INTRODUCTION
The use of the Internet among students has increased in recent years. Internet use is nearly ubiquitous among students. The academic use of the Internet is primarily intended for learning and research purposes. The Internet has become an important part of student life.
However, excessive Internet use has also become a significant mental health concern among students. Several studies globally, and numerous anecdotal media reports, suggest possible links between overuse of the Internet by adolescents and young adults and negative health consequences such as depression, attention deficit hyperactivity disorder, excessive daytime sleepiness, problematic alcohol use, or injury. Excessive Internet use has also been associated with negative academic consequences such as missed classes, lower grades, and academic dismissal.[1] Similar observations have been made in the Behavioral Addictions Clinic (BAC) started around a year back at All India Institute of Medical Sciences, New Delhi. Psychological and environmental factors in the lives of students may leave them disproportionately vulnerable to problematic Internet use (PIU). Developmental stressors coupled with increased access to Internet services may contribute to college student's vulnerability to PIU.[2]
PIU is characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding computer use and Internet access that lead to impairment or distress.[3] PIU has been described under various pseudonyms as computer addiction, Internet addiction (disorder), and pathological Internet use.[456]
PIU has become a serious behavioral health problem in Southeast Asia. Despite the increasing relevance of this topic a systematic review of the existing literature on PIU among students in Southeast Asia examining prevalence as well as sociodemographic and clinical correlates is lacking. Our goals were to review the existing studies from this region and examine: (1) the prevalence for PIU among students; (2) explore for sociodemographic and clinical correlates; and (3) assess the physical, mental, and psychosocial impact of PIU in this population.
MATERIALS AND METHODS
All studies (cross-sectional, case–control, and cohort) conducted among population of the Southeast Asia, involving students (school students to postgraduate students) of any age which explored etiological factors and/or the prevalence or any other factor associated with PIU/Internet addiction were considered eligible for the present review. Study selection was conducted in two phases: In the first phase, abstracts and titles were selected and in the second phase, full texts of the selected titles were obtained and read to determine the final sample set. The epidemiological questions investigated in this study were as follows: (1) What is the prevalence of PIU among students in Southeast Asia and (2) what are the sociodemographic as well as psychosocial factors associated with it. Studies investigating physical and mental health outcomes associated with PIU were also included.
Search strategy
The electronic databases of PubMed and Google Scholar were systematically searched for the relevant published studies in October 2016. All the studies published till and including October 2016 were eligible for inclusion. Only the articles published in English language were selected. The following search terms were used: “Internet addict*”, “Internet gaming addiction”, “gaming addiction”, “Internet Gaming Disorder”, “pathological Internet use”, “excessive internet use”, or “problematic Internet use” AND (India/Bangladesh/Nepal/Indonesia/Timor Leste/DPR Korea/Thailand/Myanmar/Maldives/Sri Lanka). Search was limited to include only studies conducted in student population (school students/undergraduate/postgraduate students of any discipline). The search was conducted independently by two authors (AM and PS).
Studies retrieved from the databases were selected after reading the abstracts and titles, following a calibration exercise with 10% of the studies read by two independent reviewers to determine interexaminer agreement (Kappa: 0.68–0.97). Disagreements were resolved by consensus. The following were the inclusion criteria for the initial selection process: reviews, epidemiological studies with subjects who fulfilled the criteria of being a student enrolled in school, undergraduate or postgraduate course in any discipline, studies addressing risk factors for PIU/Internet addiction, and studies reporting socioeconomic indicators. No cohort studies or randomized controlled trials were found by the search process. For this reason, cohort studies were not considered in this review. Reviews were also not included, although their reference lists were searched in turn for any studies not retrieved by the electronic search. Qualitative studies, commentaries, and expert opinions were not included.
Data synthesis
The extraction of the data was based on the study design, population characteristics, and the type of socioeconomic indicators used. A high degree of heterogeneity was found among the methodologies and types of socioeconomic indicators used. Measures of PIU and socioeconomic variables had several categories and cut points. Therefore, it was not possible to group data for meta-analysis. Instead, narrative synthesis was conducted in this review.
RESULTS
Our search strategy initially yielded 549 articles, 295 of which were initially eligible based on their publication in English language in a peer-reviewed journal. Of excluded studies, 186 were not conducted in the countries under the Southeast Asia and 58 were not focused on students, and 13 were in languages other than English [Figure 1].
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Figure 1: Search results.
A total of 38 studies met the inclusion criteria and were included in the review. These studies are presented in Table 1. The included studies mostly used community samples and focused on the sociodemographic characteristics of the population as well as the prevalence of PIU/Internet addiction among students. All the studies were cross-sectional in nature. No cohort studies could be obtained. There were also no intervention studies conducted for PIU in Southeast Asia.
Table 1: Summary of the studies included in the current review
Country of origin
Of the 38 studies included in the current review, the most were from India (27),[16171819202122232425262728293031323334353637383940414243] followed by Nepal (three),[101112] Bangladesh (two),[78] and Sri Lanka (two).[1314] There was one study each from Bhutan,[44] Indonesia,[9] and Thailand.[15]
Study population
Six out of the 38 studies were conducted among school students, 13 in graduate/postgraduate college students, and 19 in students of health sciences (medical, nursing, etc.). The sample size of the studies ranged from 30 to 3264.
Prevalence of problematic Internet use
Most of the studies (23 out of 38) used the Young's Internet Addiction Test (IAT) to quantify the level of Internet use. The IAT is a 20-item self-report scale that measures the extent of Internet addiction based on criteria for substance dependence and pathological gambling and includes loss of control, neglecting everyday life, relationships and alternative recreational activities, behavioral and cognitive salience, negative consequences, escapism/mood modification, and deception.[45] However, the cutoff scores for defining the PIU varied across the studies. In majority of the studies, an IAT score <50 was taken as that of an average Internet user and a score of >80 reflected Internet addiction. A score of 50–79 reflected PIU. However, few studies have taken the IAT score <20 to be of normal users and quantified Internet addiction as mild, moderate, and severe based on IAT scores of 20–49, 50–79, and 80–100, respectively. The prevalence of Internet addiction across these studies varied from 0% to 47.4%. The prevalence of over users/problematic use ranged from 7.4% to 46.4%. Among other problematic behavior related to Internet use, online pornography use, fraudulent financial transactions, and cyberattacks were reported, among which online pornography use was most common. The prevalence of online pornography use ranged from 20.8% to 40%.
Another assessment measure used was the Online Cognition Scale,[46] which is a 36-item questionnaire that measures cognitions related to PIU and includes subscales on loneliness/depression, diminished impulse control, social comfort, and distraction. In another study, the Chen's Internet Addiction Scale [47] was used, which is a 26-item self-report measure of core Internet addiction symptoms, including tolerance, compulsive use, withdrawal, and related problems (i.e., negative impact on social activities, interpersonal relationships, physical condition, and time management).
Sociodemographic correlates
The age of students included in the sample varied from 11 years to 26 years. Majority of the studies found male students to have more PIU than female students. Students in urban areas were found to have more PIU compared to rural areas.[24] More number of students using smartphones were reported to be addicted to the Internet than those using simple phones.[21] An association has been found between time spent on using Internet per day and Internet addiction by few of the studies. Krishnamurthy and Chetlapalli [31] reported Internet addiction to be associated with male gender (adjusted odds ratio [AOR] 1.69, 95% confidence interval [CI], 1.081–2.65, P = 0.021), continuous availability online (AOR 1.724, 95% CI, 1.018–2.923, P = 0.042), using the Internet less for coursework/assignments (AOR 0.415, 95% CI, 0.263–0.655, P < 0.001), making new friendships online (AOR 1.721, 95% CI, 1.785–2.849, P = 0.034), and getting into relationships online (AOR 2.283, 95% CI, 1.424–3.663, P = 0.001). Chaudhari et al.,[26] exploring the factors associated with Internet addiction in medical students found male gender, staying in private accommodation, lesser age of first Internet use, using mobile for Internet access, higher expenditure on Internet, staying online for longer time, and using Internet for social networking, online videos, and watching website with sexual content to be significantly associated with Internet addiction.
A multicountry study by Balhara et al.,[32] including India found that Indians student scoring more than the cutoff score (>30) on the IAT were more likely to be males and had a significantly greater (P < 0.05) average duration of daily use of the Internet. Moreover, a significantly higher (P < 0.05) proportion of participants who scored above the cutoff score on the IAT social networking, chatting, gaming, shopping, and viewing pornography, as compared to those with lower scores.
Physical, mental, and psychosocial impact of problem Internet use
A study among college students from India found that students with Internet addiction had poor physical and mental health score on the Duke Health Profile.[25] Late night Internet surfing leading to sleep deprivation was reported in up to 31.53% college students.[10] Physical impairments in the form of insomnia (26.8%), daytime sleepiness (20%), and eye strain (19%) were also reported among problem users.[10]
A study conducted in Thailand among university students found three health risk behaviors (sedentary lifestyle, illicit drug use, and gambling) and three health outcomes (being underweight, overweight, or obese and having screened positive for posttraumatic stress disorder) to be associated with heavy Internet use.[2]
Another study conducted among postgraduate students in India demonstrated significant association between psychological distress (measured by Kessler's Distress Scale) and Internet addiction.[30] A cross-sectional study exploring Internet addiction among university students found 44.7% male and 41.6% female students had depression when measured using the Beck Depression Inventory.[15] A similar study conducted in medical students showed depression and anxiety scores to be positively correlated with severity of PIU.[26] A study exploring the role of personality traits associated with Internet addiction found that Internet addiction was positively correlated with neuroticism, loneliness (r = 0.272, P < 0.01), and negative affect, while it was negatively correlated with extraversion and positive affect.[22] The IAT scores were found to be significantly associated with negative affect score in another study.[43] However, in contrast to previous findings, another study from India among students of health sciences reported no significant association of PIU with mental status, global satisfaction, interpersonal relationship, or personality type.[28]
A number of studies have demonstrated association of decline in academic performance with the severity of PIU and related behaviors. A study from Nepal exploring the role of social networking through Internet among medical, dental, nursing, and allied health science undergraduate students found that almost two-third had a negative impact on their academic performance.[12]
DISCUSSION
The prevalence of severe PIU/Internet addiction ranged from 0% to 47.4%, whereas the prevalence of Internet overuse/possible Internet addiction ranged from 7.4% to 46.4% among students in Southeast Asia. PIU was associated with male gender, living in urban area, use of smartphone, lesser age at first Internet use, online relationships, social networking, and watching sexually explicit content on the Internet. It was also frequently associated with psychological distress, depression, anxiety symptoms, sleep deprivation, insomnia, daytime sleepiness, and eye strain. PIU frequently led to poor academic performance among students.
There are few major concerns with the current research exploring extent and consequences of PIU in student population in Southeast Asia. Heterogeneity in the assessment tools and cutoff parameters for PIU led to difficulty in comparing the results across the studies. There are no longitudinal studies to explore the association between PIU and subsequent development of psychopathology. Similarly, research studies have considered limited outcome variables from the perspective of psychological morbidity. The impact of PIU on emotional, behavioral, academic as well as cognitive functioning has not been systematically assessed till now. Overall, there is a lack of intervention studies to investigate the effectiveness of interventions among the students in Southeast Asia.
However, despite the current limitations, it was heartening to note that seven out of the ten Southeast Asia nations have started to focus on PIU in student population from a research perspective, which till recently was considered an obscure entity. Furthermore, clinical services are being set up for such persons in this region. A BAC has been set up at All India Institute of Medical Sciences (AIIMS), New Delhi, around a year back. In addition, resources on identification and management of behavioral addictions are being developed for the region. This includes recommendations on identification and management of behavioral addictions being developed by BAC, AIIMS in collaboration with the World Health Organization-Regional Office for Southeast Asia.[48]
Although majority of the studies are preliminary in nature, they provide the initial information regarding the status of PIU in this specific population from this region. The current studies provide incontrovertible evidence regarding the adverse effect of PIU on physical as well as mental health of students. The evidence thus generated should garner focus on the health consequences of PIU and spur further research with more robust methodology in order to fill the current gaps in our understanding as well as to formulate intervention strategies.
There are certain limitations to the current review. We restricted our search to two databases. Only English language publications were included in this review. Finally, it must be remembered, this is an active area of interest among researchers and more evidence is likely to have emerged between submission of this manuscript and its publication.
CONCLUSIONS
PIU among the student population in Southeast Asian Region has been a focus of attention in the recent years, and it has the potential to become one of the significant public health issues in the near future. There is an imminent need to conduct further research in this area in order to explore the protective and risk factors associated with it and also longitudinally assess the trajectories of the outcome. Furthermore, there is a need to formulate culturally-informed intervention as well as preventive strategies for the same.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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