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Problematic smart phone use in medical undergraduates in a tertiary teaching hospital in South India during COVID lockdown

 Department of Psychiatry, P.E.S Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Date of Submission19-Mar-2021
Date of Decision18-Apr-2021
Date of Acceptance20-May-2021
Date of Web Publication11-May-2022

Correspondence Address:
P Sreeelatha,
Department of Psychiatry, P.E.S Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_33_21


Background: The COVID-19 pandemic has influenced all spheres of existence. Medical education, especially undergraduates, had to cope with the changing trends in the delivery of teaching modules. This has substantially influenced smart phone usage in medical students. Aims: The aim of the study is to evaluate the impact of COVID-19 lockdown on smart phone usage in medical students Materials and Methods: Using a cross-sectional online survey design, 556 medical undergraduates in a teaching hospital were included and assessed using questionnaires to measure problematic smart phone use/addiction. Results: Majority of the medical students scored high on problematic mobile phone use questionnaire short version-dependent subscale and SMARTPHONE ADDICTION SCALE-SHORT VERSION scales used to assess smart phone usage. Significant increase in the smart phone use during COVID lockdown was observed when compared to smart phone use before lockdown. Conclusion: COVID-19 pandemic with resulted in nationwide lockdown affected the smart phone usage in medical students. Problematic smart phone use and smart phone addiction is prevalent in medical undergraduates. Smart phone use for recreational use exceeds the smart phone use for academic achievement.

Keywords: COVID-19, medical education, medical undergraduates, smart phone addiction

How to cite this URL:
Sreeelatha P, Kumar M S. Problematic smart phone use in medical undergraduates in a tertiary teaching hospital in South India during COVID lockdown. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Mar 22]. Available from: https://www.anip.co.in/preprintarticle.asp?id=345003

  Introduction Top

The COVID-19 pandemic has drastically influenced our lives. In March 2020, Government of India declared a nationwide lockdown which further impacted the day-to-day functioning. Though the lockdown was later lifted in a phase-wise manner, most schools and colleges still remained closed or partially open. Particularly, the medical colleges across the country shifted to online education amid the uncertainty of the COVID-19 outcome. This e-learning may have maintained a sense of continuity in medical education, but the medical undergraduates did not get the clinical exposure that is crucial in molding them. Earlier outbreaks in the recent past (SARS-CoV) had also witnessed the effect on academics with curriculum changes and rapid integration of information technology.[1],[2],[3]

In the current scenario, internet learning through the use of electronic gadgets is fast gaining popularity. Recorded lectures and live streams have become the need of the hour which are in contrast to a traditional in person classroom approach.[4] In this background, students have gained easy access to high-speed internet, computers, and smart phones. Especially smart phones being portable devices with multiple functions are becoming obvious necessity among students and enriching their learning activities.[5] Some features of smart phone such as multimedia, camera, and e-mail access have heightened the interaction among students and teachers with better feedback.[6],[7] This has to some extent bridged the gap of loss of collaborative experiences, lack of communication, and skill acquisition forced by the pandemic situation. Specifically some medical apps that can be easily downloaded in smart phones have opened new avenues of information gathering and further strengthening the quest for knowledge in medical students.[8] This nurtures adaptability and innovation and guides students to rise to unique challenges in the present turmoil.[9] Medical students also utilize smart phones for sharing notes, lectures, and assignments.[10] Some students also utilize smart phones for entertainment such as watching movies, videos, playing games, and online chatting.[11]

When these devices are being overused for the purpose of other than education, this hampers students' academic achievement.[12],[13] This mobile phone overuse has been associated with problematic behavior which reflects one's inability to regulate use of the mobile phone, leading to negative consequences in daily life.[14] Problematic smart phone use is “an inability to regulate one's use of the smartphone, which eventually involves negative consequences in daily life.” Some researchers preferred the use of the term smart phone addiction due to the similarities in symptoms caused by excessive smart phone use and substance use. Smartphone addiction or problematic phone use is evaluated based on four main components: compulsive phone use, tolerance, withdrawal, and functional impairment. Excessive mobile usage has detrimental effects on physical health and mental health issues such as depression, anxeity, inattention and insecure attachments, poor sleep quality, and academic achievement.[15],[16] Significant association between increased smart phone usage and problematic phone use has been established.[17] Smart phone use to avoid negative emotions and to create pleasure and mood regulation increases the possibility of problematic or addictive phone use. While life satisfaction reduces the proneness to smartphone addictive disorders,[18],[19] COVID-19 and lockdown had significantly impacted pleasure seeking and life satisfaction particularly of youngsters. Their ability to self-regulate phone use in the background of lack of restrictions and supervision by parents in view of online teaching during lockdown has further reinforced problematic phone use. Although much research is available on smart phone addiction in medical students, the current study embarks to investigate the influence of COVID lockdown and subsequent changes on smart phone usage in medical students.

  Materials and Methods Top

This was an observational, cross-sectional online self-administered survey carried out in a teaching hospital in Andhra Pradesh, India. All medical students were having online classes since the lockdown was instituted in March 2020. Semi-structured questionnaire was developed using Google Forms to collect sociodemographic and relevant details pertaining to smart phone addiction. Rating tools used to measure problematic phone use, smart phone addiction, and consent form were also appended to it. The link to questionnaire was sent via WhatsApp and e-mail to all the medical students. The voluntary nature of the study and the maintenance of confidentiality were also explained while forwarding the link. On receiving and clicking on the link, the participants are directed to the nature of the study and the consent form. Once the participants have consented, they are directed to series of questions regarding sociodemographic details followed by questionnaire on smart phone addiction.

Medical students willing to participate in the study, aged 18 years and above, who understood the content of the survey, were included in the study. Those with preexisting psychiatric conditions were excluded. Approval from the institutional ethics committee was taken before conducting the study. Data were collected from November 11, 2020, to December 11, 2020. Demographic details included age, gender, area of residence, and parents' income.

Problematic mobile phone use questionnaire short version

It is a 15-item scale. It has three subscales: dependent use, dangerous use, and prohibited use. For the purpose of this study, 5-item dependence subscale was administered. The five items included: (a) “It is easy for me to spend all day not using my mobile phone;” (b) “It is hard for me not to use my mobile phone when I feel like it;” (c) “I can easily live without my mobile phone;” (d) “I feel lost without my mobile phone;” and (e) “It is hard for me to turn my mobile phone off.” Items were scored from 1 “I strongly agree” to 4 “I strongly disagree” (except three items that were reverse scored: 2, 4, and 5), and scores ranged from 5 to 20, with higher scores indicating higher perceived dependence on the mobile phone. The Cronbach's alpha of the “dependence subscale” across all countries and languages demonstrated acceptable to excellent internal reliability.

Smartphone Addiction Scale-Short Version

This scale is a validated scale developed from smartphone addiction scale (SAS). It is a self-reported measure comprising 10 items rated on 6-point Likert scale from 1 (“I strongly disagree”) to 6 (“I strongly agree”). The total scores were summated and then converted to mean scores with cut off values where higher scores indicated higher levels of smart phone addiction. The concurrent validity and internal consistency were found to be high for Smartphone Addiction Scale-Short Version (SAS-SV, Cronbach's alpha: 0.91).

The data were analyzed using the IBM SPSS Statistics for Windows version 21.0 (IBM Corp, Armonk, NY, USA). Descriptive statistics (mean, standard deviation, frequencies, and percentages) were used to describe the quantitative and categorical variables. Chi-square test was used for comparing level of smart phone usage among participants based on demographic characteristics. Independent t-test was used to analyze continuous variables. A P < 0.05 and 95% confidence intervals were used to report the statistical significance and the precision of the results.

  Results Top

Medical students from 1st to 4th year were approached for the study; a total of 556 students consented to participate in the study. Higher scores on problematic mobile phone use questionnaire short version (PMPUQ-SV)–dependent subscale were observed in 294 (52.9%) students with mean - 12.62 and standard deviation - 1.72. In SAS-SV, high scores noted in 281 out of 556 (50.54%) with mean - 33.53 and standard deviation - 9.82.

Male students comprised 307 (55.2%). Most students belonged to the age group of 20–21 years (n = 270; 48.56%), belonged to the 1st year of MBBS (N = 190; 34.17%), from urban background (n = 294; 52.9%), and from nuclear family (n = 483; 86.87%). Majority of the medical students used smart phone for 2–4 h/day before COVID lockdown, whereas smart phone use during lockdown in most medical students was 4–6 h/day. Most of the students reported an increase of smart phone usage during lockdown by 2–4 h/day [Table 1]. Purpose of smart phone use reported for entertainment was observed in 341 participants (61.3%) and 215 (38.67%) of them reported smart use for academics. Amount spend on recharging was 200–400/month in most of the participants (48.92%) [Table 2].
Table 1: Sociodemographic and smart phone use profile in medical undergraduates

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Table 2: Profile of smart phone use in medical undergraduates

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Most of the final-year part one MBBS students scored high on PMPUQ-SV–dependent subscale, whereas 1st year MBBS students scored high on SAS-SV scores which was statistically significant [Table 3]. Although females and age group of 20–21 years scored high on PMPUQ-SV subscale, it was not statistically significant. Medical students of age group 20–21 years scored high on SAS-SV scores which was statistically significant. Majority of the medical students who used smart phone for 2–4 h before lockdown scored high on SAS-SV scores. During lockdown, students using smart phone for >8 h/day scored high on SAS-SV scores which was statistically significant. Participants who were using smart phone for entertainment purposes also scored high on SAS-SV. Similarly, high scores on SAS-SV were also observed in students who reported of increase of smart phone subjectively during lockdown.
Table 3: Comparison of smartphone addiction scale-short version scores with sociodemographic and smart phone profile

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Respondents with smart phone use before lockdown of 2–4 h/day scored high on PMPUQ-SV–dependent subscale but were not statistically significant. However, statistically significant findings were observed in students who used smart phone 4–8 h/day during lockdown scoring high on PMPUQ-SV–dependent subscale [Table 4]. High scores on PMPUQ SV–dependent subscale scores were observed in participants who spent 2 to 4 hrs /day in smart phone use prior to lockdown whereas participants who spent 4-8 hrs/day on smart phone during lockdown scored high on PMPUQ SV–dependent subscale scores which was statistically significant [Table 5]. High scores on SAS SV [Table 6] in medical students who spent 2 to 4hrs /day using smart phone before lockdown as compared to more than 8 hrs /day during lockdown which was statistically significant.
Table 4: Comparison of problematic mobile phone use questionnaire with sociodemographic and smart phone use profile

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Table 5: Smart phone usage before and during lockdown-problematic mobile phone use questionnaire (Sc-Dependent)

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Table 6: Smart phone usage before and during lockdown-smartphone addiction scale-short version scores

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  Discussion Top

Possessing a smart phone device has become essential and the need of the hour and medical students are no exception. Literature noted that 75%–99% of e medical students owned smart phones.[20],[21] In the context of COVID lockdown and subsequent e-learning and lectures on online platform, the relevance of ownership of smart phones has elevated. This study evaluated the impact of COVID lockdown on smart phone use in medical students and the extent of problematic use during lockdown.

A survey conducted in a medical university in Nigeria[22] noted that majority of the participants used mobile devices for academic purpose, while our study highlighted that most students used it for entertainment. This survey was analyzed in 2017, whether COVID has impacted the shift in purpose of smart phone use in medical students needs further research to establish a cause–effect relationship. Studies done in India estimated high smart phone use in medical students (with SAS-SV scale) ranging from 33.3% to 85.6%.[23],[24] Study conducted in medical students in Andaman and Nicobar islands stated that high smart phone usage observed among medical students is due to lack of recreational activities on the Andaman and Nicobar islands due to which students looked up on to smart phones as the only means of entertainment. A similar situation has been created by COVID lockdown and restrictions imposed on travel and entertainment due to closure of shopping complexes, cinema theaters, gymnasiums, and restaurants which were the hub of social activities for youth.

Other studies in India on mobile addiction found a prevalence of 18.5%, 70%, and 99.7%.[25],[26],[27] A cross-sectional study in a medical college in China on smart phone addiction concluded that 29.8% of medical students had smart phone addiction.[5] A study in medical university in Saudi Arabia found excessive smart phone use in 36.5% of students.[28] A study in China during COVID 19 outbreak assessed addiction and problematic use of all electronic devices in children and adolescence (smart phone being the primary tool being used) observed excessive internet use during the COVID outbreak.[29] The discrepancies in the prevalence could be accounted for the use of different rating measures to detect mobile addiction, socioeconomic factors, age of the participants, different methodologies, and different statistical approaches.[30]

Our study did not observe significant gender differences in problematic smart phone use. Several studies have found higher smart phone addiction and problematic use in females as compared to males.[31],[32] Mobile use in females is associated with direct and indirect communication through texting and maintaining social interpersonal relationships.[33],[34] Further, usage time in females was more as compared to males who tend to utilize phone for direct calls, texting, gaming, and use in risky situations.[35],[36] The current study did not find significant differences on smart phone addiction scores and economic background. This differs from a study which found that students from high economic background have higher problematic phone use. The authors attributed it to the isolation, time spent away from home, and long study hours to excessive phone use.[37],[38]

An online survey using snowball sampling in youth of India during lockdown observed an increase in daily/weekly time spent on smart phone over a 3-week period during lockdown. This study also noted an increase in screen time with average of 5 h as compared to prelockdown screen time of 3.5 h in India.[39] The findings in the above survey from India reflect the results of our current study. Respondents in the current study reported of 2–4 h/day of subjective increase in smart phone use during lockdown. Study on medical students in Saudi Arabia[40] observed that among the addicted group, 55.8% used smart phone for more than 5 h/day which is similar to our study where majority of the addicted group according to the SAS-SV scores spent up to 4 h/day on mobile phone use before COVID, which further increased to up to 8 h/day during COVID lockdown.

Study on medical students in Maharashtra[41] carried out in July 2020 observed that mobile phone use for academics was seen in 57.6% which is higher than that observed in our study. Another finding of this study was that use of laptop for e-learning is lesser than mobile use during the COVID pandemic as students preferred smart phone for e-learning due to better communication with teachers on phone. This finding also highlights the need for evaluating smart phone use over other gadgets in medical students.

Strength of the current study is that problematic smart phone use is evaluated specifically in COVID lockdown with sparse similar studies done during this period. Limitations of the current study are that it was a single-center cross-sectional study, because of which the results cannot be generalized. As it was online anonymous self-reported questionnaire and response to the questions was given when students were off campus, how far the students have understood the questions and answered accurately is doubtful as no clarifications were provided by the researchers and also there is a risk of minimization. As data for the current study was collected after lockdown, students may have been subjected to recall bias in providing information prior to and during lockdown period. Owing to the cross-sectional design of the current study, further research may be directed at longitudinal design where smart phone use in medical students observed prospectively as the pandemic unveils. This study has no focused on mental health issues and internet gaming related to the increase in smart phone use and the impact of smart phone use on learning and academic performance during the COVID pandemic.

  Conclusion Top

Medical students have faced considerable challenges amid the COVID-19 and ensuing lockdown and significant modifications in medical education with special emphasis on online learning. A certain degree of adaptability, flexibility, and creative and innovative thinking was imposed onto the students. Although online medical education had the advantages of satiating the demands the pandemic situation has posed, it also came with certain drawbacks. One such is the excessive use of smart phone in medical students to the extent of addiction with more use for nonacademic reasons which was a substantial finding of the current study. The significant increase in mobile phone use during lockdown as compared to pre-COVID smart phone use further strengthens the evidence. Smart phone has been an essential application, in recent times, this technology having gained further significance in the current pandemic background. However, the benefits of its use should not impair our understanding of its misuse to the extent of addiction and especially in adolescents pursuing their future in medical field.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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