|Year : 2021 | Volume
| Issue : 1 | Page : 46-51
Nomophobia associated with depression, anxiety, and stress in nursing students: A cross-sectional study in college of nursing, Jeddah, Saudi Arabia
Hawazen Rawas1, Nusrat Bano2, Uzma Asif2, Muhammad Anwar Khan2
1 Department of Nursing, College of Nursing, King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, King Abdulaziz Medical City; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
2 Department of Nursing, College of Nursing, King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, King Abdulaziz Medical City; College of Medicine, King Abdulaziz Medical City, National Guard Health Affairs, King Saud bin Abdul Aziz University for Health Sciences, Jeddah, Saudi Arabia
|Date of Submission||03-Dec-2020|
|Date of Decision||10-Feb-2021|
|Date of Acceptance||14-Mar-2021|
|Date of Web Publication||31-Jul-2021|
Nursing Department, College of Nursing, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia. King Abdulaziz Medical City, National Guard Health Affairs, King Abdullah International Medical Research Center, P.O.Box 9515 Jeddah 21423
Source of Support: None, Conflict of Interest: None
Background: Nomophobia is described as the fear of losing contact with mobile phones. It is widely reported in nursing students who may also experience depression, anxiety, and stress. Little is known about the relationship of nomophobia with depression, anxiety, and stress. Objectives: This study was designed to (a) assess nomophobia in nursing students and to (b) evaluate the impact of depression, anxiety, and stress on nomophobia in nursing students. Material and Methods: The study was carried out in College of Nursing, Jeddah, Saudi Arabia. Study sample (n = 311) comprised students enrolled in all levels of bachelor of science in Nursing degree. A self-administered survey was conducted using the Nomophobia Questionnaire tool for nomophobia and DASS-21 for depression, anxiety, and stress. Results: Undergraduate nursing students were presented with mild (12.9%), moderate (46.9%), and severe (40.2%) nomophobia. The highest mean score yielded for nomophobia Factor 1 – not being able to communicate (4.74 ± 1.77), whereas the lowest score was noted for nomophobia Factor 2 – losing connectedness (4.07 ± 1.96). A significant positive correlation was noted between depression and Factor 4 – giving up convenience of nomophobia (r = 0.11, P < 0.05). A high prevalence of nomophobia was noted. Severity of depression contributed positively to severity of nomophobia. Conclusion: Findings indicate the coexistence of depression, anxiety, or stress in nomophobia.
Keywords: Anxiety, depression, nomophobia, nursing, stress
|How to cite this article:|
Rawas H, Bano N, Asif U, Khan MA. Nomophobia associated with depression, anxiety, and stress in nursing students: A cross-sectional study in college of nursing, Jeddah, Saudi Arabia. King Khalid Univ J Health Sci 2021;6:46-51
|How to cite this URL:|
Rawas H, Bano N, Asif U, Khan MA. Nomophobia associated with depression, anxiety, and stress in nursing students: A cross-sectional study in college of nursing, Jeddah, Saudi Arabia. King Khalid Univ J Health Sci [serial online] 2021 [cited 2023 Mar 29];6:46-51. Available from: https://www.kkujhs.org/text.asp?2021/6/1/46/322881
| Introduction|| |
The psychopathological impact of robust technological advancements on human lives has led to the emergence of unique and complex behavioral and mental disorders. Nomophobia or no mobile phobia is one of these contemporary mental health issues, described as “the fear of being out of mobile phone contact.” The earliest reports came from Stewart Fox-Mills survey showing that more than 13 million British people dreaded the prospect of losing contact with their mobile phones, following which in 2012, the British cellphone company SecurEnvoy reported nomophobia in 66% of people who compared their anxiety of losing contact with mobile phone to that of getting married or a dentist visit. People with nomophobia (nomophobes) are ridden with an irrational fear of losing contact with their mobile phones, and it prompts them to eliminate chances for being in that circumstance, as the prospect triggers intense stress and anxiety in them. Nomophobia is also associated with features of addiction, dependence, distress, nervousness, discomfort, and even suicidal ideation.,
Nomophobia in university students is relayed on as a widespread nondrug addiction. Decreased learning ability with a greater tendency of being distracted is noted in nursing students with mobile phone addiction. Aguilera-Manrique et al. reported continuous mobile phone use during clinical practicum by nursing students with severe nomophobia. Gutiérrez-Puertas et al. highlighted the potential risk to patient safety due to distractions in clinical settings while reporting high levels of nomophobia in Portuguese and Spanish nursing students.
On the other hand, depression, anxiety, and stress are frequently reported in nursing students.,, Depression, anxiety, and stress can adversely affect the performance of nursing students in patient care. Tung et al. reported depression in 34% of nursing students. Depression in nursing students implicates their academic performance and clinical practice., In a similar vein, psychological stress during nursing education is also commonly observed in students. Stress in nursing students affects their emotional and physical well-being. Stress and anxiety in nursing students usually go hand in hand and are shown to affect their learning experiences and raise attrition.
Certain factors contributing to depression in adolescents are also reported to be predictors of nomophobia. This is exemplified by “loneliness” which is closely associated with depression and is also related to nomophobia. King et al. (2014) reported an association of nomophobia with anxiety disorder but pointed out the need to investigate further possibilities of comorbid psychological disorders. Problematic mobile phone use is also related to neuroticism, extraversion, and anxiety disorders., However, the relationship of nomophobia with other psychological characteristics is not clearly defined, and researchers have indicated toward a need of focused research to identify predictors of nomophobia.
Nomophobia can adversely affect the learning process in nursing students and distract them in clinical settings. The academic performance in nursing students is also implicated if they have anxiety, stress, or/and depression. All of these factors can contribute to lower academic achievements, hinder the learning process, and affect patient care quality in their future professional practice. It is interesting to investigate further if one set of factors (depression, anxiety, and stress) implicates the other (factors of nomophobia). Thus, we posit that depression, anxiety, and stress are predictors of nomophobia in undergraduate nursing students based on earlier studies. The purpose of this study was to (a) assess nomophobia in undergraduate nursing students and (b) explore the influence of depression, anxiety, and stress on features of nomophobia in undergraduate nursing students.
| Methods|| |
Study design and samples
A descriptive cross-sectional study design was used to explore the relationship of depression, anxiety, and stress with features of nomophobia in undergraduate nursing students. The survey was carried out in one of the nursing colleges, Jeddah, Saudi Arabia. Undergraduate students enrolled in BSN program in the academic year 2018/2019 were invited to participate in the study. Convenient sampling was used. The study sample comprised 326 students. Incomplete surveys were excluded, and final data analysis was made for 311 respondents.
Ethical approval and data collection
Ethical approval for the study was granted by the IRB with approval number RJ19/035/J. The students were contacted in their free time to fill the self-administered questionnaires. The study purpose and nature of voluntary participation was explained to every student. They were presented with an option to withdraw from the study at any time. The survey was anonymous, participant-identifying information was concealed, and all information was kept confidential. Filled survey forms were kept in lock and key in research unit.
Data from each respondent were attained by using a set of three questionnaires described as follows: General Information Questionnaire, Nomophobia Questionnaire (NMP-Q), and DASS-21.
General Information Questionnaire
The General Information Questionnaire comprised five items. These items were related to the demographic profile of the participant including age, marital status, residence, study level, and the duration of owning a mobile phone.
The 20-item NMP-Q employed in this study was developed by Yildirim and Correia. NMP-Q is used to assess the severity of nomophobia, and the original version gives valid and reliable scores (Cronbach's alpha value of 0.945). The items were presented as “declarative statements” and valued on a seven-point Likert scale, where 1 corresponds to “strongly disagree” and 7 “strongly agree.” Values of each item were added for a total score ranging from 20 to 140. Severity of nomophobia is reflected in higher scores. A four-factor structure of the tool revealed from exploratory factor analysis corresponded to the four dimensions of nomophobia which are (a) not being able to access information comprising items 1–4 (points range from 4 to 28) (Factor 3), (b) giving up convenience comprising items 5–9 (points range from 5 to 35) (Factor 4), (c) not being able to communicate comprising items 10–15 (points range from 6 to 42) (Factor 1), and (d) losing connectedness comprising items 16–20 (points range from 5 to 35) (Factor 2). The NMP-Q was adapted and validated for the Arabic sociolinguistic context. It was pretested in 30 students. Internal consistency of the total scale was good, and the Cronbach's alpha value was 0.942.
The Depression, Anxiety, and Stress Scale-21 is a shorter version of the 42-item self-report measure of depression, anxiety, and stress (DASS) by Lovibond and Lovibond. The reliability test for the total of the original DASS-21 scales resulted in Cronbach's alpha value of 0.93. DASS-21 comprises 21 items where subsets of 7 items measure the three psychological factors, for example, depression, anxiety, and stress. It is a four-point Likert scale ranging from 0 to 3, where 0 corresponds to “did not apply to me at all” and “3” to “applied to me very much or most of the time.”
DASS-21 questionnaire was adapted and validated for the Arabic sociolinguistic context with a Cronbach's alpha value of 0.945 (total scales) which was closely similar to the original version. Reliability testing showed that depression (Cronbach's alpha = 0.866), anxiety (Cronbach's alpha = 0.813), and stress (Cronbach's alpha = 0.887) subscales (comprising 7/21 items each) were within acceptable range.
SPSS 20.0 (IBM SPSS Statistics for windows version 20.0. Armonk, NY was used for data analysis. Kolmogorov–Smirnov test was used to show a normal distribution of the data. Descriptive statistics was used to analyze data from the General Information Questionnaire, NMP-Q, and DASS-21. ANOVA and independent samples t-test were used to test the difference in NMP-Q domains related to the different participant characteristics acquired from the General Information Questionnaire. The mean and standard deviation (SD) of each item in NMP-Q were calculated. The correlation between DAS and nomophobia was analyzed by Pearson correlation analysis. Influence of depression, anxiety, and stress on nomophobia was explored by binary logistic regression analysis. P < 0.05 was considered statistically significant.
| Results|| |
Demographic profile of the participants
The median age of the study participants was 22.00 and interquartile range 21–23. All of them were females. Most of them were unmarried (89.7%). A higher number of students resided in urban regions (90.3%). Majority (74.5%) of them owned a smartphone for more than 2 years, 22.1% for <2 years, whereas only 3.3% owned smartphones for <1 year.
[Figure 1] shows varying degrees of nomophobia in nursing students. Majority of them had a moderate level of nomophobia (146, 46.9%), followed by severe nomophobia (125, 40.2%) and mild level of nomophobia (40, 12.9%). [Table 1] shows the mean and SD for each item in the nomophobia scale based on nursing student's response. The average value of the overall score on the nomophobia scale was 4.509 ± 1.85, which was greater than the median 3.5 of the seven-point Likert scale. Among the four factors of nomophobia, the highest score was for Factor 1 – not being able to communicate (4.74 ± 1.77), followed by Factor 3 – not being able to access information (4.73 ± 1.78) – and Factor 4 – giving up convenience (4.48 ± 1.88). The lowest score was noted for Factor 2 – losing connectedness (4.07 ± 1.96). Severity of nomophobia was most frequently reported for scale items that showed “anger upon not being able to look up information” (5.15 ± 1.73), “annoyed on not being able to use smartphone and/or its capabilities when wanting to” (5.07 ± 1.72), and “constantly searching for signals in the absence of wifi or data signal” (5.02 ± 1.79).
Nomophobia in undergraduate nursing students with different characteristics
[Table 2] shows the factors of nomophobia with respect to participant characteristics and offers a comparison. Comparing with residence, scores of Factor 2 and Factor 4 are higher in students from rural areas and the differences across the two groups were statistically significant (P = 0.004 and P = 0.007, respectively). Nomophobia scores were not significantly different between married and unmarried students. There was a significant difference in scores of students divided based on owning smartphone period (shown in years) in Factor 3 (P = 0.029), Factor 4 (P = 0.031), and Factor 1 (P = 0.005) of nomophobia.
|Table 2: Nomophobia in undergraduate nursing students with different characteristics (n=311)|
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Depression, anxiety, and stress
As demonstrated in [Table 3], stress scores are higher (mean = 1.93, SD = 0.65) in undergraduate nursing students, followed by depression (mean = 1.81, SD = 0.57) and anxiety (mean = 1.74, SD = 0.54) on the three-point DASS-21 Likert scale.
|Table 3: Correlation matrix for nomophobia and depression, anxiety, and stress|
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Relationships between nomophobia and depression, anxiety, and stress
A positive correlation is shown between the scores of depression, anxiety, and stress and the scores of nomophobia. Factor 4 of nomophobia giving up convenience had a weak positive correlation with stress (r = 0.052) and nomophobia Factor 3 not being able to access information had a weak positive correlation with anxiety (r = 0.045). There was a stronger positive correlation between Factor 2 losing connectedness (r = 0.91) and Factor 3 not being able to access information (r = 0.89) of nomophobia and depression. There was a significant positive correlation between Factor 4 giving up convenience and depression (r = 0.11, P < 0.05) [Table 3].
Multiple regression analysis of nomophobia
Outcomes of multiple regression analysis shown in [Table 4] indicate significant values for association of depression, stress, and anxiety with Factors 1 – not being able to communicate, 2 – losing connectedness, and 4 – giving up convenience of nomophobia.
| Discussion|| |
The purpose of this study was to assess nomophobia and to explore the effect of depression, anxiety, and stress on nomophobia among undergraduate nursing students in nursing college, Jeddah, Saudi Arabia.
This study shows that all the study participants had varying degrees of nomophobia. The results indicate the prevalence of moderate (46.9%), severe (40.2%), or mild (12.9%) nomophobia in undergraduate nursing students. These results are similar to the findings of another study that showed a high prevalence of moderate (51.9%) and severe (13.6%) nomophobia in Turkish nursing students, where only 3% (2 students) did not have nomophobia. In the present study, the average value of the overall score on the nomophobia scale (4.509 ± 1.85) was greater than the median value. The highest score was noted for Factor 1 – not being able to communicate closely, followed by Factor 3 – not being able to access information. In a similar study conducted in Spanish nursing students, nomophobia was reported with the highest scores in Factor 1 – not being able to communicate. Within nomophobia factor 1, the students strongly agreed on an item related to anxiety, upon not being able to immediately communication with friends and family (4.95 ± 1.76). They also were immensely worried if friends and family were unable to reach them (4.97 ± 1.71). However, the mean scores of these two items were comparatively lower than Portuguese nursing students, which were 4.97 ± 1.43 and 5.45 ± 1.24, respectively. Furthermore, several students agreed that they were annoyed upon being unable to look up information on their smartphone. This feature of nomophobia was comparatively higher in Saudi nursing students (5.15 ± 1.73) compared to Portuguese nursing students (5.03 ± 1.40).
Among the three psychological states, stress levels were higher in undergraduate nursing students compared to anxiety or depression. Mean stress scores (1.93 ± 0.65) were higher than the three-point Likert DASS-21 scale median 1.5. Stress is usually reported in nursing students due to the academic and clinical environment as well as financial reasons. It may also arise due to a fear of committing an error that may lead to a negative patient outcome.
A positive correlation existed between nomophobia levels and scores of stress, anxiety, and depression. In particular, a strong positive correlation was noted between depression and nomophobia Factor 4 – giving up convenience, which was statistically significant. This finding in our study is consistent with Adawi et al., who indicated depression as a predictor of nomophobia factor – giving up convenience.
Factor 4 – giving up convenience – comprises five items, for example, being scared upon phone battery drainage, being panicked upon running out of phone credits or monthly data limit, compulsively and repeatedly checking for data/wifi signals in the absence of signals, afraid of getting stranded without smartphone, and having a desire to check smartphone when not carrying it. On the other hand, depression is characterized by dysphoria, hopelessness, despair, and diminished interest in daily activities. In light of the results [Table 3], it can be deduced that depressive state may instigate anxious and compulsive behavior on losing smartphone contact. The nomophobia (Factor 4) feature that showcases a constant desire to check smartphone while not carrying it, is closely similar to the feature of smartphone addiction associated with having smartphone in one's mind even when not using it. This is interesting in the aforementioned context because depression is positively correlated with Internet addiction and social networking site addiction.
Furthermore, constantly and repeatedly checking for network signals on the smartphone reflects a compulsive behavior which is a common comorbidity with depression. The results of this study indicate that the propensity to get panicked and scared upon running out of phone credits/monthly data limit and battery drainage is higher in students with higher scores of depressions. A similar study has shown that problematic smartphone use is reported to be associated with the severity of depression and anxiety.
In summary, high levels of depression, anxiety, and stress may lead to higher degrees of nomophobia and vice versa. Therefore, it is safe to drive that nomophobia coexists with psychological traits of stress, anxiety, and in particular depression. These findings agree with Bragazzi and Del Puente, who commented that in certain conditions, a more complicated psychological condition may entail nomophobia, and therefore, it should be included in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. The study has shown us that not only nomophobia has an incredible prevalence in undergraduate nursing students but also the prevalence of depression, anxiety, and stress is very high where depression is directly and strongly associated with nomophobia.
One of the study limitations was that this is a single-organization study (city X of country Y), and all participants were female. Furthermore, the study data comprised self-reported information. Owing to the cross-sectional study design, casual relationship between depression, anxiety, stress, and nomophobia cannot be determined. Longitudinal study design is recommended for future research.
| Conclusion|| |
An abnormally high prevalence of nomophobia is noted in undergraduate female nursing students, majority of whom owned smartphones for over a period of 2 years. Stress levels were higher, followed by depression and anxiety. A significant positive correlation existed between nomophobia and depression. In face of the results that indicate a positive relationship between nomophobia and scores of depression, anxiety, or stress, it can be carefully deduced that nomophobia may exist as comorbidity in individuals diagnosed with severe anxiety, stress, and depression.
We are extremely grateful to all participants of this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]