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Contents lists available at ScienceDirect

Global Health Journal

journal homepage: https://www.keaipublishing.com/en/journals/global-health-journal/

RESEARCH ARTICLE

Determinants of internet addiction among medical students in Casablanca:

a cross-sectional study
Boubacar Traore a,b,∗, Yassine Aguilo a, Samira Hassoune a,c, Samira Nani a,c
a
Epidemiology Laboratory, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University, Casablanca, Morocco
b
Kita Health District, Regional Directorate of Health and Public Hygiene of Kayes, Kita, Mali
c
Laboratory of Cellular and Molecular Pathology/Team “Epidemiology and Histology of Chronic and Cancerous Diseases”, Faculty of Medicine and Pharmacy of
Casablanca, Hassan II University, Casablanca, Morocco

a r t i c l e i n f o a b s t r a c t
Article history: Objective: This study aimed to estimate the prevalence and determinants of Internet addiction among medical
Received 3 October 2022 students at the Faculty of Medicine and Pharmacy of Casablanca, Morocco.
Received in revised form 15 February 2023
Methods: This was a cross-sectional study conducted among students at the Faculty of Medicine and Pharmacy in
Accepted 28 April 2023
Casablanca between October and March 2020. An online questionnaire was administered to students to collect
Available online xxx
data and internet addiction was assessed by the Young questionnaire. A score threshold ≥ 50 was adopted to
Keywords: define addiction. Univariate and multivariate logistic regression analyses were used to identify factors associated
Internet addiction disorder with internet addiction.
Medical students
Results: Out of a total of 4 093 FMPC students enrolled in the 2020‒2021 academic year, 506 agreed to par-
Associated factors
ticipate in this study, including 303 females and 203 males. The mean addiction score assessed on the Young
Cross-sectional study
Morocco scale was (49.08 ± 16.11). The prevalence of Internet addiction was 44.5% (225/506, 95% CI: 40% to 49%).
Multiple regression analysis showed that being older than 20 years (OR = 0.17, 95% CI: 0.40 to 0.64), being
female (OR = 1.70, 95% CI: 1.04 to 2.78), being in the dissertation year (6th year) (OR = 5.17, 95% CI: 2.23 to
11.44), having a history of psychiatric consultation (OR = 2.64, 95% CI: 1.34 to 5.21), having divorced parents
(OR = 2.64, 95% CI: 1.05 to 5.87), use of sleeping medication (OR = 2.9, 95% CI: 1.05 to 3.70), sleep disorders
(OR = 2.06, 95% CI: 1.25 to 3.79), sleep deprivation (OR = 2.26, 95% CI: 1.39 to 3.65), excessive daytime sleepi-
ness (OR = 5.39, 95% CI: 2.19 to 13.24), anxiety disorders (OR = 1.47, 95% CI: 1.18 to 2.30), duration of internet
connection (> 4 h) (OR = 11.43, 95% CI: 4.85 to 27.66), and having frequent conflicts with parents (OR = 2.37,
95% CI: 1.49 to 3.79) and friends (OR = 0.26, 95% CI: 0.11 to 0.65) were independently associated with internet
addiction.
Conclusion: The prevalence of Internet addiction among medical students in Casablanca remains high. Targeted
action on the determinants would be of great value in prevention.

1. Introduction would be somewhat lower in the African population compared to the

As a tool for communication and social interaction, the use of the
Internet is becoming more common in the lives of most individuals, and
students in particular. Indeed, students may use the Internet for edu-
cational and academic purposes, such as searching for information in
electronic databases, communicating with teachers and classmates, and
participating in courses and learning activities. In addition, they may
use the Internet for communication, entertainment, leisure, and social
media use.1
It is estimated that more than half (51.4%) of the world’s population
will be Internet users in 2019. Young people aged 15 to 24 made up
more than 69.4% of this population. This rate of Internet use by youth
global population.2 According to the results of the survey on access and
use of Information and Communication Technologies by individuals and
households in 2018 in Morocco, it is estimated that more than 74% of
the population are internet users.3
With the growth of Internet users worldwide, and the consideration
of internet addiction (IA) as a new psychiatric disorder in the fifth edi-
tion of the Diagnostic and Statistical Manual of Mental Disorders, IA has
become a real public health problem.2 , 4
IA is considered by Douglas and colleagues to be the mandatory use
of the Internet, because if individuals are deprived of it, they become
more irritable and exhibit mood swings.5 It also refers to excessive use
of the Internet that negatively affects other social activities, resulting in

∗
Corresponding author: drbtraore@gmail.com.

https://doi.org/10.1016/j.glohj.2023.04.005
2414-6447/Copyright © 2023 People’s Medical Publishing House Co. Ltd. Publishing service by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Please cite this article as: B. Traore, Y. Aguilo, S. Hassoune et al., Determinants of internet addiction among medical students in Casablanca: A
cross-sectional study, Global Health Journal, https://doi.org/10.1016/j.glohj.2023.04.005
JID: GLOHJ
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Traore B, Aguilo Y, Hassoune S, et al.
a loss of performance in different aspects of life (i.e., professional, edu-
cational, social, family, financial and/or psychological) and a neglect of
real relationships with family and friends.6
International estimates of Internet addiction differ from the most
part depending on the test used and the characteristics of the study
population. In Europe and the United States, rates ranged from 7.9%
to 25.2% among adolescents (2014) while the Middle East and Africa
had rates of 17.3% to 23.6%.7 Studies in Asia had shown a higher vari-
ation in prevalence among youth and adolescents, ranging from 8.1%
to 50.9%.8
Morocco and Tunisia are also affected by the problem, as is the entire
world. Cyberaddiction (i.e. IA) ranged from 43.90% to 54.00% among
adolescents in Tunisia, while it was only 15.80% among Moroccan high
school students.9-11 IA may have negative consequences on the physi-
cal and mental health of users, and a negative effect on quality of life,
physical health, family life and academic performance.12
It has been shown in recent studies that IA is significantly associ-
ated with alcohol abuse, smoking, attention deficit, depression, anxi-
ety, hyperactivity, insomnia, decreased sleep duration and poor sleep
quality.13-14 Sleep disorders are associated with complications such as
headaches, learning disabilities, memory impairment, aggressive behav-
ior, and mental disorder.15-16
Because of the increasing use of the Internet in Moroccan society,
especially among students, and the importance of preventing the neg-
ative consequence of IA and improving the academic performance of
medical students, we conducted this study. In addition, no studies on In-
ternet addiction have been conducted among students in Morocco, and
specifically among medical students in the Casablanca area. This study
aimed to estimate the prevalence and determinants of Internet addic-
tion among medical students at the Faculty of Medicine and Pharmacy
of Casablanca (FMPC), Morocco.
2. Methods
2.1. Type and location of study
This was a cross-sectional study conducted among students of the
Faculty of Medicine and Pharmacy of Casablanca between October and
March 2020. The Faculty of Medicine and Pharmacy of Casablanca is
the only public Faculty of Medicine and Pharmacy in Casablanca. The
total number of students enrolled in Medicine according to the tuition
services during the academic year 2020‒2021 was 4 093.
2.2. Participants selection
Medical students enrolled in the 2020‒2021 academic year, with
access to the internet were solicited through the FMPC medical student
groups on social networks (WhatsApp, Facebook, Instagram, Twitter) to
participate in the study.
Inclusion criteria were: (1) undergraduate students; (2) active inter-
net users for at least one year; (3) with consents to participate in the
study. Exclusion criteria were: (1) graduate and PhD student; (2) non-
users, occasional users and active users of the Internet for less than one
year; (3) not consenting to participate.
2.3. Variables and measures
2.3.1. Internet addiction
IA was the primary variable in our study. It was assessed through
the French version of the twenty-item Young’s Internet Addiction Test
(YIAT) questionnaire.17 YIAT is the first validated and reliable tool to
assess IA.18-19 It was developed in 20 questions by Kimberley Young and
the question response is scored on a Likert scale of 1 to 5 (1 = rarely,
2 = occasionally, 3 = frequently, 4 = often and 5 = always). The final
score is obtained by adding the scores of all questions. The final score is
ranked and classified as 20‒49 for normal, 50‒79 moderate internet use
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(i.e. moderate dependence), and 80‒100 severe internet use (i.e. severe
dependence).20
In this study, a total score cutoff of 50 was adopted to classify stu-
dents into addictive and non-addictive (i.e. score < 50 classified as non-
addictive and those ≥ 50 as IA), while Cronbach’s alpha was 0.899.
2.3.2. Socio-demographic characteristics
Based on a literature review, the questionnaire included questions re-
lated to sociodemographic characteristics: education level, age, gender,
socioeconomic level, and lifestyle (living alone or living with someone).
2.3.3. Personal history
The questionnaire also included questions about a number of poten-
tial individual factors associated with Internet addiction. These factors
included medical surgical history, history of psychiatric illness, previ-
ous consultation with a psychiatrist, possible use of medications or psy-
choactive substances (alcohol, cannabis, tobacco); and factors related to
Internet use (duration, frequency, times of use, and favorite Internet ac-
tivities). These variables were collected from the closed-ended question
sets.
2.3.3.1. Sleep quality. We used the Epworth Sleepiness Scale (ESS) to
assess daytime sleepiness (sleepiness during the day).21 The validated
ESS consists of 8 items with responses scored on a Likert scale from 0 to
3 (0: if it is excluded “I never get sleepy”—no chance; 1: if it is not im-
possible “There is a small chance”—low chance; 2: if it is likely “I could
get sleepy”—medium chance; and 3: if it is systematic “I would sleepy
every time”—high chance). Out of a total of 24 items, scores between 1
and 8 are considered normal (no sleep debt), 9‒14 sleep deficits, and ≥
15 excessive daytime sleepiness. Cronbach’s alpha for the ESS was 0.73
in this study.
Sleep quality was assessed by the Spiegel scale consisting of six ques-
tions; thus, sleep was considered normal (absence of sleep disorder) for
a total score ≥ 15 and pathological (sleep disorder) for a score below
15.22 The Spiegel scale had a Cronbach alpha of 0.78 in our study.
2.3.3.2. Recreational physical activities. The second version of the
Global Physical Activity Questionnaire (GPAQ) was used to assess
leisure time activities.23 GPAQ was developed by the WHO to assess
physical activity in three situations (work, travel and leisure), which
covered 16 questions on physical exercise practice. We used the leisure-
time physical activity domain in our study and a Cronbach’s alpha of
0.77. Metabolic equivalent task (MET) unit was adopted to calculate
the energy expenditure or calories burnt during different activities. Ab-
sence of leisure time physical activity was considered when people with
< 600 MET- minutes per week.
2.3.3.3. Depression, anxiety, and anxiety depression syndrome. For the
screening of anxiety, depression, and Anxiety Depression Syndrome we
used the Hospital Anxiety and Depression Scale (HADS).24 According to
the domains a score ≥ 8 was considered anxious or depressed, and > 15
as anxious-depressive.
2.3.4. Other variables
Information such as socio-demographic characteristics of parents
(marital status, professional activity), internet and television use (fre-
quency, duration) by parents and relatives (friends); as well as commu-
nication with them and their attitudes towards internet use by the FMPC
students were collected through closed sets of questions.
2.4. Data collection procedures
The start date of the study was chosen to avoid assessment periods,
and facilitate student adherence to our study.
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Traore B, Aguilo Y, Hassoune S, et al.
An anonymous electronic questionnaire was used for data collection
and to facilitate completion, it was created using Google Form and dis-
seminated on the social network groups (WhatsApp, Facebook, Insta-
gram, and Twitter) of each class through the administrators. All partic-
ipating medical students were required to use the "Google Form Ques-
tionnaire" to submit responses, and the same PI could only be submitted
once. However, in order to preserve the anonymity and confidentiality
of the participants, identifiers were not collected.
The electronic questionnaire was accompanied by another electronic
consent form, and only medical students who gave their consent were
allowed to complete the survey.
Students were informed that their participation was entirely volun-
tary, that they were guaranteed confidentiality, and that they could
withdraw from the study at any time without any reason. The aver-
age time required to complete the questionnaire was approximately
20‒25 min.
We pre-tested the questionnaire with the pharmacy students. This ac-
tivity allowed for approval of the electronic questionnaire, correction of
any errors, rewording of some questions to fit the context, and adoption
of appropriate strategies for data collection.
2.5. Data analysis and processing
We used "Google Form" to directly export the data into a Microsoft
Excel format, which we then exported into R Studio Software for anal-
yses. To describe the characteristics of addicts and non-addicts, we
used standard descriptive statistics (frequency for qualitative variables,
means and standard deviation for quantitative variables). Chi-square or
Fisher’s and Student’s or Median tests were used within the limits of
their application conditions to assess the association between Internet
addiction and the different variables in medical students. In addition,
univariate and multivariate logistic regression analyses were performed
to identify the determinants of Internet addiction among medical stu-
dents. All independent variables with P < 0.25 in the univariate anal-
ysis were considered in the multivariate logistic regression analysis. A
comparison between the different multivariate models and the Hosmer
Lemeshow goodness-of-fit test were performed to retain the most appro-
priate multivariate model. Odds ratios (OR) with their 95% confidence
intervals (95% CI) were calculated. And P < 0.05 was considered statis-
tically significant.
3. Results
3.1. Sociodemographic characteristics of the participants
A total of 506 medical students were included to this study, includ-
ing 303 females and 203 males aged from 17 to 36 (21.34 ± 2.84) years.
Participation was disproportionate across grade levels with high partic-
ipation from freshmen (110/506) and seventh graders (106/506). The
majority of students (371/506) and had a median expenditure of 1 500
Dirhams [interquartile range (IQR): 800‒2 500]. Descriptive statistics
for other socio-demographic characteristics and background of FMPC
students are provided with the data from the bivariate analyses in
Table 1.
The mean IA score assessed on the YIAT scale was (49.08 ± 16.11)
among FMPC medical students. Internet use assessed on the basis of
the YIAT score was normal in 9.8% (49/506), minimal in 45.08%
(232/506), moderate in 40.9% (207/506), and excessive in 3.6%
(18/506) of students, respectively. The prevalence of IA was 44.5%
(225/506, 95% CI: 40% to 49%).
3.2. Relationship between IA and sociodemographic characteristics,
history, and substance use among FMPC medical students
The mean age of students was statically lower among addictive
students (21.19 ± 2.66) years compared with nonaddictive students
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(21.91 ± 2.91) years, and females were the most addictive compared
with males (OR = 2.46, 95% CI: 1.69 to 3.57). Indeed, the OR for IA
was 0.62 (95% CI: 0.43 to 0.90) in those aged 20 years and younger
compared with those over 20 years. Educational level was statistically
associated with IA (P < 0.05). Students in 1st grade (OR = 2.01, 95% CI:
1.16 to 3.49), 2nd (OR = 2.01, 95% CI: 1.03 to 3.95), 5th (OR = 2.45,
95% CI: 1.24 to 4.83), and those in 6th grade (OR = 2.76, 95% CI: 1.45
to 5.26) were the most addictive compared to students in 7th grade
(Table 1).
In addition, living with friends (OR = 2.94, 95% CI: 1.32 to 6.51),
having monthly expenses less than 2 000 Dirhams (OR = 2.56, 95% CI:
1.69 to 3.88), history of medical-surgical conditions (OR = 2.29, 95% CI:
1.50 to 3.49), taking medication other than hypnotics (OR = 2.77,
95% CI: 1.65 to 4.67), and psychiatric consultations (OR = 2.82, 95% CI:
1.66 to 4.79) were statistically associated with increased IA. However,
a history of substance use such as smoking (OR = 0.46, 95% CI: 0.25 to
0.84) was associated with a decrease (Table 1).
3.3. Relationship between IA and the students’ sleep- and mental health
Mean sleep duration was lower among addicts (6.94 ± 1.15) h com-
pared to non-addicts (7.06 ± 0.92) h and more than half of the stu-
dents taking sleeping pills (68.2%, 15/22) were addicts. In the ad-
dicts, the mean sleep disturbance score of ESS was statistically higher
in (10.37 ± 3.84 versus 8.23 ± 3.62 non-addictive, P < 0.0001), as
well the mean sleepiness score of Spiegel scale was statistically lower
(20.18 ± 4.19 addictive versus 21.09 ± 3.55 non-addictive, P < 0.05). In
addition, significant increases in the ORs for IA in students with patho-
logical sleep disorders (OR = 3.04, 95% CI: 1.88 to 4.91), sleep deficits
(OR = 1.93, 95% CI: 1.34 to 2.86), and excessive daytime sleepiness
(OR = 6.48, 95% CI: 3.02 to 13.93) were observed in our study (Table 2).
We used the HADS to assess the mental health of FMPC medical stu-
dents (Table 2). The mean scores for anxiety, depression and anxiety-
depressive syndrome were statistically higher in the addicted students
(10.32 ± 4.06 versus 8.74 ± 3.40, P < 0.0001; 7.97 ± 3.92 versus
7.22 ± 3.41, P < 0.05; and 18.30 ± 7.06 versus 15.97 ± 5.99, P < 0.0001,
respectively). However, except for anxiety (OR = 1.73, 95% CI: 1.17 to
2.56), no significant differences in increased addictive frequencies were
observed.
3.4. Relationship between IA and internet use by students, parents, and
friends
The median duration of internet use among addicted students
(6 h/day, IQR: 4‒8) was statically higher (P < 0.0001) compared to the
median duration of internet use among non-addictive students (4, IQR:
3‒5 h). Furthermore, 59.4% (165/278) of students who spent more than
4 h/day surfing the internet were addicted. In contrast, 24.9% (51/205)
of students who spent 4 h/day or less surfing the internet were addicted.
This increase in the OR of IA among students was statistically significant
(OR = 4.40, 95% CI: 2.96 to 6.55) (Table 3).
Less than half (44.2%, 208/471) of students logging onto the inter-
net on smartphones were internet addicts. Students surfing the internet
both day and night were the most addictive compared to those surfing
only during the day (OR = 1.18, 95% CI: 0.77 to 1.80). There was a sig-
nificant increase in IA among students with favorite internet activities
(OR = 2.76, 95% CI: 1.27 to 5.96). The ORs were variable according
to the types of favorite internet activities. However, social networking
(OR = 1.87, 95% CI: 1.09 to 3.20) and e-Learning (OR = 0.57, 95% CI:
0.36 to 0.91) were the only ones statistically and respectively associated
with increased or decreased IA.
Frequent internet use by parents and friends of FMPC medical stu-
dents were statistically associated with increased IA (P < 0.05). Indeed,
parents of students with frequent internet use had statistically higher
OR compared to those whose parents had infrequent use (OR = 2.64,
95% CI: 1.10 to 6.31). In addition, parents and friends of students using
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Table 1
Sociodemographic characteristics and distribution of the participants by IA (n = 506).

Variable Person (n) Yes [n (%)] No [n (%)] OR (95% CI) P

Socio-demographic characteristic
Age (year)a – 21.19 ± 2.66 21.99 ± 2.94 – 0.005∗ ∗
≤ 20 194 100 (51.5) 94 (48.5) 1 0.011∗
> 20 312 125 (40.1) 187 (59.9) 0.62 (0.42 to 0.90)
Gender < 0.0001∗
Female 303 161 (53.1) 142 (46.9) 2.46 (1.69 to 3.57)
Male 203 64 (31.5) 139 (68.5) 1
Nationality 0.901∗
Moroccan 493 219 (44.4) 274 (55.6) 1
Other 13 6 (46.2) 7 (53.8) 1.07 (0.35 to 2.35)
Level of study (year) 0.001∗
1st 110 56 (50.9) 54 (49.1) 2.01 (1.16 to 3.49)
2nd 53 27 (50.9) 26 (49.1) 2.01 (1.03 to 3.93)
3rd 54 20 (37.0) 34 (63.0) 1.14 (0.57 to 2.26)
4th 68 20 (29.4) 48 (70.6) 0.81 (0.41 to 1.56)
5th 52 29 (55.8) 23 (44.2) 2.45 (1.24 to 4.83)
6th 63 37 (58.7) 26 (41.3) 2.76 (1.45 to 5.26)
7th 106 36 (34.0) 70 (66.0) 1
Living conditionb 0.028∗
Alone 62 19 (30.6) 43 (69.4) 1
Family 371 156 (42.0) 215 (58.0) 1.64 (0.92 to 2.92)
Friends 46 20 (56.5) 26 (43.5) 2.94 (1.32 to 6.51)
Expenses per month (Dirham)b < 0.0001∗
< 2 000 356 182 (51.1) 174 (48.9) 2.56 (1.69 to 3.88)
≥ 2 000 145 42 (29.0) 103 (71.0) 1
Personal historyb
Medical and surgical history
Medical or surgical condition 118 71 (60.2) 47 (39.8) 2.29 (1.50 to 3.49) < 0.0001∗
Drug intake other than hypnotics 73 48 (65.8) 25 (34.2) 2.77 (1.65 to 4.67) < 0.0001∗
Psychiatric consultations 71 47 (66.2) 24 (33.8) 2.82 (1.66 to 4.79) < 0.0001∗
Taking hypnotics on prescription 51 35 (68.6) 16 (31.4) 1.79 (0.69 to 5.17) 0.280∗
Consumption of psychoactive substances
Tobacco 56 16 (28.6) 40 (71.4) 0.46 (0.25 to 0.84) 0.011∗
Electronic cigarette 32 10 (31.3) 22 (68.8) 0.54 (0.25 to 1.18) 0.120∗
Chicha 15 7 (46.7) 8 (53.3) 1.09 (0.39 to 3.06 0.862∗
Cannabis 24 11 (45.8) 13 (54.2) 1.09 (0.46 to 2.41) 0.890∗
Alcohol 48 17 (35.4) 31 (64.6) 0.65 (0.35 to 1.22) 0.185∗
Parents’ socio-demographic characteristics
Marital status 0.058∗
Divorced/widowed 39 23 (59.0) 16 (41.0) 1.88 (0.79 to 3.66)
Married 467 202 (43.3) 265 (56.7) 1
Parents’ professional activity 0.182∗
In activity 409 176 (43.0) 233 (57.0) 1
Inactive (retired, unemployed) 97 49 (50.5) 48 (49.5) 1.35 (0.86 to 2.10)

IA: internet addiction; SD: standard deviation; OR: odds ratio; CI: confidence interval; -: not applicable. a Data are
expressed as (mean ± SD). b Part of participants did’t answer those items of the questionnaire. ∗ Chi-square test. ∗ ∗
Mean test.

the internet more than 4 h/day had statistically significantly higher OR
for IA than other students (OR parent = 2.21, 95% CI: 1.35 to 3.62; and
OR friend = 1.76, 95% CI: 1.11 to 2.79) (Table 3).
3.5. IA and social relationship with parents and friends
Lack of parental availability (OR = 2.13, 95% CI: 1.01 to 4.61), com-
munication with friends (OR = 2.34, 95% CI = 1.53–3.56), and fre-
quent conflicts with parents (OR = 1.59, 95% CI: 1.12 to 2.87) were the
social relationships with statistically significant impacts on increased
IA among medical students. In contrast, frequent conflicts with friends
were associated with decreased IA (Table 4).
pills (OR = 2.90, 95% CI: 1.05 to 3.70), sleep disorders (OR = 2.06,
95% CI: 1.25 to 3.79), sleep debt (OR = 2.26, 95% CI: 1.39 to 3.65), ex-
cessive daytime sleepiness (OR = 5.39, 95% CI: 2.19 to 13.24), anxiety
(OR = 1.45, 95% CI: 1.18 to 2.20), more than 4 h/day of connection time
by students (OR = 11.43, 95% CI: 4.85 to 27.66) and frequent conflict
with parents (OR = 2.37, 95% CI: 1.49 to 3.79) were the factors sig-
nificantly associated with increased IA among FMPC medical students.
In contrast, age (≤ 20 years) (OR = 0.17, 95% CI: 0.40 to 0.64) and
frequent conflict with friends (OR = 0.26, 95% CI: 0.11 to 0.65) were
statistically associated with decreased IA. The Hosmer and Lemeshow
test (for goodness of fit) was not significant (𝜒 2 = 1.51, P = 0.121),
implying that the predicted multivariate model was robust.

3.6. Factors associated with IA in multivariate analysis 4. Discussions

Table 5 presents the results of the multivariate logistic regression
analysis of potential risk factors for IA in FMPC medical students. Results
showed that female (OR = 1.70, 95% CI: 1.04 to 2.78), 6th grade for ed-
ucation level (OR = 5.17, 95% CI: 2.23 to 11.44), history of psychiatric
consultations (OR = 2.64, 95% CI: 1.34 to 5.21), divorced/widowed par-
ents’ marital status (OR = 2.64, 95% CI: 1.05 to 5.87), use of sleeping
The objective of our study was to estimate the prevalence of Inter-
net addiction, as well as to identify factors possibly associated with this
addiction among medical students at the Faculty of Medicine and Phar-
macy of Casablanca.
The sample size was calculated beforehand, and data collection was
carried out using an anonymous self-administered questionnaire and

4
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Table 2
Sleep and mental health characteristics of the participants by IA (n = 506).

Variable Person (n) Yes [n (%)] No [n (%)] OR (95% CI) P

Sleeping
Taking a sleeping pill 0.022∗
No 484 210 (43.3) 274 (56.6) 1
Yes 22 15 (68.2) 7 (31.8) 2.79 (1.12 to 6.98)
Sleep duration (hour/day)a, b – 6.93 ± 1.15 7.06 ± 0.92 – 0.174∗ ∗
≤6 146 70 (47.9) 76 (52.1) 1.29 (0.87 to 1.92) 0.192∗
>6 330 137 (41.5) 193 (58.5) 1
Feeling of having a good quality of sleep < 0.0001∗
No 285 160 (56.1) 125 (43.9) 3.07 (2.11 to 4.45)
Yes 221 65 (29.4) 156 (70.6) 1
Spiegel scale on sleep disorder (score)a – 20.18 ± 4.19 21.09 ± 3.55 – 0.009∗ ∗
Normal 416 165 (39.7) 251 (60.3) 1 < 0.0001∗
Pathological 90 60 (66.7) 30 (33.3) 3.04 (1.88 to 4.91)
ESS (score)a – 10.34 ± 3.84 8.23 ± 3.62 – < 0.0001∗ ∗
Normal 218 72 (33.0) 146 (67.0) 1 < 0.0001∗
Sleep deficit 246 121 (49.2) 125 (50.8) 1.93 (1.34 to 2.86)
Excessive daytime sleepiness 42 32 (76.2) 10 (23.8) 6.48 (3.02 to 13.93)
Leisure activity 0.415∗
No 217 101 (46.5) 116 (53.5) 1.15 (0.81 to 1.65)
Yes 289 124 (42.9) 165 (57.1) 1
Mental health
Anxiety (score)a – 10.32 ± 4.06 8.74 ± 3.40 – < 0.0001∗ ∗
No 156 55 (35.3) 101 (64.7) 1 < 0.0001∗
Yes 350 170 (48.6) 180 (51.4) 1.73 (1.17 to 2.56)
Depression (score)a – 7.97 ± 3.92 7.22 ± 3.41 – 0.022∗ ∗
No 241 107 (44.4) 134 (55.6) 1 0.977∗
Yes 265 118 (44.5) 147 (55.5) 1.01 (0.70 to 1.42)
Anxiety-depression (score)a – 18.30 ± 7.06 15.97 ± 5.99 – < 0.0001∗ ∗
No 185 72 (38.9) 113 (61.1) 1 0.057∗
Yes 321 153 (47.7) 168 (52.3) 1.42 (0.98 to 2.06)

IA: internet addiction; SD: standard deviation; OR: odds ratio; CI: confidence interval; -: not applicable; ESS: Epworth
Sleepiness Scale. a Data are expressed as (mean ± SD). b Part of participants did’t answer those items of the questionnaire.
∗
Chi-square test. ∗ ∗ Mean test.

validated measurement tools. The results can therefore be considered
generalizable to some extent. This study is unique in that it provides
updated estimates of the prevalence of IA among medical students in
Casablanca and identifies risk factors for IA in the Moroccan cultural
context.
4.1. Prevalence of IA
The prevalence of Internet addiction was estimated at 44.5%
(95% CI: 40% to 49%). These results are comparable to the prevalence of
54% (95% CI: 49.7% to 58.3%) reported in 2017 in Tunisia among 556
students.9 Based on a comparison with the results of a study conducted
in the same year among students at Hassan II University in Casablanca,
our results suggest an increase in IA among medical students at the
FMPC.25 Moreover, this prevalence was much higher than that found in
studies of medical students in Saudi Arabia and Pakistan, which found
prevalences of 12.4% and 7.86%, respectively.26-27 It should be noted
that the comparison between the different studies is difficult because of
the differences in the tools use, as well as the influence of the character-
istics of each country, this is even more accentuated in the phenomena
of the development of addictions where the social and cultural dimen-
sions in which the individual evolves are in the foreground. However,
the general trend in Morocco seems to be an increase in the prevalence
of IA, which corresponds to the spectacular increase in the role of the
Internet in the social life of adolescents in recent years.
4.2. IA and socio-demographic characteristics of students
The students aged > 20 years were less addictive [adjusted (adj.)
OR = 0.17, 95% CI: 0.40 to 0.64] compared to the youngers. This find-
ing is consistent with the fact that Internet use is increasingly integrated
early in adolescents’ lives and underscores the need for Internet use ed-
ucation in the early school years.
Female students were more addicted to the Internet than male stu-
dents (adj. OR = 1.7, 95% CI: 1.04 to 2.78). This preponderance of fe-
males has been observed in several other studies, notably those con-
ducted among medical students.26 , 28 However, some studies that also
included medical students did not observe this gender difference.27 , 29
Indeed, gender-related differences in behavior are closely related to the
socio-cultural context and the fact that women probably use social net-
working platforms more than men, and this use of these networks was
related to Internet addiction in our study.
The influence of age on internet addiction can be explained by an-
other association found in our study which was related to years of study
(P < 0.0001). However, 1st year students were statistically less addictive
than 7th year students (adj. OR = 0.30, 95% CI: 0.07 to 1.27). This could
be explained by the fact that 1st year students would spend more time
in social environments during the process of adjusting to college while
7th year students are focused on preparing for their medical theses. In
contrast, 6th year students were more addictive than 7th year students
(adj. OR = 5.17, 95% CI: 2.23 to 11.44). Indeed, 6th year students are
at the beginning of the thesis and are preoccupied not only with prepa-
rations for clinical examinations, but also with literature searches to
make a good choice of topic and better start the thesis. Year 7 students
at the end of the curriculum are generally waiting for their defenses,
and have a more flexible schedule allowing more free time. These re-
sults are consistent with those of a recent meta-analysis and a recent
study in Morocco.8 - 25
Poor mental health is positively associated with smartphone addic-
tion.30 This could explain the significant increase in the risk of IA in stu-
dents with a history of psychiatric consultations (adj. OR = 2.64, 95% CI:
1.34 to 5.21) in our study. Like Liu et al. in China, our results agree with

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Table 3
The internet use of medical students and their parents and friends distributed by IA (n = 506).

Variable Person (n) Yes [n (%)] No [n (%)] OR (95% CI) P

Student internet use

Main source of internet connection 0.830∗
Smartphone 471 208 (44.2) 263 (55.8) 1
Tablet 7 3 (42.9) 4 (57.1) 0.94 (0.23 to 4.28)
Computer 28 14 (50.0) 14 (50.0) 1.26 (0.59 to 2.71)
Main time of internet connection 0.718∗
Daytime only 120 50 (41.7) 70 (58.3) 1
Night only 56 24 (42.9) 32 (57.1) 1.05 (0.53 to 1.99)
Day and night 330 151 (45.8) 179 (54.2) 1.18 (0.77 to 1.80)
Favorite internet activities 0.007∗
No 38 9 (23.7) 29 (76.3) 1
Yes 468 216 (46.2) 252 (53.8) 2.76 (1.27 to 5.96)
Favorite type of internet activitiesb
Social networks 0.021∗
No 69 23 (33.3) 46 (66.7) 1
Yes 399 193 (48.9) 206 (51.6) 1.87 (1.09 to 3.20)
Streaming and/or download (video, music, ebook, other) 0.146∗
No 266 115 (43.2) 151 (56.8) 1
Yes 202 101 (50.0) 101 (50.0) 1.31 (0.90 to 1.89)
Online game 0.498∗
No 333 157 (47.1) 176 (52.9) 1
Yes 135 59 (43.7) 76 (56.3) 0.87 (0.58 to 1.30
Academic research 0.301∗
No 338 161 (47.6) 177 (52.4) 1
Yes 130 55 (42.3) 75 (57.7) 0.80 (0.53 to 1.21)
E-learning 0.018∗
No 372 182 (48.9) 190 (51.1) 1
Yes 96 34 (35.4) 62 (64.6) 0.57 (0.36 to 0.91
Internet connection time (h/day)a,b – 6 (4‒8) 4 (3‒5) – < 0.0001∗ ∗
≤4 205 51 (24.9) 154 (75.1) 1 < 0.0001∗
>4 278 165 (59.4) 113 (40.6) 4.40 (2.96 to 6.55)
Internet and TV use by parents
Frequent use of the internet 0.023∗
No 29 7 (24.1) 22 (75.9) 1
Yes 477 218 (45.7) 259 (54.3) 2.64 (1.10 to 6.31)
Internet connection time (h/day)b 0.001∗
≤4 313 130 (41.5) 183 (58.5) 1
>4 85 52 (61.2) 33 (38.8) 2.21 (1.35 to 3.62)
Frequent viewing of TVb 0.287∗
No 154 63 (40.9) 91 (59.1) 1
Yes 352 162 (46.0) 190 (54.0) 1.23 (0.83 to 1.80)
Watching TV time (h/day)b 0.062∗
≤2 199 88 (44.2) 111 (55.8) 1
>2 120 66 (55.0) 54 (45.0) 1.54 (0.97 to 2.43)
Internet and TV use by friends
Frequent use of the internet 0.002
No 12 0 12 (100)
Yes 494 225 (45.5) 269 (54.5)
Internet connection time (h/day)b 0.015∗
≤4 134 51 (38.1) 83 (61.9) 1
>4 173 90 (52.0) 83 (48.0) 1.76 (1.11 to 2.79)
Frequent viewing of TV 0.084∗
No 384 179 (46.6) 205 (53.4) 1
Yes 122 46 (37.7) 76 (62.3) 0.69 (0.45 to 1.09)
Watching TV time (h/day)b 0.248∗
≤2 51 19 (37.3) 32 (62.7) 1
>2 25 6 (24.0) 19 (76.0) 0.53 (0.18 to 1.56)

IA: internet addiction; SD: standard deviation; OR: odds ratio; CI: confidence interval; IQR: Inter-Quartile Range;
-: not applicable. a Data are expressed as median (IQR). b Part of participants did’t answer those items of the questionnaire. ∗ Chi-square
test. ∗ ∗ Mean test.

those of other authors who found that the presence of a history of psy-
chiatric disorders was a risk factor for Internet addiction.25 , 31-33
Furthermore, students with divorced or widowed parents were the
most addictive compared to those whose parents were still married (adj.
OR = 2.64, 95% CI: 1.05 to 5.87). This may be explained by the hypoth-
esis that divorced or widowed parents leave young people with more
free time than those who are still married, thus allowing them to spend
more time on the Internet and subsequently develop a cyberaddiction.
Another possible explanation is that living in a family environment that
is a source of family conflict, and sometimes of family over-investment,
may be a precipitating factor towards Internet addiction.
4.3. IA and substance abuse
The fact that behavioral addictions such as pathological gambling,
eating and sex have the same mechanisms and the same neurobiological,
clinical and psychopathological characteristics as substance abuse, one
may believe that there is a link between substance abuse and Internet
addiction.34 However, our results, like those of Kamal et al. in Egypt,
showed a decrease in IA (OR = 0.46, 95% CI: 0.25 to 0.84) in tobacco
users, contrary to some Tunisian studies.9-10 , 35
Given the small number of students who reported the use of psy-
choactive substances (Tobacco, Alcohol, Cannabis, Chicha, E-cigarette)

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Table 4
Distribution of FMPC medical students by IA and their social relationship with parents and friends (n = 506).

Variable Person (n) Yes [n (%)] No [n (%)] OR (95% CI) P

Social relationship with parents

Sufficient communication 0.07
No 101 53 (52.5) 48 (47.5) 1.49 (0.96 to 2.31)
Yes 405 172 (42.5) 233 (57.5) 1
Parents’ availability 0.049
No 29 18 (62.1) 11 (37.9) 2.13 (1.01 to 4.61)
Yes 477 207 (43.7) 270 (56.6) 1
Agreement with parents 0.104
No 53 18 (34.0) 35 (66.0) 1
Yes 453 207 (45.7) 246 (54.3) 1.63 (0.90 to 2.97)
Frequent conflicts with parents 0.009
No 271 106 (39.1) 165 (60.9) 1
Yes 235 119 (50.6) 116 (49.4) 1.59 (1.12 to 2.27)
Parents’ attitudes about Internet use
Indifferent 190 85 (44.7) 105 (55.3) 1
Permissive 156 65 (41.7) 91 (58.3) 0.88 (0.57 to 1.35)
Restrictive 160 75 (46.9) 85 (53.1) 1.09 (0.71 to 1.66)
Social relationship with friends
Sufficient communication < 0.0001
No 119 72 (60.5) 47 (39.5) 2.34 (1.53 to 3.56)
Yes 387 153 (39.5) 234 (60.5) 1
Friend’s availability 0.287
No 110 44(40.0) 66 (60.0) 0.79 (0.51 to 1.21)
Yes 396 181 (45,7) 215 (54.3) 1
Agreement with friends 0.708
No 38 18 (47,4) 20 (52.6) 1
Yes 468 207 (44,2) 261 (55.8) 0.88 (0.45 to 1.70)
Frequent conflicts with friends < 0.0001
No 361 179 (49,6) 182 (50.4) 1
Yes 145 46 (31,7) 99 (68.3) 0.47 (0.31 to 0.70)
Attitudes of friends about using the internet < 0.0001
Indiffèrent 320 159 (49,7) 161 (50.3) 1
Permissive 123 34 (27,6) 89 (72.4) 0.38 (0.24 to 0.60)
Restrictive 63 32 (50,8) 31 (49.2) 1.04 (0.60 to 1.79)

IA: internet addiction; OR: Adjusted Odds Ratio; CI: confidence interval. P refers chi-square test.

no association was found between these toxic habits and internet ad-
diction in the multivariate analysis. A possible non-response bias in the
use of psychoactive substances is therefore to be feared in the Moroccan
socio-cultural context.
4.4. Online activities, internet use and social relations between students,
their parents and friends
As an interface for social contact, the Internet, especially social net-
works, is the main means of communication and affirmation of social
status among adolescents.7 Indeed, students with favorite activities on
the Internet were the most exposed to addiction (OR = 2.76, 95% CI:
1.27 to 5.96) and social networks were considered the most addictive
(OR = 1.87, 95% CI: 1.09 to 3.20). This result is consistent with re-
search conducted in different countries.7 , 36 The facilities offered by so-
cial networks for communication, sharing of activities related to train-
ing (teaching aids, group discussions, exchanges with teachers) could be
explanations for this increase in IA.
The interactivity offered by the Internet, its accessibility and its use
through the use of smartphones, means that the duration of connection
is high, particularly among students, with an increased risk of addiction.
This remained consistent in our study where online time was associated
with risk of cyberaddiction (adj. OR = 11.43, 95% CI: 4.85 to 27.66,
≥ 4 h versus <4 h). Other studies in medical students had confirmed the
significant association between high Internet time and risk of Internet
addiction.8 - 9
Adolescence is a sensitive period when peer relationships can be very
important to be accepted in the group. This attitude increases the risk
of IA in students with classmates who demonstrate addictive Internet
use. Thus, our results highlight this possibility of peer influence by a
significant increase in the OR of IA in students with friends who log on
more than 4 h/day (OR = 1.76, 95% CI: 1.11 to 2.79).
There was also an increase in the OR for IA among students with
parents who logged on more than 4 h/day (OR = 1.54, 95% CI: 1.35 to
3.62). This could mean that parental addictive Internet use influences IA
in students. Indeed, parents are a role model for their children and exert
a constant influence on their children’s life habits, and Internet use may
not be considered a major problem for parents who use it themselves.
The influence of peers and parents on IA has been found in several
other studies.8 , 10 , 37-39
In addition, the relationship with parents may also influence the oc-
currence of Internet addiction. Indeed, our study found a significantly
higher adj. OR for IA in students with frequent conflicts with parents
(adj. OR = 2.37, 95% CI: 1.49 to 3.79). The family plays a very im-
portant role in the psychosocial development of children and problem
behaviors are more likely if families have high levels of conflict. Like
ours, a Taiwanese study had that parent-adolescent conflict predicts In-
ternet addiction in children.40-41
Furthermore, our results highlight that frequent conflict with friends
statistically decreases IA (adj. OR = 0.26, 95% CI: 0.11 to 0.65). This
could be explained by a decrease in interactions with friends when con-
flicts occur. This result corroborates those of Hasmujaj et al. who con-
cluded that students who did not communicate sufficiently with their
friends were less addictive.39
4.5. Sleep, mental health and internet addiction
Sleep is a physiological need, the disruption of which can have a
detrimental impact on daytime activities and especially learning activi-
ties.

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Table 5
Determinants of IA in medical students by multivariate analyses (n = 506).

Factor Person (n) ORadj. (95% CI) P

Socio-demographic characteristics
Ages (year) 0.009
≤ 20 194 1
> 20 312 0.17 (0.40 to 0.64)
Gender 0.034
Female 303 1.7 (1.04 to 2.78)
Male 203 1
Level of study (year) < 0.0001
1st 110 0.30 (0.07 to 1.27)
2nd 53 0.45 (0.10 to 1.96)
3th 54 0.24 (0.06 to 0.93)
4th 68 1.94 (0.83 to 4.54)
5th 52 2.26 (0.99 to 5.17)
6th 63 5.17 (2.23 to 11.44)
7th 106 1
Personal history
Psychiatric consultations 71 2.64 (1.34 to 5.21) 0.005
Socio-demographic characteristics of parents
Marital status 0.037
Divorced/widowed 39 2.64 (1.05 to 5.87)
Married 467 1
Sleeping
Taking sleeping pills 0.013
No 484 1
Yes 22 2.90 (1.05 to 3.70)
Sleep disorder (Spiegel scale) 0.019
No 416 1
Yes 90 2.06 (1.25 to 3.79)
Sleepiness (ESS)
Normal 218 1 < 0.0001
Sleep deficit 246 2.26 (1.39 to 3.65)
Excessive daytime sleepiness 42 5.39 (2.19 to 13.24)
Mental health
Anxiety 0.006
No 156 1
Yes 350 1.47 (1.18 to 2.30)
Internet use by students
Duration of internet connection (hour/day) < 0.0001
≤4 205 1
>4 278 11.43 (4.85 to 27.66)
Social relationship with parents and friends
Frequent conflicts with parents 235 2.37 (1.49 to 3.79) < 0.0001
Frequent conflicts with friends 236 0.26 (0.11 to 0.65) 0.004

IA: internet addiction; ORadj : Adjusted Odds Ratio; CI: confidence interval; ESS: Epworth
Sleepiness Scale. P refers likelihood ratio test.

Our study showed a significant increase in the OR of IA in students
with sleep deficits (adj. OR = 2.26, 95% CI: 1.39 to 3.65) and excessive
daytime sleepiness (adj. OR = 5.39, 95% CI: 2.19 to 13.24). These re-
sults are consistent with a study that found a significant increase in the
prevalence of IA in nursing students with sleep deficits and excessive
daytime sleepiness.42 In addition, a significant increase in IA was ob-
served in students with sleep disorders (adj. OR = 2.06, 95% CI: 1.25 to
3.79). These results may be explained by the accessibility of the Internet
from almost anywhere, at any time and its excessive use that stimulates
the central nervous system, causing delayed sleep and short sleep dura-
tion. Similarly, the blue light emitted by screens suppresses the release
of melatonin, thus reducing sleep duration.43 This could be the reason
for the use of sleeping pills in addicted students (adj. OR = 2.90, 95% CI:
1.05 to 3.70).
Anxiety was significantly associated with the risk of IA (adj.
OR = 1.47, 95% CI: 1.18 to 2.30) but this was not the case for depres-
sion. Indeed, among psychiatric comorbidities, anxiety and depression
are the most widely sought after with IA. Depression, social phobia, hos-
tility, hyperactivity and attention deficit are the conditions most often
associated with IA in children and adolescents.44 This assertion was con-
firmed by a meta-analysis which found a significant association between
Internet addiction and various mental disorders.14 Some authors have
tried to explain this association by the avoidance behavior of patients
suffering from anxiety. Indeed, the use of the Internet allows anxious
or depressive subjects to avoid phobic situations and can generate or
aggravate depression in young people.45
5. Limitations
This was a cross-sectional study; no causal link can be established be-
tween Internet addiction and other factors such as depression or social
anxiety. Analytical studies are needed to confirm this causal relation-
ship. Because the study population was limited to those attending med-
ical school in a specific city, the sample may not represent all Moroccan
medical students.
Our study did not examine the impact of internet addiction on aca-
demic success, in terms of grades, failure, or achievement, or its rela-
tionship to eating disorders, which may warrant further research in this
area and exploration of these particular aspects. In addition, as with any
declarative study, there may be a discrepancy between what the student
says and what he or she actually does, however, our results are consis-
tent with other studies in comparable contexts which suggests that our
results are valid and interpretable. Despite these possible limitations,
the results observed in this study are important and warrant further in-
vestigation.

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ARTICLE IN PRESS
Traore B, Aguilo Y, Hassoune S, et al.
6. Conclusion
The prevalence of internet addiction seems high among students.
Internet addiction thus seems to be a real public health problem with
a significant link to several physical and psychological conditions and
awareness of this risk should be raised. Further cross-sectional studies
should be conducted to monitor the trend of this problem and to find
the impact of Internet addiction on the psychosocial health of students.
Ethical approval and contents to participate
This study was approved by the Ethics Committee for Biomedical Re-
search (CERB) of the Faculty of Medicine and Pharmacy of Casablanca
under the number 03/2022 CERBC before the commencement of the
study. All aspects of this research study was carried out in accordance
with the guidance and recommendations of the Ethical Committee,
with informed consent obtained from the participants prior to data
collection.
CRediT author statement
Boubacar Traore: Conceptualization, Methodology, Formal analy-
sis, Visualization, Writing – original draft. Yassine Aguilo: Data cu-
ration, Project administration, Writing – original draft. Samira Has-
soune: Conceptualization, Project administration, Writing – original
draft. Samira Nani: Conceptualization, Project administration, Writing
– original draft.
Competing interests
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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