Prevalence of Internet, Gaming, and Porn Addiction and Their Relation With Increased Stress, Anxiety, and Depression Among Medical Students in the MENA Region, a Multinational Cross-sectional Study
Conditions: Internet Addiction, Gaming Disorder, Porn Addiction
Sponsor: Zagazig University

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Prevalence of internet, gaming and porn addiction and their relationship with 
increased Stress, anxiety, and depression among Medical students in some 
countries in the Middle East, a cross-sectional study. 
NCT Number: Not yet registered 
Document date: 29 July 2025 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Introduction 
 
Internet usage has increased greatly. It is expected to be more than 4 billion by the 
end of this year(1). About 80% of them spend most of their internet time on social media, 
and are expected by 2026 to be about 50% of the total population to use social media at 
least once a month(1). The internet is mainly used to connect with friends, relatives, learn 
new skills, or for entertainment, such as video gaming (2). However, with this increasing 
usage, internet addiction can easily increase. 
Internet addiction or pathological internet use is defined as uncontrolled, excessive 
use of it, with uncontrolled time consuming that can cause distress, and impairment (3,4). 
The prevalence of internet addiction varied between regions. A study in the seven 
countries in Europe reported a prevalence of addiction among adolescents to be 1%, and 
an additional 12.7% at risk of having addiction(5). In Turkey, a recent cross-sectional 
study conducted by Sayili et al found a prevalence of 18.3% (6) . In the Middle East, the 
prevalence varied greatly from 0.9% to 33% among adolescents (7–9). For Egypt, 
Ibrahim et al, 2020 assess the prevalence of internet addiction among undergraduate 
medical students in Assiut University. They collected data from 321 students, revealing a 
prevalence being 9%. They also found a statistical association between internet addiction 
and increasing depression among these students(10). Sayed et al, 2022 was another cross-
sectional study that was conducted among pharmacy students in Egypt. They also found a 
prevalence being 38.5%. They also found a statistically significant association between 
internet addiction and stress, depression and anxiety.(11) 
Additionally,  internet video gaming is another addictive problem that can affect 
adolescents. A previous meta-analysis showed that gaming addiction prevalence ranged 
from 0.9% to 19.9%, with males being higher than females(12). Also, Pitanupong et al 
2025 showed a prevalence of about 8.4% among Thailand medical students. (13). 
Shouman et al 2023 was a cross-sectional study conducted among university students in 
Egypt at Mansoura university. They found a 6% prevalence among these students. Again, 

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they found a statistically significant association between gaming addiction and 
psychological factors. (14) 
On the other hand, overuse of the internet can lead to an increase in problematic 
pornography use. Karim et al. 2025(15) found a significant association between increased 
usage of the internet and pornography addiction (P value: <0.001). Additionally, previous 
studies showed a prevalence of porn addiction ranging from 3.2% to 16.6%(16). Also, a 
negative correlation between education level and porn addiction was observed.(17). 
All these behavioral addictions increase depression, anxiety, and stress for addicts.  
Several cross-sectional studies have assessed the positive correlation between either 
internet, gaming, or porn addiction, and an increase in anxiety and depression. 
(6,10,13,15,18) However, to our knowledge, no single study has assessed these three 
addictive behaviors together with depression, anxiety, and stress in  Arab countries. 
Rational 
 
Medical students, in particular, use the internet frequently. They use it in training, 
faculty assignments, research projects, and so on, which can make them depend greatly 
on the internet. This potentially can increase their addiction to the internet, subsequently 
increasing their addiction to video gaming and porn addiction. (19). In the Middle East, 
few studies have tried to assess the prevalence of internet addiction and its association 
with increased depression, anxiety, and stress(7,9,18) among medical students. Despite 
that, there is a lack of studies on gaming addiction and porn addiction.  
We aim to assess the prevalence of internet addiction alongside video gaming and 
porn addiction among medical students and interns in the Middle East (MENA region). 
We also aim to assess the relationship of these three addictive behaviors with each other 
and their relationship with increased stress, anxiety, and depression among this 
population. 
Research Questions 

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1. What is the prevalence of internet, gaming, and porn addiction among medical 
students in the MENA region? 
2. What is the prevalence of stress, anxiety, and depression among this population? 
3. What is the relation between these types of addictions and the level of stress, 
anxiety, and depression among this population? 
Aim 
To assess the prevalence of internet, gaming, and porn addiction among medical students 
in the Middle East region to help improve their quality of life. 
Objective 
1. To assess the prevalence of internet, gaming, and porn addiction among Medical 
students and interns in the MENA region 
2. To assess the prevalence of anxiety, depression, and stress among this population. 
3. To assess the relation between these addictions and depression, anxiety, and stress. 
Methodology 
Technical Design 
1. Study design: Cross-sectional study 
2. Setting: Medical students in some Middle East countries (Egypt, Sudan, Somalia, 
Libya, Morocco, United Arab Emirates, Jordan, Syria, Yemen, Iraq, and Palestine)  
3. Time: From July 2025 to December 2025 
4. Population: Arabic Medical students in the MEAN region 
5. Inclusion Criteria 
• Arabic Medical students and interns 
• Studying medicine in the Middle East countries 
• Have access to online platforms 
• Agree to participate in the study 
6. Exclusion Criteria 

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• Students or interns who refused to participate 
7. Sampling 
We calculated the total sample size using Epi Info version 7.2.60(Epi InfoTM | 
CDC, n.d.) Assuming a 50% prevalence rate and a 5% error margin with a 95% 
confidence interval, the sample size required for each country is 383. After adding 
a 10% nonresponse rate, the final sample size is about 422 for each country, so the 
total sample size will be 4642 
8. Sampling Technique: Convenience Sampling 
Operational design 
1. Pilot: We will perform a pilot study in each country before starting the study to 
assess the readiness of the questions and the reliability of the questions via the 
Cronbach's alpha test. 
2. Study field: an online questionnaire will be shared via an online platform with the 
target population. 
3. Data collection method 
An online questionnaire will be shared via social media platforms such as 
Facebook, WhatsApp, and Telegram. 
The questionnaire is composed of 8 sections as follows: 
➢ The first section provides a brief introduction to the topic, its importance in 
the research field, and consent to participate in the study. 
➢ In the second section, sociodemographic data will be collected, such as age, 
gender, type of university, smoking level, number of sleeping hours, 
difficulty in accessing the internet, and reason for using internet platforms 
➢ In the third section, we will ask about internet addiction. We will use the 
Internet Addiction Scale (IAT) (21,22) This scale is a 20-question Likert 
scale, and each question has six answer scales from 0 to 5 (Not applicable, 
rarely, occasionally, frequently, often, and always). This makes a range of 
scores from 0 to 100.  

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The participants can be classified into normal usage, mild, moderate, and 
severe levels of addiction if they score (0-30), (31-49), (50-79), and (80-
100), respectively. 
➢ In the fourth section, Gaming addiction will be assessed. We will use the 
Internet Gaming Disorder Scale–Short-Form (IGDS9-SF) (23,24) 
This scale consists of a 9-question Likert Scale. Each question has five 
answers, scored from 1 to 5. Total score ranges from 9 to 45, with a higher 
score indicating a higher level of gaming disorder. 
➢ We used the GAD-7 scale (25,26) in the fifth section to assess the level of 
anxiety. This scale consists of a 7-question Likert scale, each one has four 
answers scored from 0-3, making a range of scores from 0-21. 
 Students can be classified into minimal, mild, moderate, and severe levels 
of anxiety if they score (0-4), (5-9), (10-14), and (15-21), respectively.  
➢ In the sixth section, we used the Patient Health Questionnaire-9 (PHQ-9)  
(26,27)to assess the level of depression. 
A 9-question Likert scale with four answers for each question. Scores range 
from 0-3, making the range of scores from 0-27. 
Students can be classified into minimal, mild, moderate, moderately severe, 
and severe levels of depression if they score (0-4), (5-9), (10-14), (15-19), 
and (20-27), respectively. 
➢ In the seventh section, we asked about stress level through the Perceived 
Stress Scale-10 (PSS-10) (Ali et al., 2021; Cohen et al., 1983). A 10-
question Likert Scale, and each question has 5 answers, which score from 
0-4. A total score ranges from 0-40. 
Students can be classified into mild, moderate, and severe levels of stress if 
they score (0-13), (14-26), and (27-40), respectively. 
➢ Finally, the eighth section will ask about porn addiction. The Problematic 
Pornography Consumption Scale (PPCS) (29) will be used, which consists 
of an 18-question Likert Scale. Each question consists of 7 answers, and 

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their scores range from 1-7. A total score ranges from 18-126, with higher 
levels indicating a higher level of porn addiction. A 76 score will be used as 
a cut-off value to indicate a high risk of porn addiction. 
We used the Arabic version alongside the English version of the validated 
questionnaire because some Arabic countries did not teach medicine in English 
so the English will be a challenge for them. 
4. Statistical analysis 
First, data will be summarized according to its type. Categorical data will be 
summarized using frequency and percentage. Continuous data will be tested for 
normality. if the data is normally distributed, we will summarize it using mean and 
SD, and if not, median and IQR will be used. We will assess the difference between 
the population according to their sociodemographic data using a Chi-square and a 
Mann-Whitney U test.  A p-value of <0.05 will be used as a cutoff point for 
statistically significant results. We will assess the correlation between all continuous 
data (internet addiction, gaming, porn addiction, stress, depression, and anxiety 
levels). Finally, a multiple linear regression test will be used to assess the relationship 
between the assessed variables.  
Administrative design 
1. Ethical consideration 
• The study protocol will be approved by the Institutional Review Board of 
Zagazig University, Faculty of Medicine 
•  Study participants will be included after informed consent.  
2. Confidentiality and data retention 
Data collected will be kept confidential.  
3. Risks and benefits of the participants 
There is no cost for this study  

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Results 
Collected data will be presented in tables and suitable graphs, and analyzed according to 
standard statistical methods.  
Discussion 
Discussion will be done on the results compared to the relevant literature and scientific 
Research  
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