|Year : 2020 | Volume
| Issue : 2 | Page : 115-121
Psychological distress and social media usage: A survey among undergraduates of a university in Calabar, Nigeria
Udeme Asibong1, Chidi John Okafor2, Inyang Asibong3, Essien Ayi4, Ogban Omoronyia3, Udofia Owoidoho2
1 Department of Family Medicine, University of Calabar, Calabar, Cross River State, Nigeria
2 Department of Psychiatry, University of Calabar, Calabar, Cross River State, Nigeria
3 Department of Community Medicine, University of Calabar, Calabar, Cross River State, Nigeria
4 Department of Biological Sciences, University of Calabar, Calabar, Cross River State, Nigeria
|Date of Submission||30-Oct-2019|
|Date of Decision||24-Jan-2020|
|Date of Acceptance||20-Feb-2020|
|Date of Web Publication||11-Apr-2020|
Dr. Chidi John Okafor
Department of Psychiatry, University of Calabar, Calabar, Cross River State
Source of Support: None, Conflict of Interest: None
Context: Access to social network sites (SNS) is commonplace, especially among young people globally. Cumulatively, long duration of daily exposure may be having effects on psychological health outcomes, including increased and in some cases, decreased risk of depression and anxiety. Despite these potential effects, there is a paucity of literature on patterns and effects of exposure to social media, especially in developing countries where regular mental health screening is generally unavailable. Aim: This study aims to assess the psychological effects of Internet/social media usage among undergraduates in Calabar. Settings and Design: A descriptive cross-sectional study conducted in the University of Calabar, Nigeria. Methodology: Multi-staged sampling technique was used to recruit equal proportions of the undergraduate students from five selected Faculties in the University. Internet Addiction Test and General Health Questionnaire-28 were used to measure addiction to Internet and psychological health status of the respondents, respectively. Socio-demographic questionnaire was used to obtain information on demographic and social media characteristics of the respondents. Statistical Analysis: Chi-square and independent t-test were used as inferential statistics, with P value set at 0.05. Results: Four hundred and eighteen (418) respondents completed the questionnaires. The mean age was 21.5 ± 3.6 years. Male:female ratio was 1:0.99. WhatsApp (59.8%) was the most commonly visited social media platform, whereas entertainment (52.2%) was the most common reason for social media use. About one-fifth (20.1%) had moderate-to-severe forms of Internet addiction, whereas one-third (33.1%) were psychologically distressed. Psychological distress was found to be significantly more common among respondents with mild/none, compared with those with moderate-to-severe forms of Internet addiction (P = 0.00). Respondents with moderate-to-severe forms of Internet addiction had significantly lower mean depression and anxiety scores compared with those with mild or no form of addiction (P = 0.00). Conclusions: There is high degree of psychological distress among students, and this was found to be more common among those that were less/not addicted to SNS. Specifically, high degree of Internet addiction may be protecting against the increased risk of depression and anxiety. The implications of these findings on youth counselling and the prevention of mental illnesses in developing countries are discussed in this article.
Keywords: Internet addiction, Nigeria, psychological health, social media, undergraduates
|How to cite this article:|
Asibong U, Okafor CJ, Asibong I, Ayi E, Omoronyia O, Owoidoho U. Psychological distress and social media usage: A survey among undergraduates of a university in Calabar, Nigeria. Niger Postgrad Med J 2020;27:115-21
|How to cite this URL:|
Asibong U, Okafor CJ, Asibong I, Ayi E, Omoronyia O, Owoidoho U. Psychological distress and social media usage: A survey among undergraduates of a university in Calabar, Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 Nov 28];27:115-21. Available from: https://www.npmj.org/text.asp?2020/27/2/115/282312
| Introduction|| |
Mental illnesses are on the rapid rise, especially in developing countries, possibly due to the increasing prevalence of risk factors among scarcity of public mental health interventions., Among the several preventable risk factors are adolescent's exposure and addiction to advances in digital communication technology. One such advancement which has generated much interest in recent times is the exposure and use of social media.
Social media refers to any Internet-based platform or service (s) (such as Facebook, WhatsApp and Twitter), with which individuals can interact with each other verbally and/or nonverbally. Social media usage (SMU) comprises posting of created content (contributing), distribution of content from others (sharing) and learning/acquiring knowledge from content posted by others (consuming). Many young people in current technology-driven humanity are highly dependent on social media platforms to define their identities. An individual's consistent connection to the content and functionalities in this platform is, therefore, the key to the fulfillment of their perceived needs and wants.
Yet, there is evidence to suggest a direct relationship between SMU and impaired mental health status, including depression, anxiety, loneliness and narcissism. A cross-sectional study of the mental health effects of SMU was conducted among 702 young adults (18–49 years) in the USA. Each unit increase in SMU yielded 33% increased odds of depression (odds radio [OR] = 1.33). However, active SMU was associated with 15% decreased odds of depression (OR = 0.85). In the study, depression was assessed using the Patient-Reported Outcomes Measurement Information System brief depression scale. A longitudinal survey of the effect of Facebook use on well-being was conducted by Shakya and Christakis, among 5208 patients in the USA. The authors assessed the level of Facebook activities, real-world social networks, physical and mental health, life satisfaction and body mass index. Subjects that used Facebook had a poorer sense of wellbeing overall. Measures of Facebook use included the number of 'likes clicked' and 'status updates.'
Furthermore, a cross-sectional study among 972 high school students in Bangkok, Thailand, assessed Facebook addiction and mental health status using Bergen-Facebook Addiction Scale and General Health Questionnaire (GHQ-28), respectively. There was 41.9% and 21.9% prevalence of Facebook addiction and abnormal mental health, respectively. Having Facebook addiction increased odds of abnormal general mental health (OR = 1.7), anxiety and insomnia (OR = 1.3), social dysfunction (OR = 1.5), depression (OR = 1.5) and somatic symptoms (OR = 1.2). Furthermore, a survey among 237 young adults in Pakistan found 38.4% and 9.7% prevalence of psychological stress and political activism of social network sites (SNS). There was a significantly higher prevalence of stress and political activism compared with non-activism (65.2% vs. 34.7%, P < 0.01). Young people who are the predominant users of social media may, therefore, be at increased risk of deterioration in their mental health. Impairment of physical and mental health is thought to also result from associated sedentary behaviour, especially during the long duration of usage, interruption of sleep (due to exposure to screen's blue light) and distorted perceptions concerning relationships.
Although the use of social media by the youths in Nigeria appears to be rapidly increasing due to widespread availability of low-cost smartphones, yet there remains a dearth of studies on the relationship between SMU and mental health status of young Nigerians. Most local studies had focused on the pattern of SMU/addiction without relating it with the mental health of the users., In a cross-sectional survey of 907 undergraduate students of the University of Ibadan– Nigeria, the investigators found a high level of social media addiction (SMA) among the respondents. Furthermore, they reported that Facebook (90.2%) and Twitter (77.6%) were the SNS most frequently visited while meeting friends (78.2%) and getting news (67.9%) were the major purposes for visiting the sites. A multi-institutional study that investigated the impact of social media on the academic performance of university students in Nigeria revealed that the most common SNS visited by the students were Facebook (40.8%) and WhatsApp (20.4%), whereas the most common reasons for using social media were to get information (30.6%) and to reach out to friends (24.5%). The results of the same study also suggest that exposure to SNS has a negative effect on the academic performance of the students. In a cross-sectional study that assessed Internet addiction and psychological distress among 480 adolescents in Enugu, southeastern Nigeria, Okwaraji et al. found mild, moderate and severe Internet addictions in 28.5%, 23.5% and 11.0% of the respondents, respectively. The study also showed that patients who were more addicted to Internet, had more psychological distress compared to those who were less or non-addicted.
Yet, Internet use, however, also has beneficial effects. Analysis of data from a sample of 3075 retiree respondents at four sessions within 6 years in the USA was conducted by Cotten et al. In that study, the odds of depression were found to reduce by 33% due to Internet use. Remediation of loneliness and social isolation is thought to be the mechanism for such positive mental health effects. Furthermore, a cross-sectional study among 626 adults in the Netherlands found 56.2% prevalence of addiction to SNS. The study, however, found no relationship between site usage and loneliness and mental health status.
Unfortunately, the factors associated with the pattern and mental health outcomes of SMU have been sparsely researched in many developing countries. Currently, Nigeria is densely populated, and a projected 420 million population in 2030 may pose a potential risk for the overwhelming burden of mental illnesses if evidence-based preventive measures are not put in place among present youths who represent future generation., This is key, towards attainment and sustenance of optimal mental health in tune with current sustainable development goals. This study was, therefore, aimed at assessing patterns and mental health effects of addiction to internet/use of social media among undergraduate students in Calabar, Southern Nigeria.
| Methodology|| |
Ethical clearance (with protocol number CRSMOH/RP/REC/2018/136) was obtained from the Health Research Ethics Committee of the Cross River State Ministry of Health on 10th April 2019. Permission was also obtained from the student affairs unit of the university before proceeding with the study which lasted from 17th of April to 10th June 2019. The participation of the respondents was strictly voluntary.
Study setting and design
This was a descriptive cross-sectional study conducted in the University of Calabar, Cross River State, Nigeria. The University was established in 1975 as a full-fledged University. Currently, it has one Graduate School, fourteen Faculties and three Institutes. The fourteen Faculties are Faculty of Agriculture, Arts, Education, Law, Management Science, Social Science, Medicine, Biological Sciences, Physical Science, Engineering, Pharmacy, Dentistry, Basic Medical Science and Allied Medical Science The institutes include Institute of Education, Institute of Oceanography and Institute of Policy and Administrative Studies. The average undergraduate student population in the University is 14,696 with slightly more male students (7582) than females (7114).
The study was conducted among the undergraduate students of the University of Calabar. A minimum sample size of 305 was calculated with Leslie Kish formula (n = Z2 pq/d2) where n = the desired minimum sample size,
Z = standard normal deviate for desired significance level = 1.96 (for 95% confidence),
P = 27.3% = proportion of subjects that were addicted to social media in the previous study,
q = 1 − p = 1−0.273 = 0.727
d = margin of error = 0.05
Thus, n = (1.96)2 × 0.273 × 0.727/(0.05)2 = 305
The sample size was adjusted to 420 to take care of non-response/inappropriately filled questionnaires.
The inclusion criterion was (1) Consenting adult undergraduate students of the university. The exclusion criteria were (1) Students that did not give consent to participate in the study. (2) Students that had previous contacts with psychiatric services. A multi-staged sampling technique was employed to select the required number of respondents. At the initial stage, we used balloting (simple random sampling) to select five faculties out of the 14 faculties of the university. Thereafter, one department from each of these five faculties was selected also by balloting. In each selected department, random sampling was used to select a level (or more when a level cannot provide the number of students needed to be recruited from the department). The respondents were recruited using YES/NO balloting from the selected departmental levels. With the aid of the undergraduate enrolment list, the recruitment was done in a way to reflect the relative contribution of each faculty to the total number of students in the five sampled faculties. For example, Faculty of Arts which has 1353 (20%) out of the total number of (6697) undergraduate students in the selected faculties, contributed 84 students (20%) of the required sample size (420). In like manner, Faculty of Agriculture contributed 58 students (13.8%), Education, 143 students (34%); Basic Medical Sciences, 55 students (13.1%) and Allied Medical Sciences contributed 80 students (19.1%). This was to ensure that the equal proportion of students was recruited into the study from each of the sampled faculty.
Data were collected using the Socio-Demographic Questionnaire, Internet Addiction Test (IAT) and GHQ-28.
The Socio-demographic Questionnaire which was designed by the researchers has two parts; the first part was used to collect the demographic information of the respondents such as age, gender and religion, among others. The second part of the questionnaire was used to obtain information regarding the respondents SMU such as the major reason for subscribing to social media; social media site most frequently visited and estimated daily duration spent on social media sites.
The IAT was used to assess for Internet addiction among the respondents. The IAT is a reliable and valid instrument developed by Dr. Kimberly Young for measuring addictive use of the Internet. This instrument consists of 20 questions on the use of Internet. Each question has a 6 point Likert scale format of 0, 1, 2, 3, 4 and 5 (representing none, rarely, occasionally, frequently, often and always, respectively). Every respondent is required to rate on the Likert scale how each of these 20 questions applies to him or her. At the end, the scores on the 20 questions are summed and the higher the sum, the greater the level of the Internet addiction of the individual. Whereas a total score in the range from 0 to 49 indicates no or minimal problem with the use of Internet, scores of 50–79 indicate that the individual is experiencing frequent problems because of the Internet. Scores in the range of 80–100 implies that the individual's Internet usage is causing significant problems in his or her life. The GHQ-28 was used to assess the mental health status of the respondents. This instrument (GHQ-28) which consists of 28 questions assesses for somatic symptoms (questions 1–7), anxiety/insomnia (questions 8–14), social dysfunction (questions 15–21) and depression (questions 22–28). Higher scores indicate worse mental health status and vice-versa A total score of 25 and above indicated the presence of psychological distress.
Verbal permission was obtained from the heads of the selected departments before proceeding with data collection. The class representative of each of the selected departmental level was approached to help facilitate the process. Using the departmental level time table, each selected level was visited before or after a lecture for data collection. The aim of the study was explained to the students in the classroom and their consent to participate was sought. The required number of respondents for each sampled faculty was selected from consenting students who were eligible to participate. The research instruments were administered in the classroom during the research period. Data obtained were entered and analysed using the SPSS version 21.0. All analyses were carried out at 5% level of statistical significance (P value set at 0.05).
| Results|| |
A total number of 420 respondents were given the study questionnaires to fill. Of these, a total of 418 returned their questionnaires properly filled, giving a response rate of 99.5%. The age range of the respondents was from 15 to 41 years, and the mean age was 21.5 ± 3.6 years. There were more males than females, with a male:female ratio of 1:0.99. Most respondents were within 21–30 years of age (54.1%) and single (95.7%). The most common place of residence was hostel (46.4%). These are shown in [Table 1].
[Table 2] shows the SMU characteristics. It can be seen from the table that the most common social media sites subscribed to were WhatsApp (59.8%) and Facebook (32.1%). Entertainment (52.2%), meeting new people (15.8%) and maintaining relationships (15.8%), were the most common reasons for social media use. Majority of the respondents either spent more than 4 h (26.8%) or <1 h (24.4%) on social media daily. Common duration on social media sites was >4 h (26.8%) and <1 h (24.4%).
[Table 3] shows the frequency distribution for each of the IAT items. Items with high frequency of being at least frequently reported include fearing that life without Internet was worthless (47.8%), finding oneself staying online longer than expected (42.6%) and trying to cut down on Internet access to no avail (36.8%). Items with the highest frequency of being rarely reported were school grades suffering due to Internet time (65.1%) and checking e-mails before doing other things (56.9%).
|Table 3: Frequency distribution of responses to internet addition test items (n=418)|
Click here to view
[Table 4] shows the frequency distribution of Internet addiction categories. About one-fifth (20.1%) of respondents had moderate-to-severe forms of Internet addiction, whereas about four-fifth (79.9%) had none or mild forms of Internet addiction.
|Table 4: Frequency distribution of Internet addiction test categories (n=418)|
Click here to view
Approximately one-third (33.1%) of respondents were psychologically distressed, while the rest (66.9%) had normal psychological health status. [Table 5] shows the relationship between Internet addiction and psychological health status. Psychological distress was found to be significantly more common among subjects with mild/none, compared with those with moderate-to-severe forms of Internet addiction (35.9% vs. 19.0%, P = 0.00).
|Table 5: Relationship between Internet addiction and mental health status|
Click here to view
As shown in [Table 6], respondents with moderate to severe forms of Internet addiction had significantly lower mean depression scores compared with those with mild or no form of addiction (P = 0.00). On the other hand, respondents with mild/no forms of Internet addiction had significantly higher mean anxiety/insomnia scores compared with those with moderate-to-severe forms of addiction (P = 0.00).
|Table 6: Relationship between Internet addiction test category and general health questionnaire scores (n=418)|
Click here to view
| Discussion|| |
There are varying opinions concerning beneficial or harmful mental health effects of Internet addiction. This study, which was aimed at assessing the effect of Internet addiction on mental health status found beneficial effects of Internet usage among undergraduates. Approximately one-fifth (20.1%) of respondents had moderate-to-severe forms of internet addiction, whereas one-third (33.1%) were psychologically distressed. Psychological distress including depression and anxiety were found to be significantly more common among subjects with mild/none, compared with those with moderate to severe forms of Internet addiction (35.9% vs. 19.0%, P = 0.00). This finding is at variance with the one from a cross-sectional study among university students in Lebanon. While the Lebanese study found depression and anxiety to be commoner among social media addicts (direct relationship), the present study found that anxiety and depression were more common in subjects who were mildly or non-addicted to social media (inverse relationship). This suggests that SMA may be playing some roles in stress relief/coping against everyday stressors and thus, may be protective against anxiety and depression in the present study setting. The mechanisms by which SMA relieves stress may include through interactions with friends and acquaintances, positive distraction with other (unrelated trending) stories, possible exposure to (counselling) solutions to daily challenges and social connectedness. Most other sources of stress relief (such as cinema/movie houses, biking and indoor sports) seen in developed countries are either unavailable or unaffordable to most citizens in less developed countries including the present study setting. SMA may, therefore, be one of the most cost-effective and readily available means of stress relief in the current study setting. Stress prone individuals in the study setting who are unexposed or non-addicted to social media may, therefore, be deprived of this potential benefit resulting in their eventual manifestation of psychological distress. The finding from the present study is also in contrast to that of Okwaraji et al. who found a direct relationship between the severity of Internet addiction and psychological distress among adolescents in Enugu. A study conducted in Korea found that Internet addiction increases the risk of anxiety while smartphone use reduces the risk of depression. Smartphone use which was commoner among females, was essentially for initiation and sustenance of the interpersonal relationship. This variety of findings underscores the role of differences in sociodemographics, cultural conditions and other characteristics, all of which could affect the mental health status of the respondents. Unfortunately, these extraneous factors were not assessed in this study, therefore limiting more practical interpretation but indicating potential gaps for further studies.
Studies that find depression resulting from addiction to Internet posit that it often occurs due to user's perception of social exclusion, negative post, unsettling/breaking news, conflicting views and recall of past traumatic experiences., However, it has been shown that many studies that find a direct relationship between Internet usage and psychological distress do not control for potential confounders. For instance, Elhai et al., in their review of the literature found much smaller effects of the relationship between Internet addiction and psychological stress after controlling for relevant variables. Furthermore, Kraut and Burke in their systematic review found the psychological effects of Internet use to be highly dependent on the type of Internet activity and audience. Depression was found to be improved by Internet communication with close friends and partners, but not acquaintances or strangers. Topics or themes discussed during communication, as well as the manner of communication, were found to be key determinants of the psychological effects of Internet use. Consequently, the apparent protection against anxiety and depression found in the present study may be a reflection of Internet use for potentially stress-relieving activities by students in the study setting. Evidently, such activities which include entertainment, meeting new people and maintaining relationships were found to be the most frequent reasons for subscription to SNS [Table 2].
It is often thought that Internet use may limit or replace actual interpersonal communication and physical interaction, with potential untoward psychological effects. There is, however, evidence to suggest a direct correlation between offline and online communication., In other words, Internet users mainly communicate online with the same people they communicate with offline. Hence, online communication may complement or supplement offline communication, with potential beneficial effects on interpersonal relationships., Regular online communication may improve recognition and volume of social support available to Internet users., Improved social support may be the medium for the improvement or prevention of depression and anxiety., Furthermore, deep and critical thinking are thought to result from active Internet usage. This may incite and sustain creativity, which may constitute a positive distraction from stressful factors accruing from daily life events. When online communication is of high value either for entertainment and/or promotion of critical deep thinking, its psychological effects are often beneficial. This position further contributes to the protective effect of Internet use/addiction against depression and anxiety as found in the present study. With WhatsApp and Facebook being the most common SNS and entertainment being the most frequent reason for social media use in this study, respondent's online communication and interaction with friends may be consolidating their relationships and potentially minimising depression and anxiety. However, such position may be better established through further longitudinal research into more detailed online activities including volume, frequency/regularity, intensity and subjects/topics discussed with various categories of friends and significant others.
| Conclusions|| |
The study found a high prevalence of psychological distress among undergraduates and this was less common in those that were more addicted to the use of Internet. Lower levels of depression and anxiety among Internet addicts may be due to their use for entertainment, as well as connecting with friends and family, a means of minimising the effect of daily stressors. These findings do not exclude the presence of other potentially harmful effects of Internet use, but rather suggest that the overall or resultant effect tends to be beneficial in the study setting. Further research with more robust quantitative and qualitative study designs and a larger sample is, however, recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry 2016;3:171-8.
Votruba N, Thornicroft G. The importance of mental health in the sustainable development goals. BJPsych Int 2015;12:2-4.
Hanna R, Rohm A, Crittenden VL. We're all connected: The power of the social media ecosystem. Bus Horiz 2011;54:265-73.
Kuss DJ, Griffiths MD. Online social networking and addiction – A review of the psychological literature. Int J Environ Res Public Health 2011;8:3528-52.
Pantic I. Online social networking and mental health. Cyberpsychol Behav Soc Netw 2014;17:652-7.
Escobar-Viera CG, Shensa A, Bowman ND, Sidani JE, Knight J, James AE, et al
. Passive and active social media use and depressive symptoms among United States adults. Cyberpsychol Behav Soc Netw 2018;21:437-43.
Shakya HB, Christakis NA. Association of facebook use with compromised well-being: A longitudinal study. Am J Epidemiol 2017;185:203-11.
Hanprathet N, Manwong M, Khumsri J, Yingyeun R, Phanasathit M. Facebook addiction and its relationship with mental health among Thai high school students. J Med Assoc Thai 2015;98 Suppl 3:S81-90.
Hisam A, Safoor I, Khurshid N, Aslam A, Zaid F, Muzaffar A. Is political activism on social media an initiator of psychological stress? Pak J Med Sci 2017;33:1463-7.
Idubor I. Investigating social media usage and addiction levels among undergraduates in university of Ibadan Nigeria. Br J Educ Soc Behav Sci 2015;7:291-301.
Okereke CE, Oghenetega LU. The influence of social media on academic performance of university students in Nigeria. J Educ Pract 2014;5:21-4.
Okwaraji EF, Aguwa NE, Onyebueke CG, Arinze-Onyia US, Shiweobi-Eze C. Gender, age and class in school differences in internet addiction and psychological distress among adolescents in a Nigerian urban city. Int Neuropsychiatric Dis J 2015;4:123-31.
Cotten SR, Ford G, Ford S, Hale TM. Internet use and depression among retired older adults in the United States: A longitudinal analysis. J Gerontol B Psychol Sci Soc Sci 2014;69:763-71.
Aarts S, Peek ST, Wouters EJ. The relation between social network site usage and loneliness and mental health in community-dwelling older adults. Int J Geriatr Psychiatry 2015;30:942-9.
Adebayo O, Labiran A, Emerenini CF, Omoruyi L. Health workforce for 2016–2030: Will Nigeria have enough. Int J Innov Healthc Res 2016;4:9-16.
Gureje O, Lasebikan VO. Use of mental health services in a developing country. Results from the Nigerian survey of mental health and well-being. Soc Psychiatry Psychiatr Epidemiol 2006;41:44-9.
National University Commission. Full Time Student Headcount Enrolment by Gender, University of Calabar – Actual Academic Year; 2012. p. 54-73.
Boumosleh J, Jaalouk D. Depression, anxiety, and smartphone addiction in University students: A cross-sectional study. J Addiction Sci 2015;5:12-8.
Choi SW, Kim DJ, Choi JS, Ahn H, Choi EJ, Song WY, et al
. Comparison of risk and protective factors associated with smartphone addiction and Internet addiction. J Behav Addict 2015;4:308-14.
Tandoc E, Ferrucci P, Duffy M. Facebook use, envy, and depression among college students: Is Facebook depressing? Comput Hum Behav 2015;5:139-46.
Steers M, Wickham R, Acitelli L. Seeing everyone else's highlight reels: How Facebook usage is linked to depressive symptoms. J Soc Clin Psychol 2014;33:701-31.
Elhai JD, Dvorak RD, Levine JC, Hall BJ. Problematic smartphone use: A conceptual overview and systematic review of relations with anxiety and depression psychopathology. J Affect Disord 2017;207:251-9.
Kraut R, Burke MN. The connection between online communication and psychological well-being depends on whom you are communicating with. Commun ACM 2015;58:94-101.
Cummings J, Butler B, Kraut R. The quality of online social relationships. Commun ACM 2002;45:103-8.
Ellison N, Steinfeild C, Lampe C. The benefits of Facebook friends: Social capital and college students' use of online social network sites. J Comput Mediat Commun 2007;12:143-68.
Boase J, Horrigan J, Wellman B, Rainie L. The strength of internet ties. Pew Research Center's Internet and American Life Project 2006:1-52.
Rain S, Young V. A meta-analysis of research on formal computer-mediated support groups: Examining group characteristics and health outcomes. Hum Communications Res 2009;35:309-36.
Steinfield C, Ellison N, Lampe C. Social capital, self-esteem, and use of online social network sites: A longitudinal analysis. J Appl Dev Psychol 2008;29:434-45.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]