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jha 2024, 27(3): 36-53 |
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Ghanei Gheshlagh R, Amiri J, Baghi V, Dehvan F. A systematic review and meta-analysis of smartphone addiction among Iranian high school and university students. jha 2024; 27 (3) :36-53
URL: http://jha.iums.ac.ir/article-1-4518-en.html
URL: http://jha.iums.ac.ir/article-1-4518-en.html
1- Lahore School of Nursing, The University of Lahore, Lahore, Pakistan. & Nursing Department, Biruni University, 34010, Istanbul, Turkey.
2- Shohada Hospital, Kermanshah University of Medical Sciences, Sarpol-e Zahab, Iran. & Shohada Hospital, Kermanshah University of Medical Sciences, Sarpol-e Zahab, Iran.
3- Be’sat hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran. & Be’sat hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran.
4- Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. & Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. ,f.dehvan@yahoo.com
2- Shohada Hospital, Kermanshah University of Medical Sciences, Sarpol-e Zahab, Iran. & Shohada Hospital, Kermanshah University of Medical Sciences, Sarpol-e Zahab, Iran.
3- Be’sat hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran. & Be’sat hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran.
4- Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. & Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. ,
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Figure 1. The process of review, screening, and selection of articles based on the PRISMA guidelines
Figure 2. Forest plot of the standardized smartphone addiction scores among Iranian high school and university students
Figure 3. Metaegression results. the relationship between the standardized score of smartphone addiction and sample size (a) and year (B)
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Introduction
Nowadays, the use of smartphones provides users with various pleasures, such as social connectivity, entertainment, access to information, time management, and maintaining social identity [1]. Smartphones have become such an integral part of daily life that their absence can lead to separation anxiety [2]. Excessive use of smartphones is rapidly increasing worldwide and has become a global concern [3]. It is claimed that 40% of individuals use smartphones for more than four hours a day [4]. Smartphone addiction, as an emerging issue in modern societies, particularly among younger generations, has significant impacts on physical, mental, and social health. In Iran, due to increased access to smartphones and their widespread use by high school and university students, concerns have arisen regarding the consequences of this phenomenon. However, studies conducted in this area in Iran have yielded conflicting results and a single comprehensive study in this regard seems to be lacking. . Therefore, this study aims to fill this knowledge gap by employing a systematic review and metaanalysis to estimate the standardized score of smartphone addiction among Iranian high school and university students. The findings will provide precise information to support policymaking decisions and preventive educational interventions.
Methods
This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Search strategy: Six databases, including SID, MagIran, PubMed, Scopus, Web of Science, and ScienceDirect, were searched without time limitations. A variety of keywords were searched (Supplement). The inclusion criteria included observational studies, publications in Persian or English, studies reporting smartphone addiction scores, research conducted on Iranian high school and university students, articles published in 2016-2022, and access to the full text of articles. Exclusion criteria included review articles, interventional studies, letters to the editor, and qualitative studies. To minimize bias, the search, selection, quality assessment, and data extraction processes were carried out independently by two researchers. In cases of disagreement, the decision of the corresponding author was considered as the final one. The Population consisted of Iranian high school and university students and the primary Outcome was the standardized score of smartphone addiction in the target population.
Data extraction: The mean and standard deviation of smartphone addiction scores among Iranian students were reported. However, since different tools with varying numbers of questions were used to measure this construct, the reported mean scores were not directly comparable. To enable comparison and report a unified score, the raw scores (mean and standard deviation) were converted into standardized scores (on a scale of 100).
Quality assessment: Eight questions from the JBI checklist were used for evaluating the quality of the articles in cross-sectional studies. These 8 questions covered topics such as clear definition of inclusion criteria, detailed description of study subjects and setting, valid and reliable measurement of exposure, use of standard criteria for measuring the condition, identification of confounding factors, strategies to address confounding factors, valid and reliable measurement of outcomes, and appropriate statistical analysis. If any of these criteria were met, a score of 1 was given, and if not, a score of 0 was assigned. The final score ranged from 0 to 8. The articles were categorized into three groups based on their qualities: weak (less than 4), moderate (5-6), and strong (7 and above)[5].
Statistical analysis: As that the smartphone addiction scores were converted into standardized scores, a binomial distribution was used to estimate the pooled standardized score for smartphone addiction. Cochran's Q test and the I² statistic were applied to assess heterogeneity among studies. Accordingly, studies were categorized into three levels of heterogeneity: low (less than 25%), moderate (25%–75%), and high (greater than 75%) [6]. Due to the observed heterogeneity among the selected studies (I² = 96.4%), the pooled standardized score for smartphone addiction was estimated using a random-effects model. Subgroup analyses were conducted based on the target group, quality and type of instrument. Meta-regression was utilized to examine the relationship between smartphone addiction scores and variables such as participant age, study sample size, and year of publication. Funnel plots combined with Egger’s regression test were employed to assess the impact of publication bias [7]. All analyses were performed using STATA software, version 16.
Results
Following the search in national (n = 557) and international (n = 830) databases, a total of 1,387 articles were identified. During the initial review phase, 435 duplicate articles were removed. In the identification and screening phase, 924 articles (unrelated studies, review articles, interventional and qualitative studies, and letters to the editor) were excluded, leaving 28 articles for further evaluation. In eight of these studies, the required data for analysis were not reported, resulting in their exclusion. Consequently, the analysis was conducted on the remaining 20 articles (Figure 1).
Nowadays, the use of smartphones provides users with various pleasures, such as social connectivity, entertainment, access to information, time management, and maintaining social identity [1]. Smartphones have become such an integral part of daily life that their absence can lead to separation anxiety [2]. Excessive use of smartphones is rapidly increasing worldwide and has become a global concern [3]. It is claimed that 40% of individuals use smartphones for more than four hours a day [4]. Smartphone addiction, as an emerging issue in modern societies, particularly among younger generations, has significant impacts on physical, mental, and social health. In Iran, due to increased access to smartphones and their widespread use by high school and university students, concerns have arisen regarding the consequences of this phenomenon. However, studies conducted in this area in Iran have yielded conflicting results and a single comprehensive study in this regard seems to be lacking. . Therefore, this study aims to fill this knowledge gap by employing a systematic review and metaanalysis to estimate the standardized score of smartphone addiction among Iranian high school and university students. The findings will provide precise information to support policymaking decisions and preventive educational interventions.
Methods
This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Search strategy: Six databases, including SID, MagIran, PubMed, Scopus, Web of Science, and ScienceDirect, were searched without time limitations. A variety of keywords were searched (Supplement). The inclusion criteria included observational studies, publications in Persian or English, studies reporting smartphone addiction scores, research conducted on Iranian high school and university students, articles published in 2016-2022, and access to the full text of articles. Exclusion criteria included review articles, interventional studies, letters to the editor, and qualitative studies. To minimize bias, the search, selection, quality assessment, and data extraction processes were carried out independently by two researchers. In cases of disagreement, the decision of the corresponding author was considered as the final one. The Population consisted of Iranian high school and university students and the primary Outcome was the standardized score of smartphone addiction in the target population.
Data extraction: The mean and standard deviation of smartphone addiction scores among Iranian students were reported. However, since different tools with varying numbers of questions were used to measure this construct, the reported mean scores were not directly comparable. To enable comparison and report a unified score, the raw scores (mean and standard deviation) were converted into standardized scores (on a scale of 100).
Quality assessment: Eight questions from the JBI checklist were used for evaluating the quality of the articles in cross-sectional studies. These 8 questions covered topics such as clear definition of inclusion criteria, detailed description of study subjects and setting, valid and reliable measurement of exposure, use of standard criteria for measuring the condition, identification of confounding factors, strategies to address confounding factors, valid and reliable measurement of outcomes, and appropriate statistical analysis. If any of these criteria were met, a score of 1 was given, and if not, a score of 0 was assigned. The final score ranged from 0 to 8. The articles were categorized into three groups based on their qualities: weak (less than 4), moderate (5-6), and strong (7 and above)[5].
Statistical analysis: As that the smartphone addiction scores were converted into standardized scores, a binomial distribution was used to estimate the pooled standardized score for smartphone addiction. Cochran's Q test and the I² statistic were applied to assess heterogeneity among studies. Accordingly, studies were categorized into three levels of heterogeneity: low (less than 25%), moderate (25%–75%), and high (greater than 75%) [6]. Due to the observed heterogeneity among the selected studies (I² = 96.4%), the pooled standardized score for smartphone addiction was estimated using a random-effects model. Subgroup analyses were conducted based on the target group, quality and type of instrument. Meta-regression was utilized to examine the relationship between smartphone addiction scores and variables such as participant age, study sample size, and year of publication. Funnel plots combined with Egger’s regression test were employed to assess the impact of publication bias [7]. All analyses were performed using STATA software, version 16.
Results
Following the search in national (n = 557) and international (n = 830) databases, a total of 1,387 articles were identified. During the initial review phase, 435 duplicate articles were removed. In the identification and screening phase, 924 articles (unrelated studies, review articles, interventional and qualitative studies, and letters to the editor) were excluded, leaving 28 articles for further evaluation. In eight of these studies, the required data for analysis were not reported, resulting in their exclusion. Consequently, the analysis was conducted on the remaining 20 articles (Figure 1).
Figure 1. The process of review, screening, and selection of articles based on the PRISMA guidelines
The sample sizes of the studies ranged from 111 to 623 participants. The highest and lowest standardized smartphone addiction scores were reported in the studies by Sadri et al. (65.14%) [8] and Mameshali et al. (9.8%) [9], respectively. Six studies focused on school students, while 14 were conducted among university students. The findings indicated that the pooled standardized score for smartphone addiction.
Figure 2. Forest plot of the standardized smartphone addiction scores among Iranian high school and university students
The results of the subgroup analysis, based on the target population, indicated that the standardized smartphone addiction score was 39.5% (95% CI: 32.6–46.5) for university students and 36.6% (95% CI: 24.6–48.6) for high school students. There was no significant difference between the two groups in terms of standardized scores (p = 0.677). Additionally, the subgroup analysis by data collection tools showed that the standardized smartphone addiction score was 39.8% (95% CI: 32.7–46.9) based on the Cell-Phone Over-Use Scale and 28.8% (95% CI: 16.5–41.1) based on the Savari scale. The standardized smartphone addiction score was lower in high-quality studies compared to medium-quality studies (37.2% vs. 41.5%; Table 2).
Table 2. Standardized score of smartphone addiction based on the type of instrument, sample type, and article quality
| Between subgroups | Between studies | Standard score (95% CI) |
Number | Subgroup | ||||
| P | Q | Q | P | I2 | ||||
| 0.114 | 4.34 | 87.95 | 0.001 | 93.18 | 39.8% (32.7%-46.9%) | 7 | Savari | Tools |
| 150.17 | 0.001 | 97.34 | 28.8% (16.5%-41.1%) | 5 | COS | |||
| 97.46 | 0.001 | 92.82 | 43.9% (36.7%-51.2%) | 8 | Other | |||
| 0.677 | 0.14 | 362.50 | 0.001 | 96.41 | 39.5%(32.6%-46.5%) | 14 | University students | Target group |
| 165.76 | 0.001 | 96.98 | 36.6%(24.6%-48.6%) | 6 | High school students | |||
| 0.368 | 0.81 | 41.08 | 0.001 | 83.14 | 41.5%(36.7%-46.6%) | 7 | Moderate | Quality |
| 0.81 | 0.001 | 97.3 | 37.2%(29.1%-45.3%) | 13 | Strong | |||
COS: Cell-Phone Over-Use Scale
The metaregression results also indicated that there was no significant relationship between the standardized score of smartphone addiction and the sample size of the selected studies (p = 0.834) and the year of publication (p = 0.648) (Figure 3). Publication bias was not significant either (p = 0.211).
Figure 3. Metaegression results. the relationship between the standardized score of smartphone addiction and sample size (a) and year (B)
Discussion
In this study, the standardized score of smartphone addiction among Iranian high school and university students was 39.5% and 36.6%, respectively. It appears that the rates of smartphone addiction is relatively low. Various studies have shown that the standardized score of smartphone addiction among students in Saudi Arabia and India was 36.5% [10] and 44.7% [11], respectively. In the study by Ching and colleagues [12] , the level of smartphone addiction among medical students was 46.9%. In the study by Sethuraman and colleagues [13] in India, the standardized score of smartphone addiction among medical students was reported to be 40.63%, which is quite similar to our study Boumosleh and colleagues [14] also reported a moderate smartphone addiction rate among students.
Studentsmay use smartphones for some urgent needs such as accessing information , : however, this usage can expose them to excessive use and smartphone addiction. One study revealed that smartphone use negatively affects students' learning, academic performance, and cognitive skills and abilities [15]. Smartphone addiction can expose students to the risk of developing various mental disorders, including bipolar disorder, depression, anxiety, physical disorders, dependent personality disorder, and obsessive-compulsive personality disorder [16]. Other important influencing factors in smartphone addiction include family communication patterns, family interactions, parental attitudes, and intra-family violence or cohesion [17, 18]. It seems that the growth of technological tools such as smartphones, along with their numerous benefits, may challenge many family interactions and functions, particularly the interactions between parents and adolescents or young adults.
In this study, there was no significant correlation between the standard score of smartphone addiction and the publication year of the articles. Similarly, the study by Zhang et al. [18] showed no significant relationship between the publication year of articles and the level of smartphone addiction. Thus, it may be concluded that the state of smartphone addiction has reached a relative temporal saturation point among students. Therefore, instead of focusing solely on the year of publication, attention should be given to other factors that may influence the level of addiction. Interestingly, Ratan et al. [19] demonstrated that with the increasing use of new technologies, the prevalence of smartphone addiction has risen in recent years. The authors attribute this increase to easier access to technology, the expansion of high-speed internet, and the development of engaging applications and social networks. This phenomenon is particularly noticeable among students and adolescents, and it has been exacerbated due to the widespread use of smartphones for education, entertainment, and social communication purposes.
Limitations
Some limitation of this study are the incomplete reporting of findings in some of the articles and the lack of data on smartphone addiction based on gender or academic discipline. As a result, analysis based on these variables was not possible.
Conclusion
In this systematic review and metaanalysis, the cumulative standard score of smartphone addiction among Iranian high school and university students was calculated. Although the cumulative standard score for smartphone addiction was low among both groups, the average addiction score was slightly higher inthe latter group compared with the former, despite the fact that no significant difference was found between the two groups. Additionally, differences were observed based on the results demonstrated by the tools which were used to measure addiction, with the COS scale showing a higher score compared to the Savari scale. Analysis of article quality indicated that the addiction score was higher in studies with medium quality compared to those with high quality. Metaregression results also showed that sample size and publication year had no significant impact on the addiction score. These findings underscore the importance of addressing smartphone addiction as a serious challenge among younger populations. The results of this study could provide a foundation for designing educational intervention programs in mental health and improving the use of technology among high school and university students. Furthermore, the need for creating and using standardizing measurement tools and conducting high-quality studies in this field is emphasized.
Declerations
Ethical considerations:In this review study, ethical principles related to literature reviews were carefully observed. These included ensuring the accuracy and integrity of data collection and interpretation, and avoiding any form of bias or prejudice.
Author contributions: RGhGh: study supervision, conceptualization and study design, methodology, validation, data analysis, writing – review and editing. FD: conceptualization and study design, data collection, validation, writing – review and editing. JA: data collection, validation, writing – original draft.VB: data collection, validation, writing – original draft. All authors have read and approved the final version of the manuscript.
Consent for publication: Not applicable.
Data availability: The data supporting this study are available from the corresponding author upon reasonable request via email.
Use of Artificial Intelligence: ChatGPT by OpenAI was used for editing the English section of this manuscript. All content generated or edited using this tool was thoroughly reviewed and approved by the authors.
Acknowledgments: The authors would like to express their sincere gratitude to all researchers whose studies were included and reviewed in this work.
Funding: The authors received no financial support for the research, authorship, or publication of this article.
Conflict of interest: The authors declare that there is no conflict of interest regarding the publication of this paper.
In this study, the standardized score of smartphone addiction among Iranian high school and university students was 39.5% and 36.6%, respectively. It appears that the rates of smartphone addiction is relatively low. Various studies have shown that the standardized score of smartphone addiction among students in Saudi Arabia and India was 36.5% [10] and 44.7% [11], respectively. In the study by Ching and colleagues [12] , the level of smartphone addiction among medical students was 46.9%. In the study by Sethuraman and colleagues [13] in India, the standardized score of smartphone addiction among medical students was reported to be 40.63%, which is quite similar to our study Boumosleh and colleagues [14] also reported a moderate smartphone addiction rate among students.
Studentsmay use smartphones for some urgent needs such as accessing information , : however, this usage can expose them to excessive use and smartphone addiction. One study revealed that smartphone use negatively affects students' learning, academic performance, and cognitive skills and abilities [15]. Smartphone addiction can expose students to the risk of developing various mental disorders, including bipolar disorder, depression, anxiety, physical disorders, dependent personality disorder, and obsessive-compulsive personality disorder [16]. Other important influencing factors in smartphone addiction include family communication patterns, family interactions, parental attitudes, and intra-family violence or cohesion [17, 18]. It seems that the growth of technological tools such as smartphones, along with their numerous benefits, may challenge many family interactions and functions, particularly the interactions between parents and adolescents or young adults.
In this study, there was no significant correlation between the standard score of smartphone addiction and the publication year of the articles. Similarly, the study by Zhang et al. [18] showed no significant relationship between the publication year of articles and the level of smartphone addiction. Thus, it may be concluded that the state of smartphone addiction has reached a relative temporal saturation point among students. Therefore, instead of focusing solely on the year of publication, attention should be given to other factors that may influence the level of addiction. Interestingly, Ratan et al. [19] demonstrated that with the increasing use of new technologies, the prevalence of smartphone addiction has risen in recent years. The authors attribute this increase to easier access to technology, the expansion of high-speed internet, and the development of engaging applications and social networks. This phenomenon is particularly noticeable among students and adolescents, and it has been exacerbated due to the widespread use of smartphones for education, entertainment, and social communication purposes.
Limitations
Some limitation of this study are the incomplete reporting of findings in some of the articles and the lack of data on smartphone addiction based on gender or academic discipline. As a result, analysis based on these variables was not possible.
Conclusion
In this systematic review and metaanalysis, the cumulative standard score of smartphone addiction among Iranian high school and university students was calculated. Although the cumulative standard score for smartphone addiction was low among both groups, the average addiction score was slightly higher inthe latter group compared with the former, despite the fact that no significant difference was found between the two groups. Additionally, differences were observed based on the results demonstrated by the tools which were used to measure addiction, with the COS scale showing a higher score compared to the Savari scale. Analysis of article quality indicated that the addiction score was higher in studies with medium quality compared to those with high quality. Metaregression results also showed that sample size and publication year had no significant impact on the addiction score. These findings underscore the importance of addressing smartphone addiction as a serious challenge among younger populations. The results of this study could provide a foundation for designing educational intervention programs in mental health and improving the use of technology among high school and university students. Furthermore, the need for creating and using standardizing measurement tools and conducting high-quality studies in this field is emphasized.
Declerations
Ethical considerations:In this review study, ethical principles related to literature reviews were carefully observed. These included ensuring the accuracy and integrity of data collection and interpretation, and avoiding any form of bias or prejudice.
Author contributions: RGhGh: study supervision, conceptualization and study design, methodology, validation, data analysis, writing – review and editing. FD: conceptualization and study design, data collection, validation, writing – review and editing. JA: data collection, validation, writing – original draft.VB: data collection, validation, writing – original draft. All authors have read and approved the final version of the manuscript.
Consent for publication: Not applicable.
Data availability: The data supporting this study are available from the corresponding author upon reasonable request via email.
Use of Artificial Intelligence: ChatGPT by OpenAI was used for editing the English section of this manuscript. All content generated or edited using this tool was thoroughly reviewed and approved by the authors.
Acknowledgments: The authors would like to express their sincere gratitude to all researchers whose studies were included and reviewed in this work.
Funding: The authors received no financial support for the research, authorship, or publication of this article.
Conflict of interest: The authors declare that there is no conflict of interest regarding the publication of this paper.
Type of Study: Review |
Subject:
Health Information Technology
Received: 2024/07/1 | Accepted: 1901/12/14 | Published: 2025/06/7
Received: 2024/07/1 | Accepted: 1901/12/14 | Published: 2025/06/7
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