferred that there is an influence of game types on the knowledge levels of pregnant women. This result is following previous research that states there is knowledge improvement in pregnant women after game intervention which attracts their interaction and interest, and also enhance study motivation and curiosity in pregnant women (13).
The maturation crisis experienced by every mother during pregnancy can cause stress. If this phase can be handled by the mother, the mother is ready to take responsibility and care for her pregnancy. Personal concepts also change to prepare for parenthood. However, if the mother cannot handle this phase, it can cause serious psychological problems, such as stress and anxiety.
and depression. Especially during the first pregnancy, pregnant women often worry about the various kinds of changes that might happen to them, such as changes in appearance after pregnancy, or decreased self-confidence due to changes after pregnancy. Most people think of playing video games as a normal recreational activity, with minimal risk to the health and physical, social, or physical well-being of players. However, for some video game players it can lead to pathological behavior. Pathological players are characterized by excessive use of time when playing, interfering with daily and social activities, difficulty breaking away from playing, and feeling the compulsion of playing. Pathological gambling is also called online gaming and has been compared to gambling-like behaviors or compulsions. Excessive play activity will cause various problems, including loss of control over time, lack of concern for the social environment, decreased health, financial problems, and other important life functions. The main danger that arises from addiction is over-investment of time in play (9).
Addiction is an activity that is done or done repeatedly or continuously even though it has various kinds of negative consequences. The basis is the feeling of satisfaction and pleasure that is sought, but the fact is that many people are unable to control it and end up becoming addicted.
When feeling addicted, a person will feel uncomfortable so that it can cause pain if his desire is not fulfilled. Many psychologists argue that addiction or addiction can be interpreted as a psychological dependence that crosses the boundaries of various things such as sex,
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 18 pornography, food, spiritual obsession, idols, and online games. Addiction or addiction can be interpreted as a very deep desire for something such as watching television, playing games, surfing the internet and others, where someone will always look for ways to get it. Addiction can also be interpreted as a feeling of great curiosity about something. Addiction can also be seen as repeated involvement in a substance or activity even though it has a negative impact. At first the individual only seeks satisfaction and comfort, but in the end it is difficult not to do these things.
Addiction Game is officially classified as a mental disorder by WHO. Addiction Game is included in the International Statistical Classification of Diseases and Related Health Problems (ICD) which is a disease classification system. Based on the ICD, gaming disorder is included in the list of diseases that are under the sign of a disease caused by addictive behavior. Addiction online game is characterized by a person who has difficulty controlling himself when playing online games. For example, people who are addicted to online games cannot control how long they play. Another symptom that is obtained is that sufferers will put online games as a priority to the point of forgetting other activities, even the level of addiction will increase even though sufferers are aware of the negative impacts. Game addiction can disrupt the personal and social life of sufferers. Someone who is addicted to online games will spend a lot of time playing online games for 14 hours per day (16).
Addicted players scored higher on depression, loneliness, social anxiety, and negative self- esteem. There is a complex relationship between online game, online game, and psychosocial health. Especially in cases with strong social elements, such as loneliness and self-esteem, online games may have a dualistic effect. First, broaden knowledge and new environments for experimentation, and second can lead to limitations of social choices in real life and overshadow the first life. With this loneliness, depression, negative self-esteem can decrease when they play, on the other hand, this correlation can increase for others because online relationships may not necessarily provide full support for the social relations and needs of players in real life. The development of times and technology is accompanied by developments in antenatal education methods. The use of digital media in promoting health is one form of technological development.
Through digital media, everyone can access various information and can interact between people.
With this media, one can create a community or association of people who have the same background or interests. In the last 10 years the use of the internet by pregnant women has greatly increased, so this can be a challenge for health workers in providing maximum education to pregnant women. The involvement of digital media in delivering information about pregnancy has been shown to change the behavior of pregnant women and help pregnant women in making decisions (17).
Education during antenatal care is very helpful for mothers to understand their condition, pregnancy care, childbirth and baby care. Various countries have studied in developing countries and found that psychological support in antenatal education plays a significant role in accelerating the time of delivery and reducing pain during labor. Women who are pregnant, both in the early and late trimesters, will be required to be physically and psychologically stable, many things can affect during pregnancy such as depression or psychological stress as well as increased physical needs such as nutrition and daily habits. During pregnancy it is very necessary to watch out for various things that can have a negative impact on the mother and fetus. On the other hand, online games have a good impact if used wisely such as reducing stress, relaxing, increasing knowledge and increasing intelligence, there are also negative impacts such as unstable emotions, triggering depression, causing bad habits, making a person unproductive and many others. Other things, pregnant women who play online games are something that must be considered because pregnancy and playing online games that are not wise can trigger various effects on the mother.
In pregnant women who play online games with a high frequency can cause addiction to online games and receive various negative things, especially on the mother's psychology such as difficult to hold back emotions to depression while playing. Another psychological impact that may be felt from high addiction is that it can make the mother less taking care of themselves and their fetus
Jurnal Publikasi Kesehatan Masyarakat Indonesia, Vol. 9 No. 1, April 2022 19 because they focus on the games being played, this certainly has an impact on the possibility of behavioral deviations in the mother during her pregnancy (17).
Various types of games have their own influence on players, both positively and negatively.
The impact is relaxing, relieving stress but if it reaches the addiction stage it can make emotions unstable to depression. While games of the puzzle and educational type actually provide more positive benefits such as broadening knowledge, sharpening intelligence and others, games of this type rarely cause addiction and other negative effects of online games because there are few enthusiasts and they tend to be boring.
CONCLUSION
Based on the analysis results found that there was a relationship between the long duration of playing online games with the emergence of pathologic conditions and depression. Still, no relationship between long duration playing online games and knowledge improvement in pregnant women. There is also a significant relationship between pathologic condition and knowledge improvement, yet no positive relationship on depression in pregnant women. The conclusion is that pregnant women which play online games have a risk of pathologic conditions regardless of play duration or played game types.
As a piece of advice for pregnant women who play games better properly arrange the scheme of playing online games to prevent pathologic conditions that adversely affect both pregnant women and babies. This research can become a reference for further research and continue with more samples so that will give more good results.
ACKNOWLEDGMENT
Biggest thanks from the author to the incredible mentor and proud parents. Also, all of the colleagues who assist as long as the author makes this article both in moral and material support terms.
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