Social Anxiety and Internet Addiction among Primary Health Care Workers at PSMMC, Riyadh

Social Anxiety Disorder (SAD) and Internet Addiction (IA) significantly impact the quality of life and professional efficacy among Primary Health Care Workers (PCWs). Given their prevalence and the potential for negative comorbidities, including depression, this study aims to explore the occurrence and correlation of SAD and IA among PCWs in Riyadh, Saudi Arabia. Methods: This cross-sectional, questionnaire-based study assessed SAD and IA among 154 PCWs using the Social Phobia Inventory (SPIN) and Internet Addiction Test (IAT). The study was conducted over 12 months from April 2023 to March 2024 at Prince Sultan Military Medical City (PSMMC), Riyadh; it employed random sampling to ensure diverse participation. The Social Phobia Inventory (SPIN) and Internet Addiction Test (IAT) questionnaires were used to assess the prevalence of SAD and IA, respectively. Pearson’s correlation was used to determine the association between both variables. Results: The study found that 27.3% of participants exhibited some level of social anxiety, while 45% showed signs of IA. Specifically, mild to moderate internet addiction was present in 44.8% of respondents. Only 8.4% of participants fell into the severe category of social anxiety, while severe internet addiction was absent. A significant positive correlation was observed between SAD and IA (r = 0.36, P < 0.001). Additionally, higher income and certain professional roles were associated with lower instances of both conditions. Conclusion: The study highlights the prevalent but primarily mild to moderate levels of SAD and IA among PHCWs, underscoring the need for targeted interventions. While present, these issues may not severely impact PHCWs at PSMMC. The correlation between SAD and IA suggests the internet's dual role as a coping mechanism and potential risk factor, indicating areas for future research and intervention strategies.


Introduction
Research has shown the negative impact of social anxiety disorder (SAD) on the quality of life in many aspects, including simple daily tasks at work, family, and social interaction [1].Furthermore, SAD has been linked with other disabling comorbidities like depression and suicidal thoughts [2,3].Regarding academic performance, people with social anxiety reported negative academic performance.In a study conducted on 504 medical students at Taibah University, the prevalence of severe and very severe forms of social anxiety was 13.5%.Mild and moderate are estimated as 18.8% and 19.6% [4].Another study conducted in Abha-Saudi Arabia on 454 student males aged 15 to 20 years reported a social anxiety prevalence of 11.7%, where severe and more severe forms were presented in 36% and 11.4%, respectively [5].The prevalence of social anxiety among healthcare professionals, particularly medical and nursing students, is a significant concern.Studies have found a high prevalence of social anxiety among medical students, ranging from 30.5% to 85% [6,7], which is much higher than the reported prevalence of 7-13% in 5 the general population [8].Social anxiety is associated with various factors such as age, gender, and academic performance satisfaction [6,7], can lead to avoidance behavior and somatic symptoms [9], and is often comorbid with other psychiatric disorders [10,11].Early recognition and prompt treatment are crucial in addressing this issue [8].The previous findings are concerning, as social anxiety can lead to negative attitudes towards communication skills [12].This is particularly concerning given the potential impact on patient care and the well-being of medical professionals.This is concerning as social anxiety can lead to withdrawal from society and depression [7].The relationship between internet addiction (IA), social anxiety, impulsivity, self-esteem, and depression in Turkish undergraduate medical students revealed significant correlations, suggesting that IA exacerbates social anxiety and depression while lowering selfesteem among medical students [13].Similarly, a study conducted in India among university students found a positive correlation between IA and social anxiety, indicating a widespread issue beyond geographical and cultural confines [14].The advances in the digital era, while enhancing efficiency and access to information, have also ushered in challenges, particularly in the domains of social anxiety and internet addiction among PHCWs.Exploring the mediating role of IA in depression, SAD, and psychosocial well-being among adolescents in six Asian countries confirmed the significant impact of internet addiction on worsening SAD and depression [15].The impact of internet addiction on job satisfaction and mental health symptoms among Portuguese workers highlights the complex interplay between digital use and mental well-being, as high IA was associated with lower job satisfaction and increased mental health symptoms [16].This correlation emphasizes the importance of a balanced approach to internet use, especially among healthcare workers who provide direct patient care.Furthermore, the association between social media use, IA, and SAD among young adults provides a complex understanding of how digital platforms might increase SAD, possibly compromising professional relationships and personal well-being [17].PCWs need to be aware of and deal with the adverse effects of SAD and IA.Recognizing the negative impact of both disorders by healthcare workers is essential for their health and the level of care they provide to patients.Individual, organizational, and societal strategies are needed to make the most of the digital age's benefits while also protecting the mental health and general well-being of PCWs.This study aimed to assess the prevalence of both SAD and IA in a sample of PCW in Riyadh, Saudi Arabia, and explore the possible association between both disorders.

Study Design
This investigation was a cross-sectional, questionnairebased study aiming to explore the prevalence of social anxiety and internet addiction among PCWs at PSMMC, Riyadh, Saudi Arabia.Conducted over 12 months from April 2023 to March 2024, the study utilized validated instruments to measure the variables of interest within a broad sample of healthcare professionals.

Participants and Recruitment
Eligible participants included all primary care physicians, nurses, and pharmacists working at PSMMC primary health care centers, covering a sample of approximately 154 participants.Inclusion criteria were set to encompass healthcare workers of all educational backgrounds and levels of practice, provided they had access to the Internet.Exclusion criteria included non-PSMMC healthcare workers, those without internet access, and non-consenting individuals.A simple random sampling technique was employed to select participants, ensuring equitable representation across different demographics and specialties.

Study Questionnaire
The data collection instrument was a self-administered questionnaire divided into two main parts.The first part collected socio-demographic information, including age, educational level, region of residence, and other relevant details.The second part consisted of the Social Phobia Inventory (SPIN) to assess social anxiety and the Arabic-validated Internet Addiction Test (IAT) for evaluating internet addiction.Both tools were chosen for their validated psychometric properties and relevance to the study's objectives.The SPIN questionnaire includes 17 items, with responses for each item ranging from 0 (Not at all) to 4 (Extremely).For the IAT, a 20-item scale with responses from 1 (Rarely) to 5 (Always) was used.These instruments allowed for quantitative analysis of social anxiety and internet addiction among the participants.

Sample Size Calculations
Given the exploratory nature of this study, the sample size was determined based on the expected prevalence of social anxiety (13.5%) among the target population, aiming for a precision of 5% at a 95% confidence interval [4].Considering these factors, a sample size of 180 physicians was needed.All primary care physicians, nurses, and pharmacists working at PSMMC-affiliated primary care centers were enrolled in the study, resulting in a Comprehensive sample.

Questionnaire Scoring
The determination of cut-off points for the Social Phobia Inventory (SPIN) and the Internet Addiction Test (IAT) was guided by established psychometric criteria to ensure accurate classification of social anxiety and Internet addiction levels among participants.For the SPIN, a widely recognized tool for assessing the severity 6 of social phobia symptoms, cut-off points were set as follows: scores of 0-20 indicated no or minimal social anxiety, 21-30 suggested mild social anxiety, 31-40 indicated moderate social anxiety, 41-50 were indicative of severe social anxiety, and scores above 51 denoted very severe social anxiety.For the IAT, which assesses the severity of internet addiction, the scoring was categorized into 0-30 for non-addiction, 31-49 for mild internet addiction, 50-79 for moderate internet addiction, and 80-100 for severe internet addiction.These cut-off points, validated through previous research and psychometric analysis, provided a robust framework for evaluating internet addiction levels, facilitating the identification of physicians at risk, and guiding subsequent interventions or support mechanisms.

Statistical Analysis
Statistical processing was conducted using R v 4.3 [18].Counts and percentages were used to summarize categorical data.The mean ± standard deviation was used for continuous data.The chi-square test of independence was used to assess the association between categorical variables.Spearman's correlation was used to determine the association between continuous variables.Cronbach's alpha was used to assess the reliability of both questionnaires.Hypothesis testing was performed at 5% level of significance.

Ethical Considerations
Ethical approval was secured from the Institutional Review Board of the Medical Services Department for the Armed Forces.All participants provided informed consent and were assured of their confidentiality and the voluntary nature of their participation.The study adhered to ethical standards for research involving human subjects, prioritizing participant welfare and data integrity.) Note: Data were summarized using counts and percentages for categorical variables and the mean ± SD for continuous variables.

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A total of 154 PCWs were included in the study sample (Table 1).The average age was 31.6 ± 7.34 years, where a significant majority (63.6%) were under 30 years old, 31.2% fell into the 30 to 50 years age bracket, and 5.19% were older than 50.The distribution of males and females was approximately equal, with females representing 51.9%.Regarding marital status, more than half of the respondents were single (57.1%), with married participants making up 41.6.The professional roles were predominantly occupied by medical doctors (77.9%), followed by nurses (14.9%) and pharmacists (7.14%).The family size of participants was diverse; 55.2% had less than six family members, 37.7% had between 6 and 10, and 7.14% hailed from families larger than ten members.When examining perceived family income, less than one-half (44.8%) reported earning more than 24,000 Saudi Riyals monthly.Non-smokers constituted a significant majority (78.6%) of the cohort.

Figure 1: Distribution of Responses to the Social Phobia Inventory (SPIN) Questionnaire
Each statement is evaluated on a Likert scale from 0 (Not at all) to 4 (Extremely), and the responses are summarized as mean scores with standard deviations (SD) and percentage distributions across the scale.Figure 1 shows a summary of the results of the SPIN questionnaire.Higher levels of distress were reported in situations with a potential for negative evaluation: fear of embarrassment or looking stupid was a significant concern (2.22 ± 1.39), and apprehension towards public speaking was also prominent (2.12 ± 1.23).Conversely, scenarios that involve less direct interaction or evaluation by others, such as talking to strangers (1.44 ± 0.72) and going to parties (1.51 ± 0.91), had lower mean scores, suggesting these contexts are less challenging for the respondents.Each statement is evaluated on a Likert scale from 0 (Not applicable) to 5 (always), and the responses are summarized as mean scores with standard deviations (SD) and percentage distributions across the scale.Figure 2 shows the responses for the IAT.The item with the highest mean score was "Exceeding planned online duration" (3.40 ± 1.24).Other notable findings include "Choosing Internet over household responsibilities" (2.66 ± 1.12) and "Failing attempts to cut back on Internet usage" (2.60 ± 1.19).The item "Checking email before essential tasks" (2.97 ± 1.23) received the second-highest mean score, reflecting a common tendency to prioritize internet activities over other responsibilities.Lower mean scores were noted for "Being secretive or defensive about what one does online" (2.05 ± 0.92) and "Reduced work productivity due to internet usage" (2.19 ± 0.95), suggesting the participants less frequently endorsed these behaviors.individuals (37.0%), showed mild levels of internet addiction, and a smaller segment, 12 (7.8%),displayed moderate internet addiction levels.Notably, none of the participants were categorized with severe internet addiction (Figure 3b).These results indicate that while a majority of the participants do not demonstrate social anxiety or internet addiction, a notable portion exhibits mild to moderate levels of these conditions.The average SPIN score was 13.8 (13.1), while the average AIT score was 29.0 (14.3).Cronbach's alpha showed that the reliability of both questionnaires (0.92 and 0.95) was adequate for the SPIN and IAT questionnaires, respectively.Association Between SPIN and IA Scores There was a statistically significant positive association between SPIN scores and IAT scores among participants (r = 0.36, P < 0.001), suggesting a statistically significant moderate correlation; as social anxiety symptoms increase, so does the tendency towards internet addiction.The majority of participants with no social anxiety (65.2%) also do not exhibit internet addiction.
As the severity of social anxiety increases, there was a corresponding increase in the proportion of participants exhibiting mild to moderate internet addiction, supported by Fisher's exact test result (p = 0.001), which suggests a significant association between the categories of the two conditions.Note: Data were summarized using counts and percentages; Analysis was performed using the Chi-square test of independence

Factors Association with SPIN and IA Scores
In the analysis of SPIN and IAT categories stratified by demographics and professional attributes (Table 2), the proportion of medical doctors with no social anxiety yet exhibiting mild to severe internet addiction was significantly lower compared to nurses (P = 0.022).Meanwhile, pharmacists were not represented in the mild to severe internet addiction category among those without social anxiety.A significant association was observed between perceived family income and the SPIN None category (P = 0.004), with individuals earning more than 24000 SR per month less likely to exhibit mild to severe internet addiction than those with lower income brackets.
The other demographic factors, such as gender, marital status, family size, and smoking status, did not show a significant association with the presence of mild to severe internet addiction or social phobia.

Discussion
The current study explored the prevalence of social anxiety and internet addiction among healthcare workers at PSMMC, employing a cross-sectional, questionnaire-based design.The findings reveal insightful patterns and associations that contribute significantly to understanding these conditions within a critical workforce segment.The prevalence of any social anxiety and any internet addiction among healthcare professionals reported in this study (27.3% and 45%, respectively) aligns with the majority of the existing literature, indicating a variable but noticeable presence of these conditions in healthcare settings.Notably, a majority of participants did not meet the criteria for severe social anxiety or internet addiction, suggesting that while these conditions are present, they may not be common among PCWs at PSMMC.A range of studies have explored the prevalence and impact of internet addiction among healthcare professionals, including primary care workers.A systematic review conducted by Buneviciene reported a 9.7% prevalence of internet addiction among healthcare professionals, with a higher burden of mental health symptoms and fatigue ( Bunevicius, 2021).In addition, the prevalence of severe internet addiction was negligible in many studies, similar to what was reported in the current study.The study also showed that the healthcare job (resident vs nurse vs physician) was not associated with internet addiction.It is worth noting that only a few studies evaluated internet addiction in healthcare workers [20][21][22].

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Our findings are consistent with those from two studies conducted by Nagori and Prakash [20,23].The former study included medical students and found that problematic internet addiction was prevalent in 9.3% of the included students with an internet addiction frequency of 0.9% [23], which is similar to what was reported in the current study.Prakash conducted a cross-sectional study of junior doctors with similar findings where 13% of junior doctors had moderate addiction to the Internet while no severe addiction was found [20], which mimics the 7.8% reported in the current study.Zhang and colleagues reported similar prevalence rates of internet addiction in the literature, who reported a pooled prevalence rate of 30.1% for internet addiction among 3,651 medical students, similar to that reported in the current study [24].
Nonetheless, the study included medical students who usually report a higher prevalence of IA for several reasons.The accessibility hypothesis proposes that medical students are at a higher risk of IA because they often utilize the Internet to seek medical information and engage in online learning and evaluation [25].Furthermore, medical students may engage in the virtual world of the Internet as a means of avoiding academic stress [26], which explains why such findings were replicated in other studies that included medical students [27,28].
The current study also explored the prevalence of social anxiety among primary care workers.However, only a limited number of studies were found.Employing a cutoff point of 20, the prevalence of SAD was 27.3%.The prevalence rate was slightly lower than that reported in a sample of 200 family medicine residents [29] in Saudi Arabia.The prevalence of social anxiety in this study was greater than the prevalence reported in the previous Saudi research if we compared it with the prevalence of this condition in the general Saudi population.It was estimated that the prevalence of social anxiety in Saudi Arabia was roughly 51% among medical students, with 8% and 4% reporting severe and very severe social anxiety [30].Research has consistently shown a high prevalence of social anxiety among medical students, with some studies reporting rates as high as 56% [31,32].In Czech, a study showed that 85% of Czech medical students showed some symptoms of avoiding behavior, and 56% experienced somatic symptoms of social anxiety.The study proposed the efficacy of an educational program on social phobia to educate physicians and medical students about the illness and its treatment options [9].
Other studies showed that a significant proportion of medical students, particularly females, experienced social anxiety [7,33].The prevalence of social anxiety among hospital doctors was also notable, with occupational constraints such as night work and psychological demands being significant risk factors [34].This study's reduced prevalence of social anxiety is likely due to medical students having more exposure to clinical settings, leading to more patient interaction and improved interviewing skills.The current study also explored the possible association between social anxiety and internet addiction.While the prevalence of both was considerably low in the study population, a statistically significant association was found between both.These results are similar to those reported in two other studies, which found a significant association between internet addiction and anxiety among medical students and junior doctors, respectively [20,23].Another study found that undergraduate medical students with internet addiction exhibited higher social anxiety, lower self-esteem and were more depressed than those without IA [13].
The association between social anxiety and internet addiction is particularly noteworthy.Our findings, indicating a moderate correlation between social anxiety symptoms and tendencies towards internet addiction, echo the results of prior research suggesting that individuals with social anxiety may engage more in internet use as a coping mechanism [35].This pattern highlights the potential for the Internet to serve both as a refuge and a risk factor for individuals with social anxiety, emphasizing the complex relationship between digital media use and mental health.A similar context reported a statistically significant association between IA and psychological problems such as depression, burnout, and stress [36] in a sample of medical residents in India.In other populations, similar results were reported.Weinstein reported that internet addiction is associated with social anxiety in young adults [37].
The current study also explored the possible predictors of social anxiety and internet addiction.Only the monthly income and profession were significantly associated with both disorders.A range of factors have been associated with social anxiety in primary care workers.These include sleep duration, communication problems with teaching staff, feelings of inferiority, and family problems (Nayak, 2021).In addition, several studies found a statistically significant association between gender and social anxiety, although no such association was reported in the current study [31,33], which may be attributed to the small sample size.A range of factors have been associated with social anxiety in healthcare professionals, including age, history of chronic illness, academic performance satisfaction, language barrier, and increasing academic years of exposure [6,7].However, some studies have found no significant associations with variables such as gender, religion, number of siblings, type of previous school, and partner status [31,38].The fear of negative evaluation, fear of physical symptoms, and fear of 12 uncertainty in social situations have been identified as key dimensions of social anxiety [39], similar to what was reported in the current study.Social anxiety has also been linked to depression and poor quality of life [40].
Regarding internet addiction, Chaudhari explored the determinants of internet addiction among medical students and showed that gender, accommodation, age of first internet use, and online activities were associated with higher internet addiction [41].A range of factors have been associated with internet addiction in healthcare professionals.These include greater mental symptom burden and fatigue (Bunevicius, 2021), male gender, computer ownership, preferred time of internet use, login status, and mode of internet access (Gedam 2017), age, daily internet use, marital status, and job type [42], method of job selection, workload, regular sleep, hobbies, marriage, and having children [43], and depression, social anxiety, low selfesteem, and low perceived social support [44].These findings suggest that a combination of personal, professional, and mental health factors contribute to internet addiction in healthcare professionals.Despite a majority of participants not meeting the criteria for severe internet addiction or social anxiety, the presence of mild to moderate levels of social anxiety and internet addiction underscores the necessity for targeted interventions and support systems.The significant correlation between social anxiety and internet addiction suggests that for some healthcare professionals, the Internet may serve as a coping mechanism for social discomfort, thereby potentially exacerbating underlying mental health issues.The findings also highlight the role of socioeconomic and professional factors in predisposing individuals to these conditions, indicating the need for comprehensive approaches to addressing mental health within healthcare settings.

Limitations
The current study had several limitations.First, we could not specify the pattern of internet use and whether it was limited to non-professional or nonessential use only.PCP often use the Internet for their routine academic purpose, which is quite high.Second, the cross-sectional design limits the ability to infer causality between observed variables, such as the relationship between social anxiety and internet addiction.Second, the reliance on self-reported questionnaires, despite their validated status, may introduce response bias, including social desirability or recall bias.Third, the study's sample was confined to healthcare workers at a single military medical city in Riyadh, which may limit the generalizability of the findings to other healthcare settings or regions.

Conclusion
The results suggest that social anxiety and internet addiction, although non-severe, are common in primary care workers.The correlation between social anxiety and internet addiction among participants suggests a potential area for intervention.Recognizing the importance of mental health support, we recommend developing targeted strategies to address these issues within the healthcare sector.Further research is needed to explore effective interventions and support mechanisms.

Figure 4 :
Figure 4: (A) Correlation and (B) Association Between Social Phobia Inventory (SPIN) Scores and Internet Addiction Test (IAT) Scores Figure (4a) shows the Trend line indicating the direction and strength of the relationship.R = correlation coefficient.p = P-value for statistical significance of the correlation.Figure (4b) is a Bar chart showing the percentage distribution of IAT categories within each SPIN category.N = Total number of participants.df = Degrees of freedom for Fisher's exact test.φ = Phi coefficient, measuring the association's effect size.Fisher's p = P-value was used to measure the statistical significance of the association between categories.There was a statistically significant positive association between SPIN scores and IAT scores among participants