Facebook,Stress,and Incidence of Upper Respiratory Infection in Undergraduate College Students

Abstract

Having a large social network is generally beneficial to health. However, it is unclear how Internet-based social networks might influence health. Chronic stress can have negative health consequences, and some data suggest that Facebook could be a new source of psychological stress. Thus, we examined undergraduate college student perceptions of Facebook use and incidence of upper respiratory infections (URIs). We hypothesized that subjects with more diverse networks (i.e., more friends on Facebook) would have fewer URIs than their less diverse counterparts; that subjects reporting Facebook-induced stress would be more susceptible to URIs; and that subjects with more diverse networks who report Facebook-induced stress would be less susceptible to URIs than subjects with less diverse social networks who reported Facebook-induced stress. In this prospective study, healthy college students completed online questionnaires that assessed use and perceptions of Facebook and technology, and then were interviewed weekly for 10 weeks to track incidence of URI. URI episodes were defined by a symptom-based criterion. The social network size was significantly related to the rate of URI, such that, the larger the social network, the greater the incidence rate of URI. Most (85.7 percent) respondents experienced some degree of Facebook-induced stress. The effects of Facebook-induced stress on incidence of URI varied across the social network size, such that, the impact of stress on the URI incidence rate increased with the size of the social network. These results are largely in contrast to our hypotheses, but clearly suggest an association between Facebook use, psychological stress, and health.

Introduction

Multiple ties to friends, family, work, and community have been demonstrated to benefit physical and psychological health. For example, individuals with more diverse social networks live longer,¹ have less incidence of depression,² are more likely to survive myocardial infarction,³ and are less likely to suffer a recurrence of cancer⁴ than individuals with fewer social relationships. In addition, studies of host resistance to upper respiratory infections (URIs) found that individuals with more diverse social networks were less likely to develop a cold following exposure to a virus,⁵ and those with low numbers of social ties mounted poorer antibody responses to an influenza vaccination.⁶

While it is clear that having a large social network is generally beneficial to health, it is less clear how Internet-based social networks might influence health. With the advent of social-networking Web sites, such as Facebook, individuals are becoming more and more connected through the Internet and spending significant amounts of time engaging in Internet-based social networks.⁷ Estimates are that 90 percent of undergraduates and 90 percent of high school students use social media sites, such as Facebook.⁸ Furthermore, research conducted in the area of emotional disclosure,⁹ an intervention in which individuals write or talk about emotionally stressful material reveals beneficial effects in some, but not all participants.¹⁰ It remains unclear if emotional disclosure will work or actually have detrimental effects in a social networking setting. Thus, understanding how social network usage might influence health is of great importance.

The few studies that have examined the influence of Facebook on health have been equivocal. For example, one study found that using Facebook affected undergraduate's perceptions of others, such that, the longer one used Facebook the more likely they were to believe that others were happier and had better lives and the less likely they were to believe that life was fair.¹¹ A separate study found that spending a lot of time on Facebook was associated with feelings of low self-esteem.¹² In contrast, a recent report suggested that larger social networks predicted higher levels of life satisfaction and perceived social support on Facebook.¹³ In another study of undergraduates, researchers found that Facebook use resulted in users' positive affective state.¹⁴ Interestingly, this study also found that Facebook use resulted in increased respiration and skin conductance, suggesting that Facebook use results in activation of the physiological stress response. While the long-term health effects of Facebook-induced activation of the stress response are unknown, a recent case study provides evidence that a Facebook-induced stress response can serve as a trigger for asthma attacks.⁷ In addition, it remains unclear what percentage of Facebook users actually perceive their use of Facebook to be stressful.

Numerous studies indicate that exposure to chronic stress (a stress that persists for several hours a day for weeks or months) can be immunosuppressive, and hence, may be detrimental to health.¹⁵ Given that Internet-based social networks, such as Facebook, could be a new source of psychological stress, and that chronic stress can have negative health consequences for an individual, we examined undergraduate college student perceptions regarding Facebook use and incidence of URIs using a prospective study design. Because network diversity has been associated with improved host resistance, we predicted that those with more diverse networks (i.e., more friends on Facebook) would have fewer URIs than their less diverse counterparts. We also hypothesized that people reporting Facebook-induced stress would be more susceptible to URIs than individuals not reporting Facebook-induced stress. Lastly, we predicted that people with more diverse social networks reporting Facebook-induced stress would be less susceptible to URIs than people with less diverse social networks reporting Facebook-induced stress.

Materials and Methods

Participants

Participants were college undergraduates (n=88; 11 men and 77 women) aged 18–24 years who responded to in-class recruitment solicitations during the Fall 2011 semester (see Table 1). All reported no chronic or acute illness, no regular medication regimen (with the exception of birth control), and good health before the study onset. All procedures were approved by the University Institution Review Board.

Table 1.

Demographic Characteristics of Participants Completing Technology and Mental Health Survey

Characteristic	Number (%)
Sex
Male	11 (12)
Female	77 (88)
Age (years)
18–19	52 (59)
20–21	30 (34)
22–24	6 (7)
Class level
Freshman	13 (15)
Sophomore	54 (61)
Junior	8 (9)
Senior	12 (14)
Race/ethnicity
Caucasian	61 (69)
African American	6 (7)
Hispanic or Latino	12 (13)
Asian	5 (6)
American Indian or Alaskan Native	1 (1)
Other	3 (3)

Procedures

All participants completed an informed consent, and then completed a Web-based survey adapted from the Jed Foundation/Associate Press technology and mental health poll (see Tables 2 and 3).¹⁶ After completing the survey, participants were then instructed about the 10-week follow-up period. For 10 weeks, participants completed a weekly diary to provide information concerning URI symptoms. The majority (n=77; 87.5 percent) of participants completed and returned all weekly diaries.

Table 2.

Use and Perceptions of Facebook

Question		Percent of responses
1. About how many friends or connections would you say you have on Facebook?
0–199	200–999	1,000+	NA
20.4	59.2	16.3	4.1
2. Which of the following best describes how you feel about receiving friend requests on Facebook?
Like receiving friend requests	Neutral about receiving friend requests	Dislike receiving friend requests	NA
37.8	53.1	4.1	5.1
3. Which of the following best describes how you feel about defriending someone on Facebook?
Feel happy	Neutral	Feel angry	Feel sad	NA
11.2	68.4	2.0	7.1	11.2
4. When you realize that someone else has defriended you on Facebook, which of the following best describes how that makes you feel:
Feel happy	Neutral	Feel angry	Feel sad	NA
0	63.3	8.2	20.4	8.2
5. Does using Facebook make you feel anxious?
Yes	No	NA
16.5	78.4	5.2
6. Have you ever delayed replying to friend requests on Facebook because you were anxious about the request?
Yes	No	NA
45.9	49.0	5.1
7. Has rejecting friend requests on Facebook ever made you feel guilty or uncomfortable?
Yes	No	NA
32.7	62.2	5.1
8. In the last 7 days, did you use the Internet to use Facebook?
Yes	No
95.9	4.1
9. Do you feel that increased use of technology has made it harder to feel close to people, easier to feel close to people, or has it not really had an impact?
Easier	Harder	No Impact
39.8	43.9	16.3
10. Would you say that unplugging from technology, meaning no access to a computer, cell phone, or TV would make you feel…
A little more stressed	No Difference	A little less stressed	A lot less stressed
40.8	10.2	27.6	4.1

Table 3.

Technology Use, Self-Reported Stress and Happiness

Question		Percent of responses
In a typical day, how many hours, if at all, do you use the Internet on any electronic device, such as a computer, cell phone, or gaming console?
<1	1–<2	2–<6	6–<8	8+
1.0	8.2	52.0	28.6	10.2
On a typical day, how many minutes do you spend talking on your cell phone?
0	1–10	11–20	21–40	41–60	60+
1.0	32.7	32.7	18.4	12.2	3.1
On a typical day, how many text messages do you send on your cell phone?
0	1–15	16–30	31–50	51–100	101–200	201+
1.0	16.3	19.4	21.4	19.4	11.2	11.2
At any point, during the past 3 months, have you ever felt so stressed that you could not get your school work done?
Yes, it happened once or twice	Yes, it happened several times	No, it has not happened at all
41.8	31.6	26.5
When you think about how things are going in your life in general, would you say you are..
Very unhappy	Somewhat unhappy	Neither	Somewhat happy	Very happy
2.0	10.2	2.0	52.0	33.7

Facebook use and perceptions survey

Stress can be defined as a constellation of events, consisting of a stimulus (stressor), which precipitates a reaction in the brain (stress perception), that activates physiological fight-or-flight systems in the body (stress response).¹⁵ It is difficult to assess one's perceptions of stressors, thus, we took a multiquestion approach in an attempt to define and quantify Facebook-induced stress. Based on results from questions 2–7 described in Table 2, we rated each participant's level of Facebook-induced stress. We reasoned that questions 2–7 could be viewed as stressors for some and, therefore, questions answered that demonstrated a negative state when using Facebook (e.g., disliking receiving friend requests, feeling angry or sad about defriending someone, feeling angry or sad when defriended by someone else, feeling anxious about Facebook, delaying response to a friend request due to anxiety, feeling guilty or uncomfortable rejecting a friend request) were totaled. Participants answering 0 questions in a negative fashion were rated as having no stress, those answering 1–2 questions in a negative fashion were rated moderate stress, and those answering 3 or more questions in a negative fashion were rated high stress.

Self-reported symptoms

Weekly symptom scores were derived by summing answers to the following eight items, completed on a five-point Likert scale with ratings of zero (none) and one (mild) to four (very severe): nasal congestion, sneezing, runny nose, cough, headache, scratchy/sore throat, fever, and feeling under the weather. As previously reported,^17,18 these symptoms resulted from an analysis of the self-reported symptoms that participants used to characterize their natural clinical colds after viral challenge.¹⁹ Using a previously reported methodology,^17,18 we derived a symptom-based cold incidence measure from a participant report of two of the eight symptoms at the severe level. On the basis of this criterion, 45 participants were defined to have experienced a URI. Previous research demonstrates that this method of self-reported URI symptoms correlates with verified URI by health care clinicians.¹⁸

Data analysis

To determine if main effects were present, all analysis utilized analysis of variance (ANOVA). Alpha was set at 0.05. All figures are shown with group means and standard error bars. Consistent with the literature,¹² no differences were observed between male and females and, therefore, analysis was done on all subjects regardless of sex.

Results

Use and perceptions of Facebook and technology

Of the 88 subjects who completed the survey, the vast majority (95.9 percent) used Facebook in the 7 days before completing the survey and most users had between 200-999 friends on Facebook (Table 2; 0–199, n=20; 200–999, n=51; 1,000+, n=17). Table 2 summarizes subject's responses.

Self-reported stress and happiness

Most subjects stated they experienced high levels of stress that prevented them from completing academic assignments over the previous 3 months (Table 3). However, the great majority (85.7 percent) of subjects reported feeling at least “somewhat happy” at the time of the survey.

Self-reported URI symptoms

During the 10-week follow-up period of the participants (n=77) who completed and returned all weekly diaries, 45 (58 percent) had at least one URI defined by self-reported symptoms. Of those who reported at least one URI, the average number of infections over the 10-week period was 2.5 infections/individual.

Social network size, Facebook-induced stress and self-reported URI symptoms

The social network size was significantly related to the rate of URI (Fig. 1A, B). ANOVA revealed a main effect of the number of Facebook friends on the incidence rate of URI [Fig. 1A, F(2, 74)=3.0, p=0.05] and a trend for the average number of URI/individual (Fig. 1B, p=0.07), such that, the greater the social network (i.e., number of Facebook friends) the greater the incidence rate of URI. No relationship between hours spent using the Internet, minutes spent talking on cell phones/day, or text messages sent/day and incidence of URI was observed. Additionally, there was not a relationship between subject self-reported stress levels, or degree of happiness (Table 3), and incidence of URI.

FIG. 1.

Observed incidence rates (A) and average number (B) of upper respiratory infections (URIs) during the 10-week follow-up as a function of the number of Facebook friends. Bars are means±standard errors of the means.

Of the six questions (questions 2–7, Table 2) used to assess participant's level of Facebook-induced stress, ANOVA revealed a significant relationship between those that felt angry or sad when someone else defriended them and the incidence of URI [Fig. 2A, F(1, 68)=9.1, p=0.003] (85.7 percent vs. 49 percent). Two-factor ANOVA demonstrated significant main effects of social network diversity [Fig. 2B, F(2, 64)=4.2, p=0.01) and feelings associated with being defriended [Fig. 2B, F(1, 64)=7.9, p=0.006]. These results indicate that increased social network diversity and negative feelings after being defriended are both associated with increased incidence of URI. In addition, the effects of having negative feelings following being defriended on incidence of URI varied across the social network size. Individuals with the smallest network size demonstrated a 22.7 percent increase in the URI rate when comparing individuals who reported no difference or feeling angry/sad following being defriended (27.3 percent vs. 50 percent). In comparison, individuals with the largest network size demonstrated a 50 percent increase in the URI rate when comparing individuals who reported no difference or feeling angry/sad following being defriended (50 percent vs. 100 percent). No significant differences were observed for the remaining five questions examining Facebook-induced stress and URI incidence (p>0.05 for all), although a trend (p=0.1) was observed when examining URI incidence in those who reported that Facebook made them anxious (URI incidence=73.3 percent) compared with those that reported Facebook did not make them anxious (URI incidence=54.8 percent).

FIG. 2.

Observed incidence rates of URIs during the 10-week follow-up as a function of subjects' feelings following being defriended (A) and feelings following being defriended by the number of Facebook friends (B). Bars are means±standard errors of the means.

The majority of respondents (53.2 percent) experienced moderate Facebook-induced stress, a sizeable group experienced no Facebook-induced stress (32.5 percent), and a significant minority (14.3 percent) experienced high Facebook-induced stress. ANOVA demonstrated no significant main effect of Facebook-induced stress on incidence of URI or the average number of URI/individual (Fig. 3A, p=0.3). Two-factor ANOVA confirmed significant main effects of social network diversity [Fig. 3B, F(2, 68)=4.4, p=0.01], but not Facebook-induced stress (Fig. 3B, p>0.05) on incidence of URI. In addition, a reliable social network diversity by Facebook-induced stress interaction was observed [Fig. 3B, F(4, 68)=2.5, p=0.04] suggesting that a greater social network diversity was associated with increased incidence of URI and the impact of Facebook-induced stress on incidence of URI varied across different sized networks. No relationship between hours spent using the Internet, minutes spent talking on cell phones/day, or text messages sent/day and incidence of Facebook-induced stress was observed.

FIG. 3.

Observed incidence rates of URIs during the 10-week follow-up as a function of Facebook-induced stress experienced by subjects (A) and Facebook-induced stress by the number of Facebook friends (B). Bars are means±standard errors of the means.

Discussion

Individuals with larger social networks have been demonstrated to have physical and psychological health benefits. However, studies examining how Internet-based social networks influence psychological health have produced mixed results. To our knowledge this is the first study to examine how Internet-based social networks influence physical health (i.e., URI). Given recent estimates that approximately 8 percent of the world's population and 42.3 percent of the entire American population use Facebook,²⁰ this issue is of the utmost importance.

In contrast to our hypothesis and the literature examining traditional social networks,^5,6 Internet-based social network size was associated with an increased rate of URI (Figs. 1 –3), such that, the larger the social network (i.e., number of Facebook friends) the greater the incidence rate of URI. Although having a diverse social network is generally beneficial to health, there are studies that report increased numbers of URIs with increased exposure to others.²¹ Diverse social networks are associated with a face-to-face contact with a wide range of people that could ultimately increase risk of exposure to infectious agents. Moreover, in situations, where one's host resistance is compromised, increased social contact and exposure to a larger range of infectious agents could possibly lead to a greater incidence of URI communicated through social contact. Thus, it has been suggested that the protective effect of having a diverse social network is reserved only for times when one's immune system is functioning appropriately.¹⁸ In the current study, we had no direct measure to indicate if having more Facebook friends was associated with more face-to-face contact with those friends. However, a recent study reported a strong overlap between online and offline friends suggesting that those with more Facebook friends are likely to interact with those friends face-to-face,²² thereby increasing the likelihood for disease transmission.

A number of factors can compromise host resistance, including age, immunosuppressive drugs, and exposure to chronic stress.^23–26 The results from our study suggest that many Facebook users find use of the social networking tool to be stressful. According to our analysis, the majority of respondents (53.2 percent) experienced moderate Facebook-induced stress, and 14.3 percent experienced high Facebook-induced stress. Specifically, almost a third of respondents stated that being defriended made them angry or sad, while 9.1 percent stated defriending someone made them angry or sad, and a small number of users (4.1 percent) stated they actually disliked receiving friend requests. When asked directly if Facebook made them feel anxious, 18 percent answered in the affirmative; however, 45.9 percent of respondents stated that they delayed replying to a friend request because they felt anxious about the request and 32.7 percent stated that rejecting friend requests made them guilty or uncomfortable. Consistent with the idea that Facebook use is resulting in user stress for some individuals, 31.7 percent of respondents stated unplugging from technology would result in less stress and 43.9 percent of respondents stated that the increased use of technology has made it harder to feel close to people.

Given that chronic stress can compromise the immune system, and Facebook use results in stress for some users, users experiencing Facebook-induced stress might have compromised immune systems. Indeed, individuals who reported feeling angry or sad following being defriended had a higher URI incidence rate compared to those reporting feeling neutral following being defriended (85.7 percent vs. 49 percent; Fig. 2). Although increased social network diversity was also associated with increased incidence of URI (Fig. 1), having negative feelings following being defriended was associated with a greater incidence of URI in subjects with the largest network diversity. In addition, when examining subjects' overall level of Facebook-induced stress (no stress, moderate, high), it was found that subjects experiencing high Facebook-induced stress who had more diverse social networks were more susceptible to URIs than subjects experiencing high Facebook-induced stress who had less diverse social networks (Fig. 3). The observation that subject's self-reported levels of overall stress and happiness (Table 3) were not associated with incidence of URI lends support to the suggestion that these results were specific to Facebook-induced stress. Our data are similar to previous studies reporting that increased social contact is associated with great incidence of URI under stress.^17,18,27 Importantly, the results from the current study add to this literature by demonstrating that increased virtual social contact (i.e., via Facebook) is also associated with a greater incidence of URI when subjects are under stress.

One explanation for these results is the possibility that having more Facebook friends results in more Facebook-induced stress, and this increased stress further compromises the immune system. There is evidence, for example, that the amount of time spent on Facebook correlates with the number of Facebook friends.¹² Increased time spent on Facebook, theoretically, would provide more opportunity for Facebook-induced stress. However, we did not find a relationship between the number of Facebook friends and any measure of stress in the current study (data not shown). Thus, having more Facebook friends did not necessarily result in more Facebook-induced stress. In addition, spending more time using the Internet (including using Facebook) did not result in more Facebook-induced stress or incidence of URI, suggesting increased frequency of Facebook use does not necessarily result in greater stress or incidence of URI.

In conclusion, the results of the current study indicate that the virtual social network size might influence human health, users frequently report feelings of stress associated with Facebook, and the social network size and Facebook-induced stress might interact to influence health. These data suggest that people who have more diverse social networks reporting high Facebook-induced stress are more susceptible to URIs than people with less diverse social networks reporting high Facebook-induced stress. How and why Facebook might induce the physiological stress response remains a topic of investigation. One limitation of the current study was the unequal number of male and female subjects. Additionally, the small number of subjects with 1,000+ Facebook friends makes analysis of various subgroups within this group difficult. Future studies should attempt to have a more balanced subject population. It seems clear, however, that for some individuals Facebook use and technology in general are sources of psychological stress.

Footnotes

Acknowledgment

We thank the undergraduate students at Regis University for participating in this study.

Author Disclosure Statement

No competing financial interest exists.

References

House

, Landis

, Umberson

. Social relationships and health. Science, 1988; 241:540–545.

Kawachi

, Berkman

. Social ties and mental health. J Urban Health, 2001; 78:458–467.

Berkman

. The role of social relations in health promotion. Psychosomatic Medicine, 1995; 57:245–254.

Helgeson

, Cohen

, Fritz

. 1998. Psycho-oncology. New York: Oxford University Press.

Cohen

, Doyle

, Skoner

et al. Social ties and susceptibility to the common cold. JAMA, 1997; 277:1940–1944.

Pressman

, Cohen

, Miller

et al. Loneliness, social network size, and immune response to influenza vaccination in college freshmen. Health Psychology, 2005; 24:297–306.

D'Amato

, Liccardi

, Cecchi

et al.

Facebook: a new trigger for asthma?

Lancet, 2010; 376:1740.

Group CBaAS Student Poll. 2009. www.artsci.com/studentpoll/v7n2/index.aspx

Pennebaker

, Kiecolt-Glaser

, Glaser

. Disclosure of traumas and immune function: health implications for psychotherapy. Journal of Consulting and Clinical Psychology, 1988; 56:239–245.

10.

Vedhara

, Brant

, Adamopoulos

et al. A preliminary investigation into whether attentional bias influences mood outcomes following emotional disclosure. International Journal Behavioral Medicine, 2010; 17:195–206.

11.

Chou

, Edge

. “They are happier and having better lives than I am”: the impact of using Facebook on perceptions of others' lives. Cyberpsychology Behaviors Social Network, 2012; 15:117–121.

12.

Kalpidou

, Costin

, Morris

. The relationship between Facebook and the well-being of undergraduate college students. Cyberpsychology Behaviors Social Network, 2011; 14:183–189.

13.

Manago

, Taylor

, Greenfield

. Me and my 400 friends: the anatomy of college students' Facebook networks, their communication patterns, and well-being. Developmental Psychology, 2012; 48:369–380.

14.

Mauri

, Cipresso

, Balgera

et al. Why is Facebook so successful? Psychophysiological measures describe a core flow state while using Facebook. Cyberpsychology Behaviors Social Network, 2011; 14:723–731.

15.

Dhabhar

. Acute stress enhances while chronic stress suppresses skin immunity. The role of stress hormones and leukocyte trafficking. Annals of the New York Academy of Sciences, 2000; 917:876–893.

16.

Foundation

. mtvU AP 2010 technology and mental health poll. 2010. www.halfofus.com

17.

Cobb

, Steptoe

. Psychosocial stress and susceptibility to upper respiratory tract illness in an adult population sample. Psychosomatic Medicine, 1996; 58:404–412.

18.

Hamrick

, Cohen

, Rodriguez

. Being popular can be healthy or unhealthy: stress, social network diversity, and incidence of upper respiratory infection. Health Psychology, 2002; 21:294–298.

19.

Jackson

, Dowling

, Spiesman

et al. Transmission of the common cold to volunteers under controlled conditions. I. The common cold as a clinical entity. AMA Archives of Internal Medicine, 1958; 101:267–278.

20.

Springer

. Social media-risk management. Plastic Surgical Nursing, 2012; 32:22–24.

21.

Graham

, Woodward

, Ryan

et al. Acute respiratory illness in Adelaide children. II: the relationship of maternal stress, social supports and family functioning. International Journal of Epidemiology, 1990; 19:937–944.

22.

Reich

, Subrahmanyam

, Espinoza

. Friending, IMing, and hanging out face-to-face: overlap in adolescents' online and offline social networks. Developmental Psychology, 2012; 48:356–368.

23.

Dhabhar

. Enhancing versus suppressive effects of stress on immune function: implications for immunoprotection and immunopathology. Neuroimmunomodulation, 2009; 16:300–317.

24.

Fleshner

, Nguyen

, Cotter

et al. Acute stressor exposure both suppresses acquired immunity and potentiates innate immunity. American Journal of Physiology, 1998; 275(3 Pt 2)R870–R878.

25.

Maier

, Fleshner

, Watkins

. 1998. Neural, endocrine, and immune mechanisms of stress-induced immunomodulation. New frontiers in stress research: modulation of brain function. Chur, Switzerland: Harwood Academic Publishers, 175–185.

26.

Moraska

, Campisi

, Nguyen

et al. Elevated IL-1beta contributes to antibody suppression produced by stress. Journal of Applied Physiology, 2002; 93:207–215.

27.

DeLongis

, Folkman

, Lazarus

. The impact of daily stress on health and mood: psychological and social resources as mediators. Journal of Personality and Social Psychology, 1988; 54:486–495.