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ORIGINAL ARTICLE

Addiction‑like behavior associated with social media usage in undergraduate

students of a government medical college in Delhi, India
Saurav Basu, Ragini Sharma, Pragya Sharma, Nandini Sharma
Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

ABSTRACT

Background: Excessive use of social media is increasingly being recognized as a source of technological addiction in
young people globally.
Objective: The aim of this study is to assess social media addiction in medical students using a self‑designed questionnaire.
Materials and Methods: We collected data from undergraduate medical students (MBBS) in Delhi, India using a
self‑administered 20‑item social media addiction questionnaire (SMAQ) to measure addiction‑like behavior, and the
Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality.
Results: We enrolled 264 (62.3%) male and 160 (37.7%) female participants of mean (standard deviation) age 19.83 (1.6)
years. The Cronbach’s alpha of the SMAQ was 0.879. A principal component analysis revealed a 4‑component SMAQ
structure based on eigenvalue cutoff (>1), loading score >0.3, and inspection of the Scree‑plot that explained 54.7% of
the total variance. We observed strong loadings of impaired control items on Component 1, decreased alternate pleasure
items on Component 2, intense desire items on Component 3, and harmful use items on Component 4. The mean SMAQ
score was significantly higher in the students reporting poor sleep quality and older students.
Conclusion: The SMAQ has acceptable psychometric properties, with higher scores associated with sleep deprivation.
A majority of students were unable to reduce their time spent on social media despite wanting to do so, signifying the
presence of tolerance and impaired control.

Key words: India, sleep deprivation, social media addiction, validation

INTRODUCTION exponentially increased in the previous decade due to

Social media constitutes a variety of internet applications
that have provided >3 billion people with a platform to
connect in real‑time and share texts, messages, photos,
and videos. The popularity of social media networks has
Address for correspondence: Dr. Saurav Basu,
Department of Community Medicine, Maulana Azad Medical
College, New Delhi, India.
E‑mail: saurav.basu1983@gmail.com
Submitted: 25‑Feb‑2020, Revised: 08‑Jul‑2020
Accepted: 12‑Aug‑2020, Published: 15-Feb-2021
Access this article online
Quick Response Code
Website:
www.indianjpsychiatry.org
the dissemination of affordable Internet and smartphone
technology in developing countries, especially among
their younger populations.[1] However, there is growing
recognition that excessive use of social media is a form of
behavioral addiction associated with high levels of anxiety
and depressive symptomatology.[2,3] Some researchers have
even compared extreme cases of addiction to social media
comparable to substance‑related addictions involving
tobacco smoking or alcohol.[4]
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Basu S, Sharma R, Sharma P, Sharma N.

DOI:
Addiction-like behavior associated with social media usage in
undergraduate students of a government medical college in
10.4103/psychiatry.IndianJPsychiatry_153_20
Delhi, India. Indian J Psychiatry 2021;63:35-40.

© 2021 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow 35

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Basu, et al.: Addiction to social media in medical students
Social media can promote the feeling of social envy
and anxiety, and can potentially interfere with sleep.[5]
Responding to late‑night social media ping notifications
on smartphones can reduce sleep quality, whereas blue
light emissions can increase sleep latency by disturbing
the circadian rhythm.[6] Furthermore, an extended number
of hours spent on social media contributes to sleep
displacement.[7] In younger age‑group students, poor
sleep quality can cause cognitive impairment and reduced
concentration.[8] Studies have also linked excessive social
media use with diminished academic performance in young
students.[9]
The prevalence of social media addiction has been estimated
to be particularly high among adolescents and young
people in developed countries.[10,11] India, the country with
the largest youth population globally, has become a world
leader in the adoption of smartphones and mobile data in
the past 5 years, which has materialized the growth and
popularity of social media use.[12] However, there are very
few studies that have evaluated social media addiction
in India, especially with locally validated questionnaires.
A recent study estimated that 36.9% of students in Southern
India had social media addiction by using a questionnaire
adapted from Young’s internet addiction test.[13] A previous
study among medical students in Delhi had reported
a high prevalence of mobile phone addiction, which
coupled with academic stress and anxiety, possibly renders
them susceptible to social media addiction and sleep
deprivation.[14]
We conducted the present study to assess social media
addiction in medical students using a self‑designed
questionnaire.
MATERIALS AND METHODS
Design, setting, and participants
We conducted a cross‑sectional study among adult medical
undergraduate (MBBS) and interns of a government
medical college in Delhi situated in Northern India during
September–November 2019. All the students could read,
comprehend, and respond in the English language, and it is
the official medium of instruction.
Study instruments
1. We constructed a 20‑item social media addiction
questionnaire (SMAQ) in the English language after the
application of the following steps: (a). Identification
of domains that corresponded to the International
Classification of Diseases, 10th Revision criteria for
substance dependence syndrome,[15] and the inclusion
of items from the literature search and previously
validated questionnaires related to behavioral and
technological addiction.[14,16,17] The SMAQ assessed
the presence of intense desire (Q.1, 2, 3, 4, 5, 6, 7, 8,
36
9, 10, 19), impaired control (Q. 3, 11, 12, 15, 16, 19),
withdrawal (Q. 13), tolerance (Q. 5, 6, 11, 12, 16, 18),
decreased alternate pleasure (Q. 5, 6, 7, 8, 9, 10, 13),
and harmful use (Q. 14, 15, 17, 18, 19, 20). The SMAQ
also corresponded to the four components of the CAGE
screening questionnaire for potential drinking‑related
problems[18] and Griffith’s six core components of
addictions,[19] (b) Pretesting of the questionnaire was
conducted in 10 students who were not part of the final
study, (c) Content validity of the items was determined by
two experts on behavioral health who went through each
of the items and their pretest responses. Subsequently,
they, by consensus, accepted the appropriateness of all
the items subject to language modification in certain
items. The response to the each of the SMAQ items
was self‑rated by the students on a 6‑point Likert scale
with options being 1 (strongly disagree), 2 (disagree),
3 (weakly disagree), 4 (weakly agree), 5 (agree), and
6 (strongly agree). The total SMAQ score was the sum of
individual scores for all the 20 items of the questionnaire,
with higher scores indicating a greater risk of addiction
2. Pittsburgh Sleep Quality Index (PSQI) ‑ The PSQI is a
valid instrument used to differentiate “poor” from
“good” sleep by measuring seven domains: subjective
sleep quality, sleep latency, sleep duration, habitual
sleep efficiency, and sleep disturbances, use of sleep
medication, and daytime dysfunction over the last
month.[20] The cutoff for poor and good sleepers
was considered at a PSQI score >6, which has been
previously validated in Indian university students.[21]
Sampling and data collection
The college has five batches of undergraduate medical
students for the MBBS course lasting for five and a half years
duration. We selected a total of 95 students from among
the 250 cohorts in each batch, with final year students
and interns considered as one‑batch during participant
selection. A sample size of ≥400 with item‑to‑respondent
ratio of 20:1 is considered excellent for factor analysis.[22]
We selected the participants by simple random sampling
using a computer‑generated set of random numbers for
selection through student roll numbers. The selected
participants were administered the questionnaires in groups
in a separate lecture room. An investigator was present at
these sites during this time to resolve any participant query
regarding filling of the questionnaires and also prevent any
interpersonal interaction among the participants.
Statistical analysis
We analyzed the data with the IBM SPSS Statistics for
Windows, Version 25.0 (Armonk, NY: IBM Corp.).
Handling of missing data
We assumed that the missing data was at random. We
excluded questionnaires with more than  ≥4 incomplete
entries in the social media questionnaire. Missing items
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Basu, et al.: Addiction to social media in medical students

were imputed, taking the item median score as per the
gender and age‑group to which the participant belonged.
The quantitative data were expressed in terms of mean,
median, and standard deviations (SDs) and qualitative data in
terms of frequency and proportions. The significance of the
association between categorical variables was determined
by Chi‑square/Fisher’s exact test. The independent samples
t‑test was applied to test for the significance of the mean
difference between groups. A P < 0.05 was considered
statistically significant. We also conducted a principal
component analysis (PCA) of the SMAQ.
Psychometric properties of the social media addiction
questionnaire
The Cronbach’s alpha of the 20‑item SMAQ was 0.879 and
the split‑half reliability coefficient was 0.765, indicating
very good reliability. The dataset was assessed to be
suitable for the application of PCA in terms of sampling
adequacy. The overall Kaiser‑Meyer‑Olkin (KMO) measure
was 0.89 classifications of “Meritorious” according to
Kaiser. All the individual KMO measures were >0.8. The
correlation matrix showed that all variables had at least one
correlation coefficient >0.3. The Bartlett’s test of Sphericity
was statistically significant (P < 0.0001).

Ethical considerations We found four components that had eigenvalues >1, which

The study was approved with an exemption from full review
by the Institutional Ethics Committee of the medical college.
We obtained written and informed consent from all the
study participants, and we maintained data confidentiality,
with the data being used for research purposes only.
RESULTS
Participant characteristics
We distributed a total of 475 questionnaires to medical
undergraduate students and interns of the selected
medical college with a response rate of 100%. We excluded
51 questionnaires with incomplete responses, and hence,
the effective sample size was 424. We enrolled 264 (62.3%)
male and 160 (37.7%) female participants. The mean (SD)
age of the participants was 19.83 (1.6) years.
explained 30.4%, 10.5%, 7.4%, and 6% of the total variance,
respectively, thereby cumulatively explaining 54.7% of
the total variance. Visual inspection of the Scree plot also
indicated that four components should be retained [Figure 2].
We observed strong loadings of impaired control items
on Component 1, decreased alternate pleasure items on
Component 2, intense desire items on Component 3, and
harmful use items on Component 4. Component loadings
and communalities of the rotated solution are presented
in Table 1.
Construct validity of the social media addiction
questionnaire
On dichotomizing responses into “agree” and “disagree”
categories, higher mean scores were seen for items
1, 2, 3, 6 (eye‑opener/intense desire), 11 (cut‑down/

Social media usage Table 1: Rotated structure matrix for principal

The total typical weekly mean (SD) time spent on social component analysis with varimax rotation of a
media by the participants was 21.8 (11.2) hours, with 4‑component social media addiction questionnaire
adolescents reporting significantly lower time spent on social showing major loadings
media compared to older participants (P < 0.001), although Item Component Communalities
no association existed with participant gender (P = 0.165). 1 2 3 4
Popular social media platforms such as Facebook and YouTube SAS16 0.832 0.722
were accessed more frequently by older or male students SAS15 0.735 0.629
SAS17 0.694 0.362 0.627
compared to adolescent or female students [Figure 1]. SAS12 0.683 0.326 0.591
SAS11 0.670 0.477
SAS10 0.695 0.319 0.588
SAS7 0.684 0.304 0.585
SAS9 0.630 0.388 0.548
SAS8 0.615 0.588
SAS13 0.478 0.312 0.473
SAS14 0.472 0.413 0.436
SAS6 0.390 0.465 0.412 0.563
SAS3 0.750 0.639
SAS1 0.655 0.496
SAS4 0.641 0.549
SAS2 0.608 0.445
SAS5 0.490 0.569 0.572
SAS19 0.320 0.687 0.592
SAS20 0.664 0.532
SAS18 0.598 0.476
Figure 1: Social media usage in medical students of Delhi Extraction Method: Principal Component Analysis
(n = 424). *Mean number of days accessed in a typical week Rotation method: Varimax with Kaiser normalization

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Basu, et al.: Addiction to social media in medical students

tolerance) and 11, 15, 16 (impaired control) [Table 2].
Older students compared to their junior counterparts
were significantly more likely to agree that “life would
be less interesting,” “they could not imagine living”
and “felt unhappy and annoyed when not connected”
to social media. The students with poor quality sleep
were also significantly more likely to agree regarding the
harmful consequences of social media use compared to
good sleepers [Table 3]. The average time spent on social
media showed a moderate correlation with the SMAQ
score (r = 0.4, P < 0.001).
spent on social media also correlated with higher addiction
scores. The evaluation of item‑responses of the SMAQ
revealed that a majority of participants were unable to
reduce their time spent on social media despite wanting
to do so signifying the presence of tolerance and impaired
control.
Although it is well‑established that school‑going adolescents
are at high risk of social media addiction,[10] in the present
study, college‑going adolescents reported less likelihood
of addiction‑like behavior compared to their senior

Association with sleep quality

The mean (SD) global PSQI score was 5.66 (2.6). We classified
276 (65.1%) participants as having a good sleep (PSQI ≤6)
and 148  (34.9) as having a poor sleep  (PSQI  ≥7). The
mean SMAQ score was significantly higher in the students
reporting poor sleep compared to those showing good
sleep quality [Table 4].

DISCUSSION

The exponential increase in social media users globally

intensifies the need for its measurement, which is particularly
challenging in the absence of validated instruments.[23] We
found the 20‑item SMAQ displayed acceptable psychometric
properties for the assessment of self‑reported social media
addiction in young medical undergraduates. Social media
addiction scores were significantly higher in poor sleepers Figure 2: Scree plot of a 4-component social media addiction
compared to good sleepers. Furthermore, increased time questionnaire

Table 2: Distribution of responses to the social media addiction questionnaire in medical students (n=424)
Item Question Corrected item‑total Cronbach’s alpha Mean
correlation if items deleted (SD)
1 Check my social media notifications as soon as I receive them 0.493 0.873 3.7 (1.6)
2 Check my social media notifications right after waking up from sleep 0.438 0.875 3.8 (1.8)
3 Check my phone for social media notifications even during classes 0.456 0.874 3.2 (1.7)
4 Constantly check my phone so as not to miss out on social media updates from groups/those I 0.554 0.871 2.8 (1.6)
follow/followers
5 Cannot imagine living without social media 0.510 0.872 2.7 (1.6)
6 Prefer spending time on social media when alone 0.526 0.872 3.8 (1.6
7 Feel life will be very less interesting without social media 0.457 0.874 3.1 (1.5)
8 Prefer communication with friends and family through social media 0.306 0.879 3.0 (1.6)
9 Feel my online friends on social media are more interesting and captivating than those offline 0.406 0.876 1.9 (1.2)
10 Feel my online personality in the world of social media to be more popular compared to that 0.432 0.875 2.2 (1.4)
offline
11 Often think that I should shorten my time spent on social media 0.414 0.876 4.2 (1.5)
12 Feel that I am increasingly spending more and more time on social media 0.563 0.871 3.6 (1.6)
13 Feel unhappy and annoyed when not connected to social media 0.589 0.870 2.6 (1.4)
14 Feel anxious and stressed on getting less than expected likes for a social media post like a 0.495 0.873 2.1 (1.4)
picture or video
15 Feel that my academic performance and productively suffers due to excessive social media usage 0.548 0.871 3.3 (1.7)
16 Feel that I am wasting my time on social media 0.519 0.872 3.9 (1.6)
17 Feel tired and lack adequate sleep from excessive social media use 0.535 0.871 3.0 (1.7)
18 See social media as an escape from the real world 0.483 0.873 3.0 (1.7)
19 Compulsively check for social media notifications even in places where it is dangerous to do so 0.488 0.873 2.0 (1.4)
like driving or crossing the street
20 Reading other people’s posts on social media makes me envious and feel that I am missing out 0.466 0.874 2.6 (1.6)
on things

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Basu, et al.: Addiction to social media in medical students

Table 3: Item agreement on the social media addiction questionnaire and association with age, gender, and sleep
quality among medical students (n=424)
Item Agree Gender Age (years) Sleep quality
number Male (n=264) Female (n=160) 18‑19 (n=187) ≥20 (n=237) Good (n=276) Poor (n=148)
1 249 (58.7) 157 (59.5) 91 (56.9) 106 (56.7) 143 (60.4) 157 (56.9) 92 (62.1)
2 262 (61.8) 166 (62.9) 95 (59.4) 108 (57.8) 154 (65) 170 (61.6) 92 (62.1)
3 197 (46.5) 120 (45.5) 77 (48.1) 83 (44.4) 114 (48.1) 125 (45.3) 72 (48.5)
4 152 (35.8) 100 (37.9) 52 (32.5) 60 (32.1) 92 (38.8) 101 (36.6) 51 (34.5)
5 133 (31.4) 85 (32.2) 48 (30) 49 (26.2) 84* (35.5) 76 (27.5) 57 (38.5)
6 254 (60) 155 (58.7) 98 (61.2) 112 (59.9) 142 (59.9) 159 (57.6) 85 (57.4)
7 184 (43.4) 118 (44.7) 66 (41.2) 68 (36.4) 116* (48.9) 104 (37.7) 80* (54)
8 162 (38.2) 106 (40.1) 56 (35) 71 (38) 91 (38.4) 102 (37) 60 (40.5)
9 48 (11.3) 31 (11.7) 17 (10.6) 18 (9.6) 30 (12.6) 26 (9.4) 22 (14.9)
10 83 (19.6) 54 (20.4) 29 (18.1) 36 (19.2) 47 (19.8) 45 (16.3) 38* (25.7)
11 304 (71.7) 181 (68.6) 122 (76.2) 127 (68) 177 (74.7) 190 (68.8) 114 (77)
12 230 (54.2) 144 (54.5) 85 (53.1) 96 (51.3) 134 (56.5) 143 (51.8) 87 (58.8)
13 110 (25.9) 73 (27.6) 37 (23.1) 37 (19.8) 73* (30.8) 68 (24.6) 42 (28.4)
14 88 (20.7) 57 (21.6) 31 (19.4) 33 (17.6) 55 (23.2) 54 (19.5) 34 (23)
15 197 (46.5) 120 (45.4) 77 (48.1) 84 (45) 113 (47.7) 113 (40.9) 84* (56.7)
16 260 (61.3) 162 (61.4) 98 (23.1) 115 (61.5) 145 (61.2) 152 (55) 108* (73)
17 172 (40.5) 102 (38.6) 70 (16.5) 78 (41.7) 94 (39.7) 98 (35.5) 74* (50)
18 164 (38.7) 102 (38.6) 62 (38.7) 72 (38.5) 92 (38.8) 91 (32.3) 73* (49.3)
19 73 (17.2) 49 (18.6) 24 (15) 28 (15) 45 (19) 40 (14.5) 33* (22.3)
20 133 (31.3) 81 (30.7) 52 (32.5) 53 (28.3) 80 (33.7) 78 (28.3) 55 (37.2)
*Statistically significant

Table 4: Construct validity of the social media addiction previously linked to diminished academic performance.[7,24]
questionnaire in medical students (n=424) In this study, nearly half (46.5%) of the students were in
Variable Total SMAQ score Mean Difference between P agreement with the view that excessive social media use
(n=424) (SD) 60.9 (17.5) means, 95% CI was negatively affecting their academic performance.
Age (years) However, another study in Eastern India reported a majority
18-19 187 (44.1) 58.8 (16.1) 3.7 (0.35-7.05) 0.028 of medical students having a positive perception of social
≥20 237 (55.9) 62.5 (18.4)
media impact on their academic performance.[25]
Gender
Male 264 (62.3) 60.9 (17.5) 0.07 (−3.4-3.5) 0.968
Female 160 (37.7) 60.9 (17.6) Finally, most participants did not agree that social media
Sleep quality diminished their interpersonal relationships, promoted
Good 276 (65.1) 59 (17.7) 5.3 (1.8-8.8) 0.003 narcissism, or impacted their self‑esteem, in contradiction
Poor 148 (34.9) 64.3 (16.7)
to a study in Norway,[11] suggesting significant cross‑cultural
CI – Confidence interval; SMAQ – Social media addiction questionnaire;
SD – Standard deviation differences in the long‑term influence of social media on an
individual’s personality.
counterparts reiterating the persistent addiction potential
of the technology among youth. In conclusion, self‑reported social media overuse leading
to addiction‑like symptoms was reported by a large
In this study, gender was not associated with the potential proportion of medical undergraduates when assessed
for social media addiction in contradiction to a previous with a self‑designed SMAQ. Despite the lack of compelling
study conducted in India that found male gender to be evidence for recognizing social media addiction as a
a risk factor.[13] However, another large‑scale study in disorder,[23] we found it was significantly associated with
Norway found women to be predisposed to a higher risk objective parameters like poor sleep quality.
of addiction to activities on social media[11] indicating
nonavailability of any definite evidence in studies limited by There are certain limitations to the study. In the absence
the cross‑sectional design. of an objective or gold standard for the measurement of
social media addiction,[26] we could not determine a cutoff
The study revealed that one in three medical undergraduates point for distinguishing addiction and lack of addiction.
experienced poor sleep, with bad sleepers more likely Moreover, as the collected data were self‑reported, it is
to report excessive social media use compared to good likely to be influenced by the social desirability bias. The
sleepers. This corroborates the evidence from previous test–retest reliability analysis was also not performed. The
studies, which also found worsening sleep with increasing cross‑sectional study design precluded the identification
duration of social media use.[7] Poor sleep has been of any potential causality between addiction and adverse

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Basu, et al.: Addiction to social media in medical students
health, academic or interpersonal problems in the students.
The estimated time spent on social media could be
overestimated since multiple social media accounts can be
handled simultaneously and often in short bursts rather
than in prolonged sessions. Finally, we conducted the
study in medical students who are more likely to have a
better awareness of addiction compared to other student
populations, reducing the generalizability of the study
findings.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Indian Journal of Psychiatry Volume 63, Issue 1, January-February 2021