The utilization of the internet has witnessed a substantial surge in the last two decades [1]. Studies indicate that 73% of college students engage with the internet daily, dedicating approximately 1.6 to 4.5 hours online [2]. Prolonged engagement in online activities can contribute to problematic internet use, characterized by risky, excessive, or impulsive internet behavior, leading to detrimental consequences in various life domains, including physical, emotional, social, or functional impairment [3]. The prevalence of problematic internet use (PIU) in the college-based population was reported to be around 9.22% [4]. Existing studies indicate a PIU detection rate among Chinese medical students of approximately 30.1%, significantly surpassing that observed in non-medical undergraduate students [5]. The problematic internet use (PIU) among medical students could detrimentally affect their academic performance and contribute to an increased prevalence of insomnia [6, 7], psychiatric disorders such as depression, anxiety, social withdrawal, and attention deficit [8]. This situation can have profound repercussions for medical students with aspirations to become healthcare professionals, disrupting their academic pursuits and jeopardizing their long-term career objectives [9]. Additionally, it may entail extensive and adverse implications for the future physicians' capacity to deliver high-quality care to patients and the broader community [10].
Previous studies focused on the prevalence and negative effect of PIU among medical students [11, 12, 13, 14], while few studies have investigated the driving factors and inner mechanism of PIU among medical students. Given the scarcity of empirical studies in this domain and the escalating prevalence of internet usage in China, particularly among medical students, it is imperative to enhance comprehension of the underlying factors and associated mechanisms of PIU. This knowledge is crucial for preventive efforts to avert medical students from succumbing to pathological internet use. Individual personality traits (e.g., rejection sensitivity), emotional states (e.g., loneliness), and individual positive qualities (e.g., self-control) may be closely associated with pathological internet use (PIU) in medical students. However, existing research has not yet explored how and when these factors influence the PIU of medical students [15, 16]. Therefore, this study aims to investigate the mechanistic impact of individual risk factors and positive factors on PIU among medical students.
Rejection sensitivity refers to the anxious, angry, and anticipatory cognitive-affective responses individuals exhibit when facing interpersonal rejection [17]. These individuals tend to readily construe ambiguous interpersonal situations as instances of social rejection, projecting negative responses to actual or perceived emotions [18]. Research confirmed that individuals with a trait of fearing rejection are more likely to engage in pathological internet use behaviors, highlighting rejection sensitivity as a threatening factor triggering pathological internet use [19]. Individuals with high rejection sensitivity, after experiencing social rejection, tend to immerse themselves in the online realm to seek a sense of security [20]. Medical students with elevated rejection sensitivity may find greater comfort in online interactions as opposed to face-to-face interactions, attributed to their heightened sensitivity to interpersonal rejection [21].
Loneliness is characterized as an individual's adverse emotional reaction to social isolation and absence of companionship, frequently accompanied by feelings of anxiety [22]. Previous study found that individuals with high rejection sensitivity often generate negative emotions such as hostility in social interactions and tend to adopt avoidance coping strategies, negatively impacting the establishment and maintenance of positive interpersonal relationships [23], leading to the experience of loneliness [24]. Therefore, individuals with elevated rejection sensitivity demonstrate increased levels of loneliness [25]. The emotional experience of loneliness in adolescents can contribute to internet addiction. Individuals experiencing loneliness tend to favor online interaction over face-to-face interaction due to perceived deficits in social skills. They may use online interaction as a compensatory mechanism, akin to a form of social ‘Prozac’, leading to compulsive internet use and subsequent adverse outcomes, such as problematic internet use (PIU). According to Davis’s [26] Cognitive-Behavioral Model, individuals with maladaptive cognitions may perceive the online world as more capable of fulfilling their needs compared to real-life experiences. Those with elevated levels of loneliness are predisposed to utilize the internet as a means to seek emotional support for alleviating negative emotions [27]. Numerous studies confirmed that individuals with higher emotional experiences of loneliness are more prone to developing tendencies toward internet addiction[28, 29, 30]. Park et al.’s study identified a positive correlation between loneliness and internet use in medical students [31]. Therefore, the rejection sensitivity of medical students may influence their problematic internet use through the mediating role of loneliness.
Self-control, as defined by Duckworth [32], encompasses the ability to monitor, inhibit, persevere, and adapt one's behavior, emotions, thoughts, and desires to achieve specific goals. Individuals with robust self-control demonstrate superior proficiency in regulating behavioral, emotional, and attentional impulses to attain long-term objectives [32]. Young (1998) posited that Problematic Internet Use (PIU) is essentially an impulse control issue[33]. Previous research has indicated that self-control plays a significant role in PIU, surpassing the impact of other variables [34]. Higher levels of self-control are associated with a decreased likelihood of Internet addiction. Following the affect regulation model of vulnerability, individuals facing challenges in emotional control are predisposed to addiction problems, with the intensity of this correlation contingent upon their level of self-control [35]. Therefore, the impact of loneliness on Problematic Internet Use (PIU) may be subject to moderation by self-control. For medical students with low self-control, individuals with high loneliness tend to excessively rely on the internet as a tool for interpersonal communication, making it challenging to control their internet use, consequently leading to PIU. Li et al. (2013) explored the moderating influence of self-control in the relationship between school connectedness, deviant peer affiliation, and Problematic Internet Use (PIU)[36]. Thus, self-control may moderated the relationship of the loneliness and PIU.
To our knowledge, no research has examined the mediating role of loneliness between rejection sensitivity and PIU among medical students, and whether the mediation model is moderated by self-control. This study constructs a moderated mediation model (Fig. 1) to investigate the influence and mechanism of rejection sensitivity on PIU among medical students. Specifically, this study will examine the mediating role of loneliness in the association between rejection sensitivity and PIU, and the moderating role of self-control in the mediation model. The aim is to provide theoretical guidance and empirical support for interventions addressing PIU among medical students. Based on the above theoretical analyses and empirical evidence, we propose the following hypotheses:
Hypothesis 1
There is a positive correlation between rejection sensitivity and pathological internet use among medical students.
Hypothesis 2
Loneliness mediates the impact of rejection sensitivity on problematic internet use among medical students.
Hypothesis 3
Self-control moderates the influence of loneliness on problematic internet use among medical students.