Review of Related Literature

Coronavirus Disease-19 has become a global public health problem since its outbreak in
early 2020. It not only causes several physical problems but also affects people's mental
health. Currently, the COVID-19 pandemic still continues to challenge people's livelihoods
and economies around the world and bring tremendous changes to people's daily life
(Moreno et al., 2020; Vindegaard, 2020; Kooli, 2021). The education industry, especially the
higher education industry is one of the most affected fields. Due to the prevention and
control of COVID-19 requirements, such as online teaching, outdoor activities' suspension,
and gatherings prohibition in the public field, college students have to increase their online
time and social media usage, which result in poor sleep quality, irregular eating pattern, and
even anxiety and depression (Fu et al., 2021). As the outbreak of COVID-19, the
governments had initiated the appropriate program of health education and relevant
regulations to strictly prevent the spread of COVID-19, such as outdoor activities'
suspension, social distance keeping, and gatherings prohibition in the public field. For
college students, they had to be required to come to home study online or in group isolation
in school dormitories, which increased their online time, social media usage, and potentially
changed their learning and lifestyles. Despite cell phones could bring convenience to people,
inappropriate usage of mobile devices has the potential to be detrimental. For example,
many people used cell phones frequently, leading to internet addiction (Ozturk, 2021). One
study showed more frequent cell phone overuse among college students when compared
with the pre-epidemic period (Kim, 2018). Additionally, it was also reported that frequent use
of the internet on cell phones among college students would cause poor sleep quality,
irregular eating patterns, and even anxiety and depression (Liu et al., 2021). Within the
Chinese context, according to a report from the China Internet Network Information Center
(CINIC), up to December 2020, there were 1.614 billion mobile phone users in China, among
whom students accounted for 21%, with college students aged 18–22 being the largest- and
fastest-growing group (China Internet Network Information Center, 2021; Conrad et al.,
2021). Especially in the era of routine epidemic control and prevention after 2020, college
students are used to employ mobile phones as their daily life instrument for conducting
interactive learning activities, such as taking online lessons and completing class
assignments (Shi et al., 2021). However, there still without exception existed cell phone
dependence (CPD) among Chinese college students (Hong et al., 2021). CPD is described
as the compulsive habit of avoiding reality or producing excitement via cell phone use with
symptoms, such as salience and withdrawal (Lam et al., 2009). It included any behavioral
addiction thought to be similar to that of an internet, gambling, shopping, or video game
addiction (Chen and Oliffe, 2018). Though no evidence was present to show that the
COVID-19 pandemic directly altered the relationship between CPD and mental health, some
studies had found the mediating and moderating role of cyberchondria severity in the
association between fear of COVID-19 and smartphone addiction among individuals (Kayis
et al., 2021). Literature has reported that CPD was associated with social and emotional
intelligence (Zou et al., 2019a), in which it demonstrated that the lower emotional intelligence
(or lack it entirely) one has, severer CPD is (Xie et al., 2019a). Excessive CPD was also
found to be associated with difficulties in cognitive-emotion regulation, impulsivity, impaired
cognitive function, addiction to social networking, shyness, and low self-esteem (Volkmer,
2018; Oviedo-Trespalacios et al., 2019). For college students, it is also reported that CPD
may have a negative impact on them in terms of time allocation and management, school
performance, interpersonal relationships, and health (Dempsey et al., 2020).

Broad Internet access and increasing electronic device availability have enlightened the
world community through a wide variety of applications and benefits, including
entertainment, gaming, web surfing, electronic communication, social media applications,
instant messaging, streaming content, and educational resources. The past few years have
witnessed great developments in Internet infrastructure, which have led to increased Internet
usage among people of various age groups. However, at the same time, there have been
some negative implications associated with increased Internet usage for some individuals.
“Internet addiction” (IA) is one such negative consequence of excessive Internet use among
users (Dhir et al., 2015a, 2015b, 2015c, 2015d).

Recent research has shown that an increasing number of Internet users throughout the
world are experiencing IA, with notable issues arising among university students
(Dehghankar et al., 2019). There are two types of IA, including the generalized and specific.
To clarify, generalized IA refers to a multidimensional and general behavioral pattern of
smartphone/Internet overuse that is associated with other problems, including impaired
family functioning, interactional problems, decreased life satisfaction, poor emotional well-
being, and worsening academic performance (Chen et al. (2020b). On the other hand,
specific IA refers to smartphone /internet overuse that is focused on a particular type of
activity (e.g., social media, gaming, or gambling) and which shares similar features to
generalized IA. Specific IA also associated with poor health outcomes, cyberstalking
problems and social media induced jealousy (Chen et al., 2020a; Tandon et al., 2021; Kaur
et al. 2020).

In similar regard, smartphones provide many conveniences, but users should also be aware
of the negative effects, the most concerning of which is smartphone addiction (SA), which is
a phenomenon in which there is uncontrollable overuse. Individuals with SA may encounter
social, psychological, and/or health problems (Cha & Seo, 2018). There may also be other
behavioral problems, such as gambling and gaming addictions. Indeed, the fifth edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists Internet gaming as a
specific disorder (American Psychiatric Association, 2013).

Students are some of the most prolific users of virtual applications and social networks.
However, Internet usage can have both positive and negative effects on academic, social,
and health matters for this demographic. This includes diminished overall grade point
averages (GPAs) (e.g., average final grade values ranging from zero to 4, as inversely
reflected by the A-F letter-grading scale). In sum, reduced academic performance and less
time spent studying are negative consequences of IA. Indeed, research has shown that
students who use social networks and the Internet more often than average tend to have
poor academic achievement and low concentration levels in the classroom. A study among
Qatari students specifically showed lower GPAs for those with IA (Al-Yafi et al., 2018).
Internet addiction (IA) is characterized by mood changes and preoccupation, with an inability
to limit the time spent using the Internet and associated electronics (Zhang et al., 2014). In
turn, this may influence other areas of life, including academic performance and family
relations (Dhir et al., 2015a, 2015b, 2015c, 2015d).

A recent systematic review and meta-analysis on the association between Internet addiction
and sleep found highly negative effects in cases where adolescents and young adults with IA
failed to engage in good sleep hygiene (Alimoradi et al., 2019). This highlights the
importance of helping young people develop good sleep hygiene, including the avoidance of
Internet and smartphone usage before bedtime or while in bed. This is highly relevant in
clinical practice. Internet and electronic device addiction causes difficulty when attempting to
control excessive behaviors related to Internet access, which then leads to distress or
impairment. Other studies found evidence that internet and electronic device addiction
increases the risk of many negative social and health consequences, including poor
academic performance, deleterious personality effects, anxiety, and depression (Ting et al.,
2019). Smartphone usage just prior to sleep is also significant factor for sleep deprivation in
adolescent females. In this regard, excessive smartphone usage has negative impacts on
physical health and wellness due to impaired sleep quality and duration. Further, IA is linked
to a higher rate of insomnia (up to 3%) and sleep disturbances among individuals who are
considered heavy Internet users. Sleep problems are also more likely among students who
extensively use the Internet to check social networks and spend substantial amounts of time
watching television (Yang et al., 2019; Chen & Gau, 2016). In the context of this study, there
is a high potential for problems related to IA and SA in both investigated countries. Currently,
more than 90% of the Saudi population has Internet access, with most students now using
electronic devices (Saquib, 2020). As for Egypt, statistical reports showed approximately 36
million Internet users as of 2014 (Statista, 2020a), with 23.6 million smartphone users as of
2017 (Statista, 2020b). These numbers emphasize the need to determine potential areas of
risk.

A study conducted by Karki et al. (2020)reported that nomophobia was detected in 57.29%
of participants, while 26.82% were at risk of developing the condition. In Nepal, 42% (n = 
105) of medical students self-reported IA, while 60.8% (n = 152) reported mobile phone
overuse, and 25.6% (n = 64) reported problems concentrating in class, doing assignments,
and working due to smartphone use (Karki et al., 2020).

Correspondingly, a cross-sectional study on smartphone addiction among 2,367 students at

King Saud University, Riyadh found that 28.8% and 15.3% of students agreed and strongly
agreed that their sleep hours had decreased due to smartphone use, with 29.5% and 13.9%
agreeing and strongly agreeing that they lacked energy as a result (Alosaimi et al., 2016).
Similarly, both SA and IA have been strongly associated with longer sleep latency, poor
sleep, and daytime hyper-somnolence (Gara et al., 2020; Dhir et al., 2015a, 2015b, 2015c,
2015d).

An investigation of sleep quality and IA among 511 students at King Abdulaziz University,
Jeddah revealed a significant correlation between IA and poor sleep quality (P < 0.001)
(Khayat et al., 2018). Another study found that Internet addicts and possible addicts were
more likely to neglect adequate sleep in order to remain online (P = 0.006) (Taha et al.,
2019). In Egypt, IA was more likely associated with poor sleep quality (P = 0.004) among
students at Al-Azhar University. Similarly, IA was correlated with poor sleep quality among a
sample Indian medical students (P < 0.001) (Mohamed et al., 2019).

Internet use with digital technologies, such as smartphones or tablets (Essel et al., 2018;
Lepp et al., 2019). According to previous studies, HE students’ daily Internet use varies from
fewer than four hours to over eight hours, with the average being four to five hours (Al-
Gamal et al., 2015; Qader et al., 2015; Sumaiyah Jamaludin et al., 2018). Students engage
in online activities related to studies and work, leisure and entertainment and the use of
electronic services (e-services) (Geyer et al., 2017; Mou et al., 2017; Chern and Huang,
2018). Additionally, health-related Internet use is common. Students use online health
information to address or solve a health problem and communicate about health issues
online (Mou et al., 2017; Yang et al., 2017). The use of health services provided online—as
well as web-based health interventions and treatments—is increasing (Merchant et al., 2017;
Mou et al., 2017).

Against the positive sides of HE students’ online activities, Internet use has become a
problem for growing number of students, ascending to pathological or addictive Internet use
(Young and de Abreu, 2011; Li et al., 2015; Kumar and Mondal, 2018). This problematic
Internet use is described by numerous terms, for instance, ‘excessive Internet use’,
‘psychopathological Internet use’, ‘problematic Internet use’, ‘Internet dependence’,
‘iDisorder’ and ‘compulsive computer use’ (Nath et al., 2016; Li et al., 2018), meaning a
negative influence on various interpersonal, social, psychological and physical health
domains of students’ life (Maurya et al., 2018). Students with problematic Internet use exhibit
obesity and sleep disorders (Li et al., 2016), comorbid mood and anxiety disorders (Kuss
and Lopez-Fernandez, 2016) and behavioral problems, such as sedentary lifestyles and
lower levels of physical activity (Penglee et al., 2019). However, effective professional
treatments exist to address these issues, for example, new clinical centers have been
established to treat Internet-use-related problems (Kuss and Lopez-Fernandez, 2016
Health-threatening Internet use within the context of social health and well-being
approached Internet use mainly from the Internet-enhanced technology perspective. This
category included information on lower health-related quality of life in the social domain
(Chern and Huang, 2018), fewer numbers of close friends (Lee et al., 2016), hyper-
connectivity with peers and peer comparison (Lattie et al., 2019).

As reviewed by Li et al. (Li et al., 2018), the prevalence of Internet addiction disorders (IAD)
is greater in Asia than in Europe. For instance, in China, Internet addiction is acknowledged
as an official disorder (Kuss and Lopez-Fernandez, 2016). HE students, together with high
school students, are known to be more vulnerable to these addictions compared with other
student groups (Turnbull et al., 2018), although children and adolescents are also becoming
increasingly addicted to playing Internet games (Bener et al., 2016). Overall, currently, the
addictive or problematic form of Internet use is viewed as a notable growing health problem
among HE students, affecting their mental and physical health (Kuss and Lopez-Fernandez,
2016; Shao et al., 2018; Fernandes et al., 2019). Conclusively, health-threatening Internet
use demonstrates the necessity of preventive actions, such as focused health-promoting
social marketing actions, to avoid risky behaviors from occurring among students.

Mobile phones are now indispensable in daily life. Owing to improved standard of living in
India, mobile phone ownership is highly prevalent among teens and young adults. The
findings of this study suggest specific mobile usage patterns, various compulsions caused by
mobile use, and several important relationships between mobile phone usage, health-related
behaviors, and academic activities among college students. In our study, we observed that
mobile phone use was very high among medical students of both the sexes, and all the
students had their own mobile phone, like findings in other studies.[10] Moreover, the
students from low socioeconomic status families possessed their own mobile phones. The
mobile phones that were earlier used by only high-income society are nowadays used by
most people as they have got cheaper over time. Average monthly phone bill of students
under our study was limited to Rs 300–500. This amount was found to be much less than
that spent by Malaysian students in another study.[11] However, this difference in
expenditure may be owing to the disparity in purchasing power of parents or may be that
Indian students try to keep check on their expenditure. We observed that some students
possessed another spare mobile phone, and many students were using dual sim phones,
which suggest improper usage of mobile phones as they may be hiding their contacts,
information or data from others, especially their family members.[12] Majority of the students
were possessing smart phones along with Internet facility, and they frequently used it for
taking pictures, recording videos, playing games, listening to music, and Internet surfing as
was also found in another study.[13] In our study, majority of the students used their phones
for social interaction and sharing of thoughts with their parents and friends.[14] Besides
calling, the second most common usage of mobile phone was as instrument for coordination
of day-today activities such as alarm clock or reminder, for safety purposes, and emergency
situations. These multifunction features of mobile phones cause an increase in mobile phone
value, leading the users to perceive it as a must-have tool. [4,14] The disadvantage of
having so many features on a single device is that if students lose their phone, they will lose
most of their contact numbers, recorded media, schedulers, and important personal data.

Excessive use of mobile phone leads to stress among students (Figure 01). Gladius Jennifer
et al, shows similar findings where 70.4% medical students were categorized under
moderate stress [13]. Maya Sahu et al reported that 22.5% nursing students were under low
stress, 67.7% under moderate stress and 9.8% under high stress due to mobile phone
usage, hence showing similar findings [14]. A total 51.9% participants use their phone for
more than 180 minutes in a day (Table 02). Similar finding was reported in the study done by
Dasgupta P et al [15]. Prevalence of Checking phone in between sleep was 40.5% (Table
02). Thisfinding was supported by a study conducted by Jilisha G. et al [16]. Many students
use Phone for academic purposes (Table 02). This indicates that mobile phone could be
helpful for students in academics. This is supported by a study published by Md.
Moyazzem[17]. Most participants use phone for calling
purpose (99.4%), followed by browsing internet (96.7%) and social media (97.8%) (Figure
02) and similar findings are reported in Vasanthakumaran study [12]. Our study revealed
mobile phone addiction level among university students (Figure 03). Davey S et al reported
smartphone addiction magnitude in India ranged from 39%-44% which was close to our
findings [18]. Jain P et al showed the smartphone addiction prevalence as 24.65%, which is
lower than our study finding [19]. The likely reason for different finding could be that they use
Smartphone addiction scale (SAS) to measure addiction whereas in this study the addiction
level was self-reported by the students within the university. Excessive mobile phone usage
has ill effects on health (Table 03). Similar findings can be seen in P.Stalin et al study[20].
Many other studies like Altalhi A. et alreported 62% participants suffer from burning eye
sensation [21]. Study by Logaraj M. et al presented 50% of female students complaints of
headache due to CVS (Computer vision syndrome) [22].Shantakumari N. et al reported
58.4% female students suffer from headache and 55.6% from burning eye sensation[23].
Sharma N. et al in the study reported 73% of students feels irritated without their phones and
61% suffers from headache [24]. Khan MN. et al presented that around 35- 49% US
population has sleep disorder like insomnia [25]. Khilani et al showed that 38.3% participants
were suffering from sleep disturbance [26]. Another study by Althakafi KA. et al. reported
(48.1%) early insomnia and (54.4%) late insomnia among Saudi adult population [27]. Likely
reason for different findings could be that it was a nation-wide quantitative study including all
population from age group 15-60 years whereas our study was conducted among university
students.