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Introduction

Internet usage and its biological, psychological and social impact on overall health and well‑being is an increasingly relevant yet poorly addressed topic in systematic research to date⁽¹⁾. Current behavioural addiction studies and revisions of classifications of mental disorders take strides to develop measures of internet usage, clear definitions of problematic internet usage and internet addiction^(2-6) and to gather scientific evidence for internet addiction as potential diagnostic category within the newly coined behavioural addictions field^(4-10). 

Studies on the biological effects of internet addiction have shown physical symptoms due to sleep deprivation induced by internet addiction⁽¹¹⁾, modification of reward, sensory-motor coordination and impulse control in prolonged internet gaming⁽¹²⁾, changes in the volumetric size of the ventral striatum of the brain, and the similarity of dopamine release in drug abuse and video gaming addiction⁽¹²⁾.Studies on the psychological effects of internet addiction have shown greater tendency of ADHD, depression, anxiety, symptoms of withdrawal, and difficulty thinking^(13,14).

Studies on the social effects of internet addiction have shown social withdrawal, avoidance of household chores, distancing of family members⁽¹⁰⁾, conflict with parents⁽¹⁴⁾, and poor academic performance⁽¹⁵⁾.

Study aim

The aim of this study is to investigate the associations between the level of internet usage and self-reported well-being, and also the association between the level of internet usage and demographic parameters (age, gender, faculty, year of study, relationship status, country of permanent residence) in foreign medical students.

Materials and method

Participants

The current study included 110 students in the English and French sections from years 1 through 6 attending general or dental medicine at the “Iuliu Haţieganu” University of Medicine and Pharmacy from Cluj-Napoca, Romania. Only students who signed the informed consent participated in the study. Data was collected in the period 1.05.2019 – 31.05.2019.

Assessment tools

This study used three self-assessment questionnaires:

• The Internet Addiction Test (IAT) ^(16,17)

The IAT questionnaire used in the study is based on Young’s latest model, and includes 20 questions. The frequency of behaviours regarding internet use included in the items is scored on a 1 (rarely) to 5 (always) Likert scale.
 

• World Health Organization well-being questionnaire (WHO-5)⁽¹⁸⁾

To assess the level of well-being of the students in the sample we used the WHO (World Health Organization) self-reported well-being questionnaire composed of 5 items. The well-being domain in each item is scored from 0 (poorest well-being) to 5 (highest well-being), providing a total score between 0 and 25 points.
 

• Demographics questionnaire

We collected demographic data of students such as age, gender, country of residence, relationship status, study year, and study faculty.

Statistical assessment

The data collected from participants were analyzed in IBM SPSS version 24. One-sample Kolmogorov-Smirnov test was used to assess the distribution of quantitative continuous variables. Student t test or ANOVA was used to compare normally distributed variables, according to the number of samples compared. Pearson’s and Spearman’s correlation were used, as appropriate, to assess the association between variables.
 

Results

The study included 110 foreign students from English and French sections of the “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania, aged from 19 to 36 (median age: 24 years old), 64% female. 89% of the sample studied medicine, and 11% studied dentistry. The distribution of the sample according to study year was as follows: year 1: 6%; year 2: 10%; year 3: 18%; year 4: 21%; year 5: 18%; year 6: 27%.

The participants’ countries of residence were categorized into EU and economically associated countries, and Non-EU, respectively, based on access to similar social and economic opportunities of citizens from countries in EU and those economically associated with EU. 90% of the sample reported a EU or economically associated citizenship; more specifically, the most frequent citizenship reported was German, in 39% of the sample.

Regarding relationship status, 55% of the participants reported they were single, 42% – dating, and 3% – married.

Discussion

The largest part of the study sample includes students from medicine. Only 11% of participants are dentistry students. Regarding study year, 27% of students are in the sixth year. The largest part of the study sample have their residence in EU countries or countries associated with EU. Germany is the country of residence most frequently reported by participants, with 39% of the sample. Most participants in the study are females. More than half of students interviewed reported that they were single.

This study shows that male students reported higher levels of internet usage than female students, but the differences in scores were not statistically or clinically significant. Our study includes an academic, non-clinical, young, culturally diverse and mostly female sample. Another study on an adult non-academic sample (62% men) with problematic internet usage (PIU) showed that there was a significant difference in levels of internet usage between genders⁽¹⁹⁾. Another study on an Indian population of engineering students also reported significantly higher levels of problematic internet usage in men compared with women⁽²⁰⁾.
 

Also, the study shows that participants in dentistry reported higher levels of internet usage than students in medicine, but the differences were not statistically or clinically relevant.

Regarding the level of internet usage according to study year, the students from the second year reported the highest level of internet usage, and the students from the fourth and fifth years reported the lowest level of internet usage. Statistically, the differences across the sample are not significant, but clinically the differences between second year students and four or five year students are relevant.
 

The study also shows that the level of internet usage is significantly lower in students from EU countries than in those from non-EU countries. The differences between the two categories of students are statistically and clinically relevant. This suggests that further studies are required, with a larger academic sample that would allow an assessment according to country of residence.

Regarding relationship status, the participants who reported that they were married also reported higher levels of internet usage than those who were single or dating. The differences are clinically relevant, but not statistically significant. Since the sample of married students is small, further studies with a larger sample are required in order to clarify the findings. To this date, studies which address marital status in relationship with internet usage are scarce and focused on adolescents and factors regarding their families of origin, including marital status of parents, not of participants⁽²¹⁾.
 

The current study of a young adult academic sample shows that the level of internet usage is not associated with the age of the participants. This result contradicts the data from another study of young persons aged 11-18, which reports that the level of internet usage was the highest among the 15-16-year-old age subgroup and lowest in the 11-12-year-old age subgroup⁽²²⁾.

A relevant result of this study is the significant negative association between the level of self-reported well-being and the level of self-reported internet usage. To this date, there are no other studies in regards with the relationship between the level of internet usage and well-being in medical students. The latest study on this topic refers to internet usage and well-being in adults from underprivileged communities⁽²³⁾. The most extensive current study of problematic internet usage in youth also focuses on well-being, but includes a European, highschool academic population, a different assessment tool for internet usage and a more extensive approach of risk behaviours⁽²⁴⁾.

Another relevant result of this study is that the level of self-reported internet usage is significantly higher in medical students from non-EU or associated countries, compared with those from EU and associated ones. To this date, there are no other comparative studies regarding internet usage and addiction in medical students from EU and non-EU countries.

Study strengths

In this study, we decide to take a different look on internet usage. Instead of using Young’s diagnostic cut-offs for internet addiction, we take a look at the internet usage level in relationship with demographics and well-being. We find important and significant information on the negative association between internet addiction test scores and well-being scores. This shows that further prospective studies, including a larger sample of students, are required and necessary for a better prevention of problematic internet usage and its negative consequences.

Study limitations

The most important limitation of the study is the cross-sectional design which does not allow prospective assessment of the sample. Also, the sample includes students from both the English and French sections, and the study does not address the differences between them. Another limitation is the sample size. Also, we did not use Young’s cut-off scores for the Internet Addiction Test due to the fact that the instrument is not validated on the studied population.

The limitations of this study can be addressed in further studies with follow-up of participants, validation studies on the academic population (foreign medical students) for the main instrument used and development of an appropriate diagnostic tool with reliable diagnostic cut-off scores.

A downside of the IAT test is that it does not assess what the internet is being used for. The test assumes that all activities done on the internet may have the same impact on the health of the individual regardless of the type of internet usage. Based on the evidence of this study, further studies should also include a qualitative assessment of types of internet usage in participants, level of perceived stress and types of coping mechanisms generally used, in order to have a better understanding of the impact of internet usage on medical students and factors mediating this impact.

Conclusions

• Higher levels of internet usage in medical university foreign students are associated with lower levels of self-reported well-being.

• The level of internet usage is significantly lower in students from EU and associated countries than in those from non-EU countries.

• The levels of internet usage differ in students according to study year. Students in second year have the highest levels and those in years 4 and 5 have the lowest levels. Although the differences are not statistically significant, they are clinically relevant.

• Further assessments of internet usage cut-offs for internet addiction, type of internet activities of students, perceived stress and coping mechanisms can give a better understanding of the role of gender, relationship status, age and faculty in the level of internet usage and its health impact.