This is a cross-sectional, descriptive, and analytical web-based survey, conducted between November 2022 and January 2023. The questionnaire was published via medical student-related Facebook discussion groups. Participants were recruited based on a convenience sampling of medical students enrolled at the Faculty of Medicine of Sfax, who met the inclusion criteria.

The research population consisted of medical students of the Faculty of Medicine of Sfax, in Tunisia. The inclusion criteria included students with access to the Internet who were voluntarily willing to participate in the study and to complete the questionnaire fully.

The minimum necessary sample size was 174 students and was calculated based on data from (18) using the following formula:

n=sample size; N=population size; Z=the statistic corresponding to level of confidence; p=proportion of SM addiction; q=1-P; e=precision. The estimation was also based on a 5% margin of error, and a 95% confidence interval.

All the procedures performed in this study were in accordance with the ethical standards of the “Research Ethics Committee, Faculty of Medicine, University of Sfax, Tunisia” and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This research was approved by the above-mentioned committee (approval number 20/24).

Data were collected using an anonymous self-report questionnaire that was edited by free GOOGLE FORMS software and sent via a URL link with an information note presenting the scientific aim of the study, with a focus on ensuring the confidentiality and anonymity of responses. Throughout the study period, the questionnaire was published via medical student-related Facebook discussion groups.

We used a survey form to collect sociodemographic and academic characteristics, data related to lifestyle habits, personal and family clinical history, and characteristics of SM use. We also used four psychometric scales: Social Media Addiction Scale-Student Form (SMAS-SF), Big Five Inventory (BFI-10), Rosenberg Self-Esteem Scale (RSES), and Social Self-Esteem Inventory (SSEI).

The collected data were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 22. We used the Kolmogorov-Smirnov test to determine if the variables were normally distributed. Quantitative variables were presented as mean and standard deviation (SD) or median and interquartile range (IQR), according to the variable distribution. Qualitative variables were represented as numbers and percentages. Statistical comparisons of the analytical study were carried out using Pearson’s r-correlation test for quantitative variables and the power of the correlation was estimated using the rho. For qualitative variables it was carried out using Mann–Whitney U-Test. All tests were two-tailed at a 95% confidence interval, and the p-value was considered significant if <0.05.

During the study period, 150 students were voluntarily enrolled. Thirty-four participants did not answer certain questions and were consequently excluded from the study. Thus, a total of 116 students, who filled out the survey completely, were retained in this study (complete-response rate of 77.33%).

Of the 116 medical students participating in the study, 91 students (78.4%) were female. The majority (77.6%) were between 21 and 30 years of age. Almost half of them (55.20%) were enrolled in the third cycle. Concerning their clinical history, 15.5% of respondents reported having psychiatric problems, and 6% were receiving psychotropic treatment. Smoking and alcohol use were reported by 9.5% and 1.7% of the participants, respectively ( Table 1 ).

In our study, Facebook (98.3%) was the most used SM, followed by Instagram (79.3%) and TikTok (28.4%) ( Figure 1 ). The other SM platforms remained below 50%.

The description of SM-specific data among the participants is shown in Table 2 . The table shows that the median age of the first use of SM was 14.5 years (IQR=[12-17]). The median number of hours spent per day on a favorite SM was 2 (IQR= [1-3]). The median number of followers/friends or subscribers was 600 (IQR= [300-1100]). When asked which actions they carried out most often on SM, students highlighted sharing private messages in 76.7% of cases. The most frequent motivation to connect to SM reported by students was a need to keep in touch with friends (82.8%).

According to SMAS-SF, the scores ranged from 38 to 141, with a median score of 74 and (IQR= [64-587]).

The description of the participants’ scores on the Big Five personality dimensions is presented in Table 3 .

The mean score of RSES in the study sample was 30.4 ± 5.09. Of the students surveyed, 12.1% had low global self-esteem ( Table 4 ).

According to the SSEI scale, the mean score was 122.03 ± 23.25.

No significant associations were observed between the SMAS-SF score and sociodemographic and academic data. Taking psychotropic medication was significantly associated with higher SMAS-SF scores (p=0.028) ( Table 5 ).

As shown in Table 2 , participants with the highest SMAS-SF scores had a significantly younger age of first use (p=0.011, rho=-0.235). Students who spent more time on their favorite SM were more likely to develop an SM addiction (p=0.005, rho=0.260). We found that some activities performed on SM were significantly associated with higher SMAS-SF scores, namely: making comments (p=0.005), browsing SM profiles (p=0.018), and posting videos (p=0.007) or pictures (p=0.002). The lower panel of Table 2 similarly shows higher scores of SMAS-SF among students whose motivation to use SM was the need to establish an identity (p=0.011).

By examining the relationship between personality dimensions and SM addiction, it appeared that neuroticism and a low level of conscientiousness were linked to high SMAS-SF scores (p=0.006, rho=0.252 and p=0.050, rho=-0.183, respectively) ( Table 6 ).

We also found that high SMAS-SF scores were significantly related to lower global and social self-esteem scores (p=0.015, rho=-0.226 and p=0.032, rho=-0.199) ( Table 6 ).

In our study, taking psychotropic medication was significantly associated with higher SMAS-SF scores. A wealth of evidence suggests psychological distress is associated with higher levels of SM use (43, 44). The authors supported the idea that when using SM, people might engage in “harmful” comparisons in which they make erroneous inferences about the lives of other users. These comparisons could explain why SM use often leads to depressive symptoms that need treatment (45).

Our results showed that SMAS-SF scores were significantly higher among students with a younger age of first use. Several academic publications agree that SM use is highly normative among today’s adolescents and young individuals, who represent a unique population, frequently engaged in online activities, and are the first generation to grow up in a highly digitalized society (43, 46). Indeed, youngsters have more free time than older people, do not yet have full-time professional preoccupations, and are more interested in forging new relationships through social networking (43, 46, 47).

The most widely used SM among our participants was Facebook (98.3%), followed by Instagram and TikTok. These results are comparable to those found in another recent Tunisian research (48). Indeed, the birth of Facebook in 2004 left its mark on the internet, offering a new concept that continues to spread throughout the world in general, and consequently in Tunisia. Considered the archetypal online SM, it gained widespread popularity in a very short time. It has accumulated the highest number of users in the world (49). Regarding Instagram, recent statistics show that it is a relatively new SM that is gradually becoming one of the most popular platforms. This SM offers users an immediate means of capturing and sharing their personal experiences (50).

Furthermore, our findings show that participants who have the highest SMAS-SF scores spent more time connecting on all SM or on their favorite SM, and performed more SM activities, namely, making comments, browsing SM profiles, and posting videos and/or photos. These results are comparable to those reported in the literature, which show reported positive associations between daily internet use and SM addiction (51, 52). In this respect, Sun et al. have shown that signs of SM addiction can include logging on to SM for more than an hour a day and being curious to see the profiles of old friends (53). The study by Kircaburun et al. showed that introverts spend a lot of time on SM and use this time mainly to consult other people’s profiles without any interaction to avoid real-life confrontations and social interactions (52). On the other hand, it has been found that some activities, such as reading comments and sharing videos on YouTube, are associated with the gratification of entertainment (54). This may partly explain the excessive use of this SM to seek this effect.

In terms of motivations for connecting to SM, the “need to establish an identity” was associated with the highest SMAS-SF scores. Indeed, it has been shown that virtual contexts can be a means of escaping personal difficulties or compensating for a lack of social skills that would make face-to-face communication difficult (55). Users of SM display an idealized identity by presenting themselves as they wish in a positive way, and by controlling the information and elements integrated into their profiles (56). SM users construct their ideal selves, or “hoped-for possible selves”, as part of a mediated self-presentation (57). Research indicates that young people’s SM behavior involves self-exploration, which is potentially associated with the crucial task of identity development (58).

In our study, neuroticism and a low level of conscientiousness were linked to the highest SMAS-SF scores.

According to our findings, previous research identified the neuroticism dimension as a predictor of SM addiction (17, 28–30, 59). People with high scores in neuroticism used the Internet frequently, spent more time on Facebook, and sent more instant messages (60). Indeed, neurotics are characterized by anxiety and insecurity in their relationships, leading them to feel powerless (61). This would lead to excessive use of SM in order to seek support and companionship to cope with this emotional distress. In addition, neurotics are more likely to have problematic SM use because they want to relieve loneliness and increase their self-esteem by joining social groups and developing a sense of group belonging, albeit virtual (59, 62).

Conscientiousness refers to impulse control, planning, and organization. It has been well established, in prior research, that this personality dimension protects against problematic SM use (27, 60, 63). The authors explain that conscientious people give less priority to virtual activities in order to fulfill other obligations and meet deadlines for real tasks (17). These people tend to cultivate their online and offline contacts more without the necessity of sharing too much personal information publicly. They upload significantly fewer pictures than those scoring low on this personality trait (62).

Regarding extraversion, its relationship with SM addiction has been controversial. While some authors showed that extraversion predicts SM addiction (64), others, in line with our findings, found no relationship between social media addiction and extraversion (31). Extroverts have more online friends and are more self-disclosing, posting more selfies and statuses frequently (65). However, they do not use online socializing as a substitute for real-life social interaction. Thus, extroverts use SM primarily for social enhancement (62, 66).

Several psychological theories have been advanced to explain the influence of these personality traits on the development of SM addiction.

A large body of literature supports the idea that young people with frequent and unbalanced negative affect have been found to be more likely to engage in addictive behavior as a means of coping with high levels of stress. Such individuals experience difficulties in developing healthy relationships, due to their problematic management of emotional states, and consequent mood disorders. They may consider the internet an arena in which they can achieve greater self-control and engage in better communication with others (26, 27). Quaglieri et al. (27) found that individuals with high levels of neuroticism and low levels of conscientiousness showed poor emotional coping skills and experienced more depression, anxiety, and emotional dysregulation prior to the onset of their addiction, which likely emerged as an attempt to ameliorate these negative symptoms. These findings seem to be in line with the “compensatory Internet use” model developed by Kardefelt-Winther (67), which proposed Internet addiction as a coping strategy and presented it from the perspective of compensation rather than compulsive behavior. Individuals who experience negative life situations are more likely to overuse online activities in the search for instant gratification in order to ameliorate their dysphoric mood problems (27, 63).

Furthermore, several studies have linked the “fear of missing out” to the overuse of SM (68, 69), which may be considered ideal for satisfying the “desire to stay continuously connected to what others are doing”. The continuous exposure to this information could lead individuals to believe that “others” are having a better life and that one is missing out on something. This could place the individual in a reinforcement spiral of behavior, making it easier to exacerbate the anxiety and loss of control that characterize neurotics and less conscientious people (27).

Other studies have proposed a mediating role of social comparison theory in the relationship between SM addiction and personality (25, 63). This theory suggests that individuals have a natural tendency to evaluate their abilities by comparing themselves to others (70). However, when using SM, people may be exposed to idealized and unrealistic profiles. Therefore, those with certain fragile personality traits, particularly high levels of neuroticism and low levels of conscientiousness, may end up feeling envy and psychological distress (25). In fact, negative social comparisons on SM platforms can be particularly detrimental to perceptions about their selves. Given this, Piko et al. (63) suggested that fear of negative evaluation can play a decisive role in SM addiction.

In our study, high SMAS-SF scores were significantly associated with lower global and social self-esteem scores.

Most studies confirmed the negative relationship between self-esteem and SM addictive use (15, 32, 34, 62, 71, 72).

A person’s self-esteem is tied most to the amount of active engagement of their own SM and also to the engagement of others with their SM. The low levels of social self-esteem in participants with problematic SM use could be explained by the low sense of popularity induced by social comparison. Some authors have highlighted the deleterious effect of intensified social self-comparison among SM users on others perceived as more valued than themselves. These biases of comparison could contribute to increasing young people’s vulnerability. Indeed, the sociometer theory, a prominent theory of self-esteem, suggests that a person’s self-worth is primarily derived from the feedback they receive from others’ virtual profiles (10, 17, 56, 70, 73).

On the other hand, the recent rise of SM usage has been considered a safer societal interaction tool that has the potential to relieve the social anxiety that people with low self-esteem often experience in face-to-face communications. Indeed, the anonymity or selectiveness of self-presentation on SM allows them to feel more relaxed and confident in order to express themselves, build their desired persona online, withdraw from the negative evaluations and stress of interpersonal relationships encountered in real life, and escape negative feelings of self-deprecation (10, 15, 34, 74, 75). Likewise, if someone is mostly involved in negative interactions on these sites, an adverse influence on his or her social self-esteem seems plausible. By contrast, participants can usually more easily eliminate undesirable encounters or feedback and focus entirely on positive experiences, thereby enhancing their social self-esteem (76).

Moreover, research suggests that fear of missing out which is a psychological state in which people become anxious that others within their social spheres are leading much more interesting and socially desirable lives, mediates the relationship between increased SM use and decreased self-esteem (69).