The Relationship Between Social Media Use and Negative Emotions Among Chinese Medical College Students: The Mediating Role of Fear of Missing Out and the Moderating Role of Resilience

Introduction

Negative emotions are a variety of painful and unpleasant experiences that individuals perceive, with the most common negative emotions being depression, anxiety, and stress.¹ Medical college students are usually still maturing physically and psychologically, and they are more likely to experience negative emotions such as anxiety, depression, and psychological distress due to the highly specialized and academically challenging medical profession and current intense employment competitiveness.^2,3 The coronavirus disease 2019 (COVID-19) epidemic has spread to almost all countries and regions of the world. Countries around the world urged the public to take responsive care, including hand washing, wearing masks, maintaining physical distance, and avoiding large gatherings and assemblies.⁴ Reducing the mixing of susceptible and infectious individuals by early ascertainment of cases or reduction of contact is one of the most important strategies.⁵ Nonetheless, during the COVID-19 pandemic, these stringent measures (eg, lockdowns) not only caused economic consequences,⁶ but also affected individual lifestyles and mental health.⁷ During the COVID-19 pandemic, individuals utilized social media much more frequently to remain up to date with recent health-related information.^8,9 The majority of Chinese colleges implemented policies requiring students to minimize unnecessary mobility, which has prompted college students to turn to use social media to keep connected and informed.¹⁰ Meanwhile, some colleges have implemented online modes of education to sustain education.¹¹ Drastic changes in the lifestyles and learning styles of students during major public health emergencies may increase the incidence of negative emotions such as anxiety and depression^12,13 and negatively affect physical and mental health, well-being, and academic performance.⁷ Additionally, the prolonged presence of negative emotions can easily trigger individual physical and mental disorders^14,15 and lead to emotional outbursts that can have negative consequences (eg, suicidal behavior).¹⁶ The study of negative emotions in medical college students can be used to provide support and assistance to this population, and contribute to improving the medical education and training system to create a learning environment that is more conducive to the physical and mental health of medical college students. Therefore, it is crucial to investigate the mechanisms underlying negative emotions in medical college students during the COVID-19 pandemic.

Social Media Use and Negative Emotions

While numerous factors can contribute to negative emotions,¹⁷ there is increasing interest in the potential effects of social media use on mental health. Social media, which can be defined as “Internet-based applications that permit the creation and exchange of user-generated content”,¹⁸ have become an integral part of connecting with friends and family, sharing personal content, and gaining access to news and entertainment.^19,20 According to studies, the frequency with which individuals use social media can have a negative impact on their self-esteem and well-being.^21,22 Individuals are motivated to maintain a positive self-presentation on social media; however, continuous exposure to positive content posted by others may result in the distortion of perception, lack of control, and frustration in social comparisons.^22–24 Furthermore, for those with high narcissistic personality scores and low self-esteem,²⁵ this can result in negative emotions such as envy and depression. In addition, in response to the COVID-19 pandemic, China implemented strict policies restricting public gatherings and events. Due to this disease control approach (eg, spatial distance, social distance), individuals relied heavily on media, and social media in particular (eg, Weibo and WeChat), to keep up with the latest news and stay in touch.^8–10 Compared to traditional media, social media has played many positive roles in information exchange during the COVID-19 pandemic, including spreading health-related advice, improving interpersonal connectivity, providing psychological first aid,²⁶ and showcasing public attitudes, perception of the disease, and sentiments toward governments and regulatory bodies;²⁷ however, they also contributed to the rapid spread of misinformation and rumors, causing confusion and panic among audiences.²⁸ Using social media, young adults are more likely to interact with disaster-related reports.^29,30 According to the Differential Susceptibility to Media Effects Model (DSMM),³¹ media use influences the cognitive, emotional, physiological, and behavioral outcomes of the audience, which in turn influences the audience’s personality, development, and social variables, forming a recursive loop. Disaster coverage in media may induce adverse physical and mental reactions in audiences.³² The indispensability and complexity of social media may exacerbate the adverse mental effects of exposure to disasters.

Prior research has focused on the direct relationship between social media use and negative emotions among college students or students pursuing a single healthcare specialization.^33,34 However, few studies have focused on a varied group of medical-related students in the medical education setting at medical colleges. As a result of disease control measures and the need to communicate and access health information, the frequency and patterns of social media use among healthcare students have changed significantly during the COVID-19 pandemic;^35,36 therefore, further research is necessary to determine the relationship between social media use and negative emotions among medical college students.

Fear of Missing Out as a Potential Mediator

In addition to providing information, social media also facilitate communication and social-emotional support. According to the theory of uses and gratifications,³⁷ individuals actively consume, engage with, and participate in media to fulfill their needs and desires. The research of social media usage and gratifications has brought to light a broad range of previously unidentified gratification, including socializing, virtual community, interpersonal utility, reciprocity, expressive information sharing, professional advancement, career opportunities, and psychological support.³⁸ According to the compensatory motivation perspective of self-determination theory,³⁹ individuals with inadequate social connectivity or social-emotional support, in reality, may turn to use social media to compensate for these needs. Although social media may initially alleviate social-emotional deficits, concomitantly to “real world” issues that remain unaddressed, theoretically it may also lead to more fear of missing out (FoMO)-related thoughts,⁴⁰ as other people might be perceived to be enjoying a more rewarding experience than oneself.^40,41 A systematic review of short-term abstinence effects across potential behavioral addictions has found that Internet use can increase FoMO levels.⁴²

Even though it is not yet clear whether FoMO causes negative emotions,⁴³ a study using repeated measures designs has found some preliminary support that FOMO drives negative emotions over short (1-week) periods of time.⁴⁴ Furthermore, research indicates that more than half of pharmacy students reported using their smartphones more frequently because of concerns about missing messages and/or alarms and that this problematic smartphone use was associated with insomnia and anxiety.⁴⁵ Although researchers have also demonstrated a positive correlation between social media use and FoMO and mental health problems among Chinese nursing students during the COVID-19 pandemic,³⁶ it is still unclear whether the results can be generalized to the medical college student population following the pandemic as the primary setting for these studies was before the COVID-19 pandemic. Therefore, this study hypothesizes that FoMO may mediate the relationship between social media use and negative emotions during the COVID-19 pandemic.

Resilience as a Potential Moderator

Resilience is an individual characteristic that is both variable and stable, which reflects an individual’s ability to adapt positively to adversity and recover quickly.^46,47 General resilience processes act as a buffer between stressors and negative emotions.⁴⁸ Compared to others experiencing the same level of stress or adversity, resilience is manifested in superior problem-solving, where the required problem-solving skills include narrative creativity, emotion regulation, and interpersonal collaboration.⁴⁹ Enhancing hope resilience by the narrative Method of Ordering Memory is effective in reducing depression and anxiety, and burnout in participants.⁵⁰ Prior research has also demonstrated that individuals with high levels of resilience are more effective than those with low levels of resilience at regulating and reducing the incidence of their negative emotions.⁴⁸ High levels of resilience are adversely associated with negative emotions,⁵¹ but low levels of resilience may be a primary pathway to negative emotions.⁵² Moreover, empirical research has demonstrated a negative correlation between resilience and negative emotions.⁵³ A study among college students in China during the COVID-19 pandemic has found that resilience and social support co-moderated the relationship between FoMO and depression, anxiety, and stress.⁴⁷ In other words, resilience can mitigate the negative effect of risk factors (eg, FoMO) on negative emotions.

According to the emotion regulation strategies,^54,55 individuals with insufficient self-regulation and resilience may not be able to mitigate interpersonally based fears and worries, which may conducive to FoMO and negative emotions. Previous research has demonstrated that resilience is vital for alleviating mental problems in individuals.⁵⁶ During the COVID-19 pandemic, college students who require access to outbreak-related information, communication, and social-emotional support may choose to engage with others online via social media.⁵⁷ During this time, college students who have greater resilience might be able to cope effectively with stressors and adversity, whereas those with less resilience may become absorbed in the virtual world of the Internet, leading to a propensity to experience negative emotions.⁵⁸ These findings suggest that resilience may play a different role in the connection between FoMO and negative emotions.

The Present Study

Based on a review of the literature, we aimed to test a model that examines the relationship between social media use and negative emotions among medical college students, as well as its internal mechanisms (ie, FoMO and resilience), during the COVID-19 pandemic, which may contribute to develop intervention and prevention strategies for negative emotions among medical college students. As an integrated model, this study was designed to test the following hypotheses (Figure 1).

H1: Social media use is positively associated with negative emotions among medical college students during the COVID-19 pandemic.

Figure 1 Conceptual model. Abbreviation: FoMO, fear of missing out.

Materials and Methods

Participants and Procedures

In this study, we determined the estimated sample size to be 383 through the following formula: , using a power of 80%, a confidence level of 95%, and a margin of error of 5%.^59,60 Accounting for potential invalid data (ie, up to 15% invalid), the minimum number of participants were determined to be 450. We administered a series of self-reported questionnaires to 470 students of medical college recruited from Qiqihar Medical University, China, between June 2, 2022, and June 15, 2022. A total of 453 students completed the questionnaires, 46 invalid responses were excluded, and 407 (86.60%) were effectively recovered. The sample consisted of 131 male and 276 female students aged 18–26 years (mean: 21.562 ± 2.167 years), including 383 undergraduate and 24 postgraduate students. There were 104 nursing students, 107 clinical medicine students, 62 medical technology students, 97 pharmacy students, and 37 students from other medical-related disciplines. No participants had been suspected, confirmed, or cured of SARS-CoV-2 infections.

The Human Research Ethics Committee of China Medical University approved this study (ref no: 2019079). Before the investigation, all participants were informed that the study would be conducted anonymously and that their information would be kept confidential. All participants entered the study voluntarily with any incentive and could withdraw at any time.

Measures

Social Media Use

Ellison created the Facebook Use Intensity Scale to measure the intensity of individuals’ social media use.⁶¹ The scale has good reliability and validity.⁶² It has been utilized in a large body of literature on social media in China and has shown its reliability and validity among young citizens. In view of the different actual use of mainstream social media networks in the Chinese media environment, some similar widely used social media networks, such as “Weibo”and “Qzone”, were used instead of “Facebook” in the studies among the Chinese population. The original questionnaire was modified from “Facebook” to “Weibo” with a Cronbach’s α of 0.9.⁶³ Similarly, Cronbach’s α for the “Qzone” usage intensity questionnaire was 0.87.⁶⁴ In the questionnaire for this study, “Facebook” was replaced with “social media” based on the processing of previous researchers.⁶⁵ The revised scale contained eight items (eg, “How many days per month do you use social media on average?”) to measure the intensity of social media use. All items were scored on a 5-point Likert scale (1 = completely disagree, 5 = completely agree), with higher scores indicating a higher intensity of social media use. The one-factor CFA model also generated a very good fit for the Social Media Use Intensity Scale: χ²/df = 2.163, p < 0.01, RMSEA = 0.054, SRMR = 0.028, GFI = 0.978, AGFI = 0.953, NFI = 0.978, RFI = 0.964, IFI = 0.988, TLI = 0.980, CFI = 0.988. Therefore, this scale had good construct validity. Cronbach’s α was 0.880 in this study.

FoMO

FoMO was assessed by the FoMO Scale developed by Przybylski et al.⁴¹ Participants from China utilized the scale and demonstrated good reliability and validity.⁶⁶ It consists of ten items (eg, “It bothers me when I miss an opportunity to meet up with friends”.) that are rated on a 5-point Likert scale (1 = not at all true, 5 = extremely true), with higher scores indicating higher levels of FoMO. In the present study, Cronbach’s α was 0.912.

Resilience

Resilience was measured using the Chinese version of the Connor–Davidson Resilience Scale (CD-RISC) by Connor and Davidson.^67,68 The scale contains 25 items (eg, “able to adapt to change”) that evaluate the three dimensions of resilience (tenacity, strength, and optimism). All participants were instructed to respond on a 5-point Likert scale (1 = not true at all, 5 = true nearly all the time). Higher scores indicate higher levels of resilience. Cronbach’s α was 0.954 in this study.

Negative Emotions

The 21-item Depression–Anxiety–Stress Scale, which was developed by Lovibond and Lovibond⁶⁹ and subsequently revised in Chinese, was used to examine the negative emotions of medical college students.⁷⁰ It has demonstrated high reliability and validity in studies among Chinese college students.⁷¹ A total of 21 items (eg, “I found it hard to wind down”.) are categorized into three dimensions (depression, anxiety, and stress). Each item is scored on a 4-point Likert scale (0 = did not apply to me at all, 3 = applied to me very much or most of the time). The participants are required to respond according to the negative emotional symptoms of the past week. Higher total scores reflect higher levels of negative emotional symptoms. Cronbach’s α was 0.975 in this study.

Data Analysis

This study used Statistical Package for Social Sciences (SPSS 28.0 SPSS Inc, Armonk, NY, USA) and PROCESS macros (http://www.afhayes.com),⁷² specially developed for assessing complex models including mediators and moderators, for data entry and analysis. First, data screening revealed no outliers or missing values. Second, descriptive statistics, correlational analysis, and independent-sample t-tests were calculated among the primary variables. Third, we used Model 4 of the PROCESS macro for SPSS to examine the mediating effects of FoMO in the relationship between social media use and negative emotions.⁷³ Fourth, Model 14 of the PROCESS macro for SPSS was applied to test the moderating effects of resilience in the relationship between FoMO and negative emotions. Moreover, sex and age were controlled because prior evidence has shown that they are important confounders in negative emotions.⁷⁴ Based on 5000 bootstrap samples, the bootstrap confidence intervals (CIs) determined whether the effects in Model 4 and 14 were statistically significant. The 95% bias-corrected CIs did not contain zero, indicating that the effect was significant. All study variables were standardized in Model 4 and 14 before data analyses. P-values < 0.05 were considered statistically significant.

Results

Descriptive Statistics and Correlational Analysis

The means, SDs, and Pearson correlations for the study variables are shown in Table 1. Social media use was positively associated with FoMO, and negative emotions and negatively associated with resilience. FoMO was correlated positively with negative emotions and negatively with resilience. Resilience was negatively associated with negative emotions. An independent-samples t-test revealed no significant differences between men and women for the variables of social media use (t = −1.886, p > 0.05), FoMO (t = −1.170, p > 0.05), resilience (t = 0.231, p > 0.05), and negative emotions (t = 0.056, p > 0.05). There was a significant negative correlation between age and social media use (r = −0.477, p < 0.001), FoMO (r = −0.459, p < 0.001), and negative emotions (r = −0.433 p < 0.001); however, there was a significant positive correlation between age and resilience (r = 0.415, p < 0.001).

Table 1 Correlations and Means of Study Variables (N = 407)

The Mediating Role of FoMO

We examined the mediating effects of FoMO on the relationship between social media use and negative emotions, with sex and age as covariates, using Model 4 of the PROCESS macro. All data were standardized. The total effect of social media use on negative emotions was significant (β = 1.101, SE = 0.079, p < 0.001). Social media use had no significant direct effect on negative emotions (β = 0.168, SE = 0.096, p > 0.05), but it had an indirect effect on negative emotions via mediation of FoMO (β = 0.933, SE = 0.106, 95% CI: 0.731 to 1.149). Social media use affected negative emotions only through the mediating effect of FoMO, accounting for 84.782% of the total effect. Thus, FoMO entirely, rather than partially, partially mediated the relationship between social media use and negative emotions (Figure 2).

Figure 2 The relationship between social media use and negative emotion. Abbreviation: FoMO, fear of missing out. Note: ***p < 0.001.

The Moderating Effect of Resilience

To investigate the moderating effects of resilience, we employed Model 14 of the PROCESS macro with sex and age as covariates. Resilience had a significant moderating effect on the relationship between FoMO and negative emotions (β = −0.021, SE = 0.005, 95% CI: −0.032 to −0.012). We divided resilience into high (M + 1SD) and low (M - 1SD) groups in order to better explain its moderating effects on FoMO and negative emotion. Simple slope tests suggested that FoMO had a significant positive predictive effect on negative emotions at both levels of resilience (Figure 3; low resilience individuals: β = 1.079, SE = 0.076, t = 14.243, p < 0.001; high resilience individuals: β = 0.212, SE = 0.094, t = 2.256, p < 0.05), indicating that resilience reduced the effects of FoMO on negative emotions.

Figure 3 The moderating effect of resilience. Abbreviation: FoMO, fear of missing out.

Discussion

We constructed a mediated moderating model to investigate the potential mechanisms between social media use and negative emotions among medical college students during the COVID-19 pandemic. FoMO was a potential mediator, and resilience was a potential moderator in explaining the relationship.

Relationship Between Social Media Use and Negative Emotions

Social media use was significantly and positively associated with negative emotions among medical college students during the COVID-19 pandemic, thereby supporting H1. This is in accordance with previous research findings. For instance, some college students’ frequent use of social media may lead to depression, anxiety, and post-traumatic stress.⁷⁵ Moreover, increased self-exposure on social media may increase the likelihood of cyberbullying, resulting in negative emotions.⁷⁶ College students have fewer outdoor activities and face-to-face communication opportunities because of the need to prevent the spread of the COVID-19 pandemic. Consequently, utilizing social media may be one of their primary means of temporarily alleviating inner emptiness and loneliness. When social networking sites are used as a primary or secondary method of relieving stress, loneliness, or depression, the use of social networking sites may also become problematic behavior.⁷⁷ Furthermore, our study revealed a complex relationship between social media use and negative emotions.

The Mediating Role of FoMO

The effects of social media use on negative emotions were mediated by FoMO entirely rather than partially. In other words, medical college students who frequently used social media were more likely to experience FoMO, conducive to negative emotions. Even though the results did not support H2, we discovered that FoMO played a more significant role than anticipated in the relationship between social media use and negative emotions, which is consistent with previous findings that FoMO may mediate the relationship between social media use and depression.⁴⁴

FoMO is one predictor of negative emotions, and its adequate mediating role revealed it to be a significant risk factor for negative emotions among medical college students, confirming the findings of previous research on college students in China.^44,78 On the one hand, FoMO is related to unmet needs for individual social connection,⁴¹ which can conducive to negative emotions (eg, loneliness and depression). Using social media, individuals can receive emotional support and alleviate negative emotions, such as loneliness caused by the COVID-19 pandemic. When college students do not receive adequate emotional support, they seek it via social media. On the other hand, as these students continue to receive emotional support via social media, they will come to expect and anticipate it. Hence, these students are more likely to fear that they will miss out on this immediate emotional support from their friends if they temporarily stop using social media,⁷⁹ which may promote increased levels of FoMO. FoMO could be a source of negative emotions because social media use is associated with FoMO, which is related to negative emotions.⁸⁰ Subsequently, when these students seek more emotional support from social media during the COVID-19 pandemic, they may be afraid of missing out on future social engagement, which may increase the likelihood of negative emotions.

The Moderating Role of Resilience

Consistent with H3, resilience significantly moderated the relationship between FoMO and negative emotions. As previously mentioned, a lack of resilience may be positively associated with stress and depression,⁸¹ thereby making it more likely to result in negative experiences.

Compared to medical college students with high levels of resilience, FoMO predicted negative emotions in those with lower resilience with greater accuracy, indicating that FoMO may exert an increased influence on the emotions of medical college students with lower resilience. In other words, during the COVID-19 pandemic, people with lower resilience are more likely to experience negative emotions due to their FoMO. This also supports the emotion regulation strategies proposed by Min et al,⁵⁴ namely that self-regulation and resilience may alleviate negative emotions. For instance, young individuals with high levels of resilience may be able to overcome the FoMO induced by social media use, in part by talking about the experience with others and having supportive peers;⁸² this alleviates negative emotions. Individuals with high levels of resilience are less likely to experience depression and stress due to their ability to inhibit rumination and FoMO through inhibitory control.^83,84 These findings are similar to those of previous studies, which demonstrated that individuals with high levels of resilience were less likely to suffer from depression and stress.^85,86 Medical college students with low levels of resilience may be unable to adopt appropriate coping strategies and eventually demonstrate a propensity for negative emotions.⁸¹ Therefore, whether during the COVID-19 pandemic or in pre-pandemic daily life, the effects of FoMO on negative emotions can be mitigated by resilience.

Limitations and Future Directions

Several limitations should be taken into account when interpreting the findings. First, by the time we collected the data, COVID-19 had been largely contained in China, and some college students had returned to school. These data may differ from other regional data collected during the COVID-19 pandemic. Second, a cross-sectional study cannot determine a causal relationship between social media use and negative emotions. However, when the mediation and moderation models are grounded in theory and are partially supported by prior research, cross-section mediation and moderation can provide valuable information regarding the relationship of variables. Future research should utilize longitudinal designs to test this mediated moderating model. Third, response bias may exist because of self-reporting, though we took measures to alleviate medical college students’ concerns about participating, including providing clear instructions, informing them that there were no right or wrong answers, and emphasizing the confidentiality of the results. Future research should incorporate experimental methods for measuring variables or include teacher and peer evaluations. Fourth, the current study attempted to examine the intensity of social media use and negative emotional states, but separate pathways for each domain of negative emotional states, and associations between motivations for social media use and negative emotions were not assessed. Future research should investigate the role of motivations for social media use and the relationships between changes in these motivations and the intensity of social media use and negative emotions, as well as provide a more comprehensive and explicit insight into health issues related to negative emotions. Finally, medical college students are the population measured in the current study. Even though the current study showed similar results to previous studies of medical students, nursing students, and pharmacy students, there is some heterogeneity in the population of students of different specialties. Future research should expand the sample size of different specializations in colleges to examine differences in social media use and negative emotions among students of different specialties.

Despite these limitations, the current study had both theoretical and practical implications. Theoretically, the results of this study supported a relationship between social media use and negative emotions among medical college students, enriching the literature on negative emotions. In addition, an empirical framework is provided by testing a model of mediated moderating effects of FoMO and resilience. These findings may shed light on the underlying mechanisms of the relationship between social media use and negative emotions among medical college students during the COVID-19 pandemic. From a practical standpoint, our findings can aid in designing effective measures to reduce negative emotions among college students. For instance, enhancing students’ resilience (eg, seeking support from family members, teachers, and peers) may help improve their adaptability, stimulate positive emotions, and reduce the risk of depression and anxiety. Furthermore, medical educators and practitioners should pay more attention to students with high levels of FoMO. On the one hand, it’s critical to properly understand FoMO by developing a basic perspective understanding of the importance of the concept, its causes, symptoms, negative effects, and how to tackle it dealing with the problem.⁸⁷ On the other hand, checklists, self-talk, expectation management, and protective narratives can be used to develop methods to enhance hopeful resilience,^50,82 which may help students prevent and cope with high levels of FoMO.

Conclusions

The present study contributes to the literature by conducting a mediated moderating model that provides insight into how social media use can contribute to negative emotions among medical college students during the COVID-19 pandemic. The results demonstrated a positive correlation between social media use and negative emotions among medical college students. FoMO could mediate the relationship between social media use and negative emotions, and resilience could moderate the association between FoMO and negative emotions.