Nurse Education Today 81 (2019) 78–82

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Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Prevalence of internet addiction, its association with psychological distress, T

coping strategies among undergraduate students
⁎
Abd Al-Hadi Hasan , Alaa' Abu Jaber
Fakeeh College for Medical Sciences, Nursing Department, Alhamra District, Palestine Street, Jeddah, Saudi Arabia

A R T I C LE I N FO A B S T R A C T

Keywords: Purpose: This study aimed to describe the prevalence of Internet addiction (IA) among undergraduate students,
Perceived stress and its impact on psychological distress and coping strategies.
Coping mechanism Methods: Data were collected using a convenience sample of 163 student nurses.
Students Findings: The results showed that there was high prevalence rate of IA among students. In addition, the use of
Education
avoidance and problem-solving coping mechanism was statistically significant among the IA group compared
University
with the non-IA group (p < 0.05). This was associated with a more negative impact on psychological distress
Cross-sectional
and self-efficacy (p < 0.05).
Conclusions: IA is an increasing problem in the general population and among university students. It can affect
many aspects of a student's life and performance.
Practical implications: The results will raise awareness of the deleterious effects of IA on a wide range of student
life.

1. Background controversy about the diagnosis of IA, Internet gaming disorder, which
contributes to estimates of IA, is now included in DSM 5 under condi-
Shaw and Black (2015) defined Internet Addiction (IA) as excessive tions for further study (American Psychiatric Association, 2013).
or poorly controlled preoccupations, urges or behaviours regarding Another study by Al-Gamal et al. (2016) showed in a study among
computer use and Internet access that lead to impairment or distress. university students in Jordan that prevalence of IA was 40%, and that
Another consensus definition by Spada (2014) conceptualized Proble- IA was associated with a high level of mental distress. The study con-
matic Internet Use (PIU) as an inability to control one's use of the In- cluded that coping strategies, specifically the use of problem solving,
ternet which leads to negative consequences in daily life. This definition resulted in students being more likely to experience a lower level of IA.
states Internet use in general, whether on mobiles, tablets or computers, The high prevalence of IA in this study, compared to previous studies,
and for the purposes of gaming, social media or other different uses. may be explained first by the fact that it was done with a specific age
Spada concluded that several studies have stressed both similarities and group (university students), and second by the overall growth in In-
disagreements between PIU, addictive behaviours and impulse-control ternet use. 80% of young people in 104 countries now use the Internet,
disorders in relation to diagnosis and assessment tools. The disagree- a large increase over previous years, resulting from the rapid spread of
ments regarding diagnostic criteria and the lack of large epidemiolo- broadband mobile services, and the decrease in cost of these services
gical studies make it difficult to establish prevalence estimates of PIU in and mobiles themselves. According to the International Tele-
the general population. communications Union (ITU) (ICT Facts and Figures 2017. P1) half the
The Tokyo WHO report (2014, p. 10–11) concluded that studies of world's population are now Internet users, reflected in the incremental
IA and of epidemiology based on the available data are limited by use by specific sub-groups confirming the reasons for the discrepancy
several factors, including the complexity of longitudinal and qualitative between Al-Gamal et al.'s (2016) study and earlier research. According
studies, and the fact that much of the research is on specific population to the same ITU report ITU, there are 12% fewer female users of the
groups and cannot be generalized. The report concluded that better Internet worldwide than men, again explaining the differential cited
instruments or scales are needed to provide valid and reliable data, above (Tripathi, 2017).
since the instruments currently used have no international consensus Anew study by Sharma et al. (2017) of the general adult population
and have not been validated internationally. Although there is still (18–65 year old) recruiting a large sample from a house-to-house

⁎
Corresponding author.
E-mail address: [email protected] (A.A.-H. Hasan).

https://doi.org/10.1016/j.nedt.2019.07.004
Received 14 February 2019; Received in revised form 27 May 2019; Accepted 8 July 2019
0260-6917/ © 2019 Published by Elsevier Ltd.
A.A.-H. Hasan and A.A. Jaber Nurse Education Today 81 (2019) 78–82

survey, found the total prevalence of IA to be 1.3% for Internet use (2% overloaded respondents find their lives (Cohen, Kamarck &
males, 0.6% females) and for mobile phone overuse 4.1% (2.5% males, Mermelstein, 1983). Cronbach's alphas range from 0.75 to 0.86 (Cohen
1.5% females). The study found negative correlations between age, et al., 1983). In this study, Cronbach's alpha was 0.72.
number of family members and years of marriage with IA and mobile
overuse. From the previous discussion, and building on the WHO report 3.4. Coping behaviour
of 2014, in implementing this study we shall include several areas of
investigation: psychological distress and coping strategies of the sample The Coping Behaviours Inventory (CBI) was measured with a 19-
of study, using both qualitative and quantitative approaches, with well- item scale developed by Sheu et al. (2002). It consists of four categories:
validated instruments in order to gain a good understanding of the avoidance behaviours, problem-solving behaviours, optimistic coping
topic. Th aim is to describe the prevalence of IA among undergraduate behaviours and transference behaviours. Each item uses a 5-point
students, its possible relationship with psychological distress and Likert-type scale from 0 to 4. Higher scores for each factor point out
coping strategies, and possible gender differences in prevalence. more recurrent use of a certain type of behaviour. The CBI Cronbach's
alpha was 0.76 (Sheu et al., 2002), and construct validity was con-
2. Methods firmed. In this study, the Cronbach's alpha was 0.79.

2.1. Study design 3.5. Hamilton Depression Rating Scale

This study uses a descriptive correlational design to identify the The Hamilton Depression Rating Scale (HDRS) or Hamilton Rating
prevalence of IA among undergraduate students and its relationship Scale for Depression (HRSD) was developed by (Hamilton, 1986); it is
with psychological distress and coping strategies. widely use to rate depression and assess its severity, and has high in-
ternal consistency with Cronbach's alpha of 0.88 (Rush et al., 2003).
2.2. Setting The scale is composed of 24 items with different levels of answer,
ranging from zero to two, or zero to four according to the specific item,
The study was conducted during the second semester of the aca- where zero indicates absence of the symptom, and four indicates its
demic year 2017–2018, at Fakeeh College for Medical Sciences, be- most severe form. HDRS encompasses different outcome measurements:
tween September 2017 and June 2018. mood, suicidal ideation, feelings of guilt, insomnia, agitation, anxiety
and weight loss, as well as somatic symptoms.
2.3. Participants
3.6. Self-Esteem Scale
Power analysis was calculated using the following four input para-
meters: alpha of 0.05, an effect size (f2) of 0.15, and power of 0.80. The The Self-Esteem Scale (Rosenberg, 1965) is a 10-item scale that has
required sample size of 140 was determined with attrition rate of 15%. five levels of answer, ranging from 0 (strongly disagree) to 4 (strongly
Then, the required sample size was 164. agree); the higher the sum of all scale items, the higher the self-esteem.
The target population was undergraduate nursing students at The scale has internal consistency that ranges from 0.77 to 0.88, and
Fakeeh College for Medical Sciences (n = 250); the criterion for in- test-retest reliability ranging from 0.82 to 0.85.
clusion was any undergraduate nursing student on the BSc programme,
and a total of 163 students were enrolled. 3.7. Ethical consideration and approvals

3. Outcome measure IRB rules and regulations at FCMS were applied to this study (RSH,
2134); the investigators assured participants that confidentiality was
3.1. Socio-demographic data maintained. Informed consent was obtained from all participants; rules
and regulations set out by the IRB committee are applied to guarantee
All students' demographical data were obtained including age, the application of a code of ethics to both research on the students and
gender, educational level of study, family type, and income. on the educational process, and the investigator guarantees no negative
impact or harm shall occur.
3.2. Internet addiction
3.8. Data analysis
The Arabic version of the Internet Addiction Test (IAT) was ad-
ministrated to assess the prevalence rate of IA among nursing students. Data were analyzed using the Statistical Package for the Social
The test was designed by Young (1998) and the Arabic version has been Sciences (SPSS) version 23 for Windows. The level of significance for all
validated in a study conducted in Lebanon by Hawi (2013). It is a self- analysis was set at p < 0.05. The first stage of the quantitative data
rated test that contains 20 items. Each item was scored on a scale of analysis described the participants' responses to the variables. The
0–5, from 0 (Does not apply) to 5 (Always). Three categories described second stage employed descriptive statistics such as mean and standard
the level of AI: a score of 20–49 suggests controlled or average use (mild deviation to analyze social demographic characteristics as well as IA
addiction), 50–79 occasional or frequent problems (moderate addic- level, stress level and ways of coping with stressors. Strength and di-
tion), and 80–100 significant problems (severe addiction). IA was as- rection of relationships between students' IA, perceived stress and
sessed by summing the scores, and those ≥50 were classified as IA coping behaviours were determined using Pearson Correlation
(Young, 1998). IAT is the most widely used instrument for the mea- Coefficients (Field, 2013).
surement of IA, the validity and reliability of Chinese, Arabic and
English versions confirmed (Cronbach alpha ≥0.90) (Chong Guan 4. Results
et al., 2015; Khazaal et al., 2008).
4.1. Prevalence of IA
3.3. Perceived stress
Of the 163 students who returned the completed questionnaires,
The Perceived Stress Scale (PSS) is used to assess global perceptions 110 participants (67.5%) met the criteria for IA, as indicated by
of stress. The 14 items indicate how unpredictable, uncontrollable and scoring > 50 on the IA scale Advanced academic-level students are

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Table 1 Table 2
Sociodemographic data of the study participants. Results of the comparison between IA and not-addicted in total score and
subscales.
Element %
Internet Not addicted P value
Gender Mean ± (SD) Mean ± (SD)
Female 100%
Male 0% Salience 17.61 (3.10) 11.500 (3.53) < 0.05
Age Excessive use 17.66 (3.26) 11.50 (2.12) < 0.05
< 20 years 38.5% Neglect work 11.49 (2.16) 8.01 (1.01) < 0.05
21–25 years 55.2% Anticipation 7.49 (1.62) 5.21 (0.74) < 0.05
26–30 year 6.3% Lack of control 10.67 (2.30) 7.01 (1.41) < 0.05
Family type Neglect social life 7.01 (1.51) 6.012 (0.21) < 0.05
Nuclear 81.9% Total 70.21 (8.49) 49.36 (6.53) < 0.001
Extended 18.1%
Family income
< 10,000 SAR 48.8%
Table 3
10,0000–29,900 SAR 45.05
> 30,000 SAR 6.3% Utilized coping strategies among the study participants.
Parent employment Internet addicted Not addicted P value
Both parents employed 20.8% Mean ± (SD) Mean ± (SD)
One employed 25.0%
Neither employed 51.0% Avoidance 14.75 (5.66) 9.75 (2.13) < 0.05
Living status Problem Solving 17.24 (4.32) 9.41 (2.32) < 0.05
With family 95.8% Stay Optimistic 11.49 (2.16) 8.01 (1.01) < 0.05
With friend 3.2% Transference 7.62 (2.62) 6.50 (3.54) 0.12
Alone 1.1%
Father education level
Primary 15.0%
Secondary 51.15 self-esteem score, the total self-efficacy score was significantly higher
Tertiary or higher 33% among the IA group: 20.77 versus 14.65 in the non-IA group. This was
Mother education level significant at p < 0.05. Furthermore, the depression level was sig-
Primary 29.8% nificantly higher among the IA group. Table 3 presents the study par-
Secondary 40.4%
Tertiary or higher 29.8%
ticipants' scores in relation to self-esteem and depression.

4.2. Relationship between coping strategy, self-esteem, and depression with

more subject to IA than first- and second-year students. In relation to IA
socio-demographic data, the number of participants who came from
nuclear families and had a family income of > 10.000 SAR was sig- The results of the relationship between the study outcomes and IA
nificantly higher in the IA group. Conversely, other demographic are shown in Table 4. The analysis shows a significant positive corre-
variables showed no statistical significance varied between IA and non- lation between the IA sub-scales and avoidance coping mechanism
IA groups. The socio-demographic and clinical characteristics of the (p = 0.04). This indicates that students with the avoidance coping
study sample are shown in Table 1. mechanism were more likely to experience a higher level of IA. There
The analysis of the Internet Addiction Scale domains revealed that was, however, a significant negative correlation between the problem-
the salience sub-scale average (17.61 vs 11.50) was significantly higher solving strategy and total IA scores (r = −0.36; p < 0.05). This in-
in the IA group than the non-IA group (p < 0.5). In addition, the dicates that students who use problem solving as a coping strategy were
Internet was used excessively among the IA group at a significantly more likely to experience a lower level of IA. Self-esteem was also ne-
higher rate than the non-IA group (p < 0.05). This result appeared in gatively correlated with the IA group. This suggests that students who
another domain of the IA scale, as reflected in neglecting work. IA had higher self-esteem were less likely to be IA. Correlation analysis
participants were more likely to show work neglected (average 11.49) was performed to examine the association between socio-demographic
than the non-IA group (8.01). Similarly, a high rate of anticipation was data and IA. There was a negative correlation between students' age and
noted among the IA group with an average of 7.49, in contrast to the IA (r = −0.133, p < 0.001), indicating that students who are younger
non-IA group who felt less compelled to use the Internet when offline, have a higher level of IA (Table 5).
with an average of 5.21 (p < 0.05). Moreover, the IA group admitted
to trouble in managing their time as they spent a significant proportion 5. Discussion
of time online, and this was noticed by others. The average for the lack
of control sub-scale was 10.67 vs 7.01. This difference was statistically The purpose of this study was to identify the prevalence of IA and its
significant at p < 0.05. Additionally, IA respondents indicated they association with psychological distress, self-esteem and coping strate-
were more likely to go online as a coping mechanism to handle external gies among nursing students at FCMS. According to the author's
situation problems and/or to reduce mental tension and stress, as re- knowledge and based on the literature review, this is the first study to
ported in Table 1. investigate the relationship between psychological distress, self-esteem
Regarding the coping mechanisms, the results indicated a mixture. and coping strategies, with IA, in the Saudi population.
For instance, avoidance strategy was ranked the highest among the IA The study found a high prevalence (67.5%) of IA among FCMS
group (mean = 14.75) compared with the non-IA group (9.75). This
was statistically significant at 0.05. In addition, the problem-solving Table 4
strategy was statistically significantly higher among the IA group with Total self-esteem and depression scores.
an average of 17.24 as against 9.41. The stay-optimistic strategy was
Internet addicted Not addicted P value
commonly used among the IA group (mean 11.49 vs 8.01; p < 0.05).
Mean ± (SD) Mean ± (SD)
However, transference was the least used among the study participants
and the difference between groups was non-statistically significant. Self-esteem 20.77 (4.72) 14.65 (4.75) < 0.05
More details are presented in Table 2. With regard to the Rosenberg Depression 21.24 (4.97) 14.37 (5.69) < 0.05

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A.A.-H. Hasan and A.A. Jaber Nurse Education Today 81 (2019) 78–82

Table 5 might be explained by the ability to purchase advanced technology,

Correlation between IA with coping behaviours, self-efficacy and depression. offering faster and easier access to the Internet than was possible three
Pearson correlation (r) Significance years ago; and also, because the mean income in Saudi Arabia (this
study) is higher than that of Jordan (Al-Gamal's study).
Salience 0.216 0.03 As a member of a nuclear family, more resources are available to an
Excessive Use 0.226 0.02
individual than in an extended family, and there would be less com-
Neglect work 0.133 0.07
Anticipation 0.219 0.03
petition for access to the Internet, which might explain the higher
Lack of Control 0.214 0.03 prevalence of IA among students from nuclear families. The finding
Neglect social life −0.132 0.01 agrees with those of (Sharma et al., 2017). The study found that stu-
Avoidance 0.74 0.04 dents in the IA group used all coping strategies, but with a preference
Problem solving −0.36 0.03
for avoidance and problem solving rather than staying optimistic; the
Stay optimistic −0.092 0.15
Transference −0.116 0.21 transference coping strategy was used almost equally by both groups.
Self-efficacy −0.36 0.03 The negative correlation between problem solving and IA agrees with
Depression 0.24 0.04 Al-Gamal et al. (2016). The more problem-solving behaviours are em-
Age −0.64 0.02
ployed, the less IA is found; this can be explained by the student's ability
to find different strategies, solutions, and thoughts if they face pro-
blems, rather than simply searching the Internet, which could lead to
students; this is consistent with Al-Gamal et al.'s (2016) findings, al-
IA. The greater the avoidance strategy, the higher level of IA; this could
though ours is even higher (67.5% vs 40%). Again, this could be ex-
be explained by low self-esteem and low problem-solving skills and
plained by the recent rapid increase in Internet and mobile use in both
behaviours, which might drive the student to use the easiest way to
academic and non-academic settings (ICT, 2017), as well as the in-
respond to stressors, by avoiding them and using the Internet instead,
creased use of the Internet and advanced technology in academic in-
thus increasing their IA. The study found no significant difference be-
stitutions, including blackboard learning (at FCMS), and blended, in-
tween the two groups in terms of staying optimistic as a coping strategy;
teractive and distance learning. The findings of socio-demographic
that staying optimistic has no association with IA agrees with Al-Gamal
characteristics in the IA group are consistent with those of Rao et al.
et al. (2016); the low level of use of transference by both groups also
(2017) as regards the negative correlation between age and number of
agrees with these authors.
family members with IA. This could be related to the decreased interest
For self-esteem, the findings showed that students with higher self-
in the Internet and with decreased power and the senses that come with
esteem had lower prevalence of IA, agreeing with (Shaw and Black,
age.
2015; Skues et al., 2016). Many factors contribute to a good under-
The findings of this study, that advanced-level students are more
standing of stressors and positive behaviours; understanding oneself
Internet addicted than first- and second-year students is in accordance
and having a higher self-esteem may contribute to positive coping be-
with the results of Al-Gamal et al. (2016) and Bakken et al. (2009). This
haviours, in turn leading to less dependent and addictive behaviours,
can be explained from different aspects. For example, Sharma et al.
and conversely explaining the negative correlation between self-esteem
(2017) despite the current negative correlation between age and IA, it is
and IA.
expected that IA prevalence will increase among younger people, in-
Depression was found to be positively and significantly correlated
cluding the more specific group of university students. At present, the
with IA, as indicated in Fig. 1, agrees with the previous findings of Shaw
beginning students have more time, a lower study workload, and fewer
and Black (2015). Skues et al. (2016) also found that boredom and
requirements to meet. The effect of IA on the study outcome is illu-
loneliness were significantly and positively correlated with IA, while
strated in Fig. 1.
with the study of Adib-Hajbaghery et al. (2012) on university students
The IA group was found to spend longer on the Internet, with
found an association between IA and depression, somatization, ag-
greater lack of control, than the non-addicted group. However, this
gression, and psychosis, excluding paranoia. Lee (2014) also considered
finding disagrees with Al-Gamal et al. (2016), who found no association
the social interaction anxiety to be a predictor of IA. Moreover, our
between the time that students spend on the Internet and IA; this could
study finding of the association between depression and IA agrees with
be explained by the nature of Internet technology available today, with
Younes et al. (2016), Ha and Hwang (2014) and Bakken et al. (2009).
the nature of exposure different from previous years and leading
Although a large proportion of the accessible population was recruited
eventually to IA. This study found that income of > 10,000 SAR is as-
for the study, a bigger sample would offer greater understanding of the
sociated with higher levels of IA, again disagreeing with Al-Gamal and
problem, as would conducting the study over different points of time.
colleagues, who found no association between income and IA. This

Fig. 1. The internet addiction impact on the study outcomes.

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6. Conclusion association with psychological distress and coping strategies among university stu-
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