Ali Madeeh Hashmi  ( Department of Psychiatry, King Edward Medical University Hospital, Lahore, Pakistan )
Shahana Naz  ( North Manchester General Hospital, United Kingdom )
Ali Ahsan Ali  ( Department of Psychiatry, Icahn School of Medicine, New York, USA )
Aftab Asif  ( Department of Psychiatry, King Edward Medical University Hospital, Lahore, Pakistan )

Smart phones are central to communication in the current century. We administered a survey to determine the impact of excessive smart phone use on academic performance, interpersonal relationships and mental health in medical students. During the study, 700 medical students from King Edward Medical University, Lahore, Pakistan, were administered a questionnaire which recorded information about demographics, academic performance, interpersonal relationships and psychological problems. Out of 630 respondents, 255(40.5%) were males and 375(59.5%) were females with a mean age of 21.1}1.8 years. Results showed smart phone use during class lectures was associated with significant reduction in academic performance and problems with interpersonal relationships. Medical students bullied via smart phones were likely to bully others. Excessive use of smart phones was associated with students preferring to communicate emotions through texting rather than verbal communication. Various psychological problems were found prevalent in excessive users of smart phones.
Keywords: Medical students, Smart phone, Academic failure, Interpersonal problems, Psychological problems, Mental health. DOI:10.5455/JPMA.299735

Introduction

Smart phones today with hundreds of built-in applications and continuous internet access have become mobile computers and are now an essential daily need. Although smart phones are convenient for a number of reasons, like connectivity, information access etc., a number of studies have highlighted their effects on mental health.¹ In addition to web browsing, entertainment and communication, smart phones are increasingly becoming an indispensable education tool for all learners. ² They are now an integral part of our daily lives and this trend is set to get more deeply entrenched. Increasingly, however, researchers are beginning to point out negative aspects of their use, including disruption of social interactions. In addition, researchers have found close associations between their overuse and behavioural problems as well as low mood. ³ Medical students and junior doctors exhibit high ownership and usage of smart phones in their learning and work activities and may thus be more vulnerable to these effects. ⁴ Several health hazards have been linked to cell phone use, including headaches, physical ill-being, tiredness and exhaustibility. ⁵ Sleep disturbances with associated physical and mental problems have been documented in young people who use cell phones excessively for both speaking and text messaging. ⁶ Smartphones have given people more control over how, when and where they interact with other people. In addition, cell phones have allowed adolescents to be more autonomous from their parents than was the case earlier. ⁷ For many smart phone users, their phone is the first thing they look at when they wake up in the morning and the last thing they check before going to sleep at night. Many smart phone users check their phones hundreds of times a day, simply out of habit. This can result in compulsive usage or even 'phone addiction'. ⁸ The current study was planned to examine the patterns of smart phone usage in medical students in order to ascertain their impact on academic performance, interpersonal relationships and mental health. It also planned to find out if students who used smart phones excessively experienced more psychological problems compared to their peers.

Subjects and Methods

The cross-sectional study was conducted in July 2015 at the Department of Psychiatry and Behavioural Sciences, King Edward Medical University, Lahore Pakistan. Using convenience sampling, all medical students from the first to the fifth year of their professional education were included and informed consent was obtained from all subjects. An anonymous, 24-item, structured, self-administered questionnaire in English was developed. Other than demographic information, out of the 24 questions,14 were binary yes/no questions exploring the utility and perceived effects of smart phone usage on academic performance, sleep, interpersonal relationships, driving, and content of messages. Other questions explored starting age of smart phone use, reasons for carrying, place and time of day for excessive usage, frequency (interval data question) and nature of its use during class, association with relaxation / negative psychological effects and frequency of text messages and access to porn sites (interval data question). The study was approved by the institutional ethics review board. A pilot study was conducted comprising 10 medical students to rule out any ambiguity in the questionnaire, and minor changes were made in the questionnaire after the pilot study Data was analysed using SPSS v19. Percentages were calculated for different variables. Descriptive statistics were computed. Chi square test was used to analyse association between the constructs.

Results

Of the 700 medical students approached, 630(90%) responded positively; 255(40.5%) males and 375(59.5%) females. The overall mean age was 21.1}1.8 years. Of the total, 364(57.8%) respondents were living on the campus, while 266(42.2%) were day scholars. Smart phone usage had started between the age of 13 and 18 years for 394(62.5%) participants; 333(52.9%) reported using smart phones for personal needs; 297(47.1%) said they used it due to social pressure. 258(41.0%) students used smart phones primarily between 8pm and 12pm, 110(17.5%) around 4-8pm and 133(21.1%) around 12-4am. Also, 337(53.5%) students said they used to send 300-500 text messages daily, and 356 (56.5%) reported sending texts while in a state of somnolence (sleep texts) (Table-1).



Using smart phones excessively during class lectures was perceived as being associated with negative interference in terms of study habits, and academic performance as well as on interpersonal and emotional fronts (Table-2).



Overall, 360(57.1%) medical students were involved in sending sexually explicit text messages, also referred to as 'sexting', and 175(27.8%) accessed pornography using smart phones on a daily basis, while 127 (20.2%) did so once a week, and 116(18.4%) twice a week. Of the total, 141(22.4%) medical students reported sadness, 249(39.5%) frustration, 87(13.8%) hopelessness, 143(22.7%) irritability and 10(1.6%) reported other kinds of stresses. Besides, 185(29.4%) medical students reported having had accidents due to excessive use of smart phones while commuting (Table-3).



Discussion

Increasing smart phone usage, especially in teenagers and pre-teenagers, is a worldwide phenomenon. ⁹ According to our results, most of the respondents started using smart phones at age 13-18 years. One study conducted in the United States revealed 78% of adolescents aged 12-17 owned a cellular phone and almost 47% of them had smart phones. ⁹ Smartphones have become less of a status symbol and more of a fashion statement, and they have also created an unspoken social dependence. ¹⁰ In our study, 258 (41.0%) students reported using smart phones mostly around 8-12 pm, while a majority of medical students sent 300-500 text messages daily. In the US, one study revealed 78% of teenagers owned cell phones and one-third sent more than 3,000 text messages a month. ¹¹ Short message service (SMS) / text messaging has become more popular among young people compared to previous generations. Text messaging is seen as a comfortable, easy and effective means of communication by younger people. ¹² Results showed that using smart phones during class lectures was significantly associated with academic failure among medical students. Activities associated with the use of smart phone, like playing video games and high level of internet use, has been associated with lower grade point average (GPA) and higher levels of anxiety respectively.^13,14 Conversely, lower levels of internet use have been associated with better academic performance. ¹⁵ However, what the student does online should be taken into consideration. ¹⁶ In Zimbabwe, a study revealed commonly cited negative effects of cell phone use in education included chatting and texting when students should have been studying. ¹⁷The results also showed that excessive smart phone use during family time caused interpersonal problems. It has been suggested that the use of cell phones has a negative effect on social relationships, grammar and increased social anxiety. ¹⁸Furthermore, people with social anxiety are more sensitive in interpersonal relationships and struggle to communicate face to face. ¹⁹ In the current study, medical students who were being bullied by anyone via smart phone were likely to bully others through smart phone usage. Over 25% adolescents and teens have been bullied repeatedly through their cell phones or the internet. Over 80% teenagers use a cell phone regularly, making it the most popular form of technology and a common medium for cyber-bullying. About half of all young people have experienced some form of cyber-bullying, and 10-20% experiences it regularly. Victims often respond by sending mean messages back to the bully, becoming bullies themselves. ²⁰ The results showed that excessive attachment to smart phones forced students to share emotions and ideas through texting rather than verbal communication. Communicating predominantly through text message means individuals are not required to interact with others face-to-face. While this is convenient, it is changing the way individuals are interacting with others not only in a social setting, but also in how they are maintaining their existing relationships, and building new ones. ²¹ Some studies suggest that people who prefer to communicate exclusively via text messaging may have underdeveloped social skills, and excessive text messaging may have a negative impact on social skill development. ¹² Results showed that a majority of medical students, both male and female, was involved in sending sexually explicit text messages to others and a majority of them was accessing porn sites using smart phones. In the US, one study reported that approximately one-third of the participants were sending a sexually explicit image of themselves in high school to someone else using a cell phone. Those who reported more texting use in general, and those who spent more time with friends in an unsupervised setting were significantly more likely to report 'sexting'. ²² Our results showed that excessive use of smart phones was associated with many psychological problems, including sadness, frustration, hopelessness, irritability and other stresses. Thus unhealthy use of cell phones and computers may be linked to stress, sleep disorders and depressive symptoms. According to our results, 185(29.4%) medical students reported accidents due to excessive use of smart phones during commute. In Europe, the use of cell phones reportedly causes 26% car accidents, and 5% of cell phone-related crashes occur because the driver is texting. The majority of the accidents involve drivers who get distracted while talking on handheld or hands-free cell phones. ²³ The current study was limited to students of a single centre and the results cannot be generalised to all such settings in the country. Prospective cohort studies investigating the effects of smart phones on social relationships over time, as well as their long-term effects on mental health are needed.

Conclusion

In its short history, smart phones have already had a definitive impact on the way individuals interact with one another. They affect social functioning as well as family relationships and educational achievement levels of individuals.

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

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