INTRODUCTION:

The Internet use in Turkey and around the world increases every year. The number of Internet users was 3, 885, 567, 619 in 2017, accounting for 51.7% of the world population (Internet World Stats-IWS, 2017). Although the rate of the people aged between 16 and 74 years who used the Internet at least once a day or week was found to be 44.9% in a survey conducted in the first quarter of 2014, this percentage rose to 94.9% in 2016 (Turkish Statistical Institute, 2014, 2016).

Approximately, one in every six people around the world is an adolescent, and 1.2 billion of the world population comprise adolescents aged between 10 and 19 years (WHO, 2016). Adolescents constitute a risk group in terms of problematic Internet use. The rates of computer and Internet use were the highest among individuals aged between 16 and 24 years and higher among males in all age groups (Turkish Statistical Institute, 2014).

The alarming symptoms of problematic Internet use include spending an increased amount of time on the Internet, staying on the Internet more than the planned duration, lying about the time spent on the Internet, feeling unhappy when prevented from using the Internet, parents and friends showing displeasure for the excessive time spent on the Internet, preferring being on the Internet over engaging in one’s usual social activities, and suffering from physical disorders due to the excessive time spent on the Internet (Göka, 2017). Excessive Internet use results in various problems with social and behavioral aspects (Ghosh, 2015). In particular, the individuals in their adolescent years (ages 12–17) tend to have greater access to the Internet and, therefore, show a greater interest in the Internet (Pew Research Center, 2012); hence, they are at a greater risk with regards to the problematic use of the Internet. The excessive Internet use has adverse effects on real life social communication (Jang and Cho, 2010) and at the same time, increases the distress and loneliness of individuals (Shin, Yoon and Choi, 2015) and may lead to a decline in academic performance (Al-Hatamleh et al., 2018), blurred vision, neck and back pain, and sleep disorders (Kang, 2013; Kwon et al., 2013; Mok et al., 2014; Goswami and Chauhan 2017). The problematic Internet use among adolescents can also affect social activities and inter-family processes (Zhong et al., 2011). It is crucial to identify the factors resulting in problematic Internet use and take appropriate measures for the safety of adolescents and society (Ceyhan, 2008).

School nursing is accepted as a field of expertise in our country and around the world and has a crucial place in the provision of comprehensive healthcare services for children and young people (American Academy of Pediatrics-AAP, 2008). Creation and implementation of awareness raising programs by healthcare professionals related to any kind of addiction can be few of the preventive measures (Karaca et al., 2016).

In the literature, the problematic Internet use was reported to change depending on various variables, including gender (Tsai et al., 2009; Nichols et al., 2010; Çelik and Odacı, 2012; Adiele and Olatokun, 2014; Mok et al., 2014; Ghosh, 2015; Yüksel and Yılmaz, 2016; 40. Martin et al, 2018), family monthly income (Cao et al., 2011; Mohan et al., 2018; Sonalika 2019).), level of satisfaction of family relationships (Aktürk and Çiçek, 2017), level of satisfaction of relationships with friends (Selfhout et al., 2009), type of Internet connection (Sarıkaya and Seferoğlu, 2013; Cengizhan, 2013; Derin and Bilge, 2016), ability to use the Internet (Ayas and Horzum, 2013), using real names on the Internet (Çetin and Ceyhan, 2014), and the state of feeling physical pain (Ceritli and Bal, 2017; Küçük, 2017).

The present study aims to contribute to the science of nursing on the assumption that school nursing, as a major sub-specialty of public health, may be useful in preventing high school students from developing problematic Internet use and increasing their psychosocial adjustment.

MATERIALS AND METHODS:

Purpose and Stdy Design:

This descriptive and relational study was conducted to identify the factors related to Internet use and psychosocial adjustment levels of high school adolescents.

The Setting and Sample of the Study:

The population of the study comprised the 9^th, 10^th, and 11^th grade students (549 students) attending a high school located in the province of Ankara. The sample size for the study was calculated using the standard deviation value (SD = 15.47) of the “Problematic Internet Use Scale” developed by Ceyhan (2011) and the formula n= N x σ² x Z²/ (N-1) x d², which is employed when the population is known. The confidence level was accepted as 95% and deviation as d = 2 in the formula (Karasar, 2005). The sample size was calculated as [n=(549 x (15.47)²x (1.9616)² / 548 x 2²)= 231]. Simple random sampling was used to select a sample of 250 students to be included in the study. The inclusion criterion for the study was being an adolescent who is under the age of 17 as the Strengths and Difficulties Questionnaire (SDQ) was applied to the 11–16 age range.

Data Collection Tools:

Data collection tools included a questionnaire to gather socio-demographic information, another questionnaire to gather information about participants’ Internet use, the Problematic Internet Use Scale-Adolescents (PIUS-A), and the SDQ.

Socio-demographic Questionnaire:

Based on literature review, the created questionnaire (Kwonn at al, 2013; Mok et al, 2014; Muthuvenkatachalam et al. 2014) contained questions on gender, family monthly income, education level, participants’ father’s education level, participants’ mother’s education level, family type, relationship with the family, relationship with friends, having problems with school, and level of success in lessons.

Information Form for Internet Use;

This form, also developed based on literature review ( Kwonn at al., 2013;Çetin and Ceyhan, 2014; Mok et al., 2014; Sivadas, and Manoj 2017; Banga and Garg 2018), comprised 16 questions related to Internet use of high school students including the presence of computers at home, Internet connection, having a personal mobile phone and having an Internet connection on the mobile phone, the device used for accessing the Internet in general, the frequency of Internet use (daily and weekly), the main purpose of Internet use, and any physical pain while using the Internet and the location of the pain.

Problematic Internet Use-Adolescents (PIUS-A):

PIUS-A, the validity and reliability study of which was conducted by Ceyhan and Ceyhan (2014) with adolescents, employed correlation matrix analysis to evaluate the appropriateness of the data for factor analysis, and the results of this analysis revealed that correlation coefficients ranged between .02 and .77. It is a 27-item scale comprising Likert-scale questions with five anchors, and the points between 1 and 5 were given based on the answers to the questions: “Not appropriate” (1 point), “Rarely appropriate” (2 points), “Somewhat appropriate” (3 points), “Quite appropriate” (4 points), and “Completely appropriate” (5 points). The 7th and 10th items on the scale were reverse scored. PIUS-A had three sub-dimensions: negative consequences of the Internet, excessive use, and social benefit/comfort (Table 1). The Cronbach’s alpha reliability coefficient for this study was .94. The total scores obtained from the scale and the mean values of the sub-dimensions are given in Table 1.

The scale measures the problematic Internet use behaviors to determine the levels of healthy and unhealthy Internet use. In line with this, higher scores from the scale should be considered as a sign that individuals use the Internet in an unhealthy manner and the Internet adversely affects their lives, possible creating a pathological tendency such as addiction (Ceyhan and Ceyhan, 2014).

SDQ:

The SDQ, developed by Robert Goodman in 1997, has parent-report and teacher-report versions for the youth aged between 4 and 16 years and adolescent-self report versions for youngsters aged between 11 and 16 years (Goodman, 2003). In the present study, the SDQ for adolescents was used. The SDQ comprises 25 questions and 5 sub-dimensions about the positive/negative behaviors (Table 1). Each sub-dimension has its specific score and the total of the first four headings gives the total strength score. Each item is scored as “Not True” (1 point), “Somewhat True” (2 points), and “Certainly” (3 points). There are five items which are reverse scored (7, 11, 14, 21, and 25; Goodman, 1997). The Turkish validity and reliability study of the SDQ was performed by Güvenir et al. (2008). The Cronbach’s alpha reliability coefficient for this study was .59. The total scores obtained from the scale and the mean values of sub-dimensions are given in Table 1.

Table 1 - The item numbers, meaning of the scores obtained, minimum and maximum scores that can be obtained, and Cronbach’s α values for the PIUS-A and SDQ scales and their sub-dimensions

Scales and Sub-Dimensions

Item Number

Min.-Max. Score

Min.-Max. Scores in this Study

Taken in this Study

X̄ ± SD

PIUS-A

Negative Use of The Internet

Excessive Use of The Internet

Social Benefit / Social Comfort

27-135

14-70

6-30

7-35

27-123

14-67

6-30

7-31

68.9±21.9

32.4±12.9

20.4 ±5.1

16.0±6.4

SDQ

Emotional Problems

Behavior Problems

Attention Deficit / Excessive Mobility

Peer Problems

Social Behavior

25-75

5-15

36-64

5-15

5-13

6-15

48.2 ± 5.1

8.2 ± 2.3

9.2 ± 1.9

9.9 ± 2.0

7.9 ± 1.8

12.8 ± 2.0

Data Analysis:

The licensed Statistical Package for the Social Sciences software, version 20.0, was used for statistical analysis and calculations. In statistical decisions, p < 0.05 was accepted as the indicator of a significant difference. The data were summarized using numbers, percentages, mean, standard deviation, median, and quartile values. Reliability analysis of the tools to be used was conducted for this study. For normal distribution decisions, the quantitative variables whose skewness and kurtosis values were between (−1) and (+1) were considered to indicate a normal distribution. Based on the normal distribution and variable numbers, t-test, Mann–Whitney U test, and Kruskal–Wallis test were used.

In the study, the predictors of the PIUS-A were assessed using the hierarchical regression analysis. In the first model, socio-demographic variables were used, while variables related to characteristics of Internet use were added in Model 2; the SDQ-related variables were added in Model 3. The SDQ scale scores were used as the continuous variable. The dummy variables, coded below, were produced for analysis:

1 Gender (male=1, 0= woman)

2 Family monthly income (height=1, 0=low-middle)

3 Level of relationship with family (middle=1, 0=bad, very good)

4 Relationship level with friends (middle=1, 0=bad, very good)

5 School problem (always=1, 0=sometimes, i have no problems)

6 Type of internet connection (smart phone =1, 0=house)

7 Ability to use the Internet (very good=1, 0=other)

8 The family prohibits access to the Internet (yes=1, 0=no)

9 Do not go to the Internet cafe when the family forbids (yes=1, 0=no)

10 Pain when using the Internet (yes=1, 0=no)

Ethical Considerations:

Permission was obtained from researchers who developed the PIUS-A and SDQ to allow the use of their research tools in the study. Before proceeding with the study, ethical approval was obtained from the Ethics Committee of Necmettin Erbakan University (decision no. 2016/506). Permission was obtained from the Ministry of National Education of Turkey to conduct a study in Çankaya Leyla Turgut Anatolian High School and Çankaya Ümitköy Anatolian High School in Ankara. Written permissions were collected from the students who participated in the study and their parents using informed consent forms.

RESULTS:

Of the participating students, 56% were female and 44% were male. The family monthly income was low/moderate for 70% and high for 30%. Analysis of the education levels of the fathers suggested that 4% of the fathers were primary school graduates, 17% were high school graduates, 57% were university graduates, and 22% had post-graduate degrees. Analysis of the education levels of the mothers indicated that 7% of the mothers were primary school graduates, 29% were high school graduates, 52% were university graduates, and 12% had post-graduate degrees. With regards to the family type, 91% of the students were from nuclear families and 9% were from the extended/fragmented families. The extended and fragmented families were merged as their members were few in number. The analysis of participants’ relationships with their family showed that 7% of the participants considered their relationship to be bad, 18% to be moderate, 42% to be good, and 33% to be very good. However, the analysis of participants’ relationships with their friends showed that 4% of them were not satisfied with their relationships with their friends, 56% were moderately satisfied, and 40% were very satisfied. When they were asked if they had any problems at school, 19% of the participants reported they had no problems, 70% indicated that they faced occasional problems, and 11% reported they always had problems at school.

Of the participants, 67% used the Internet at home and 43% used their mobile phones to connect to the Internet. The skill level of Internet use of the participants was moderate (13%), good (53%), and very good (34%). Further, 18% reported that their families prohibited their access to the Internet, whereas 82% stated that their families did not prohibit it. When their families prohibited their access to the Internet, a small proportion of the participants reported that they went to an Internet cafe (10%), whereas the majority did not (90%). In terms of having a social media account, 95% of the participants had social media accounts, whereas 5% did not have any. When they were asked if they used their real names on the Internet, 55% stated they used their real names, 7% did not disclose their real name, and 38% indicated that they used their real names occasionally. When assessed in terms of having any physical pain while using the Internet, 60% of the participants said they experienced physical pain, and 40% replied they did not have any.

Based on the total PIUS-A score, gender (t = −2.537, P = 0.012), family monthly income (t = −2.954, p = 0.003), relationship with the family (KW = 31.556, P < 0.001), satisfaction from relationship with friends (KW = 29.213, p < 0.001), having school problems (9.006, P < 0.011), the type of Internet connection (t = −2.232, p=0.026), the Internet use skill level (KW = 8.839, p = 0.012), the family’s prohibition of access to the Internet (t = −6.196, p < 0.001), going to an Internet cafe when access to the Internet is prohibited (t = −4.916, p < 0.001), and physical pain while using the Internet (t = 52.347, p < 0.001) were statistically significant at the PIUS-A level, whereas participants’ fathers’ educational level (KW = 1.732, p = 0.630), participants’ mother’s educational level (KW = 1.350, p = 0.717), the family type (t = −1.794 p = 0.073), having a social media account (t = −1.160 p = 0.246), and using real names on the Internet (KW = −1.864 p = 0.062) were not found to be statistically significant at the PIUS-A level.

Based on the total SDQ score, the comparisons of participants’ scores for the following variables were not found to be significantly different: gender (t = 0.381, p = 0.704), family monthly income (t = 1.642, p = 0.102), participants’ fathers’ educational level (KW = 1.325, p = 0.723), participants’ mothers’ educational level (KW = 1.535, p = 0.674), family type (KW = −0.141, p = 0.888), relationship with family (KW = 2.795, p = 0.424), satisfaction from relationship with friends (KW = 0.341, p = 0.843), having school problems (KW = 1.573, p = 0.455), the type of Internet connection (t = −0.960, p = 0.337), the Internet use skill level (KW = 3.327, p = 0.189), the family’s prohibition of access to the Internet (t = −1.136, p = 0.256), having a social media account (t = −0.051, p = 0.959), using real names on the Internet (KW = −1.709, p = 0.088), and physical pain while using the Internet (t = 3.068, p = 0.080). However, the difference between total SDQ score and the variable of going to the Internet cafe when access to the Internet is prohibited (t = −2.051, p = 0.040) was found to be statistically significant.

The predictors of the PIUS-A for high school adolescents were assessed using the hierarchical multiple regression analysis. In Model 1, the predictive value of socio-demographic variables was examined, and it was found that male students (β = 0.169), and those whose family monthly income was high (β = 0.172), those whose relationship with their families was moderate (β = 0.210), those whose relationship with their friends was moderate (β = 0.224), and those who indicated they always had problems at school (β = 0.186) influenced the PIUS-A variable. Socio-demographic variables explained 20% of the variance for problematic Internet use. In Model 2, to which variables concerning the Internet use were added, it was found that male students (β = 0.155), those whose relationship with their family was moderate (β = 0.114), those whose relationship with their friends was moderate (β = 0.167), those who stated that they had always problems at school (β = 0.158), those whose family prohibited access to the Internet (β = 0.166), those who went to the Internet cafe when access to the Internet was prohibited (β = 0.162), and those who reported that they experienced pain while using the Internet (β = 0.345) were predictors of problematic Internet use have negative influence and increase problematic Internet use. When the Internet use was added to the model, the predictive value rose from 20% to 43%. In Model 3, to which the SDQ variable was added, it was determined that the SDQ variable had no effect on the predictive value and the SDQ variable did not change the predictive power of the model (Table 2).

Table 2 - Predictors of Problematic Internet Use (PIUS-A) (Multiple Regression Analysis - Hierarchical Model)

	β	t value	p value
Model 1 - Socio-demographic predictors
Constant		22.070	<0.001
Gender (male-1)	0.169	2.931	0.004
Family monthly income (high = 1)	0.172	2.949	0.003
Relationship with the family (moderate = 1)	0.210	3.561	<0.001
Relationship with friends (moderate = 1)	0.224	3.804	<0.001
Having school problems (always = 1)	0.186	3.212	0.001
Model 2 - Socio-demographic and Internet use-related variables
Constant		16.952	<0.001
Gender (male-1)	0.155	3.059	0.002
Family monthly income (high = 1)	0.092	1.782	0.076
Relationship with the family (moderate = 1)	0.114	2.209	0.028
Relationship with friends (moderate = 1)	0.167	3.269	0.001
Having school problems (always = 1)	0.158	3.128	0.002
Type of Internet connection (smartphone = 1)	0.062	1.246	0.214
Internet use skill level (very good = 1)	0.026	0.517	0.605
Family’s prohibition of access to the Internet (yes = 1)	0.166	2.766	0.006
Going to an Internet cafe when access to the Internet is prohibited (yes = 1)	0.162	2.832	0.005
Pain while using the Internet (yes = 1)	0.345	6.748	<0.001
Model 3 - Socio-demographic, Internet use, and SDQ-A related variables
Constant
Gender (male-1)	0.155	3.059	0.002
Family monthly income (high = 1)	0.092	1.782	0.076
Relationship with the family (moderate = 1)	0.114	2.209	0.028
Relationship with friends (moderate = 1)	0.167	3.269	0.001
Having school problems (always = 1)	0.158	3.128	0.002
Type of Internet connection (smartphone = 1)	0.062	1.246	0.214
Internet use skill level (very good = 1)	0.026	0.517	0.605
Family’s prohibition of access to the Internet (yes = 1)	0.166	2.766	0.006
Going to an Internet cafe when access to the Internet is prohibited (yes = 1)	0.162	2.832	0.005
Pain while using the Internet (yes = 1)	0.345	6.748	<0.001
SDQ-A	−0.025	−0.499	0.618
Model 1:	R = 0.454	R² = 0.206	F = 12.649, p < 0.001
Model 2:	R = 0.657	R² = 0.432	F = 18.183, p < 0.001
Model 3:	R = 0.658	R² = 0.433	F = 16.500, p < 0.001

DISCUSSION:

The Internet has many uses as an ever growing technology that facilitates our lives and it is increasingly adopted by people. Thanks to this technology, people can access any information they are looking for or find answers to any questions easily and expediently.

Although it has uses in many areas including information, research, correspondence, education, and communication, it may lead to certain psychosocial problems when used in an unregulated manner particularly during the adolescence period (Kaur and Sharma 2019). This study was conducted to assess the Internet use and psychosocial adjustment levels of adolescents studying in high schools. It was found that the Internet use of adolescents is correlated with their gender, family monthly income, family type, relationship with family and friends, having school problems, and success levels.

The results suggested that the problematic Internet use mean scores of male students are significantly higher than female students. Many studies in the literature reported that the problematic Internet use was higher among male adolescents than female adolescents (Tsai et al., 2009; Nichols et al., 2010; Çelik and Odacı, 2012; Adiele and Olatokun, 2014; Mok et al., 2014; Yüksel and Yılmaz, 2016). In this regard, our study’s findings are in line with the literature. It is believed that the problematic Internet use is more widespread among male adolescents because men tend to show greater interest in technology, can go to Internet cafes more easily, and spare more time to spend on computers and online games. However, it is assumed that this difference will drop to insignificant levels with the recent increase in and proliferation of the Internet use.

The examination of the results in our study showed that problematic Internet use changes depending on the family monthly income variable. There are studies that have reported parallel findings (Cao et al., 2011; Yüksel and Yılmaz, 2016; Mohan et al., 2018; Sonalika 2019). However, there are also studies which have not found a correlation between family monthly income and the problematic Internet use of adolescents (Zorbaz and Dost, 2014). The increasing demand for Internet access in our country has made Internet access affordable and ubiquitous. Hence, it is believed that the effect of differences in socio-economic level on Internet use will disappear over time.

Examination of the findings revealed that the problematic Internet use differed based on the relationship of adolescents with their families. Thus, those whose relationship with the family was not good tended to indulge in problematic Internet use. In line with the findings our study, Aktürk and Çiçek (2017) reported that the students who did not have a good relationship with their families tended to use the Internet as a means to distance themselves from their families; as a result, it was concluded that the level of Internet addiction was higher among such students. The adolescents who fail to get the attention of their families may opt for searching for a replacement. It is believed that the satisfaction adolescents can get from their relationship with their family is crucial with regards to problematic Internet use.

In the present study, we found that the problematic Internet use changed based on the variable of satisfaction from relationship with friends. Thus, the adolescents who were not satisfied with their relationship with their friends tended to indulge in more problematic Internet use. Zorbaz and Dost (2014) argued that relationship with peers was not a significant predictor of the problematic Internet use of adolescents, whereas Selfhout et al. (2009) reported that individuals with low levels of relationship with their friends tended to use the Internet for communication purposes as they suffered from higher levels of social anxiety. It is known that peer relations are prioritized during adolescence. During this period, relationship with friends is crucial in terms of providing assurance for an adolescent and ensuring that the adolescent can relax by trying to solve his/her problem with his/her peers. In this sense, it is assumed that the adolescents who are satisfied with their relationship with friends seek to compensate this on the Internet.

According to the findings of the present study, the Internet use is more problematic for the adolescents who have access to the Internet via their smartphones than those who connect to the Internet at home. There are many studies that reported findings similar to those of our study in terms of preference for access to the Internet using mobile phones (Derin and Bilge, 2016; Goswami and Chauhan 2017; Patel et al. 2017; Bhut et al. 2019). Access to the Internet using mobile phones has been made more attractive as the use of smartphones has increased and the access to the Internet has become easier. It is believed that this situation may lead to failure to self-control in accessing the Internet, increased Internet use, and withdrawal from face-to-face communication resulting in increased difficulties in social adjustment.

In the present study, it was found that the problematic Internet use increased in line with the increase in Internet use skill levels. Young (1998) reported that spending more time on the computer and the Internet increases skills in these areas, and as a result, people become more addicted to the Internet. Assuming that increased Internet use is directly proportional to increased Internet use skill, spending more time on the Internet boosts skills, and this is believed to affect problematic Internet use.

According to the findings of the present study, those who did not use their real name on the Internet and those who occasionally used their real name on the Internet had greater problems in social adjustment compared to those who used their real name on the Internet. Caplan (2007) argued that virtual communication creates greater privacy than face-to-face communication, and the individuals with social anxiety tend to find virtual communication less risky and opt for it more frequently.

According to the findings of the present study, those who felt any physical pain while using the Internet had more problems in social adjustment compared to those who did not feel any physical pain during Internet use, and the former’s use of the Internet was more negative, excessive, and problematic. Similar to our study, there are many studies in the literature on various forms of physical pain during Internet use (Ceritli and Bal, 2017; Küçük, 2017). An increased amount of time spent on the device used to access the Internet (computer or mobile phone) as a result of problematic Internet use may cause adolescents to develop various forms of physical pain. The physical problems that may develop during this period in which body image is considered to be crucial by adolescents may result in psychological problems and affect adolescents from a psychosocial perspective.

In the literature, gender was reported as a significant predictor of problematic Internet use through regression analysis (Çelik and Odacı, 2012; Zorbaz and Dost, 2014; Oktan, 2015). In their regression analysis, Zorbaz and Dost (2014) found that the variable of peer relations was a significant predictor (explaining 6% of the variance) of the problematic Internet use among high school students.

CONCLUSION:

The ever increasing use of the Internet, which has become an integral part of the modern age, poses a risk for adolescents in terms of problematic Internet use. Therefore, the factors that affect the problematic Internet use among adolescents were identified in our study. It was found that socio-demographic variables such as gender, family monthly income, satisfaction from the relationship with family/friends, and having school problems, as well as the Internet use-related variables such as type of Internet connection, Internet use skill level, families’ prohibition of access to the Internet, going to an Internet cafe when access to the Internet is prohibited, and having physical pain while using the Internet affected problematic Internet use. This study draws attention to the fact that problematic Internet use affects the psychosocial adjustment levels of adolescents.

Study limitation:

The present study is limited to the adolescents (aged 11–16) living in a specific region of Turkey and cannot be generalized to other age groups or the entire population of the country.

Implications for nursing practice:

School nurses should conduct training sessions on healthy Internet use at schools in cooperation with a professional team. They should collect extensive data on the factors that affect the development of negative Internet use by conducting routine interviews with students, and such data should be effectively used in promoting healthy Internet use behaviors. School nurses should provide information on the physical disorders that may develop as a result of excessive Internet use and how to prevent such disorders. Moreover, considering the relation between social adjustment and problematic Internet use, studies can be conducted that aim to support face-to-face interactions of public health nurses during their one-on-one practices with students.

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Received on 25.09.2019 Modified on 12.11.2019

Int. J. Nur. Edu. and Research. 2020; 8(2):141-148.

DOI: 10.5958/2454-2660.2020.00032.0