Effect of Facebook on the life of Medical University students

Background Facebook is a social networking service launched in February 2004, owned and operated by Facebook, Inc. As of June 2012, Facebook reports more than 1 billion active users. Objective of study was to evaluate the effect of Facebook on the social life, health and behavior of medical students. Methodology It was a cross sectional, observational and questionnaire based study conducted in Dow University OF Health Sciences during the period of January 2012 to November 2012. We attempted to interview all the participants who could be approached during the period of the study. Participants were MBBS students, while all students of other courses and programs were taken as exclusion criteria. Approximately 1050 questionnaires were distributed to participants. Fifty questionnaires were rejected due to incomplete answers, yielding 1000 usable responses for an approximate 95% response rate. Informed verbal consent was taken from each participant. Study was ethically approved by Institutional Review Board of Dow University of Health Sciences. All the data was entered and analyzed through SPSS 19. Result Out of total 1000 participants, males were 400 (40%) and females were 600 (60%). Participants were in the age group of 18–25 years with a mean age of 20.08 years. Most of the participants were using Facebook daily (N = 640, 64%) for around 3–4 hours (N = 401, 40.1%). Majority of them (N = 359, 35.9%) believed that they were equally active on Facebook and in real life while few believed their social life became worse after start using Facebook (N = 372, 37.2%). Most of the participants admitted that they were considered as shy in real world (N = 390, 39.0%) while in the world of Facebook they were considered as fun loving by their friends (N = 603, 60.3%). A large number of participants (N = 715, 75%) complained of mood swings. Conclusion Youngsters are willing to compromise their health, social life, studies for the sake of fun and entertainment or whatever satisfaction they get after using Facebook. What we observed in our study was that although majority of our subjects showed multiple signs of Facebook addiction, they don’t realize it and if even they realize it they don’t want to quit Facebook and even if they want to quit, they can’t. Our observance concluded that majority of the users are highly addicted.


Background
Online social networks are rapidly changing the way human beings interact [1]. Facebook is a social networking service launched in February 2004, owned and operated by Facebook, Inc. As of June 2012, Facebook reports more than 1 billion active users. It is particularly attractive to young adults and over half of member being in the age group of 18-34 [2,3]. University life without Facebook is almost unthinkable and since its inception in 2004, it has quickly become both a basic tool and a mirror for social interaction, personality identity and network building amongst students [4]. Facebook deeply penetrate its users everyday life and now it has become a medium for "change and expression" in every aspect of life [5]. It is one of the incredible inventions of this modern scientific era which fasten every one into its enchantment. It is now available on cellular phones and tablets, anyone can attach to their relative, friend and with news, wherever in the world [2]. There is no lack of examples how the meaning of communication has been changed as a result of social media. Emotion has replace words as a tool for express feelings perhaps most importantly; social media helps to make a society that values frequent communication more than meaning full communication [6].
Beside its huge advantages it has now become a hot topic of debate that either it is a useful invention or an invention with full of hazards. Most of the users don't realize the negative impact of social media on their life because they are already addicted to it. It has been notified in studies that excessive use of Facebook will make a person to take less interest in his or her surroundings. There is no doubt that excessive use of Facebook affects the real world interaction abilities and communication, while social skills gradually decrease. There is a long list of its negative impact on society as it's indicated in one study that Facebook is popular mostly among immature people who create bizarre statuses, upload awkward images, and carry out absurd actions, leading to conflict mostly. Facebook addiction is the new term invented by psychiatrists as its addiction will damage the sleeping habits, health and interest in studies and interaction abilities of real life [7].
Pakistani internet users have been on the rise at an accelerated pace, been recognized as one of the emerging nation of internet users. Users of social networking site Facebook in Pakistan have crossed the nine million mark, making Pakistan the 27th most popular country on Facebook. Out of these nine million users, 70% are aged 25 years or younger, while male users are 6.4 million in number and females 2.7 million. Around 44,000 new Pakistani users join Facebook every week [8].

Objectives
Prior researches provide mixed clues about how Facebook use should influence subjective well-being. Some cross-sectional researches reveal positive associations between Facebook and well-being, other work reveals the opposite. Still other work suggests that the relationship between Facebook use and well-being may be more nuanced and potentially influenced by multiple factors including number of Facebook friends, perceived supportiveness of one's online network, depressive symptomatology, loneliness, and self-esteem. There is no such data available from Pakistan or internationally regarding the effect of Facebook on individual's health. Whatever is present is lacking in quality and focuses on percentage of its usage, health and psychological effects. Therefore the main reason of our research was to evaluate the effect of Facebook on social interaction, behavior, studies and health of medical students.

Measures
It was a cross sectional study, observational and questionnaire based study conducted during the period of January 2012-November 2012 at Dow University of Health Sciences. Participants were MBBS students. Approximately 1050 questionnaires were distributed to participants. Fifty questionnaires were rejected due to incomplete answers, yielding 1000 usable responses for an approximate 95% response rate. In view of our research objectives, only MBBS students were included, while students of all other courses and programs were excluded. Thus convenience sampling was employed. Sample size was calculated by using open-epi calculator. Informed verbal consent was taken from all participants.

Questionnaire
Study tool was designed with the help of the Department of Community Medicine, Dow University of Health Sciences. Extensive keyword search was undertaken on Pub med and Google Scholar in order to draft the initial questionnaire. The keywords utilized were "social networking" and "Facebook". A group of medical students was initially approached and presented with a number of open-ended questions. Output was then incorporated with a thorough review of the literature in order to design the best possible questionnaire. A pretest of this preliminary questionnaire was done on a sample of 15 students in class; questionnaire was revised accordingly in order to ensure best possible form. Final questionnaire demonstrated immediate internal consistency. Conbach's alpha was calculated for the final data, which came out to be 0.692 for 1st section and 0.648 for 2 nd section.
Based on our topic, we made thirty two questions Performa, divided into two sections Section I Section I assess the basic demographic characteristics and pattern of using Facebook. It also assessed the psychological and behavioral impact of Facebook. Q1-Q4 assesses demographic information (name, age, gender and name of college). Q5 and Q6 assess the frequency of internet and Facebook usage. Q7 was about the reason of using Facebook. Q89-Q10 was about effect of using Facebook on social life, time spend with family and friends, and regarding more active either on Facebook or in real life. In Q11 it was asked, do you think Facebook is a source of inspiration and motivation for you. Q12 was about curiosity regarding display pictures. In Q13 it was assess that what are the comments of your friends on your personality in real and on in Facebook. Q14 and Q15 assess the usage if Facebook on late night and waking up at late night especially for logging into Facebook. Section II This section evaluates the side effects of Facebook on health and studies. Q15-Q24 was regarding the side effects of Facebook use (decrease energy level, effect on eye sight and appetite, headache, mood swing, weight problem, headache, irritation and aggressiveness). Q25-Q28 was regarding effect of Facebook on studies. In Q29 it was asked, do you feel loniless inspite of hundreds of Facebook friends while in Q30 it was asked is it difficult for you to spent whole day without using Facebook. Q31 and Q32 were regarding any attempt to reduce Facebook and usage and about future plan of using it. In last Question it was asked whether respondents feel them as an addict of Facebook or not.

Ethical approval
Research was approved by Institutional review board of Dow University Of health Sciences.

Analysis
Data from the questionnaire was entered in SPSS (Statistical Package for the Social Sciences) version 19 for analysis and the results were compared. Descriptive statistics formed the basis of the statistical analysis. Frequency and percentages were evaluated for categorical variables. Mean and Standard deviation used for continuous data.

Result
Demographics A total of 1000 questionnaire was correctly filled (response rate 95%). Participants were in the age group of 18-25 years with a mean age of 20.08 years. Majority (N = 600, 60%) consisted of females.

Reason of using Facebook
Mostly participants used Facebook for keeping in contact with friends and family (N = 717, 71.7%), while (N = 501, 50.1%) people had the reason of making new friends and increase their list of contacts ( Table 1).

Effects of using Facebook
Majority of students admitted that they give much more time to their family and friends before having Facebook in their life as compare to now (N = 370, 37.0%); this has been one of the dilemmas for our society. Most of the people believe that they were socially active both on Facebook and in real life (N = 359, 35.9%) while few considered that their social life became worse after Facebook (N = 372, 37.2%), ( Table 1). Majority of participants were clearly rejected the fact that they feel lonely inspite of many Facebook friends (N = 619, 61.9%). Nearly 50% people felt difficult to pass a day without using Facebook while (N = 512, 51.2%) people didn't feel so (Table 2).
Mostly admitted themselves as "shy" in real world (N = 390, 39.0%) but in the world of Facebook they were considered as "fun loving" by their friends 603 (60.3%) ( Table 3).
Mostly admitted themselves as "shy" in real world (N = 390, 39.0%) but in the world of Facebook they were considered as "fun loving" by their friends 603 (60.3%). Mostly participants also complaint of mood swing (N = 715, 71.5%) ( Table 2).

Health effects
Mostly participants complain about headache (N = 600, 60%) and eye sight problem due to excessive usage of computer and mobile devices for operating Facebook. After start using Facebook, many of them also feels change in their work potential which decrease gradually (N = 51.3, 51.3%) ( Table 3).
Majority of them didn't notice any effect on their appetite 498 (49.8%) and on weight 361 (36.1%). More than half of participants suffered from backache due to postural changes 690 (69%) ( Table 3).
When question about disturbance was asked, mostly (N = 526, 52.6%), responds that they get irritated when someone asked them to do any thing unimportant during Facebook surfing. A large number of participants disagrees the fact that Facebook addicts were aggressive in nature (N = 616, 61.6%). Nearly half of the respondents thought Facebook didn't impose any negative impact on their personality (N = 535, 53.5%) ( Table 3).

Future plans
When asked "What is your future plan regarding Facebook?" most interviewees responded with "I'll keep using it in future life". Mostly users didn't consider themselves as addicted of Facebook (Table 4).
Rest of the comparison and frequencies were in Tables.

Discussion
Within a relatively short time span, Facebook has revolutionized the way people interact. Although a number of studies aimed at assessing the behavioral and psychological impact of Facebook have been published, this is the 1 st article from Pakistan that attempt to elucidate the behavioral, heath and psychological effect on Medical students. Social media as a medium of communication has been continuous to grow around the globe with more than 1 billion users. Each Facebook user has an average of 130 friends who have access to their postings, which may be available to friends of friends or public, depending on the user's privacy settings. Habitual use of Facebook and its integration into daily life indicated that it has now become an indispensable tool for social, capital and communication with large number of people.
Over past 5 years, social media sites like Facebook have become a central, virtually unavoidable medium for social interaction. Social media sites were particularly attractive to young adults of 18-25 years age group. Findings was also consistent with the data of other studies [9,10]. This age group usually comprises of individuals who were just at the beginning of their educational and professional career and wanted to develop their professional identities.
It was our principle finding that mostly people daily visit their Facebook timeline to update and check or edit their profile, These findings were much higher as compare to previous studies [3,9].
Our study highlighted that 71% of respondents were suffered from mood swing and depression which was much higher in contrast to another studies [11,12]. These preliminary findings did not claim the usage of Facebook as a source of depression; as diagnosis of depression comprised of symptoms and pattern over time with clinical evaluation. Reason of these findings might be excessive use of Facebook by which one encounters relationship changes, luxurious styles and success of other users which put users into a mode of depression. It is the most common health impacting problem of young generation and due to this new invention depression among students has increased up to 56% in the last six years [12].
Mostly users spend 1-2 hours daily on Facebook, same as indicated in a study conducted by Ellison et al. [13]. Most of them used it to keep in touch with friends  and relatives [13]. This was demonstrated through the fact that most commonly included information on member's profile was likely regarding to their professional career or about educational history. (e.g. about their high school). Statistically our research indicated that there was 50-50 response regarding curiosity, half were curious about uploading attractive pictures while half didn't [14,15].
Despite the name "Social networking" most users activity on Facebook were self focused, but in our study it was also reported that mostly people didn't regard Facebook as a source of self motivation or self esteem, only small number of people had claimed that Facebook was a source of inspiration for them which was contrary to past study [16].
Addiction to Facebook is one of the major complain of young generation. When asked about addiction, mostly denies but on contrary when they were asked about disturbance created by social networking sites in their life, mostly claims that Facebook had ruined their social life and now they spent less time with their loved ones. These observations were same as shown in a past study [7]. This might be due to reason that mostly users were so active in editing and constructing themselves on these sites as they entirely forgot their real life problems, necessities and responsibilities [17].
Facebook and other networking sites also give shy people a way to socialize which might otherwise be lacking altogether. It was evaluated in our study that participants who show unwilling-to-communicate or shy in their real life, had considered by their friends as fun loving in Facebook world. These findings were contradicted to past study [18].
Every invention has its both negative and positive effects, same case was with Facebook, and it also has a negative impact on the life of human beings. Mostly its hazardous effects were same as of internet or computer like headache, backache, gain or loose in weight and eye problems [19,20].

Strength and limitations
The strength of our study lies in interviewing large number of medical students regarding behavioral, psychological and health effects of Facebook. Previous studies have targeted different communities or age groups; we use a medical university for extracting the data in order to provide a different perspective with regard to our study topic. All attempts were made to ensure that the data collected was reliable and the methods were   reproducible. However, our study was also not free from limitations. The most important limitation was that it just occurs in one medical university which comprises of three medical colleges. Although, these medical colleges consist of a heterogeneous population coming from different backgrounds, they cannot be used to predict the overall situation in the country. Furthermore, convenient sampling was employed, which may have led to selection bias, and hence is not truly representative of the population under study. However, since this was just an observational study, the sampling method did seem to fulfill its purpose.

Future researches
Although these findings raise numerous future research questions, few stand out as most pressing. Do these findings generalize? We concentrated on students of only one medical university.
This implies that further studies should be conducted on a larger scale, with a more diverse set of institutes in order to minimize bias and for better generalization. Future research should also examine whether these findings generalize to other online social networks.

Conclusion
The human need for social connection is well established, as are the benefits that people derive from such connections. On the surface, Facebook provides an invaluable resource for fulfilling such needs by allowing people to instantly connect. It also has been evaluated that online social networking may interfere with physical activity, which has cognitive and emotional replenishing effects and trigger damaging social comparisons. Any social network has two sided picture, on one hand where it a way of communication between friends and families on the other there are not only bad effects on youth but also great loss of precious time. So it should be used for creative and productive work not as a harmful tool for health and real life relations.