The Effects of Internet Addiction on the Academic Performance of Medical Students at Omdurman Islamic University: An Online Cross-sectional Study

Background: In general, the emergence of new technologies such as the internet, social networks and providing opportunities to facilitate and improve global communications quality have created some threats, as Internet Addiction Disorder (IAD), which is an emerging psychological problem across the globe. Young dened it as “an individual’s inability to control his or her use of the internet, which eventually causes psychological, social, school, and/or work diculties in a person’s life”. Students are among the most critical internet and social networks, particularly during the coronavirus recent pandemic. The prevalence of internet addiction and its association with academic performance among Sudanese medical students has not been discussed yet. Therefore, this study aimed to assess the effects of internet addiction on medical students’ academic performance. Methods: This study was an observational descriptive cross-sectional study conducted on medical students at Omdurman Islamic University in Sudan from 321 sample size by stratied random technique. Data were collected using a questionnaire that contains four sections; the last one is the Internet Addiction Test (IAT), a 20-item scale that measures the presence and severity of internet addiction, developed by Young. Data were analyzed using the statistical package for social science (SPSS) version 24. A P-value < 0.05 was considered statistically signicant. Results: mean internet addiction score is 47.7, and most of the respondents (55.8%) show moderate-level addiction. The Internet Addiction Test’s application to medical students’ sample concerning the academic performance found no signicant association between Internet Addiction Test score and CGPA score.


Introduction
The internet is the basis of the revolution of information technology [1]. Social networks play a vital part in learning environments as a primary communicational channel and social support source [2]. Generally, the development of new technologies such as the internet, social networks and providing chances to ease and improve global communications have created some threats [3].
Ivan Goldberg rst proposed the term 'Internet Addiction Disorder' for pathological, compulsive internet usage [4]. This disorder's criteria are based on similar substance abuse disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [5]. However, internet addiction is not included in the o cial classi cation system of mental illness and disorder, and there are no formal diagnostic criteria available in the International Classi cation of Diseases and Related Health Problems (ICD-10) (WHO, [6]) and DSM-5 [7], except online gaming disorder.
Young de ned it as "an individual's inability to control his or her use of the internet, which eventually causes psychological, social, school, and/or work di culties in a person's life" [8]. Some authors mention that excessive internet use could be addictive behavior with mental health consequences [9][10][11]. Psychological and environmental factors in college students' lives may make them vulnerable to internet addiction [8,12].
Internet addiction among students has received considerable scholarly attention in recent years as students are among the most critical internet and social networks. The addiction to social networks has positive and negative academic, social and health implications [13]. Although a small fraction of students uses the internet for educational activities in a controlled way, a large percentage keeps wasting time by visiting 'non-educational' sites [14]. Some studies suggest that social media sites affect students' lives and their academic achievement, and the duration of their studies [15,16]. Internet addiction seems to be a relatively common behavioral addiction, and its prevalence has been approximately estimated just above or below 10% in different studies [17][18][19][20]; likewise, in studies performed on medical and allied health students, similar percentages have been reported [21,22].
As internet access is becoming widespread, problematic internet use is increasingly being reported [23].
Internet addiction is an emerging psychological problem across the globe. One report mentioned that internet addiction directly impacts depression, anxiety, and stress [24]. Worldwide, the number of internet users was 3.9 billion, up from 3.65 billion in the previous years, and 2.31 billion persons are social media users, delivering 31% global penetration [25,26]. Using the internet among students cannot be overemphasizing. Many students consider using social media sites as part of their lives [27]. It was found in one study that 90% of college students were Facebook users [28]. According to our data, the prevalence of internet addiction and its association with academic performance among Sudanese medical students has not been discussed yet. Therefore, this study aimed to assess the effects of internet addiction on medical students' academic performance at Omdurman Islamic University, which admitted online learning to compensate for the lockdown since the rst attack of the coronavirus pandemic in the rst half of 2020.

Participants:
This study was a cross-sectional study conducted on medical students at Omdurman Islamic University in Sudan. Medical students from the 2 nd , 3 rd , 4 th , and 5 th class who are using the internet for one year or more were included.
The sample size was 321 that were calculated using the following sample size: n=N/(1+(Ne 2 ) n= sample size N= total population e= level of precision A proportional strati ed random sampling technique was used for recruitment into the study. The sample was strati ed by the grade of the students, including class two until class ve. The number of students recruited for each class is shown in (Table 1):

Data collection tool
Data were gathered through a questionnaire that contains four sections. The rst one is about sociodemographic data, the second one about general questions about time spend on the internet and the type of programs used, the third one is about the Cumulative Grade Point Average (CGPA), which assesses the academic performance of the participants. The last one is the Internet Addiction Test (IAT), an instrument for diagnosing problematic internet use developed by Young [8], and available online open source. It is a 20-item scale that measures the presence and severity of internet addiction. This test wasdesigned as a research and diagnostic tool based on theDSM-IV criteria for pathological gambling diagnosis.The IAT is a symptom-measuring tool for internetaddiction. Internet addiction is de ned here as online compulsive behavior that causes hindering normalsocial interactions and increases daily stress andfeelings of solitude, anxiety, and depression. The testmeasures the degree of involvement in online activitiesusing responses on the 5-degree Likert type scale with a range of 0 to 5 (e.g., How often do you stay online longer than you planned? (0= never; 1= seldom; 2= occasionally; 3= frequently; 4= very often, 5= always). The total range of the questionnaire is from 0 to 100. Participants can be classi ed into several categories, and the result of 0 to 19 indicates the absence of addiction, from 20 to 39 indicates a low level of addiction, and the average online user, from 40 to 69, represents a moderate level of addiction. In contrast, the result of70 to 100 assumes a severe level of internet addiction.

Procedure
As our study was conducted in unusual circumstances, there were restrictions on most activities and movements, and person-to-person contacts are maximally reduced for fear of the spread of COVID-19 infection. Data collected using an internet-mediated questionnaire, a new valid, cheap and rapidly growing data collection tool in the social sciences.

Data analysis
Data were analyzed using the statistical package for social science (SPSS) version 24, after being primarily analyzed by Google Form. Descriptive analysis was used to describe the demographic data, time spent on the internet, type of programs used, CGPA and severity of the addiction. Demographic data, time spent on the internet and type of programs used were compared to the addiction score by ANOVA or T-tests after doing normality test for addiction score. The internet addiction score was compared with CGPA using Spearman correlation. Mean and the standard deviation was calculated for numerical variables like CGPA of participants, whereas frequency and percentage for categorical variables like gender and categories of each questionnaire item. The data presented in tables and charts. A P value < 0.05 considered statistically signi cant.

Results
In this study, we enrolled 321 medical students; the majority were females 186 (58.3%) (  (Fig. 1). We found an association between the duration of internet time consumption and the IAT score, with 5-6 hour/day scoring the highest (mean 50.1 ± 14.3). Also, there is a signi cant association between platforms that consume most of the participant time and IAT score, with games scoring the highest (IAT mean 56.4 ± 15) ( Table 1). We found an insigni cant negative correlation between IAT grade and CGPA (P-value = .07) ( Table 3).

Discussion
Several studies have been conducted globally, especially among students concerning internet addiction.
Our study was an initial step toward understanding the extent of internet addiction among medical college students (29).
The Mean internet addiction score in the current study was 47.7, which is considered higher than the study done by Muhammad Alamgir Khan (Mean = 38) (1) and Akhtar (Mean = 39.23) (30). Regarding the purpose of internet use, most of the participants select social media (88%), which was lesser than the study done in Turkey that assessed social media usage by medical students (93.4%) (31). We found that most participants (88.2%) spend 3 hours or more per day on the internet. Students' time on social networks highlights that medical students have been spending signi cant time on these social networks. These results were consistent with a study performed on the students of the University of Baghdad (2018) and University of Babylon (2017) (32,33), which demonstrated that a signi cant proportion of students spent more than three hours per day on social networks.
Those who reported using the internet for the educational sites were (8%), which was considered higher than an Indian study, which only found that (0.1%) of participants are using the internet for educational purposes (29).
Most of the respondents in our study show a moderate level of addiction (55.8%). In contrast to a study done by Cynthia that found most of the students are mild addicts (52.6%) (34), and another one has done in Iran, which found that the larger percentage show a mild form of internet addiction (51.3%) (35).
The level of severe internet addiction in the current study was considered to be high (%10.9), severe addiction was found to be only (0.9%) In a study done among Iranian students and was not observed at all in Cynthia's study (34).
Internet addiction in this study was higher than other studies in terms of mean internet addiction score and number of severe internet-addicted individuals that may be due to the lockdown and a dramatic increase in internet usage in all aspects of life to the COVID-19 pandemic. Decreasing everyday social interaction and global direction toward online learning makes students seek other like social media alternatives to share their feelings and ideas.
A recent study done by Blossom Fernandes shows that the use of social media, streaming services and gaming sites and apps signi cantly increased during lockdown (36).
Young students with no enough sense of responsibility to be addicted to social media as it is increasingly available, which can explain the ndings that said there is a signi cant association between platforms that consume most of the participant time and IAT score, with games scoring the highest (IAT mean 56.4 ± 15) (P-value =. 001).
In line with the current study ndings, recent studies found no difference between male and female social media use among medical students (37)(38)(39).
In contrast to our study, Andreassen et al. (2017) showed that being female is one of the factors that have a statistically signi cant relationship with social networking addiction (40), which was surprisingly in contrast with other previous studies that found males have higher addiction than females (41,42).
Increased use of the internet via laptops, smartphones, tablets and other handheld devices, along with cheaper data services, make internet use more widespread. Some studies found that students using social media to communicate with their colleagues and for learning, and many students rely on social media to access the knowledge in a free and easy way (43).
Our study not in agreement with many studies (44)(45)(46)(47)(48)(49) that revealed a negative and signi cant correlation between internet addiction and academic performance. Speci cally, during those years as COVID-19 stay-at-home directives considered a unique situation that made decision-maker at educational institute establish online learning as a right choice for continuing the learning process, so students have to be in touch and update themselves. However, internet use has positive and negative consequences, so there is a study (50), which con rmed that most students agreed that social networking media have a positive in uence on their academic performance. Finally, and surprisingly, our study is similar to other studies (41,51-55) that found no correlation between social internet addiction and academic performance as the majority found to be addicted by the screening regardless of high or low the CGPA seems like a matter of time management.

Conclusion
This study reveals only 7.2% have no internet addiction. The mean internet addiction score is 47.7, and most of the respondents (55.8%) shows moderate-level addiction. Despite that, the Internet Addiction Test's application to the sample of medical students concerning academic performance found no signi cant association between Internet Addiction Test score and CGPA score.

Limitations Of The Study
This study had several limitations. The cross-sectional nature of the study is one of them. As our study tracks the overall accumulative academic performance with addiction degree at the time of study only, there may be a failure to detect or underestimate new onset of the negative impact of new-onset addictive behavior in some respondent (which may be raised signi cantly at last year due to COVID-19 lockdown).
Other limitations are the small sample size, single-center and internet-mediated questionnaire.

Recommendations
As there is a relatively high prevalence of addiction, real intervention and awareness of complete addiction evaluation via specialists need to be carried on. There is low usage of the internet for learning purposes, raising awareness about the bene ts of online learning websites. Further studies should be conducted after the period of COVID-19 lockdown.

Declarations
Ethics approval and consent to participate The ethical clearance was obtained from the Research Ethical Committee (REC), Faculty of Medicine, Omdurman Islamic University. Written consent was taken from participants through the questionnaire. Informed consent to participate in study was taken from all participants. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication
Not applicable.

Availability of data and materials
The materials datasets used and/or analyzed during this study are available from the corresponding author on reasonable request.