Prevalence and Associated Factors of Nomophobia Amongst the General Population in Makkah Province and Al-Madinah Province, Saudi Arabia: An Analytical Cross-Sectional Study

2.1. Study Design, Setting, and Participants

This study was a web-based analytical cross-sectional study. Data were obtained through an online questionnaire targeting the population of Makkah Province and Al-Madinah Province, Saudi Arabia, from July to October 2023 through social media platforms, like Facebook, WhatsApp, Instagram, and X platform. The inclusion criteria were adults aged 18 years old and older who lived in any city in these two provinces in Saudi Arabia. The participants were recruited using a convenience sampling approach. The Makkah and Madinah Provinces have a high population density in the Kingdom of Saudi Arabia [19].

2.2. Questionnaire

An online Arabic questionnaire was created using Google Forms. Respondents received electronic links that included the research objectives, target population, and a request to participate voluntarily. The questionnaire included four sections, encompassing demographic data, the Patient Health Questionnaire-2 (PHQ-2), the Nomophobia Questionnaire (NMP-Q), and the Insomnia Severity Index (ISI).

The first section collected demographic data, including age, sex, nationality, marital status, level of education, employment status, province, city, personal income, family income, personal history of mental disorders in addition to diabetes and irritable bowel syndrome, and family history of mental disorders in addition to diabetes and irritable bowel syndrome. We also asked the participants about the duration of daily smartphone usage for leisure activities (Less than 1 hour, 1-2 hours, 2-3 hours, 3-4 hours, or More than 4 hours).

The second section included the PHQ-2, which was developed by Kroenke and colleagues [20]. It assesses the frequency of low mood and anhedonia in the previous two weeks and includes the first two components of the PHQ-9. The PHQ-2 is designed to screen for depression in a “first-step” manner. Patients screened positive should be assessed further with the PHQ-9 to see if they satisfy the criteria for a depressive illness. PHQ-2 scores range between 0 and 6. The best cutoff criterion for screening for depression with the PHQ-2 is a score of 3. Major depressive disorder is likely present if the score is 3 or higher. The sensitivity and specificity (95% CI) of the PHQ-2 for cutoff scores of 3 or higher were found to be 0.72 (0.67–0.77) and 0.85 (0.83–0.87), respectively. It has been shown that the Arabic version of the PHQ is a reliable and valid instrument for screening a Saudi Arabian sample for depression, anxiety, somatic disorders, and panic disorders [21].

The third section included the NMP-Q to assess nomophobia. The NMP-Q was developed by Yildirim and Correia in 2015 [5] and consists of 20 questions, each of which is assessed on a seven-point Likert scale. The total NMP-Q score ranges from 20 to 140. The interpretation of the NMP-Q score into the level of nomophobia is shown in Table 1. NMP-Q consists of four factors: factor 1: inability to communicate; factor 2: loss of connectivity; factor 3: inability to acquire information; and factor 4: sacrifice of convenience. The internal validity and reliability of the NMP-Q dimensions are considered good (0.78–0.92). Exploratory factor analysis indicated that the NMP-Q has a four-factor structure that correlates to the characteristics of nomophobia [5]. The questionnaire has been validated in the Arabic language, exhibiting satisfactory psychometric properties, with a Cronbach’s alpha coefficient of 0.879 [22]. In this study, we used the Arabic version of the measure, available from the Saudi Ministry of Health’s website [23].

The fourth section focused on insomnia using the Insomnia Severity Index (ISI) to identify cases of adult insomnia over the past month [24, 25]. A five-point scale was employed in the assessment of insomnia severity, with response options ranging from 0 (no problem) to 4 (a very severe problem) for all items. An aggregate score was calculated, ranging from 0 to 28. The interpretation of the ISI score into the level of insomina is shown in Table 2. In this study, the validated Arabic version of the scale was used, which has demonstrated good psychometric properties [26].

2.3. Sample Size Calculation

The minimum sample size necessary for this research was computed using the OpenEpi version 3.0, considering the following factors: a Confidence Interval (CI) of 95%; an anticipated percentage of frequency of 50%; and setting the design effect as 1, and that the population size of Makkah and Al-Madinah Provinces combined is approximately 10,159,446 according to the General Authority [27]. The sample size was estimated to be 385 participants. To allow for possible data loss, the total required sample size was 450 participants. The survey link was available to accept responses during the data collection period and it was re-posted weekly through social media channels to increase response. The response rate was high and the required sample size was achieved before the data collection period ended. During the process of data cleaning, participants with missing data were eliminated, and the total number of participants after elimination was 1022.

2.4. Statistical Analysis

Data were analyzed using RStudio (R version 4.3.0). The data variables have been presented as frequencies and percentages. The association between the participants’ characteristics, such as sociodemographic and clinical characteristics, including personal and family history, and nomophobia or insomnia was assessed using inferential analysis tests, including a Pearson’s Chi-squared test or a Fisher’s exact test whenever applicable. Risk factors for having moderate-to-severe nomophobia or moderate-to-severe insomnia were assessed using a binary logistic regression analysis with each outcome in a separate model. The variables that were significantly associated based on the inferential analysis were entered into the multivariable models as independent variables. The results have been expressed as Odds Ratios (ORs) and 95% Confidence Intervals (95% CIs). A p-value < 0.05 indicated statistical significance.

3.1. Sociodemographic and Clinical Characteristics

In the current study, we analyzed data from 1022 participants. The majority of the participants were in the age range of 18 to less than 30 years (79.7%), were of Saudi nationality (88.5%), and were female (75.0%). Regarding marital status, a significant proportion were single (74.8%), and in terms of education, the highest proportion had completed college or university education (58.9%). A substantial number of the participants were identified as students (64.3%) in terms of employment status, and the most prevalent province was Makkah Province (63.7%). Additionally, the majority of participants reported a personal income of less than 5000 SAR per month (80.9%), while 44.6% had a family income within the range of 5000 to 15,000 SAR per month. Based on the PHQ-2 questionnaire, the likelihood of major depressive disorder was identified among 47.3% of the respondents. In terms of personal psychiatric history, the most common mental disorders the participants were diagnosed with by a physician or psychiatrist included generalized anxiety disorder (9.9%) and major depressive disorder (9.7%), while a confirmed family history of these conditions was reported by 10.2% and 14.3% of the respondents, respectively. Diabetes and irritable bowel syndrome were prevalent among 3.3% and 15.0% of participants and among 43.5% and 33.2% of participants’ families, respectively (Table 3).

3.2. Frequency of Mobile Device Usage per Day and Characteristics of Nomophobia

Only 10.1% of the respondents indicated that they use their mobile phones two hours or less per day, whereas 61.6% of them used mobile devices more than four hours per day (Fig. 1). Notably, only 3.2% of the respondents were not affected by nomophobia, and 23.6% of them had mild nomophobia. Moderate and severe nomophobia were prevalent among 47.8% and 25.3% of the respondents, respectively (Fig. 2).

3.3. The Association between Sociodemographic Characteristics and Nomophobia and Insomnia

The inferential analysis revealed a statistically significant association between the number of hours spent using a phone daily and the severity of nomophobia (p < 0.001). Among those spending less than one hour per day, a majority exhibited “no/mild nomophobia” (76.5%), whereas a substantial proportion of participants spending more than four hours per day on their phones exhibited “moderate/severe nomophobia” (82.1%; Table 4).

More than one-third of the respondents had sub-threshold insomnia (37.1%), whereas 17.2% had moderate insomnia and 6.0% had severe insomnia (Fig. 3). Notably, the proportion of individuals with “moderate/severe insomnia” varied significantly by age (p = 0.013), with a higher prevalence observed among participants aged 18 to <30 years (25.3%) compared to those in older age groups. The province of residence also showed a significant association with insomnia (p = 0.009), as a higher proportion of individuals in Al-Madinah Province (27.8%) experienced “moderate/severe insomnia” compared to individuals in Makkah Province (20.6%). Importantly, the presence of nomophobia (p < 0.001) and the number of hours spent using a phone daily (p < 0.001) were both strongly associated with the severity of insomnia. Specifically, participants with “moderate/severe nomo- phobia” (27.9%) and those spending more than four hours per day using their phones (28.3%) had significantly higher proportions of “moderate/severe insomnia” (Table 4).

3.4. The Association between Clinical Characteristics and Nomophobia and Insomnia

A substantial and statistically significant association was observed between the presence of depression, as indicated by a PHQ-2 score ≥ 3, and the severity of nomophobia (p < 0.001). Notably, 82.0% of participants with depression exhibited “moderate/severe nomophobia,” while 65.3% of those without depression reported the same. Likewise, a significantly higher proportion of participants with a previously confirmed diagnosis of depression had moderate-to-severe nomophobia (81.8%) compared to those without depression (72.3%, p = 0.041). Additionally, there was a statistically significant association between irritable bowel syndrome and the severity of nomophobia (p = 0.029), with 80.4% of individuals with irritable bowel syndrome reporting “moderate/severe nomophobia” compared to 71.9% of those without the condition (Table 5).

Furthermore, the presence of depression, as indicated by a PHQ-2 score ≥ 3, was strongly associated with the presence of “moderate/severe insomnia” (p < 0.001). Among those with depression, 36.4% experienced “moderate/severe insomnia,” while only 11.3% of individuals without depression reported the same. Additionally, generalized anxiety disorder was significantly associated with insomnia (p = 0.002), with 35.6% of individuals with the disorder experiencing “moderate/severe insomnia” compared to 21.8% of those without it. Panic disorder was also significantly associated with insomnia (p = 0.008), as 42.4% of participants with panic disorder exhibited “moderate/severe insomnia,” while 22.5% of those without the disorder reported the same. Furthermore, several familial factors were significantly associated with insomnia, including familial major depressive disorder (p = 0.001), familial panic disorder (p = 0.045), familial generalized anxiety disorder (p = 0.029), familial irritable bowel syndrome (p = 0.035), and familial diabetes mellitus (p < 0.001; Table 5).

3.5. Risk Factors for Nomophobia

The variables that were significantly associated with nomophobia in the inferential analysis were used as independent variables in the multivariable logistic regression model; however, since we had two measures of depression based on PHQ-2 and a previously confirmed diagnosis, we sought to incorporate PHQ-2-based depression in the model to avoid the risk of multicollinearity of the same condition. The results revealed that as the daily duration of mobile phone use increased, the risk of nomophobia significantly escalated, with ORs of 4.13 (95% CI: 1.76–10.6, p = 0.002) for two to three hours per day, 8.62 (95% CI: 3.74–21.9, p < 0.001) for three to four hours per day, and 13.0 (95% CI: 5.89–31.7, p < 0.001) for more than four hours per day. Additionally, participants with depression, as indicated by a PHQ-2 score ≥3, exhibited a significantly increased risk of nomophobia, with an OR of 1.99 (95% CI: 1.46–2.72, p < 0.001). Furthermore, individuals with irritable bowel syndrome had a significantly elevated risk of nomophobia, with an OR of 1.62 (95% CI: 1.04–2.60, p = 0.037; Table 6).

3.6. Risk Factors for Insomnia

Participants with “moderate/severe nomophobia” had significantly higher odds of experiencing insomnia (OR = 2.60, 95% CI: 1.66–4.18, p < 0.001) compared to those with “no/mild nomophobia.” Similarly, individuals with depression, as indicated by a PHQ-2 score ≥3, exhibited substantially increased odds of insomnia (OR = 3.49, 95% CI: 2.50–4.93, p < 0.001) compared to those without depression. Furthermore, the presence of familial diabetes mellitus was associated with a higher likelihood of experiencing insomnia (OR = 1.57, 95% CI: 1.12–2.21, p = 0.010). Finally, residing in Al-Madinah Province was found to be a significant risk factor for insomnia (OR = 1.55, 95% CI: 1.12–2.13, p = 0.008) compared to Makkah Province (Table 7).