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Abstract

Background and Aim

Internet addiction can cause anxiety and depression. Exams and living far from home can cause anxiety as well. This research aimed to explore the correlation between Internet addiction, exam-related anxiety, and adult separation anxiety among students.

Methods

This study used a correlational descriptive method to select a varied group of 258 students from Shahroud University of Medical Sciences by using a multistage sampling technique. Several university majors were selected by using a random selection process. The demographic form, Internet Addiction Test (IAT), Frieden Test Anxiety Scale (FTA), and Adult Separation Anxiety (ASA) were the data collection tools.

Results

The average Internet addiction score was 37.34 ± 10.18, demonstrating a positive correlation with test anxiety (r = 0.28, P < .000). The average adult separation anxiety score was 35/44 ± 18/24, which showed a significant positive correlation with Internet addiction (r = 0.37, P < .000). Internet addiction was also related to the amount of Internet usage, self-phone usage, being native or not, and studying only the night before the exam instead of studying throughout the semester.

Conclusion

Internet addiction can be related to test anxiety in students. Moreover, students who experience adult separation anxiety due to living away from familiar situations and people can experience Internet addiction more.

Keywords

Internet addiction test anxiety adult separation anxiety disorder nursing students

Introduction

Excessive Internet use has a significant relationship with higher anxiety levels, such as test anxiety and separation anxiety. People with more anxiety might also be more likely to develop Internet use problems. Regarding the possible impact of demographic variables and students’ academic practices, this present study examined how Internet addiction, test anxiety, and separation anxiety are related among Shahroud University of Medical Sciences students.¹ The Internet is a crucial means of interaction and communication, providing people around the world with easy access to information. Because of this, it has rapidly become a popular thing for everyone, particularly young people, and has become a tool that can result in psychological dependency.²

When COVID-19 emerged, it transformed the Internet into a more valuable tool in people's lives. The COVID-19 pandemic led to the shutdown of universities and schools; therefore, remote education was employed through the Internet due to the Internet's great capacity. Almost every nation implemented quarantines during the COVID-19 pandemic, increasing Internet usage.³ As a result of the pandemic and a significant rise in Internet usage, numerous jobs, relationships, organizations, and university training programs were facilitated.⁴ Despite many benefits of using the Internet, especially during COVID-19, it has caused many issues from its use, such as Internet addiction, especially among young people.⁵

The COVID-19 pandemic led to more people working or studying remotely to prevent the spread of the disease (e.g., lockdowns, quarantines, self-isolation), resulting in increased internet use.⁶ A cross-sectional study looking at how the COVID-19 lockdown affected internet addiction among Nigerian university students demonstrated that 45% were classified as normal internet users, 42% as mildly addicted, and 13% as moderately addicted, with an average Internet Addiction Test (IAT) score of 32.6 out of 100. Internet addiction was notably linked to factors including income status, boredom, and faculty of study. The results show that students’ risk of internet addiction was significantly influenced by boredom during lockdown.⁷ As the use of the Internet increased, obviously due to pandemic situations, professionals raised concerns about Internet Addiction (IA). A rise in Internet use may have both advantages and disadvantages.

The first proposal about IA recognition criteria was expressed by Young.⁸ Scientists have not agreed on a primary definition for IA. In addition, IA is sometimes used in conjunction with phrases such as Internet dependency, compulsive Internet use, Internet use disorders among individuals, and problematic Internet use.⁹ The IA has sometimes been indicated as a failure to manage Internet use by individuals, which ultimately triggers social and emotional challenges in an individual's professional and personal life.^10,11

A meta-analysis study published in 2014 showed Internet Addiction scores for 31 nations across seven global areas, suggesting a projected worldwide prevalence of 6.0%.¹² Regarding the reported prevalence of IA which exhibits considerable variation, with rates in the general population ranging from 6% in countries such as the United States, Spain, Australia, and Canada to as high as 40.2% in several Asian nations, including South Korea, Taiwan, and China.¹³ A study found that Iran's IA prevalence rate is about 22%.^14,15 A meta-analysis and systematic study also showed’/that the Internet addiction rate among university students in Iran was 31.51 percent.¹⁶

Julius Burkauskas et al. have done research that surveys current studies on the frequency of problematic Internet use (PIU) before and during the COVID-19 outbreak. A meta-analysis study conducted before the epidemic reported prevalence estimates of PIU ranging from 6% to 9.7%. Researchers predicted higher PIU during COVID-19 due to increased internet use. Significant variation was observed during the COVID-19 pandemic, with reported prevalence ranging from 4% to 43.8%. Oka et al. found that the incidence of PIU increased 1.6 times among young people and adults during the COVID-19 pandemic. Nakayama et al.'s longitudinal study demonstrated these patterns by evaluating Internet use among high school students following prolonged school closures caused by COVID-19.⁵ A systematic review study by Masaeli et al.³ shows that Internet use increased considerably during the COVID-19 pandemic. Internet use increased by about 52% during this time, the study found, with mobile devices being used mainly by users to connect to the Internet.³ A study conducted in India (2020) with 315 people indicated that the COVID-19 epidemic caused a significant increase in Internet use for 70% of the participants. The study showed that about 40% of the participants also relied on the Internet.¹⁷ A research study on the links between cyberchondria (excessive online health-related searching), COVID-19 anxiety, and internet addiction among nursing students demonstrated that internet addiction, cyberchondria severity, and anxiety about COVID-19 were positively related.¹⁸

IA has garnered more attention recently, particularly following the COVID-19 pandemic.⁶ Studies have shown that problems resulting from too much Internet use are highly related to mental health disorders, including anxiety, sadness, and stress. Excessive internet use and associated conditions have become more common during and after the COVID-19 epidemic.³ So, one of the common results of Internet addiction is anxiety.¹⁹ Also, research has shown that depression and anxiety are predictors of Internet addiction.²⁰ The study by Priego-Parra et al. indicates essential new perspectives on the mental health consequences of COVID-19 among the Mexican people. Similar to trends observed globally, the fear of SARS-CoV-2 infection in Mexico has led to severe mental health disorders, including sleep disturbances, anxiety, and depression. Excessive internet use and its consequences, including the quick spread of false information (infodemia), are connected to higher degrees of anxiety and sadness.²¹

A systematic review and meta-analysis study verified the correlation between mental health and smartphone and internet addiction during COVID-19. Experts discovered notable links between smartphone addiction and anxiety, smartphone addiction and depression, internet addiction and anxiety, and internet addiction and depression.²² The young public's mental health has become more of an issue during and after COVID-19.²⁰ Research indicates that Internet addiction and anxiety are frequently observed in adolescents and are positively linked to each other.²³

Anxiety disorders rank as the most common type of psychiatric condition. According to large-scale population studies, as many as 33.7% of people will suffer from an anxiety condition at some time in their lives. These disorders lead to significant functional impairment, increased use of healthcare services, and a substantial economic impact on society.²⁴

Anxiety is a mental state focused on anticipating challenges, often lacking the resources to handle them effectively. Tension, frustrating thoughts, and physical symptoms, such as higher blood pressure and a faster heart rate, characterize this feeling. It manifests as an uncomfortable sense of fear and worries about potential threats. It can take various forms, such as generalized anxiety, panic with agoraphobia, compulsive behavior, obsessive-compulsive disorder, test anxiety, social anxiety, separation anxiety, and some other specific phobias, which can lead to significant issues in daily life.²⁵

The results of Naeim et al.'s study showed a statistically significant positive relation between IA and test anxiety. This indicates that those with more Internet addiction are more likely to feel more anxiety under test circumstances.¹ Test anxiety is an issue that can impact individuals’ academic performance and lead to considerable adverse effects on their long-term social and educational outcomes.²⁶ The present study focused on the student body at Shahroud University of Medical Sciences, who face academic and emotional challenges that affect their mental health. Among medical students, the challenging academic curriculum, complex academic tests, and clinical training experiences can all contribute to higher levels of test anxiety. Examining the interactions between these psychological constructs in a medical student population can offer insightful analysis of the particular mental health issues experienced by these students and guide the creation of focused interventions and support systems within medical education.

A considerable amount of research accumulated over many years has recognized test anxiety as a significant obstacle to academic success.²⁷ Test anxiety is consistently associated with various detrimental effects on students at all levels of education, from elementary school to university. These adverse outcomes include reduced academic achievement and grades, diminished motivation and self-confidence in educational settings, and increased general anxiety and stress.²⁶ Emotional, behavioral, and physiological responses to the expected negative consequences of a test also define test anxiety.²⁸

Based on recent studies, which demonstrated that between 10% and 40% of students suffer from different degrees of test anxiety. Additionally, about 15% of students face severe test anxiety during assessments. Furthermore, students with disabilities, minor students, and women tend to report even higher instances of test anxiety.^29,30 Additionally, students who experience a more significant amount of test anxiety tend to show poorer test performance regardless of the type of exam or circumstances. Nevertheless, the actual extent of this issue may remain unclear.³¹

Another form of anxiety is separation anxiety disorder, which can disrupt different areas of life, including academic and social functioning.³² Childhood separation anxiety disorder is not a temporary or passing issue. If left untreated, it persists into the teenage years and adulthood. This prolonged separation anxiety leads to significant difficulties and challenges for the individual throughout their life.³³ Research indicates that Separation Anxiety Disorder (SAD) can persist into adulthood or emerge later in life. As a result, the DSM-5, published in 2013, reclassified separation anxiety—previously viewed as a childhood disorder—as a condition that can affect individuals of all ages and can be diagnosed at any point in a person's life.³⁴

People who have Adult Separation Anxiety Disorder (ASAD) experience intense worry when separated from significant attachment figures, such as a spouse, child, or parent. They often feel a strong need to remain close to these individuals and may eventually become unable to function without them. Adults with SAD commonly indicate that they experienced symptoms of separation anxiety during their childhood, which suggests a connection between childhood and adult separation anxiety disorder.³⁵

A recent survey found that the lifetime prevalence rate for adolescents between 13 and 17 is 7.7%, compared to 6.6% for adults aged 18–64. Additionally, the 1-year prevalence rate stands at 1.9%.³⁶ However, a cross-sectional study in Iran involving 29,699 individuals found that the prevalence of SAD was 5.3%.³⁷ With a high prevalence rate of 4.8%, SAD was observed in the World Health Organization's (WHO) World Mental Health Surveys, which assessed data from a community-based population of roughly 39,000 people across 18 nations. Of individuals with SAD, 43.1% also acquired the condition after age 18.³⁸

A study evaluating university students found a 21% prevalence of ASAD. On the other hand, two further investigations found a 6% rate among elderly people over 60 and a 24.5% prevalence in pregnant women hospitalized in the antenatal clinic of the hospital.³³

Importance of investigating Internet addiction and its consequences—especially in the wake of COVID-19 and its negative implications for student performance—this study aims to examine the relationship between Internet addiction, exam anxiety, and separation anxiety among adult students.

Methods

Study design, setting, and sampling

The current study is a descriptive-analytical research project employing a cross-sectional design, and its research community consisted of all students at the Nursing Faculty of Shahroud Medical Sciences. The samples were selected using a multistage stratified sampling method, which included three stages: (a) selecting students based on their gender and major, (b) random selection of students from each group, and (c) continuous sampling of students from classrooms of each selected school. For this purpose, the researcher randomly selected several classes of each major in the university by using a Cochran's formula with a CI of 95% and then randomly distributed questionnaires within their class. This approach ensured that the sample represented the diversity of students across different majors while maintaining randomization within each class. A minimum sample size of 258 students was required to establish a statistically significant correlation between the three variables. To ensure the sample size was adequate, a power analysis was performed, targeting a power of 90% and a significance level of 0.05. This confirmed that 258 participants were sufficient to detect meaningful correlations between the three key variables—Internet addiction, test anxiety, and adult separation anxiety—consistent with similar studies in this field (e.g., Naeim et al.¹). The sample size calculation was based on information from a previous study,²⁴ with a power of 90% and a significance level of 0.05.

Inclusion criteria include willingness to participate in research, having a smartphone, being a bachelor's student or higher, having studied for at least one semester, and having experience in exams and virtual training in the last 6 months; the participant has not had a severe psychological incident (defined as traumatic events causing significant distress or impairment, such as the loss of a loved one, life-threatening health issues, or exposure to disasters or violence). Also, the exclusion criteria included incomplete filling of the questionnaires, suffering from anxiety disorders such as panic disorder, generalized anxiety disorder, or social anxiety disorder, and the use of neuropsychiatric drugs for a mental health condition.

Data collection tools

Data were collected using four different forms in this study: the Demographic form, the IAT, the Friedben Test Anxiety Scale (FTA), and the Adult Separation Anxiety (ASA) scale (as provided in the Supplementary File).

The Persian versions of the IAT, FTA, and ASA used in this study were obtained from previous Iranian researchers who translated and validated the reliable Persian version of these questionnaires with their permission. These versions are cited in the explanation below.

Demographic forms include age, sex, marital status, field/major of study, academic semester, level of education, income, residential status (being native or non-native), average hours of Internet use per day, average hours of phone or tablet use per day, average hours of laptop use per day, preferring virtual vs non-virtual courses, facing psychological trauma in the last 6 months, use of anti-anxiety drugs, being under the supervision of a psychiatrist, distance from home (kilometers), how often do you go home in one semester? (for non-native respondents), the degree of difficulty of the lessons of the current semester and studying on the night of the exam (on a scale of 0–10).

The IAT is a 20-item scale that measures Internet addiction severity on a 5-point Likert scale, created by Kimberly Young.³⁹ Participants self-assess their Internet use, with total scores ranging from 20 to 100. Scores are categorized as follows: 20–39 indicates controlled use, 40–69 suggests frequent problems, and 70–100 signifies severe addiction. In a study conducted by Mohammadsalehi et al., the researchers investigated the psychometric characteristics of the Persian Language Version of the Yang Internet Addiction Questionnaire among Iranians. Their findings indicated that Cronbach's alpha was .917, and the average scale-level Content Validity Index (CVI) for the Persian version was 0.74.⁴⁰

The FTA is a 23-item scale assessing test anxiety across three dimensions: Social Derogation, Cognitive Obstruction, and Tenseness. This scale was developed by Friedman and Bendas-Jacob in 1997. Five items are positively framed, while the scale measures concerns related to criticism, focus, problem-solving, and physical or emotional discomfort in testing situations.⁴¹ Baezzat et al. conducted a study on the validation and standardization of the Persian version of the FTA. Their findings indicated that Cronbach's alpha for the various sections of the questionnaire ranged from .83 to .90.⁴²

The ASA self-report questionnaire was created by Manicavasagar et al. in 2003.⁴³ This questionnaire assesses adult separation anxiety symptoms. Responders rate each item using a 4-point Likert scale (ranging from 0 to 4). The questionnaire consists of five subscales: separation anxiety (10 items), concerns about significant others (8 items), excessive talking (2 items), sleep disturbances (5 items), and fears of harming significant others (2 items). Higher scores indicate greater severity of separation anxiety. The psychometric characteristics of the Persian version of the ASA questionnaire for students were analyzed by Mowlaie et al., demonstrating strong reliability with a Cronbach's alpha of .88 and a test–retest correlation of .64.⁴⁴

Data collection process

Data collection was performed from May to July 2023. This research was conducted during the end-of-semester exams, when students were under the pressure of final exams. For this purpose, the researcher visited in person and interviewed the students of each field who were present at the university.

If the students were willing to participate and met the inclusion criteria, they were provided with the necessary explanations about the research, its objectives, and the confidentiality of their information. Written informed consent to participate in the study was obtained from all the students who were willing to participate. The students from each discipline were chosen, and their informed consent was obtained before distributing the questionnaires to them. Finally, the students completed the questionnaires in a self-reporting format.

Statistical analysis

The independent t-test and analysis of variance were used to assess the relationship between qualitative demographic variables and internet addiction, exam anxiety, and separation anxiety scores. Moreover, to examine the association among internet addiction, exam anxiety, and separation anxiety scores, and also the relationship between them and demographic variables, the Pearson correlation test was used. Correlation tests were chosen due to the continuous nature of the variables and the aim to explore potential interactions. Pearson's correlation coefficient was calculated to assess the strength and direction of the associations. Multiple regression analysis was also conducted to investigate the contemporary effects of demographic variables, test anxiety, and separation anxiety. Variables were age, gender, major of the study, place of residency, study habits, test anxiety, and separation anxiety. All statistical analyses were performed with a significance level of .05 using appropriate software.

Ethical considerations

The study adhered to the ethical standards approved by the Ethics Committee of Shahroud University of Medical Sciences, with the code IR.SHMU.REC.1401.151 Participants’ demographic characteristics were kept anonymous, and their information was used solely for the purposes of this study. Necessary explanations about the study were provided to those who met the inclusion criteria and were willing to participate, including its aims and the confidentiality of their information. Then, informed consent was obtained from the nurses in person. Honesty was maintained in recording information and statistics obtained from the study during data collection, sample selection, and data analysis. Moreover, participants were assured that they could withdraw from the study at any time.

Results

A total of 320 individuals completed the questionnaires. Out of these, 62 participants were excluded due to various reasons: 45 individuals had experienced severe mental events, five were taking medication, one was under the supervision of a psychiatrist, and 11 submitted incomplete questionnaires.

The study results revealed that the mean age of the students was 22.24 ± 3.08 years. The mean Internet use was 4.47 ± 2.68 h, cell phone use was 5.25 ± 2.79 h, the distance from the place of residence was 315.83 ± 376.94 km, and the mean of days students stayed at dormitory before they returned to their homes was 50.64 ± 48.66 days. The perceived difficulty of the courses was 7.10 ± 1.77 on a scale of 0–10 from their perspective. The majority of participants were male (69.4%) and single (91.1%), nursing students (37.6%) with an income of less than 2 million Iranian Tomans (72.5%), and studying in a bachelor's degree course (67.8%). Additionally, most of the students were non-native (65.5%) (Table 1).

Table 1.

Demographic variables of students of Shahroud University of Medical Sciences in 2022.

Variable		Statistics
Field of study (n. (%))	Emergency medical services	13 (5%)
	Nursing	97 (37.6%)
	Midwifery	34 (13.2%)
	Medicine	55 (21.3%)
	Health	22 (8.5%)
	Radiology	8 (3.1%)
	Operating room	9 (3.5%)
	Laboratory science	8 (3.1%)
	Anesthesiology	11 (4.3%)
Sex (n. (%))	Male	179 (69.4%)
Sex (n. (%))	Female	79 (30.6%)
Marital status (n. (%))	Single	235 (91.1%)
Marital status (n. (%))	Married	23 (8.9%)
Income (n. (%))	<2 million tomans	187 (72.5%)
	2–4 million tomans	28 (10.9%)
	4–6 million tomans	13 (5%)
	>6 million tomans	30 (11.6)
Education level (n. (%))	Bachelor's	175 (67.8%)
	Master's	21 (8.1%)
	PhD	62 (24%)
Residence status (n. (%))	Native	89 (34.5%)
Residence status (n. (%))	Non-native	169 (65.5%)
Preferring online or face-to-face education (n. (%))	Online training	58 (22.5%)
Preferring online or face-to-face education (n. (%))	In-person training	200 (77.5%)
Studying during the semester or on the night before an exam (n. (%))	During the semester	117 (45.3%)
	On the night before an exam	141 (54.7%)
Age (Mean ± SD)		22.24 ± 3.08
Use of Internet (Mean ± SD)		4.47 ± 2.68
Use of cell phone (Mean ± SD)		5.25 ± 2.79
Use of laptop (Mean ± SD)		1.64 ± 1.89
Distance from place of residence to university (Mean ± SD)		315.83 ± 376.94
Return to home in non-native students (Mean ± SD)		50.64 ± 48.66
Difficulty of courses during the current semester (on a scale of 10) (Mean ± SD)		7.10 ± 1.77

The mean of Internet addiction score and test anxiety score were 37/34 ± 10/18 and 45/11 ± 7/73, respectively. Also, Table 2 indicates a significant and positive relationship between Internet addiction and exam anxiety (P < .000). It shows that excessive Internet use is associated with students’ anxiety in academic situations.

Table 2.

The relationship between internet addiction and test anxiety in students of Shahroud University of Medical Sciences in 2022.

Variable	Mean ± SD	Internet addiction
Variable	Mean ± SD	Pearson coefficient test	P-value	Effect size
Social derogation	15.32 ± 5.49	−.23	<.000	Weak
Cognitive obstruction	17.34 ± 5.23	.95	<.000	Strong
Tenseness	12.44 ± 3.63	−.40	<.000	Moderate
Total test anxiety score	45.11 ± 7.73	.28	<.000	Weak

The mean of adult separation anxiety score was 35/44 ± 18/24. The Pearson coefficient test showed a positive relation between IA and adult separation anxiety in adults (P < .000). This suggests that Internet addiction is positively correlated with separation anxiety in adults. While the effect sizes of social derogation and total test anxiety are weak, the results indicate a moderate effect size in tenseness and a strong effect size in cognitive obstruction (Table 3).

Table 3.

The relationship between internet addiction and adult separation anxiety in students of Shahroud University of Medical Sciences in 2022.

Variable	Mean ± SD	Internet addiction
Variable	Mean ± SD	Pearson correlation test	P-value	Effect size
Concerns about significant others	10.83 ± 6.55	.23	<.000	Weak
Excessive talking	3.06 ± 1.80	.23	<.000	Weak
Sleep disturbance	5.98 ± 3.62	.30	<.000	Moderate
Fears of harming significant others	2.58 ± 1.51	.40	<.000	Moderate
Total adult separation anxiety score	35.44 ± 18.24	.37	<.000	Moderate

Table 4 shows that exam anxiety was related to students’ majors (P = .004). It also shows that the level of Internet addiction was significantly different in native vs non-native students (P = .005). Moreover, both Internet addiction and exam anxiety had a significant relationship with the habit of studying (Studying the lessons throughout the semester or only on the night before an exam) (P .000, .000, respectively). The Pearson Correlation Test showed that the amount of internet usage had a positive and significant correlation with Internet addiction, exam anxiety, and separation anxiety (r = .29, .15, .13, respectively). Also, the number of students who used their phones had a positive and significant correlation with Internet addiction and exam anxiety (r = .22, .16). Lastly, the difficulty of courses and lessons during the student's semester, as perceived by them, based on a 10-point poll, had a significant negative correlation with exam anxiety (r = −.17). The results indicate the weak effect size of concerns about significant others and excessive talking; however, it shows a moderate effect size in sleep disturbance, fears of harming significant others, and total adult separation anxiety score.

Table 4.

The relationship between internet addiction, test anxiety, separation anxiety, and demographic characteristics in students of Shahroud University of Medical Sciences in 2022.

Variable		Internet addiction		Test anxiety		Separation anxiety
Variable		Mean ± SD	P-value	Mean ± SD	P-value	Mean ± SD	P-value
Field of study	Emergency Medical Services	40.69 ± 12.90	.441^a	51.23 ± 5.35	.004^a	35.38 ± 20.04	.814^a
	Nursing	36.17 ± 8.57		42.70 ± 7.82		35.85 ± 17.84
	Midwifery	39.64 ± 11.83		44.82 ± 6.32		36.82 ± 19.80
	Medicine	37.78 ± 10.12		46.61 ± 8.20		36.30 ± 20.21
	Health	35.72 ± 9.86		45.68 ± 8.02		33.54 ± 18.44
	Radiology	41.37 ± 17.48		44.87 ± 6.15		31.12 ± 10.53
	Operating room	40.00 ± 7.26		46.88 ± 6.35		39.22 ± 11.62
	Laboratory science	32.50 ± 7.36		46.12 ± 5.51		30.75 ± 13.05
	Anesthesiology	36.54 ± 12.42		48.63 ± 7.90		28.36 ± 17.81
Sex	Male	36.67 ± 10.38	.108^b	45.36 ± 7.75	.434^b	35.14 ± 18.06	.695^b
Sex	Female	38.88 ± 9.61	.108^b	44.54 ± 7.71	.434^b	36.11 ± 18.75	.695^b
Marital status	Single	37.50 ± 10.25	.428^b	45.26 ± 7.75	.316^b	35.54 ± 18.30	.764^b
Marital status	Married	35.73 ± 9.53	.428^b	43.56 ± 7.54	.316^b	34.34 ± 17.94	.764^b
Income	<2 million tomans	37.16 ± 9.96	.897^a	45.32 ± 7.85	.532^a	35.71 ± 18.03	.660^a
	2–4 million tomans	36.96 ± 9.85		43.25 ± 8.56		37.07 ± 20.52
	4–6 million tomans	38.92 ± 15.21		44.30 ± 5.66		29.69 ± 17.08
	>6 million tomans	38.16 ± 9.74		45.90 ± 5.97		34.70 ± 18.25
Education level	Bachelor's	37.45 ± 10.31	.600^a	44.89 ± 7.42	.537^a	36.27 ± 17.66	.238^a
	Master's	35.23 ± 8.76		44.23 ± 8.93		29.14 ± 18.95
	PhD	37.77 ± 10.35		46.01 ± 8.20		35.22 ± 19.47
Residence status	Native	39.79 ± 10.97	.005^b	45.06 ± 8.00	.946^b	37.25 ± 16.88	.247^b
Residence status	Non-native	36.05 ± 9.53	.005^b	45.13 ± 7.61	.946^b	34.48 ± 18.89	.247^b
Preferring online or face-to-face education	Online training	40.32 ± 10.67	.011^b	45.43 ± 7.84	.722^b	34.01 ± 17.07	.500^b
Preferring online or face-to-face education	In-person training	36.48 ± 9.90	.011^b	45.02 ± 7.71	.722^b	35.85 ± 18.59	.500^b
Studying during the semester or on the night before an exam	On the night before an exam	40.42 ± 9.37	.000^b	38.11 ± 18.15	.000^b	46.63 ± 7.39	.10^b
Studying during the semester or on the night before an exam	During the semester	33.64 ± 9.93	.000^b	32.22 ± 17.90	.000^b	43.27 ± 7.76	.10^b
Age		r = −.047	.452^c	r = −.44	.485^c	r = −.119	.057^c
Use of the Internet		r = .294	.000^c	r = .151	.015^c	r = .132	.034^c
Use of a self-phone		r = .224	.000^c	r = .161	.010^c	r = .102	.101^c
Use of a laptop		r = .066	.290^c	r = −.013	.834	r = −.008	.903
Distance of the place of residence from the university		r = −.070	.270^c	r = −.028	.656	r = .030	.639^c
Frequency of returning home among non-native students in one semester		r = −.028	.713^c	r = −.040	.603^c	r = .069	.367^c
Difficulty of courses during the current semester		r = −.018	.768^c	r = −.171	.006^c	r = .119	.057^c

^a Analysis of variance (ANOVA) test.

^b Independent samples test.

^c Pearson correlation test.

Table 5 presents the Correlation Matrix results. Based on this table, Internet addiction and exam anxiety showed a significant positive correlation (r = .285, P < .001). Also, Internet addiction and separation anxiety had a significant and positive correlation (r = .372, P < .001). On the other hand, exam anxiety and separation anxiety had a significant negative correlation (r = −.173, P = .005).

Table 5.

The correlation matrix results.

		Test anxiety	Separation anxiety
Internet addiction	Correlation	.285	.372
Internet addiction	P-value	<.001	<.001
Test anxiety	Correlation		−.173
Test anxiety	P-value		.005

Table 6 shows the multiple linear regression model to examine the simultaneous effect of demographic variables, test anxiety, and separation anxiety on Internet addiction. The stepwise method was used to enter the variables into the model; the table below shows the final model. According to this table, the effects of separation anxiety, studying only the night before the exam, amount of Internet use, place of residency, and test anxiety were significant on the score of Internet addiction (P = .001, .001, .004, .009, respectively).

Table 6.

Simultaneous effect of demographic variables, test anxiety, and separation anxiety on internet addiction.

Variable	Coefficient	SD	Wald test	P-value
Separation anxiety	0.18	0.03	5.79	<.001
Studying only the night before the exam	−4.58	1.20	−3.81	<.001
Amount of Internet use	0.91	.210	4.21	<.001
Place of residency (being native or not)	−11.27	3.82	−2.95	.004
Test anxiety	0.21	0.08	2.66	.009

The confidence intervals for the correlations among Internet addiction, test anxiety, and separation anxiety were as follows: 95% CI [0.171, 0.395] for Internet addiction and test anxiety, 95% CI [0.249, 0.470] for Internet addiction and separation anxiety, and 95% CI [−0.271, −0.074] for test anxiety and separation anxiety, which indicates a reasonable range for correlation coefficients. The multiple regression analysis yielded an R² value of 0.42 with 8 degrees of freedom, indicating that the model accounted for a significant proportion of the variance in IA. Among the entered variables, separation anxiety, exam anxiety, studying habits, and place of residency emerged as significant predictors of internet addiction (P = .001, .001, .004, and .009, respectively).

By examining the contributions of test anxiety and separation anxiety to Internet addiction among Iranian students, our study extends previous research that mainly focused on Western populations. This highlights the significance of cultural factors in examining the psychological correlates of Internet addiction.

The current study indicates significant links between test anxiety, academic majors, and Internet addiction in native and non-native students. Positive correlations were observed between digital technology usage, Internet addiction, and anxiety, while perceived course difficulty was negatively associated with test anxiety. These results emphasize the need for targeted mental health support based on students’ backgrounds and technology use.

Discussion

The objective of this study was to examine the relationship between Internet addiction, exam anxiety, and separation anxiety disorder in students at Shahroud University of Medical Sciences. The findings indicated a statistically significant and positive correlation between Internet addiction and exam anxiety.

This finding can be linked to the negative consequences of over-reliance on the Internet, which may cause individuals to become detached from reality and less involved in fulfilling activities. This disconnection can diminish happiness and social interactions, potentially contributing to anxiety, stress, and depression.⁴⁵ In other words, individuals who experience anxiety frequently seek refuge from distressing thoughts through the use of the Internet. Conversely, individuals who use the Internet in moderation tend to exhibit reduced anxiety levels and are less susceptible to the adverse effects associated with excessive Internet use.⁴⁶

As people, especially students, become more connected through virtual means, they may become less engaged with the physical world around them. This could potentially lead to a decline in academic performance.⁴⁷ Prasanna et al. have validated these results by noting a rise in educational challenges among students who used the Internet excessively.⁴⁸ Other studies have also explored this topic. For example, Kheyri et al. identified a significant correlation between Internet addiction and anxiety levels in students.⁴⁹ Additionally, the results of the Do et al. study⁵⁰ and Azizi et al.⁵¹ showed a link between depression, anxiety, and Internet addiction. Moreover, the research conducted by Agah-Heris et al. found that students who suffer from Internet addiction displayed elevated anxiety levels in multiple areas, such as fear, autonomic reactions, neurophysiological signs, and psychological aspects.⁵²

As students increasingly engage in online activities, they may overlook their academic responsibilities, resulting in poor time management, reduced concentration, and a decline in their overall academic performance.⁵³ A study on attention disorder suggests that the Internet provides numerous opportunities for engaging in multiple activities simultaneously, and its instant gratification can help alleviate boredom and deliver quick rewards. This makes individuals with ADHD more susceptible to Internet addiction. Additionally, research has shown that people with ADHD exhibit atypical brain activity that affects their ability to inhibit impulses, leading to reduced self-control. As a result, these individuals may find it even harder to resist the lure of the Internet, making them more vulnerable to Internet addiction.⁵⁴

The Internet's constant distractions and ability to provide instant satisfaction can make it difficult for students to focus and study effectively. This can worsen their academic anxiety. Students feel pressure to meet educational standards, but the Internet is addictive, creating a negative cycle. When academic anxiety increases, students use the Internet more, which then increases their anxiety. With the COVID-19 pandemic, students have had to rely more on the Internet for school, which has exacerbated these problems.^55,56 A systematic review study conducted by Masaeli et al. reported that Internet-based addictive behaviors, such as Internet addiction, have increased during the COVID-19 pandemic.³

This outcome can also be linked to the increased uncertainty and fear brought about by the pandemic, which has led people to look for information and connect with others online. Nevertheless, excessive Internet use may intensify anxiety by exposing individuals to troubling news and creating distance in their relationships with friends and family. The research conducted by Priego-Parra et al. also reinforces these findings, highlighting the harmful effects of fearing SARS-CoV-2 infection on mental disorders, such as anxiety, depression, and sleep issues. The improper use of the Internet and the overexposure to the rapid dissemination of misinformation (infodemic) are linked to increased anxiety and depression.¹⁸

Different research conducted by Kumar et al. revealed that high levels of Internet usage, especially among students during the COVID pandemic, led to increased anxiety and had a detrimental impact on mental health.⁵⁷ Additionally, the research conducted by Akpinar et al. showed a positive relationship between Internet addiction and anxiety related to COVID-19.¹⁸ Bayzan and Aksakallı also reported a moderate positive relationship between social anxiety and Internet addiction among pupils.⁵⁸ These findings align with the results of the present study.

According to our results, test anxiety was significantly related to students’ majors (P = .004). Mousa et al. reported that test anxiety in students of Saudi Arabia was significantly higher in health college students compared with non-health college students.⁵⁹ Kheyri et al. also noted that academic discipline was associated with Internet addiction.⁶⁰ In our present study, the Emergency Medical Services (EMS) students exhibit more test anxiety, which needs to be investigated further in future research. Ramezani et al. also suggest that test anxiety has a high frequency in nursing and EMS students in Iran.⁶¹ Alzahrani et al. indicated that high levels of anxiety in EMS students are related to being faced with traumatic events, students’ special professional experiences and relationships, the atmosphere they are in, the challenges in their training and curriculum, and the pressure of expectations on them.⁶² To sum up, test anxiety seems to be relatively high in health-related majors, especially EMS and nursing, but to understand more of this concept, further research is highly suggested.

In our study, Internet addiction was significantly different in native vs non-native students, and native students had higher Internet addiction scores. This could be related to the fact that they cannot receive information face-to-face in the dormitory and therefore should rely on the internet to receive information. We also suggest that this could be related to the fact that the students in dormitories often live in crowded rooms with many friends, resulting in less time to surf the internet and social media. However, these potential reasons still require investigation through scientific research and have not yet been proven. In a study by Kıvrak et al. in Turkey, dormitory students reported less Internet addiction compared to students staying at home, which supports our results in this part.⁶³

Internet addiction can also vary between races and regions. According to the research by Zhang et al., future studies should also explore this topic. IA appears to be more common in certain Asian countries than in the United States.⁶⁴ One potential explanation for this discrepancy could be the variations in sociocultural contexts. Shahbazirad and Mirderikvand⁶⁵ and Pirzadeh⁶⁶ in Iran found a significant relationship between place of residence and Internet addiction.

One of the topics we were curious about in this present research was the impact of different study habits. As we can see, some students study their lessons daily throughout the semester, while others try to review all the lessons learned the day before the exam. The results revealed that these two types of students had significantly different scores for Internet addiction and exam anxiety. Although these habits were recorded based on a self-reported questionnaire, to the best of our knowledge, there is no previous research investigating this topic in detail. We suggest that researchers pay attention to this topic in future research.

Our results also showed that the amount of internet usage had a positive and significant correlation with Internet addiction, exam anxiety, and adult separation anxiety. Also, the amount of self-phone usage had a positive and significant correlation with Internet addiction and exam anxiety. However, the difficulty of courses and lessons during the students’ semester, as perceived by them based on a 10-point poll, had a significant negative correlation with test anxiety. This means that when the students thought a lesson was easier, they had less test anxiety, which was an acceptable result. It also seems that the more students used the internet and smartphones, the more they experienced Internet addiction, exam anxiety, and adult separation anxiety when using the internet more. Kılıçaslan et al. suggested that Nomophobia is closely related to adult separation anxiety disorder and can increase anxiety levels in students, which is supported by our research findings.⁶⁷

We also found that test anxiety had a negative relationship with adult separation anxiety. It means that the more students were worried about their final exams, the less they experienced adult separation anxiety. The students who experience higher separation anxiety develop more effective coping strategies to manage academic stressors, thus reducing test anxiety. Understanding the importance of coping strategies in adolescents with anxiety disorders, such as adult separation anxiety, underscores the need for further investigation into the relationship between test anxiety and separation anxiety. It is essential to explore various coping strategies that might contribute to the negative correlation between test anxiety and separation anxiety, which warrants a closer examination, demonstrating that individuals with higher test anxiety might limit their social interactions. To better investigate this, relevant exploration research would be suggested. The findings on cognitive coping strategies emphasize the significance of targeting these strategies in psychological assessment and treatment, which could also apply to addressing test anxiety and separation anxiety in students.⁶⁸

To the best of our knowledge, we have not found any related research to compare these results. Therefore, this topic could be a great research idea for further study.

The results of this study may serve as a foundation for future research on the role of emotional regulation strategies and behavioral addictions. The relationship between internet addiction and adult separation anxiety disorder is yet to be understood, as few and limited studies have assessed this subject.

On the other hand, this study also has its limitations. The nature of cross-sectional studies indicates that we cannot interpret the direction of the results. This means that it is unclear which of the correlated variables can act as a cause of the other. Additionally, the limited sample size, resulting from this being a one-center study that assessed students from Shahroud University of Medical Sciences, limits the generalizability of our findings to other universities or student groups. However, future studies should consider employing multi-center or nationally representative samples to investigate the relationships between Internet addiction, test anxiety, and separation anxiety among students. Doing so will contribute to a more comprehensive understanding of these psychological constructs across diverse populations. Also, using self-report measures to gather the data and not using triangulation methods to prove the correctness of the collected data were among the limitations as well. These limitations suggest that further studies in this field are needed to fill these gaps.

Additionally, the various internet addiction patterns (for example, social media, film and series websites, news channels, etc.) can be explored in more detail in future research. The habits, reasons, personalities, and types of circles of peers who actively or inactively encourage students to use the internet excessively can be of more interest in the future. The impact of internet addiction on the social life of students and its relationships with different anxieties is a serious matter in today's world. We suggest that further research focus on actionable strategies to reduce student Internet addiction.

Conclusions

Internet addiction can have a relationship with test anxiety in students. Moreover, students who experience adult separation anxiety due to living away from familiar situations and people can experience Internet addiction more. However, test anxiety had a negative relationship with adult separation anxiety. It means that the more they were worried about final exams, the less they experienced adult separation anxiety.

We also found that various factors were related to Internet addiction, including the amount of Internet and self-phone use, being native versus living in the dormitory, and studying habits like studying only the night before the exam rather than studying throughout the semester.

In addition, according to our results, test anxiety was related to students’ majors.

By finding measures to reduce adult separation anxiety, we can ultimately reduce Internet addiction, too, which leads to better students’ psychological well-being. Additionally, promoting digital literacy and encouraging healthy Internet usage habits can empower individuals to maintain a balanced relationship with technology, reducing the risk of Internet addiction and associated anxieties.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076251361678 - Supplemental material for Internet addiction, test anxiety, adult separation anxiety disorder: Is there a connection?

Supplemental material, sj-docx-1-dhj-10.1177_20552076251361678 for Internet addiction, test anxiety, adult separation anxiety disorder: Is there a connection? by Hadi Hasani, Mahdi Manoochehri, Fatemeh Zarezadeh, Fatemeh Ramezanian, Milad Bazghaleh, Behnaz Alafchi and Amir Mohammad Chekeni in DIGITAL HEALTH

Footnotes

Acknowledgements

We would like to thank Mrs. Solmaz Vahedi from the Department of Nursing Management, School of Nursing & Midwifery, Tehran University of Medical Sciences, Tehran, Iran, and Miss Fatemeh Khoshandam Shorche from the Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran, for their scientific support during the research.

ORCID iD

Hadi Hasani

Ethical considerations

This study was approved by the ethics committee of Shahroud University of Medical Sciences (code: IR.SHMU.REC.1401.151).

Author contributions

Mahdi Manoochehri: investigation. Fatemeh Zarezadeh: writing—original draft. Hadi Hasani: conceptualization, methodology, writing—review and editing, and project administration. Milad Bazghaleh: funding acquisition and supervision. Behnaz Alafchi: formal analysis. Amir Mohammad Chekeni: investigation. Fatemeh Ramezanian: writing—review and editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received financial support from Shahroud University of Medical Sciences (code: 14010039).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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Internet addiction,test anxiety,adult separation anxiety disorder: Is there a connection?

Abstract

Background and Aim

Methods

Results

Conclusion

Keywords

Introduction

Methods

Study design, setting, and sampling

Data collection tools

Data collection process

Statistical analysis

Ethical considerations

Results

Discussion

Conclusions

Supplemental Material

sj-docx-1-dhj-10.1177_20552076251361678 - Supplemental material for Internet addiction, test anxiety, adult separation anxiety disorder: Is there a connection?

Footnotes

Acknowledgements

ORCID iD

Ethical considerations

Author contributions

Funding

Declaration of conflicting interests

Supplemental material

References

Supplementary Material