*Article* **Emerging Health and Education Issues Related to Internet Technologies and Addictive Problems**

**Olatz Lopez-Fernandez 1,2**


**Abstract:** This timely editorial paper outlines some of the main emerging research on technological topics on health and education approaches to Internet use-related problems before and during the beginning of coronavirus disease 2019 (COVID-19). Background: The aim is to provide a brief overview to facilitate a rapid comprehensive and practical approach to these new trends to promote research, interventions, education, and prevention. Methods: The rapid review includes an analysis of both health and education technologies studies on Internet use-related addiction problems included in the Special Issue "Internet and Smartphone Use-Related Addiction Health Problems: Treatment, Education and Research" to extract recent findings and a few reflections about the development of the field before and during the first wave of the COVID-19. Results: Main findings highlighted studies which tended to be empirical, with a relational type associating specific addictive problems with individual and a few contextual factors in adult populations. Psychometric studies about scales are prevalent, but predictive and mixed methods ones are starting to emerge, together with reviews about conceptualisation, measure, treatment, and prevention. Conclusions: From the arrival of Internet, our societies have converged in a global culture which has impacted health and educational domains. Internet use-related addiction problems have globally emerged and common knowledge, advances, and strategies exist to overcome challenges which are starting to be tested, and prevention interest has arisen in a pandemic situation with global health problems holistically tackled.

**Keywords:** Internet addiction; Internet problematic use; problematic mobile phone use; Internet use-related addiction problems; technologies; education; health; treatment; prevention; COVID-19

### **1. Introduction**

Over the last 25 years there has globally been an increasing use of Internet technologies and electronic devices in our daily lives, especially during the last two decades according to the International Telecommunication Union (ITU [1]). The Internet, usually defined as a set of Information and Communication Technologies (ICTs), is now a global network which has inter-connected more than half of the world population [1], who are informed, and constantly communicated (e.g., via social media, messaging applications (apps)) through domestic and mobile devices (e.g., smartphone). However, negative aspects have commonly emerged producing health, educational, and social problems, such as intercultural or intergenerational gaps (e.g., in African countries there is a dual digital divide [2], and older generations still live the grey digital divide [3]).

Our societies have progressively changed, having become more digital in many ways despite the online inequalities. It has especially impacted our human behaviours because of the ubiquity of the Internet on our everyday life activities [4]. This increase of online uses has had important benefits for health (e.g., eHealth), education (e.g., eLearning), and social life (e.g., social media) sectors, but problems have arisen (e.g., Internet userelated addiction problems, cyberbullying, or cybercrime). Furthermore, the coronavirus disease 2019 (COVID-19) has unexpectedly impacted our societies, strengthening the

**Citation:** Lopez-Fernandez, O. Emerging Health and Education Issues Related to Internet Technologies and Addictive Problems. *Int. J. Environ. Res. Public Health* **2021**, *18*, 321. https://doi.org/10.3390/ ijerph18010321


Received: 4 December 2020 Accepted: 31 December 2020 Published: 4 January 2021

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role of ICT in our new restrictive daily lives to support the rapid public health response worldwide [5].

In the psychological field, the Internet has transformed some of our regular behaviours, which have been enriched due to the new contexts we live in (i.e., online, off-line, and both), and opportunities have emerged (e.g., to working remotely via the Internet from home or any other place, to enjoy streaming TV shows online through laptops, smartphones, etc.). Individuals now manage themselves in online and offline domains indistinctively using many devices and apps. The psychology of the Internet (or Cyberpsychology), therefore, is studying the relationship between ICT and the psychological mechanisms, covering both positive and negative issues in a cyberspace which is digitally and humanistic mediated. According to Wallace [6], for instance, the taxonomy of online environments includes the web, the deep (or dark) web, email, forums, chats, blogs, social networks, texting, and virtual reality, which are almost all usually managed by individuals connected through the Internet, especially through smartphones.

The COVID-19 pandemic has made these environments part of our daily lives and pushed us to use ICT in great parts of our daily routines, work or study duties, and entertainment, and to become a part of our personal and social lives. These online settings are, therefore, influencing our daily emotions, cognitions, and behaviours, such as the case of some excessive online habits which put a small proportion of the population (e.g., youth) at risk of developing addiction problems. Internet addiction (IA) or problematic Internet use is understood as a set of potential addictive online problems [7] (reason why in this paper it is used the term "Internet use-related addiction problems"); but the only formally recognised problem is (video) gaming disorder (GD [8]). However, a broader spectrum of Internet use-related addiction problems have largely been researched beyond GD [9]; mainly through descriptive and relational studies (i.e., studies which look for associations among variables) about social media addiction (SMA; e.g., Facebook addiction), problem mobile phone use (PMPU; e.g., problem smartphone use (PSU)), cybersex addiction (e.g., problematic usage of pornography (PUP)), online gambling (OG), buying addiction (e.g., problem Internet shopping (PIS)), among other related problems (e.g., cyberchondria).

Reasons which drive the generation of this second Special Issue "Internet and Smartphone Use-Related Addiction Health Problems: Treatment, Education and Research" after the successful previous Special Issue "Internet and Mobile Phone Addiction: Health and Educational Effects" [10]. The present introductory article offers a rapid overview of the new advances on Internet use-related addiction problems collected from health and education approaches before and during COVID-19, and to offer a few editorial reflections from environmental and cyberpsychology perspectives.

#### **2. Materials and Methods**

This study is a rapid review (i.e., rapid evidence assessment), an evidence-based knowledge synthesis. The systematic review process components are simplified to produce information as a summary of the evidence discovered promptly. The aim was to examine articles included in the cited Special Issue (2019–2020), which were qualitatively reviewed by the author (i.e., invited editor) through a content analysis to provide a rapid outline of the state of the art on these addictive problems associated with using current technologies from a health, educational, or both settings simultaneously. The procedure was the following: (i) to collect all published papers within the Special Issue, (ii) to design a set of variables in a table to rapidly review them one by one (i.e., see Results section and Table 1), (iii) to read article by article extracting all the information previously included in the table (i.e., columns), and (iv) to write the information extracted in the table.

The methodological aim of this type of research study is to collect evidence-based conclusion to rapidly make an informed decision usually by policymakers or to justify the need for further research. In the present editorial paper, the pretension has been to inform within the same year of closing the Special Issue, about how this productive field of Internet-use related addiction problems has grown in pre-COVID times and how it seems the pandemic has also swift the productivity and priorities of this clinical and scientific field.

#### **3. Results**

The main content of the articles is presented in Table 1. It includes the following set of variables to analyse the characteristics of the Special Issue:







*Int. J. Environ. Res. Public Health* **2021**, *18*, 321







(PUP), problematic Internet shopping (PIS),

Internet gaming disorder (IGD), IGD short form scale (IGDS9-SF), online gambling (OG), quality life (QoL), non-medical use of prescription drugs (NMUPD), Internet pornography

(IPU), psychological

addiction (SA).

 inflexibility (PI), experiential avoidance (EA), Parental Smartphone Use Management

social-networks-use

 disorder (SNUD), need to belong (NTB), online

self-regulative

 Scale (PSUMS), attention deficit hyperactivity

 competences

 (OSRC), social networking sites (SNS),

 disorder (ADHD), smartphone

 use

#### **4. Discussion**

The present editorial paper offers a rapid overview of the pre-COVID-19 advances on Internet use-related addiction problems research collected in this second special issue. The main aim was to invite research on these health problems from the areas of treatments, education, and other research advances in the field. After the first wave of the pandemic, the editor would also like to share a few reflections from cyberpsychology and environmental perspectives.

Regarding the first main finding, compared with the previous Special Issue on this theme [10], using the same even stricter peer-review process, the second Special Issue has collected double the number of papers (i.e., 40 versus 20 papers) in approximately a year, which indicates the increasing interest and publication rate in this research field. Related to the authors' affiliations, this second Special Issue includes peer-reviewed papers from international samples (ordered by frequency): Europe (i.e., Spain, Germany, UK, France, Turkey, Sweden, Czech Republic, Slovakia, and Poland), Asia (i.e., China, Korea, Taiwan, Hong Kong, Malaysia, and Iran), America (USA, Canada, Perú, and Colombia), and one from Australia. However, no papers were included from Africa, which is consistent with the existence of the dual digital divide and international data reported [1,2]. This fact does not mean that there is no existence of these type of problems on this continent, but it highlights that no work has been submitted for a review in this case as we were sensitive to it.

On the other hand, the main aim was to cover health and education approaches in the context of these problems, which has partially been achieved, as the majority of papers (74%) included both approaches. However, half of the papers (54%) were studies undertaken in educational settings (i.e., high schools [14,18], universities [12,13]) with a health purpose, such as to adapt a diagnostic tool [12,13,20,21,32,37,45] or to study psychological mechanisms or comorbid problems which affect or mediate these problems to be used in prevention and treatment plans [17,22–25,46]. Only a few studies (20%) were conducted in health settings (i.e., hospitals [44] or health centres [33]) or were health reviews about these problems [46]). In the current literature, the method of extracting health knowledge through educational environments is quite common, but at the same time it shows its maturity is still compromise, as more research is needed in non-educational and clinical sectors with qualitative, mixed methods and manipulative research designs (e.g., quasi-experiments and experiments) to go in-depth on knowing better what the mechanisms behind these problems are, what seems to be the cause and how it affects to the prognostic. Thus, the need for extracting research on treatments was limited in this issue, which is a challenge the field needs to overcome.

The problems studied are more specific IA problems rather than generalised IA (23% of the papers), which is a new trend on the field, and it is conversely opposite to the first two decades of research, in which IA was more prevalent than specific Internet use-related addiction problems. In order of frequency, in this second Special Issue, which was open to research on all addictive Internet and mobile phone use, the most prevalent problems ordered by frequency were: PMPU (38% [27]), IA (26% [16]), GD (23% [19]), SMA (18% [26]), OG (8% [39]), PUP (5% [37]), and PIS (3% [23]). This means the tendency before COVID-19 in the field was to study addictive problems related to the use of mobile technologies (e.g., PSU) and its risks, and this has increased during the pandemic [50]. Reasons for this include those problems being the most researched topics due to the need of increasing and controlling our safety behaviours while travelling or commuting during the pandemic, in addition to other advantages and continuous innovations offered by mobile technologies (e.g., apps, aids, and trackers). Furthermore, as predicted a few years ago [9], other types of problematic addictive use apart from GD are studied and causing concern in population groups (e.g., OG and PUP).

This is consistent with the methodology used in pre-COVID research on Internet use-related addiction problems papers published in the Special Issue (i.e., which collected data between 2013 and 2019). Almost all works were empirical (90%) with quantitative studies (only two mixed methods and no qualitative ones). Still there are a fifth of the papers in the Special Issue which are psychometric studies, in which usually cultural validations of diagnostic tools have been undertaken, such as the Spanish and Colombian Mobile Phone Problematic Use Scale for Adolescents (MPPUSA [13]), or the Problematic Pornography Consumption Scale (PPCS [37]), which shows the interest to scientifically validate existing measures on problematic use of smartphones, gaming and pornography across cultures [51,52]. This long tradition in psychometrics in the field is probably due to the global phenomena related to the addictive uses of technologies world-wide, and the cross-cultural interest in these common problems in young populations [53]. However, it has also been criticized, as it is quite extensive in comparison with theoretical developments and conceptualisation of these problems and seems not to consolidate enough the field for its recognition as health problems [54].

Regarding the method, over half (59%) of the papers published here were correlational studies looking for associations between these problems and internal or external variables. The novelty is these studies is the inclusion of more contextual or environmental factors related to these technological use problems [31,34] and sometimes were treated as predictive ones (i.e., Relational-predictive studies) using predictive aims through statistical techniques to for example extract the factors which seems to cause an outcome (20% of the papers). Only a few studies have real independent variables manipulated by the researchers to cause an effect in other dependent ones, such as new health and educational interventions studied (e.g., Solution-Focused Group Counselling Intervention [25], an app based on cognitivebehavioural principles to avoid smartphone distractions [15]). This means applied research in the field is starting to look for explanations outside the intra-individual sphere through more controlled research designs, through new clinical and educational interventions to promote preventive strategies to minimize harms. Indeed, it can support provisional solutions and support controlling the incidence, and growth of these problems.

Thus, other external variables, such as inter-individual and environmental factors seem to impact Internet use-related addiction problems as intra-individual factors (e.g., sociodemographic, and psychological characteristics). The external indicators which emerged in this Special Issue are related to the Matthew effect (i.e., good premorbid psychosocial adjustment [17]), parent's education or socio-economic status (i.e., mother´s education [27]), parental care and monitoring (i.e., overprotection promotes these problems [31]), environmental factors (e.g., Internet cafés, advertising [40]), or professional communities (e.g., who manages those affected and their families [22]). Indeed, these contextual factors should also be considered in treatment plans, preventive actions, and policy options [46].

In the first wave of the pandemic in 2020, the lockdowns, restrictions, and isolation have affected individuals' engagement in addictive behaviours [50,55]. Indeed, the problems which depend on the Internet (the medium frequently used in pandemic times) and the need to be interconnected seems to have produced a growth in these problems [50], which means environmental factors, such as a COVID-19, can have a negative effect on these types of addictive problems in some population groups. However, the clinical, academic, and scientific communities have immediately reacted through prevention alerts and strategies [46,56–59]. For instance, according to Montag and Elhai [59], who have discussed technology overuse in young populations during the pandemic through Affective Neuroscience Theory, the neglected indirect media effects should not be overseen (i.e., those brain functions involving positive or negative emotions, such as play or sadness systems have been impacted by COVID-19). During the first lockdowns, children have translated their usual diverse leisure activities to screen time activities at home; it seems the problem has been most parents needed to telework and children, apart from home-schooling online, also spent more time online without a parent or adult guidance, which has caused in some cases lack of care, the increment of sadness, and even anger (i.e., disbalance in primary emotional systems). Thus, again, research on the causality of Internet use-related addiction problems (or Internet use disorders [60]) is needed going beyond descriptive and relational quantitative studies which have occupied almost all the scientific body of this field.

Nevertheless, there are some limitations in the present study. It is based on a limited selection of papers which have been accepted for this Second Special issue based on the editor, the journal academic editorial, and reviewer team through a procedure which usually involved at least two rounds and three reviewers per paper, and a few did not pass the quality check to proceed with the peer-review process. The bias, therefore, in the selection process of the Spanish nationality of the editor an Asiatic journal such as IJERPH, which potentially attracted more proposals from these countries, although an effort has been made to disseminate the invitation world-wide and prioritise locations, topics, and methods not commonly used in this research field to receive a representative pool of a diverse qualified papers. Furthermore, another bias of this editorial rapid review paper is the inherent weakness of conducting a fast review by an author in the same year in which we closed the Special Issue, even with the fact it was extended a few months due to the first wave of COVID-19. However, the IJERPH editorial team and I agreed on this decision and thought it was worth doing this rapid evidence assessment of the papers reviewed, collected, and published in this Special Issue, as it was more successful than initially planned, even with the pandemic factor.

Interestingly, the field is changing and moved to the need to understand the causes of these specific online problems, and the need to intervene and prevent them from individual and environmental perspectives. In the findings, a limited number of theoretical papers have been included, which are those which study the problems in-depth and sustain empirical research, which is a weakness of the field now highlighted during COVID-19 studies [58,59]. Finally, although the first wave of this pandemic and unprecedented situation has also impacted on the delay of finalising the Special Issue, the number of papers finally published are those which started the review process before March 2020, which probably means health care and scientific production even first impacted by the COVID-19 have also continued providing and producing quality outcomes such as this Special Issue.

#### **5. Conclusions**

This second Special Issue on "Internet and Smartphone Use-Related Addiction Health Problems: Treatment, Education and Research" has successfully included 40 papers (including this one) from around the globe (except Africa). It includes mainly empirical studies which are relational and a few other types about the adaptation of measures to diagnose these problems, and a few new interventions or preventive strategies to tackle the spectrum of these online usage problems in pre-COVID-19 times. Most of the related issues associated with technological usage problems still seem to be related to individual characteristics of users, who tend to be adults. The problems are about specific online activities and not only focused on gaming disorder. The components which impact their development seem to also be contextual factors, such as the pandemic which seems to have incremented the priorities on researching these health problems from a causal perspective, including environmental factors and intervention and preventive strategies. Thus, although advances have spread around the globe and in diverse Internet use-related addiction problems, maturity of the field still is compromised because there is a need for more qualitative and theoretical research, clinical trials, experimental studies, follow up studies, testing intervention and recovery strategies, policy options, and preventive actions to minimise harms and enhance users' wellbeing and quality of life, even during present pandemic times of mobility restrictions and more online time consumption.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** The data presented in this study are openly available at https://www. mdpi.com/journal/ijerph/special\_issues/Internet\_Smartphone\_Addiction.

**Acknowledgments:** To Daria J. Kuss for her support in doing a first review.

**Conflicts of Interest:** The authors declare no conflict of interest.
