Internet addiction in students from an educational institution in Southern Brazil: prevalence and associated factors

Abstract Objective To evaluate the prevalence of Internet addiction (IA) and its associated factors among students at an Educational Institution in Southern Brazil. Method This is a cross-sectional study, targeting a sample of students aged from 14 to 20 years. They were selected by random sampling to be representative of the 4038 students enrolled at the institute at the time. IA was assessed using the Internet Addiction Test (IAT). Screening for anxiety and/or depressive disorders was performed using the Well-Being Index (WHO-5). Results The prevalence of IA was 50.8% and the rate was higher among individuals who had screened positive for depressive or anxiety disorders than among those who had not (p = 0.003). There was an association between IA and access to certain types of content, such as gaming (p = 0.010), work and study related content (p = 0.030), and using the internet to access sexual content (p < 0.001). Conclusion Further studies are needed to confirm the high prevalence of IA and explore factors associated with it in samples with similar characteristics to ours. The associations between this dependency and positive screening for anxiety and/or depressive disorders and the types of content accessed are an alert to the existence of these important relationships and illustrate the importance of studying them further. Knowledge about these associations provides an opportunity to implement measures for prevention, such as psychoeducation, and to offer adequate treatment.


Introduction
The internet has become an important tool for social interaction and communication, as well as for accessing information, by creating a new virtual public space. As new forms of technology have been developed, it has also become more widespread and nowadays can be accessed via devices such as tablets and mobile phones.
This communication network has unique features such as the capacity for quick and easy gratification, which, in addition to the increasing popularity of the Internet, makes it an instrument with the potential to generate psychological dependence. There is growing evidence of cases of individuals who suffer from internet addictive behaviors. 1,2 One review has shown that the mesocorticolimbic reward system of subjects that experience internet addictive behaviors is impacted in the same manner as with substance abuse, and that the cue-induced craving phenomenon is likewise affected. 3 The symptoms of excessive use of the internet have been found to be commonly associated with behavioral addictions and present neurological similarities to other addictions. 4 Although the mechanisms of abuse of the internet and risk of relapse. 6,7 Internet use has been identified as a problem for many years, since access became widespread, allowing its excessive or problematic use. The first proposal for Internet Addiction (IA) diagnostic criteria was presented by Young. 8 Presence of five or more of the criteria was used as a cutoff to identify addicted internet users. These criteria include presence of an excessive concern with the internet; a usage pattern of between 40  In the literature, the most common terms used to describe the phenomenon are Internet addiction; problematic Internet use; pathological Internet use; and Internet abuse. 5,11,12 This study adopts the term "Internet addiction" to refer to the subject because this was the first term to be used in the literature and is also the most often used for practical purposes. 5,13 Studies around the world have found that young age is one of the risk factors most associated with IA, 12,14-16 while one study identified that being a student is also a risk factor. 15  Only one country was analyzed in South America (0%), revealing a paucity of data for the region. 24 Results are generally very heterogeneous, especially data on prevalence. This is partly due to the fact that the instruments used and the diagnostic criteria are not standardized and also due to sociocultural differences between the populations studied. Kuss et al. 13

Internet Addiction Test (IAT)
The IAT-Portuguese version 1 was used to assess Internet Addiction on the basis of DSM-IV diagnostic criteria for pathological gambling. 8 The IAT is the instrument for IA assessment most widely-used in the world. It is a valid and reliable instrument for measuring the extent of a person's involvement with the internet that classifies addictive behavior in terms of mild, moderate, or severe impairment. The IAT comprises 20 items, each of which is rated on a fivepoint Likert scale: "rarely or never" (1), "occasionally" (2), "frequently" (3), "often" (4), or "always" (5). The total IAT score is obtained by adding the scores for each response provided by the participant. The higher the score, the higher the level of addiction to the internet;   hours. There were no differences in computer usage patterns between nonaddicts, mild addicts, moderate addicts, and severe addicts (p = 0.336). We also assessed time spent using tablets, but not enough subjects used this type of device to perform statistical analysis.

Results
The prevalence of IA was 50.8%, considering subjects with mild, moderate, and severe IA. Table 2 30 We also observed that Goel et al. 32  In Turkey, a 16.2% prevalence rate was found in a sample of 468 adolescents aged from 12 to 17 years. 31 In a setting closer to us, Machado et al. 18 found a 21% prevalence rate when assessing 91 teenagers from two Brazilians schools. to 73.3% in Italy. 36 In Brazil, Méa et al. 28 also presented data this way, and found a 61.3% prevalence rate in a sample of 150 Brazilian high school students. We can therefore conclude that our prevalence rates are within the range of IA rates reported around the world, even when assessed in different ways.
In our sample, 80.9% screened positive for depression and/or anxiety symptoms, suggesting that further mental health assessments should be carried out in these subjects. Grouping together mild, moderate, and severe IA, the prevalence was higher among those who screened positive for mental health issues (55.5%), but the difference did not attain statistical significance for moderate and severe dependence.
A meta-analysis involving eight studies and 1641 patients with IA that investigated the relationship with psychiatric comorbidity found positive associations between addiction and anxiety and/or depression, with prevalence rates for these mental disorders of 20.3% and 14.3% respectively. 37 It has been established that depressive symptoms are strongly associated with IA in the adolescent population 18,[30][31][32]34,35,38 and also with anxiety symptoms. 18,31,32,34,39 It was also observed that both depressive 20,33,40 and anxiety 33 symptoms can possibly predict internet addiction behaviors. According to Li et al., 33 who observed that these symptoms were predictive factors, adolescents with internalizing problems (i.e., anxiety, depression) may use the internet as a coping strategy to alleviate their distress. They may seek recreational activities, such as gaming and anonymous communication, among others, to achieve this relief.
In our study, we investigated the main type of internet usage in the sample. We found, in our sample, that playing online games was associated with IA.
Other studies have found a similar relationship between online gaming and IA. These researchers also found that another main usage of the internet was for cyber relationships. 23,41 However, that association was not observed in our sample. Internet gaming disorder was included in the current version of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 42 as an important condition, using criteria for substance abuse and gambling disorders. However, it is still regarded as a condition in need of greater study to be considered a formal disorder. 43 Thus, the relationship between internet use for gaming and IA is not surprising, although we need to be aware that the two conditions are not the same diagnosis, although they are sometimes confused. 44 Playing online games excessively may be a way to avoid real-life problems through virtual social contact or achievement, since they offer something to people that they cannot find elsewhere. 45 One hypothesis for the growing use of the internet for online games is that they provide a whole virtual world where socially reclusive adolescents can assume another identity through their online characters, enabling them to be whoever they want to be.
Use of the internet to access pornographic content was significantly higher in subjects who had IA when compared to those who did not (70.3% vs. 47.4%, respectively). This type of access is an important factor related to IA. When an individual compulsively and chronically watches internet pornography, dopamine is continually released into the reward system, stimulating neuroplastic changes that reinforce the experience. 46 Findings from one study suggest that watching internet pornography exacerbates the risk of IA over time. 47 Taking this into account, the observation made in the present study is unsurprising and to be expected.
There are studies in the literature establishing a clear relationship between internet pornography and IA, but additional studies are still needed to better understand this. 3,46,47 Significantly more subjects who did not have IA accessed work and study related content on the internet than those who did. These findings point to a possible factor of protection against IA in subjects who access this type of content. One possible explanation is that people who access these contents do it because they have commitments to their studies or occupation, leaving less time to overuse the internet. There are no other studies in the literature reporting this relationship, therefore, we could not make comparisons. Our findings on the matter suggest a need for more studies to identify the details of this possible protection factor.
Accessing the internet to look for information and using social media were not related to IA in this sample.
It might be expected that use of social media would be related to IA, since their use has become a popular tool for social interaction and they constitute an important interactive tool for young people because they provides features that this group seeks, such as connecting people and forming online identities. 48 From our data, it appears that both groups used the internet to access social media to the same extent, and social media was the type of content most accessed in the sample. One could suggest that social media are so ingrained in the youth lifestyle that they are no longer a factor one can relate to IA, since almost everybody uses them, with stronger relationships restricted to other types of content, that are more specific, less rooted in the core of a group, and accessed by fewer subjects, such as gaming or pornography.
Our sample mainly accessed the internet using their smartphones, with an average of 7.3 hours spent online per day. The rapid increase in smartphone users can be observed all over the world; in some places, users show a clear preference for smartphones over computers. 49,50 Nowadays smartphones are part of people's routines, and excessive use is a danger, since they are small portable devices that are constantly accessible, making it easier to overuse them. 51 Many adolescents have their smartphones with them throughout the day, due to their great mobility and functionality. 49 All internet content and games can be accessed easily through those devices, making this ease of access even more dangerous. 52 Although use of smartphones provides mobility, overusing them throughout the day can become a problem when users start paying more attention to their devices than to what is happening in their surroundings. 50 One limitation of our study, which is important to emphasize, is that our findings of depressive and anxious symptoms were obtained using a screening instrument and not with a diagnostic interview or questionnaire. Of course, the prevalence of positive screening was high (80.8%), especially when we know that United Nations estimates mental health disorders among adolescents at around 7~12.7% in Brazil. 53 We should expect that if another survey based on our paper was conducted with this sample, assessment of mental health problems should be more thorough. It is nevertheless possible to infer that there was an association between IA and altered emotional states with characteristics that are common to depressive or anxious symptoms.
Another limitation of our study, and actually of most of the studies investigating IA, is that the scientific literature on this matter has been hindered by methodological problems. Studies have employed inconsistent and heterogeneous definitions and measurements, because criteria are not established, which affects the results of epidemiological studies. 43 It is therefore an urgent task for the scientific community to establish consistent and consensual criteria for defining and identifying IA, making it possible to better compare and understand the characteristics and specifics of this addiction in different populations and regions of the world.

Conclusion
Our study aimed to increase awareness of the presence of IA in this under-investigated population. these data, we seek to encourage new research, in the hope that it will contribute to improved understanding of this complex phenomenon and the specific nature of the problems associated with internet use among these individuals.

Disclosure
No conflicts of interest declared concerning publication of this article.