Study design:
The present cross-sectional (descriptive-analytical) study was conducted in 2021 on students at Alborz University of Medical Sciences. This university is located in Alborz Province, neighboring Tehran Province (where the Capital of Iran is located), and has six schools: Medicine, dentistry, pharmacy, health, nursing, and para-medicine.
Study population
Based on a study conducted by Ziggi et al. [19] and considering 𝒄𝒐𝒓𝒓𝒆𝒍𝒂𝒕𝒊𝒐𝒏=𝟎.𝟏𝟓, 𝜷=𝟎.𝟐, 𝜶=𝟎.𝟎𝟓, the sample size was determined as 345 using the following formula, but it was then increased to 350 to take account of a potential withdrawal of 10%. A weight was assigned to each school based on the number of students in it, and then, based on the weight assigned to each school, the eligible students were selected from each school until the required sample size was reached.
n={(Zα+Zβ)/C}2+3
C=0.5ln[(1+r)/(1-r)]
Inclusion criteria
Male and female Iranian students aged 18 to 29 years who had passed one academic semester, did not use psychotropic and narcotic drugs, did not take antidepressants, had physical and mental health according to their educational records and self-report, and had a cellphone that enabled them to use virtual networks were included in the study.
Exclusion criteria
The students who withdrew from the study for whatever reason or who quit studying, experienced adverse events during the study such as death of parents, and returned incomplete questionnaires were excluded.
Data collection
The Depression, Anxiety and Stress Scale - 21 Items (DASS-21) was used to assess the students’ mental health, and the 36-item short-form health survey (SF-36) was administered to assess their quality of life. Data were collected using five questionnaires and a checklist, as follows:
Checklist of demographic details
This checklist inquired about participants’ personal details, including age, gender, nationality, marital status, education, field of study, academic semester, occupation, use of virtual networks on their cellphone, being a virtual network user, type of virtual network used, and the mean duration of using social networks per day (in hours).
Socioeconomic status scale
The socioeconomic status questionnaire comprising five main items and six demographic items developed by Ghodratnama in 2013 was used to evaluate four dimensions of the socioeconomic status, i.e. income level, economic class, education and housing status. The items were scored on a five-point scale ranging from 1: very low 5: very high. Eslami et al. confirmed the face and content validity of this questionnaire in Iran. They also confirmed its reliability by calculating a Cronbach’s alpha of 0.83 (2013) [20]
Internet Emotional Relationships questionnaire
The valid and reliable questionnaire developed by Barghi-Irani et al. [21] was used to assess online emotional relationships. This 28-item questionnaire has five components, including trust, honesty, enjoyment, sexual desire and preferring virtual relationships, and is scored based on a five-point Likert scale (from totally disagree to totally agree). The validity and reliability of the questionnaire were confirmed with Cronbach’s alpha coefficients of 0.73 for trust, 0.70 for honesty, 0.71 for enjoyment, 0.79 for sexual desire, 0.84 for preferring virtual communication, and 0.90 for the whole scale [21]. In the present study, the overall reliability of this tool was confirmed with Cronbach’s alpha of 0.85.
Stress, Anxiety, Depression Scale (DASS21), Lovibond (1995) [22]
The standard DASS-21 has 21 items in the three dimensions of stress, anxiety, and depression, each with seven items, and the final score of each subscale and the total score are found by summing up the scores of the items in that subscale. Each item is given a score between zero (did not apply to me at all) to three (applied to me very much). Since DASS-21 is the short form of the original scale with 42 items, the final score of each subscale has to be doubled. The validity and reliability of this scale were confirmed in Iran by Sahebi et al. within a range of 0.77 to 0.79 [23]. The lower is the score in this scale, the better is the respondent’s mental health.
36-Item Short-Form Health Survey (SF-36):
This questionnaire was designed in the US by Ware and Sherbourne (1992) and its validity and reliability were assessed in different groups of patients [24). The survey contains 36 items in eight dimensions, including physical functioning, role limitations due to physical problems, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain and general health. Moreover, two general subscales called physical health and mental health are obtained by combining these subscales. A lower total score in this questionnaire indicates lower quality of life and vice versa. In Iran, Montazeri et al. (2005) confirmed the validity of this questionnaire as 0.58 to 0.95 and its reliability as 0.77 to 0.90 [25].
Social Networks Questionnaire
The social network and media use were assessed using Jahanbani’s (2018) standard 19-item questionnaire containing three dimensions, including degree of use, type of use, and users’ trust in networks. Scoring is based on a five-point Likert scale from very little to very much. Jahanbani (2018) confirmed the reliability of this questionnaire with Spearman’s correlation coefficient of 0.90. The internal consistency of this questionnaire was also confirmed with Cronbach’s alpha coefficient of 0.85 [26].
Procedure:
The study began after obtaining the necessary permissions from the university and a code of ethics from the university ethics committee. Due to the Covid-19 situation and the impossibility of physical presence of the students, a consent form for participation in the study was first sent to the students through related online networks, such as the Student Deputy, the Student Research Committee and student groups. Eligible students willing to take part were selected by convenience sampling. Then, the online questionnaires were forwarded to the students through these networks and they were asked to complete them in the specified timeframe (minimum two weeks). The researcher’s phone number was given to the students to contact for responding to any possible ambiguities.
The students were assured of the confidentiality of all their data and that they had no obligation to take part in the study or continue their cooperation and that they would not face any problems or restrictions if they decided not to participate in the study.
Statistical analysis:
This study assessed the fit of a conceptual model for examining the concurrent effect of social networks and Internet emotional relationships on mental health and quality of life in students. First, the normal distribution of the quantitative variables was assessed using the Kolmogorov-Smirnov test. The path analysis method is an extension of the usual regression that shows the direct effects as well as indirect effects and impact of each variable on the dependent variables, and the results of this model can provide a rational interpretation of the relationships and correlations observed. Data were analyzed in SPSS-25 (27], PLS3 [28] and Lisrel-8.8 [29]. The correlation results were presented as Pearson’s correlation coefficient, and the path analysis results as beta with a significance level of T-value>1.96.
Path analysis is considered a causal modeling technique; it can be performed with either cross-sectional or longitudinal data [30].