Background

The exponential rise in digital technology has transformed communication, education, and social interaction. With over 6.5 billion smartphone users globally, the phenomenon of nomophobia—the fear of being without a mobile device—has garnered increasing attention due to its potential psychological and physiological consequences [1, 2]. This condition has been linked to heightened stress levels, anxiety, poor sleep hygiene, and emotional dysregulation, particularly among younger populations. The Uses and Gratifications Theory posits that individuals actively use media to fulfill specific psychological needs such as companionship, entertainment, or information [3]. However, overreliance on digital media can lead to problematic usage patterns. Concurrently, Social Comparison Theory suggests that individuals evaluate themselves based on comparisons with others, especially in appearance-focused contexts like social media platforms, which can negatively influence self-esteem and body image [4].

Empirical evidence supports associations between excessive smartphone use and negative outcomes, including depression, anxiety, body dissatisfaction, and even signs of attention-deficit disorders [5,6,7,8,9]. Among young women in particular, prolonged exposure to curated and filtered images on social platforms may distort body image perceptions, promote unrealistic beauty standards, and foster dissatisfaction with one’s own appearance [10, 11]. These influences can also drive harmful weight-control practices or eating disturbances. [12] Moreover, as future physicians, their mental well-being is not only critical for their own health but also has direct implications for patient care quality, clinical decision-making, empathy, and burnout-related errors. While such associations have been studied in Western contexts [13], literature from low- and middle-income countries remains limited. In Pakistan, research has primarily focused on cyberbullying or musculoskeletal issues related to device usage [14,15,16], with little examination of the psychological or physical health correlates—especially among medical students, a group uniquely burdened by academic stress, competitive environments, and societal expectations.

Recent research across the Global South highlights a growing concern about digital dependency and its mental health impacts among university students. In low- and middle-income countries (LMICs), digital mental health interventions are expanding rapidly, yet their clinical effectiveness and long-term outcomes remain uncertain due to inconsistent methodologies and small sample sizes, as noted in a review of 13 LMICs including South Asia, Africa, and Latin America [17]. Cross-cultural analyses from China and Malawi further reveal stark contrasts in how internet addiction manifests, with emotional disturbances more prominent in China and functional impairments affecting students in Malawi, emphasizing the need for culturally tailored interventions [18]. Studies from Egypt and India similarly report high levels of digital dependency among medical and non-medical students, linked to depression, anxiety, stress, and reduced academic performance [19, 20]. These findings suggest that while digital health technologies hold promise, unregulated and excessive digital engagement may present a public health challenge with implications for future healthcare delivery, professional competence, and the emotional resilience of healthcare providers. However, few studies have examined the intersection of digital dependency, body image, and well-being—particularly in female medical students—indicating a pressing need for targeted research in this domain. This study aims to address this gap by investigating how digital dependence may relate to well-being, weight perception, and body image concerns in Pakistani female medical students, leveraging quantitative analysis for more generalizable insights.

Study objectives

  1. 1.

    To assess the prevalence and patterns of smartphone use among female medical students in Pakistan.

  2. 2.

    To examine associations between digital dependence and general well-being, weight perception, and body image.

  3. 3.

    To identify demographic and behavioral predictors of well-being using a multiple linear regression model.

  4. 4.

    To explore the influence of digital media exposure and smartphone usage on self-perception and satisfaction with body weight.

Methods

Study design, sampling strategy, and sample size

This was a cross-sectional survey conducted among female medical students at Fatima Jinnah Medical University (FJMU), Lahore, Pakistan. Using the OpenEpi tool, we calculated a required sample size of 385 participants, based on a 95% confidence level and Pakistan’s estimated population of 231 million. The survey received 1,197 clicks, and 1,115 complete responses were submitted, yielding a response rate of 93.2%. The survey was administered via a centralized Google Forms link (https://bit.ly/FJMU-Nomophobia-Study).

To ensure proportional representation across academic years (1st to Final Year), we employed a stratified random sampling method. This approach accounted for variations in stress exposure, clinical duties, and academic workload, and was intended to minimize sampling bias and enhance the internal validity of our findings. Eligibility criteria are summarized in Table 1.

Table 1 Demographic and health characteristics of participants (N = 1115)
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Survey instrument and distribution

The questionnaire for this study was adapted from three well-established and validated tools: the Nomophobia Questionnaire (NMP-Q), the Body Image Concern Inventory (BICI), and the General Well-being Scale (GWBS). These instruments were selected due to their conceptual relevance to the study’s focus on smartphone dependency, body image, and psychological well-being. Minor modifications were made to ensure cultural and contextual appropriateness for the target population.

To ensure face validity, the adapted questionnaire was reviewed by a panel of experts in medical education and clinical psychology. Internal consistency of the finalized instrument was found to be acceptable, with a Cronbach’s alpha of 0.712. Furthermore, Principal Component Analysis (PCA) supported the dimensional validity of the instrument, confirming a coherent underlying structure.

The finalized survey was developed and distributed using Google Forms, comprising sections on smartphone usage patterns, body image perception, weight-related concerns, and demographic characteristics. The survey link was disseminated via official university email channels, student associations, and targeted digital platforms. To enhance participation, reminder emails were sent midway through the one-week data collection period. Anonymity was emphasized throughout the process to encourage candid responses. The complete questionnaire is provided in the Supplementary Materials.

Anthropometric data

Participants self-reported their height and weight. Although self-reporting may introduce bias, prior research suggests strong concordance between self-reported and actual anthropometric data in university student populations, including medical cohorts. To enhance accuracy, anonymity was assured, and implausible values (e.g., BMI extremes) were flagged and reviewed during data cleaning.

Data preparation and statistical analyses

Data were extracted from Google Forms and imported into SPSS (Version 25) for analysis. Preliminary screening involved excluding incomplete (n = 17) or inconsistent responses and reviewing outliers. Descriptive statistics were computed for demographic and core variables (e.g., age, BMI, screen time, frequency of smartphone use).

The primary outcome variable was general well-being as measured by the GWBS. Predictor variables included smartphone usage patterns (e.g., daily duration, pre-sleep use, detox periods), body image perception, and satisfaction with body weight.

Multiple linear regression analysis was conducted to examine associations between GWBS scores and predictors. Categorical variables (e.g., year of study, body satisfaction) were dummy-coded.

Regression assumptions were checked and met, including linearity, multicollinearity (via VIF), normality of residuals (via Shapiro–Wilk test and Q-Q plots), and homoscedasticity. Model fit was assessed via R2, Adjusted R2, and Standard Error of the Estimate.

ANOVA was used to determine the overall significance of the regression model. Individual predictors were interpreted based on standardized coefficients, 95% confidence intervals, and p-values, with p < 0.05 considered statistically significant.

Ethical approval, study design and location

This research was conducted in full compliance with ethical principles, including adherence to the legal requirements of the study country and in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Prior to their participation, written informed consent was obtained from all individual participants involved in the study. This process was designed to ensure that all participants were fully informed about the nature of the research, their rights as participants, and the confidentiality of their responses. Ethical approval was obtained from the Ethical Review Committee (ERC) of Fatima Jinnah Medical University (FJMU) before disseminating the survey. The approval was documented under the reference number No: 47/CIERB. We conducted a cross-sectional survey at FJMU’s Medical College in Lahore, Pakistan. This study took place over one week, from September 25 to October 2, 2023.

Results

Survey reliability and principal component analysis

A reliability assessment was conducted to evaluate the internal consistency of the survey instrument. A Cronbach's alpha value of 0.712 indicated acceptable reliability. Principal Component Analysis (PCA) revealed six components that together explained 50.2% of the total variance. Items related to the Nomophobia Questionnaire predominantly loaded on the first component, suggesting internal coherence. However, some items—such as “How often do you compare your body to what you see on social media?”—cross-loaded onto multiple components, indicating potential multidimensionality that warrants further psychometric review.

Demographics

A total of 1,115 female medical students completed the survey, yielding a response rate of 93.2%. The mean age of participants was 21.46 years (SD = 1.72), with a median age of 21 years. The academic year distribution was: 1st year (17.3%), 2nd year (19.9%), 3rd year (24.8%), 4th year (15.0%), and final year (23.0%). Most students were hostel residents (65.7%), while the remainder (34.3%) were day scholars.

The average height was 160.4 cm (SD = 7.2), and the average weight was 55.0 kg (SD = 10.0). Most participants (56.9%) reported no pre-existing medical conditions. Commonly reported issues included skin conditions (16%), anxiety (14.6%), and allergies (10.5%). Depression, PCOS, and IBS were reported by 6–7% of respondents.

Regarding medication use, 76.9% of participants reported not taking any regular medication. Those who did primarily used treatments for allergies (5.6%), pain (4.8%), acne (3.8%), or menstrual issues (2.2%). A small proportion used antidepressants (1.5%) or anti-anxiety medication (1.4%).

Digital device usage

In the evaluation of participants' smartphone usage habits, several trends were identified (Table 2). Regarding the average daily duration of smartphone use, 1.8% of participants reported using their smartphones for less than 1 h, 4% used for 1–2 h, 15.2% for 2–3 h, 24.4% for 3–4 h, 26.2% for 4–5 h, and 28.3% used their phones for more than 5 h daily (P < 0.001).

Table 2 Digital device usage and habits among participants (N = 1115)
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When examining the frequency of checking their smartphones within an hour, 10.3% reported checking every 5 min, 29.5% every 10 min, 16.4% once every hour, 34.4% every 30 min, and 9.3% less than once every hour (P < 0.001). Furthermore, a substantial majority of participants (68.5%) indicated that they check their smartphones immediately upon waking up, while 31.5% do not (P < 0.001). An even larger proportion, 94.4%, check their smartphones right before going to bed, with only 5.6% refraining from this behavior (P < 0.001).

In terms of the primary purpose of smartphone usage, a predominant 88.4% of participants use their phones for a mix of both academic and leisure activities. A small fraction, 4.2%, primarily uses their smartphones for academic work, whereas 7.4% primarily engage in social media and entertainment (P = 0.006).

Attitudes and reactions to smartphone usage and accessibility

For the statement "I would feel uncomfortable without constant access to information through my smartphone", 30% disagreed, 21.5% were neutral, and 48.5% agreed, with a mean score of 4.37 (SD: 1.77). On "Being unable to get the news on my smartphone would make me nervous", 45.5% disagreed, 20.4% were neutral, and 34.1% agreed. The mean score was 3.64 (SD: 1.85). Concerning "Running out of battery in my smartphone would scare me", 46.4% showed disagreement, 15.9% were neutral, and 37.8% agreed. The average score was 3.74 (SD: 1.98). For the statement about panicking without Wi-Fi or data, 47.4% disagreed, 15% were neutral, and 41.6% agreed. The statement averaged 3.72 (SD: 1.96).

Regarding the fear of being stranded without a smartphone, 50.1% disagreed, 16.3% were neutral, and 33.5% agreed. The mean score here was 3.53 (SD: 1.98). On feeling nervous without the ability to receive messages and calls, 40.7% disagreed, 16.5% chose neutral, and 42.7% agreed, with a mean score of 3.95 (SD: 1.96). For distress over losing a smartphone for a week, 19.7% disagreed, 10.6% were neutral, and a notable 69.8% agreed. This had a mean score of 5.25 (SD: 1.87). Lastly, on the need to immediately respond to messages, 42.4% disagreed, 16.7% were neutral, and 41% agreed. The statement's mean score was 3.91 (SD: 2) (Table 3).

Table 3 Participants' attitudes and reactions to smartphone usage and accessibility
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Body image and weight perceptions

On examining perceptions related to weight and the influence of digital media, participants shared their feelings about their current weight (Table 4). Roughly 16.5% were very unsatisfied, scaling up to 12.7% who were very satisfied, with varying degrees of satisfaction in between (P = 0.035). A significant 77.6% felt that societal pressures to conform to a certain look were influenced by digital media, while 22.4% did not share that sentiment (P = 0.008).

Table 4 Responses to digital media and body perception
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When asked about how often they compared their bodies to depictions on social media, 5.7% said they always did, 14% did so often, 31.7% sometimes did, 25.1% rarely, and 23.6% never made such comparisons (P < 0.001). Further, 53.1% stated that viewing images or videos of others on social media did not affect their body image, yet 33% felt this way sometimes, and 13.9% admitted to always feeling bad about their bodies after such exposures (P = 0.001).

While 75% had never tried weight loss methods or diets they came across online, a quarter of respondents had (P = 0.171). When it came to digital influencers shaping perceptions of an "ideal" body, opinions were nearly split: 51.4% felt influencers did have such an impact, whereas 48.6% felt they did not (P = 0.011). A majority, 62.5%, did not believe that their smartphone usage influenced their body perception, but 37.5% felt the contrary (P < 0.001).

Considering more drastic measures, 84.4% had never contemplated cosmetic procedures or surgeries based on digital media trends, but 15.6% had (P = 0.004). Finally, in a strong indication of the pervasive influence of technology on body image perceptions, 86.9% believed that "filters" and photo-editing tools on smartphones contributed to setting unrealistic body standards, while only 13.1% disagreed (P = 0.568).

General well-being

On a 1 to 10 scale assessing well-being over the past month, most respondents hovered around the mid to high range: 15.8% chose 5, 18.3% selected 8, and 17.5% opted for 7 (P < 0.001). At the extremes, 2.2% rated their well-being as 1, and 3.0% gave a perfect 10. In relation to smartphone usage, 62.0% felt increased stress or anxiety from prolonged use, while 38.0% did not (P < 0.001). As for daily breaks from smartphones, 42.0% often took breaks and 38.7% did so sometimes, while a mere 1.9% never took any (P < 0.001). Importantly, 71.4% acknowledged the need for "digital detoxes" or breaks for mental well-being, with 28.6% seeing no such need (P = 0.094) (Table 5).

Table 5 Smartphone usage and general well-being responses
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Differential well-being scores across years of study: an analysis of variance (ANOVA) approach

In an analysis of the general well-being scores of students across different years of study, descriptive statistics reveal that 4th year students report the highest average well-being score (M = 6.4072, SD = 2.16532), while students in their Final Year report the lowest (M = 5.5992, SD = 2.17561). An ANOVA test was conducted to assess whether these differences in well-being scores were statistically significant across the year groups. The analysis revealed a significant effect of the year of study on general well-being, F(4, 1110) = 3.982, p = 0.003, with a small effect size (partial η^2 = 0.014). To provide a visual representation of the differences in general well-being scores across various years of study, the estimated marginal means are depicted in Fig. 1.

Fig. 1
figure 1

Estimated marginal means of general well-being across different years of study

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Further examination using post-hoc Tukey tests indicated significant differences in well-being scores between 2nd year students and those in their Final Year (mean difference =  − 0.5539, p = 0.042), with Final Year students reporting lower scores. Additionally, 4th year students had significantly higher well-being scores compared to those in their Final Year (mean difference = 0.8080, p = 0.002). No other pairwise comparisons were significant.

Regression analysis

In a regression analysis examining the relationship between GWBS (General Well-being Scale) score and predictor variables like year, residence, weight, it was observed that the predictors account for 16.1% of the variance in GWBS, as indicated by an R Square value of 0.401 and adjusted R Square of 13.7%. The model's Standard Error of Estimate was 2.02212. The ANOVA results further validated the model with a Regression Sum of Squares of 848.470, a Residual Sum of Squares of 4432.421, and a statistically significant F-value of 6.917 (p < 0.001).

The intercept for GWBS was determined to be 6.722 (p < 0.001). Notably, changes in residence were associated with a decrease in well-being by a coefficient of − 0.265 (p = 0.043). Increased frequency of smartphone checks was positively associated with GWBS, with a coefficient of 0.149 (p = 0.025). A significant positive relationship was observed between differential smartphone usage and GWBS (B = 0.434, p = 0.001). Anxiety linked to smartphone battery depletion demonstrated a positive association with GWBS (B = 0.087, p = 0.04), whereas concerns about connectivity loss were negatively associated with a coefficient of − 0.092 (p = 0.03). Satisfaction with body weight yielded a pronounced positive effect on well-being (B = 0.241, p < 0.001). In contrast, prolonged smartphone use negatively impacted well-being (B =  − 0.277, p = 0.048). Regular intervals away from smartphones were beneficial (B = 0.29, p = 0.001), though extended "digital detoxes" were correlated with a decrease in well-being (B =  − 0.298, p = 0.042) (Table 6).

Table 6 Linear regression coefficients for predicting general well-being
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Discussion

The present cross-sectional survey, conducted at a female-only medical college in Pakistan, provides crucial insights into the intricate relationships between phone usage patterns, body image perceptions, and weight disturbances among medical students. With the digitization of modern society, smartphone and digital device usage, especially in the realm of social media, has witnessed an exponential surge, and its ramifications on mental and emotional well-being cannot be understated. With a response rate of 93.2% out of 1197 clicks, the study achieved meaningful representation from its intended demographic. This engagement indicates a keen interest and possible recognition of the study's importance among female medical students, aligning with global trends highlighting increasing smartphone reliance.

In the demographic evaluation of 1,115 participants, the average age was 21.46 years with a standard deviation of 1.721 years. The distribution showed 17.3% in their 1st year and 23% in their final year of medical school. A majority of participants (65.7%) resided in hostels. The average height was 160.43 cm, and the average weight was 54.99 kg. The majority (56.9%), reported no pre-existing illnesses, while skin conditions like acne and eczema were the most common, affecting 16%. Other significant health concerns included anxiety (14.6%) and PCOS (7.4%). Regarding medications, 76.86% participants were not on any medication, while 5.56% took allergy medicines, and 4.84% used pain relievers like ibuprofen.

One of the primary strengths of our methodology was the intrinsic diversity in backgrounds, academic years, and differential exposures to clinical settings; this stratified approach ensured that the findings were not skewed by an overrepresentation from any particular subgroup. It highlights the study's commitment to generalizability and the relevance of its results to the broader community of female medical students in Pakistan. Similarly, analysis of data from the Canadian survey on teen health behaviors (N = 2,538) identified increased overall screen time and texting correlated with heightened muscle dysmorphia (MD) symptoms in both genders. However, women showed a stronger connection between video chatting and MD, whereas men's MD symptoms were more closely linked to social media usage [21].

The association between phone usage patterns and body image perceptions is a burgeoning area of research. Preliminary investigations worldwide have alluded to the potential repercussions of increased screen time on self-perception, notably among young adults [22,23,24]. Specifically for young women, smartphone use can lead to exposure to content that often idealizes slimmer physiques [25]. Platforms that cater to this group frequently present images of celebrities and models whose bodies are leaner than the average individual. This exposure is further amplified by online algorithms that recurrently promote this kind of content [26, 27]. Such consistent exposure could develop distorted self-perceptions regarding body image and might intensify weight-related anxieties, potentially pushing them towards unhealthy weight loss methods [28, 29]. Through platforms like social media, adolescents can also amplify and internalize body image concerns and ideals, such as 'thinspiration' and 'fitspiration' [30]. Furthermore, there is a heightened risk of disseminating ill-advised weight management strategies, with harmful weight loss methods potentially leading to nutritional imbalances and stunted growth [31,32,33].

In the context of our study, the finding concerning this dynamic among female medical students, a cohort already under academic and professional pressures, can illuminate specific interventions or awareness campaigns tailored to this demographic. Further, the exploration of weight disturbances in the backdrop of phone usage offers a nuanced understanding. With the surge of fitness apps, diet trackers, and social media influencers emphasizing 'ideal' body types [34,35,36], there is a pressing need to understand the psychological and behavioral shifts smartphone and digital device usage might engender.

Several regional studies corroborate our findings regarding the high prevalence of nomophobia among medical students. A recent investigation conducted at Umm Al-Qura University in Saudi Arabia reported that nearly 99% of medical undergraduates exhibited some degree of nomophobia, with younger students demonstrating higher levels of severity [37]. Despite the widespread presence of nomophobia, the study found no statistically significant impact on academic performance. This parallels our own findings, where emotional distress related to phone use did not translate into observable academic deficits, but was instead more directly linked to subjective well-being and psychological outcomes. The authors recommended targeted mental health education programs, a suggestion that aligns well with our own recommendations for integrating digital wellness into medical training.

A similar cross-sectional study from Iran explored the psychological dimensions of nomophobia among medical students and revealed elevated levels of anxiety, discomfort, and emotional insecurity in younger users and high-frequency users [38]. While no direct link to academic metrics was confirmed, the emotional toll associated with phone dependency raised concern about future burnout and impaired professional function. Given that medical students are training to become frontline healthcare providers, the cumulative emotional strain of digital overuse could compromise their clinical performance, interpersonal empathy, and decision-making accuracy. These risks extend beyond personal health to broader public health and patient safety concerns, making this an urgent area for institutional reform.

Additional evidence from Kazakhstan and Iran further emphasizes the mental health implications of smartphone dependency in university populations. Abukhanova et al. (2023) found that anxiety significantly mediated the negative impact of nomophobia on learning performance [39], while Abdoli et al. (2023) confirmed strong associations between nomophobia and symptoms of depression, stress, and anxiety, particularly among young adults [40]. These studies validate our findings and reinforce the understanding of nomophobia as more than a behavioral trend—it is a mood-related disturbance with tangible psychosocial and functional consequences. As such, our findings advocate for systematic intervention frameworks, including counseling support, digital literacy, and proactive mental health screening within academic institutions, particularly for high-risk groups like female medical students under academic and social pressure.

Limitations

This study is subject to several important limitations that must be acknowledged. First and foremost, the cross-sectional design restricts our ability to establish causal relationships between nomophobia, body image concerns, and general well-being. Longitudinal studies are needed to understand how these relationships evolve over time and whether one factor might predict changes in another.

Second, the sample was exclusively composed of female medical students from a single institution, which may limit the generalizability of the findings. While this homogeneity enhances internal validity and contextual relevance, it may not reflect the experiences of male students, non-medical disciplines, or broader populations in Pakistan or other regions. Further studies should aim for gender and institutional diversity, as well as cross-cultural comparison, to build a more generalizable understanding.

Third, the study relied on self-reported data, which are inherently vulnerable to social desirability bias, recall bias, and misinterpretation of questions. Despite efforts to preserve anonymity and clarity, participants may have underreported sensitive behaviors (e.g., mental health issues) or overestimated positive traits (e.g., smartphone breaks), potentially skewing results. The online format, while facilitating wide access, also assumes digital literacy and interest, potentially excluding those with less technological engagement—ironically, a population that might differ significantly in nomophobia levels.

Fourth, the internal consistency of the survey tool, though acceptable (Cronbach’s alpha = 0.712), indicates room for improvement. Some items were found to cross-load on multiple components in the PCA, raising concerns about the unidimensionality and interpretability of certain constructs. Future studies should consider psychometric refinement and possibly cultural adaptation of scales like the NMP-Q and BICI to ensure clearer construct validity in South Asian settings.

Fifth, while statistical assumptions were checked, certain assumptions of multiple linear regression—such as homoscedasticity, independence of observations, and multicollinearity—might not have been fully met. Violations of these assumptions could compromise the robustness of the regression results, despite the use of diagnostic checks. Moreover, the model accounted for only 16.1% of the variance in well-being, suggesting that important unmeasured variables (e.g., coping mechanisms, personality traits, or offline social support) may be at play.

Finally, external contextual factors, such as the academic calendar, exam stress, socio-political events, or pandemic-related disruptions, were not captured but may have significantly influenced students' digital habits and psychological well-being during the data collection period.

Conclusion

This study highlights a significant and multifaceted relationship between digital dependence, body image perceptions, and general well-being among female medical students in Lahore, Pakistan. With nearly one-third of participants using smartphones for more than five hours daily and over 60% reporting stress or anxiety related to smartphone use, nomophobia appears to be a pervasive issue in this population. Furthermore, a substantial proportion of students reported dissatisfaction with their weight and acknowledged the influence of digital media on their body image—a finding that underscores the role of smartphone-based content in shaping health-related self-perceptions.

These insights have implications that extend beyond academic settings. As future healthcare providers, medical students’ well-being directly influences patient care, safety, and the sustainability of healthcare delivery. Persistent digital overuse, linked to distress and distorted body image, may compromise empathy, focus, and mental resilience—skills vital in clinical practice. There is a growing need to embed digital literacy, self-care, and mental health training into medical curricula to prepare students for both professional and personal digital challenges.

While this study offers valuable context-specific data, it also opens avenues for further research. Future investigations should incorporate longitudinal designs, include diverse gender and educational groups, and assess the effectiveness of interventions such as digital detox programs or media literacy workshops. Additionally, qualitative studies may offer deeper insights into the lived experiences behind these quantitative trends.

In sum, this study not only documents a concerning pattern of digital dependence among female medical students but also signals the urgency of integrating mental health and media-use awareness into public health strategies and medical education reforms. Understanding and addressing nomophobia is no longer optional—it is essential to cultivating a resilient and well-equipped future healthcare workforce.