This study revealed the association of smartphone usage and pattern on self-reported symptoms among medical students of a Malaysian public university. Our participants’ smartphone usage reflected on SAS-M score was 101.43 (25.15). Our result is about the same with other local studies with their findings of scores above 98 (15) and 102.52 (13). Other international studies are also in agreement with our findings as they are using the same score adapted in Spanish, Arabic and Turkish language, which higher score indicates increased risk of smartphone usage or addiction (23–25). In particular, medical students could be more vulnerable due to their heavy use of smartphones for study and work (26). Especially during the COVID-19 pandemic quarantine period, where this research was being conducted (16), high dependency on smartphone for learning purposes is expected. Those with high usage of smartphones reflects the local survey that 78% of Malaysians are smartphone users (27). There are currently no established diagnostic criteria of smartphone addiction according to Diagnostic and Statistical Manual of Mental Disorders (DSM-V) in the spectrum of addiction disorder, but the high usage aspects are similar to substance-related and addictive disorder (28).
The participants owned their smartphone at an average of 7 years in line with an Indian study revealing a majority of the students owned a duration of 1–8 years, as smartphone seems to be a necessity nowadays (29). Our findings that participants make or receive calls about 32 minutes per day and spending about 4 hours per day for other than calls are somewhat consistent with South Korean students where most used 2–4 hours of smartphone daily (30). In contrast, a Pakistani study (31) revealed, 11 to 14 hours daily of smartphone use among medical doctors and this is probably because of age differences, as this study focused on young adults (mean age of 23). They spend more time on instant gratification applications whereby Malaysians seem to follow local trends by using apps like, WhatsApp, Instagram and Facebook (21). Unlike any other, a smartphone is the medium of choice for interpersonal mediated communication among young adults. This generation has a culture of smartphone being their companion, where they play, chat, shop and spend their leisure time in a profound and fundamental way different from their parents. Our participants equally use their smartphone for entertainment (50%) and non-entertainment (50%) purposes which does not support a study from India where most used their smartphones for purposes of social interaction (32). We also found the students would usually first use their smartphone within 15 minutes after wake-up in the morning differs with the Swiss youths (33) that majority spent within 5 minutes. The number of device owned has somewhat increase to an extra one device as compared to a local study (34), which may be the reason to devices’ affordability and availability in the market. It is recognized that it is difficult to draw definitive conclusions regarding the usage of smartphones, because cultures, values and beliefs vary across the world and play a role in the understanding and use of technology. The scenario supports The Uses and Gratification Theory (UGT), about why people turn to technology to meet their social and psychological needs at the same time, implies that they are deeply involved in their decision to use the technology and how to use it to meet their needs (35, 36).
Most medical students scored zero as not experiencing symptoms of headache (36.1%) and vision problem (39.3%). However, this is incomparable with 53.5% of Iranian students experienced headache (22) and 82.1% Iraqi students experienced vision problems (19). Even though findings did not support our hypothesis that headache will be the most common self-reported symptoms, it is a concerning issue, in view of the proportion of students still having symptoms of different severity which are sleep disturbance (75.4%), followed by neck pain (67.9%), headache (63.9%), vision problem (60.7%) and general exhaustion (56.7%). The symptoms distributions are somewhat varies from the Iraqi students (19) in detail, sleep disturbance (58.5%), neck pain (73.8%), headache (64.6%), vision problem (82.1%) and general exhaustion (69.9%). In 2011, the National Radiological Protection Board raised an issue that a large proportion of microwave frequency energy will eventually penetrates the user's body parts and head (37), by up to 2 inches of the human brain (38). Current guidelines set out by the International Commission on Non-Ionizing Radiation Protection (39) has raised issues in adults that, the radiation induced by smartphones has negatively affect cognitive functions, cell communication and fertility (40, 41). On the other hand, there are opposite results that indicate no such risks caused by smartphone exposure (42, 43). The non-ionising radiation emitted from a smartphone is however not strong enough to break atomic bonds and cause tissue damage (44). This could explain on our outcome of the low mean TSS score, whereby, the current evolution of smartphone inventions is more user-friendly with safety features of low emitting radiations and ergonomically proper as compared to the early generations of smartphones or mobile phones which reported side effects (45). The relevance of these consequences to human health is unclear as classified by the International Agency for Research on Cancer as group 2B (limited evidence in humans but less than sufficient evidence in experimental animals) (46). These effects have not been verified independently given the frequent lack of reproducibility of biological RF effects. With decades of cancer and neurodegenerative disease latencies, it will take some time to see the possible adverse effects (45), by that time, for many, it will be too late.
Further bivariate analysis revealed significant features associated with smartphone usage are, being Malay, having employed and highly educated parents and academic performance. Malay ethnicity was found significant as it is the majority ethnic in Malaysia (47). The findings of employed parents is inconsistent with a study from Korea, whereby, parents of the children showing the highest addictive tendency to smartphone use are predominantly lack stable jobs, and have less than a high school degree (48).The reason could be that the sample population are amongst children as compared to university students. On the other hand, increase in smartphone usage outcome differs with our finding, whereby a study from Iran found academic achievement reduces as students would have more mental occupation which leads to attention deficit and loss of focus in classroom. (49). While highly educated parents were found significantly associated with smartphone usage and certain smartphone patterns (making or receiving calls, purpose other than calls and extra devices owned). This is fairly similar to a local study that found positive correlation with smartphone usage which reflects high socioeconomic status represents the affordability to support the students’ smartphones monthly usage (12, 35).
There are two main predictors that determine the severity of symptoms, the medical students perceived they experienced. Firstly, father’s occupation or employed status contributes to the medical students’ TSS. Our finding is somewhat contrary due to age difference, focussing on South Korean children’s high usage of smartphone reflected from parents not having stable work with less than a high school diploma (48). Those parents are most likely unaware of their duty to monitor the use of their children's smartphones. The ability to adequately care for their children also lacks in identifying the symptoms that their children can encounter from smartphone exposure. It has also been verified that trends in the use of children's smartphones draws forth to psychological behaviours (50, 51), based on smartphone fascination, opportunities for peer interaction and physical activity may decrease, hence, lead to adverse physical symptoms in the long run. These phenomena signify parenting implications on children's educational environment as their development may be influenced negatively by smartphone exposure which can be translated into symptoms severity.
The other contributor to the increment of TSS score is entertainment function of smartphone use, congruent with an Iranian study (22). The medical students detailed out their most personally relevant smartphone function are entertainment such as, listen to music, play games, watch videos, read comics, and maintain social interaction on Social Networking Service especially during the time of COVID-19 quarantine period. This is backed by Zuckerman’s sensation-seeking theory of experience finding exposure and the resistance to boredom (52). However, to an extent, prolonged smartphone exposure leads to different forms of symptom severity experienced due to: (a) poor ergonomics (headaches, neck, shoulder and jaw pain) from anterior head syndrome (7) and (b) EMF or blue light exposure (sleep disturbances, blurry vision, concentration problems, dry and irritated eyes) (53, 54). More younger generations are affected by the popularity of education and entertainment technologies as they are in the midst of development that causes abnormal stress to the spine and digital eye strain can negatively influence their overall development and well-being (53).
We made all necessary steps to ensure optimum results, but the generalisability of these results is subjected to certain limitations. First, it was unavoidably conducted in different settings. The study was initially conducted before the order of nationwide quarantine due to COVID-19 global pandemic (16), and half the responses were completed during the period of quarantine, which more screening time than usual would be expected from the respondents. While they were residing at their respective locations, every student is depending heavily on the e-learning system implemented by the university (55). In regards to completing the questionnaire, we cannot avoid the probability of reporting bias from self-reported data. Nevertheless, the present study extends our knowledge of smartphone exposure towards self-reported symptoms’ severity as perceived by the medical students in addition to the available evidence of smartphones affecting psychological health (13, 15, 24, 50, 51).