Insomnia and problematic gaming: A study in 9 low‐ and middle-income countries

Study Objectives: To investigate (i) the prevalence and incidence of online and video gaming disorder in an African population, and (ii) whether gaming is associated with sleep disorders and psychopathological symptoms, including anxiety and depression. Methods: Data were collected in South Africa, Cameroon, Morocco, Rwanda, Tunisia, Gabon, Nigeria, Ivory Coast and Senegal. Participants were students aged of 24 ± 2.8 years. Problematic gaming, sociodemographic items, insomnia, associated comorbities, depression and anxiety were measured. The effect of continuous gaming time (after 1, 6 and 12 months) on severity of sleep disorders and the distribution of gamers per country and per type of device were also calculated. Results: African gamers expressed a preference for online gaming more than video gaming. Men played video games for an average of 14 hours per week, and women for around three hours per week. The smartphone was the favourite gaming tool for both men and women. Effect of continuous gaming time on the decrease of sleep is significant (F (2.1) = 40.26; p < 0.001). After 1 month, participants has no clinical insomnia, but after 6 months they developed subthreshold insomnia and clinical moderate insomnia. Problematic gaming was not associated with anxiety and depression but was associated with an increased of musculoskeletal impairments. Conclusions: After 6 months of continuous gaming time, sleep is affected. Problematic gaming, regardless if it is video or online; induced a clinical insomnia. The more months a participant spent gaming, the higher the chance for experiencing sleep disorder symptoms.


INTRODUCTION
In recent years, a number of factors have increased in contributing to the risk of developing psychological stress and mood disorders, with these being risk factors in the environment and people's lifestyles [1][2][3][4][5] . This complex combination of environmental and psychological stress may contribute to developing neurological dysfunctions, such as sleep disorders. Although some sleep disorders are consequences of cortical imbalances 6 , including insomnia and restless leg syndrome, lifestyle can influence their incidence considerably [7][8][9][10] . New technologies are part of this lifestyle, including the internet and gaming, which may affect mental health and may lead to the development of addictive behavior particularly in young individuals [11][12][13][14] . The use of smartphones, computers, and video games or online gaming can disturb the circadian process [15][16][17][18][19] . Moreover, many studies revealed the correlation between cognitive impairments and sleep disorders [20][21][22][23] . Sleep disorders often increase when individuals have mood and anxiety disorders, deficits in attention or perception, or when individuals live under stressful conditions (i.e., low income, working night shifts, living with neuropsychiatric disorders without family support) 2, [21][22][23][24] . Authors also report there is a link between behavioural and medical risk factors (i.e., high-blood pressure, obesity, and smoking) and sleep disorders [25][26][27] , as well as between lower quality of life and a stressful environment and the occurrence of sleep disorders 7 . Recently, a negative correlation was found between psychopathological symptoms (i.e., anxiety, depression and stress) and the development of behavioral problems, such as decreases in psychological wellbeing 5,10,28 . It has also been reported that the presence of or exposure to light can disturb the circadian rhythm, the melatonin cycle and cerebral plasticity 6 . To fall asleep, inhibition increases, while excitation decreases. During this process, different sleep stages occur, and neurons build new networks while replacing and repairing tissues and consolidating memory. Accordingly, lightemitting technology may affect the quality and duration of sleep 29 . Wireless devices including smartphones, laptops or tablets may therefore affect sleeping patterns as they rely on backlighting. Recent reports suggest a higher incidence and prevalence of behavioral disturbances in children and adolescents exposed to technologies and playing online games for several hours per week at home 11,30,31 . In addition to behavioral disorders related to the utilization of new technologies, the phenomenon of addiction may be another consequence, which are now being included under an addictive behaviors category in the 11 th update of the World Health Organization's International Classification of Diseases (ICD-11), Gaming Disorder generally refers to a diagnosis characterized by uncontrollable and persistent playing of video and digital games that is harmful to an individual's wellbeing, often leading to addictive behaviors. Rather than engaging in the offline world, an addicted user devotes the majority of his or her time to gaming. The addicted gamer often isolates him/herself from others, ignores more important responsibilities, and is often preoccupied with obtaining higher status / rankings / achievements in his/her favorite computer game. This may be the case for using gambling and gaming on computers and consoles as the available evidence indicates gaming with wireless devices, such as smartphones, does not appear to be problematic 32 . Similar evidence was reported for the use of online social networking sites and Massively Multiplayer Online games (MMOs) 12,33 . Although research in the area of Gaming Disorder is progressing 34 , few studies have explored the association between gaming behavior and sleep disorders [35][36][37][38][39][40][41][42][43][44] . Considering the impact of light, a stressful environment and visual stimulation on sleep mechanisms and the risk excessive use of gaming may pose for sleep and psychopathology, it may be hypothesised that gaming decreases sleep quality and increases sleep disorders and psychopathological symptoms. This hypothesis has not been reported in the available scientific literature yet. Some associations or indirect links were found between the use of technologies (internet, video games, and electronic media) and factors associated with sleep (sleep quality, sleep duration, and sleep habits) for preadolescents, adolescents and older adults m [35][36][37][38][39][40][41][42][43][44] , but a clear correlation between gaming and sleep disorders has not yet been established.
Specifically, there exists a gap in knowledge regarding the assessment of gaming behaviors and their impact on sleep in developing countries, low-and middle-income countries. There is a lack of data particularly for Africans countries, which face the same problems related to the use of the internet and gaming [45][46][47][48][49] . With the popularity of consoles, such as Playstation and the Xbox, and the possibility to use various applications on smartphones and tablets due to easy access to Wi-Fi and mobile data, gaming has become a part of life in Africa, similar to Europe and North America. Recently, some reports estimated that African countries such as Nigeria have over 146,866,356 active mobile phone lines, with mobile users interested in available entertainment content (BBC 2016) on internet, which may impact negatively on users' health (including sleep) in some cases 45,46 . It was also suggested recently by Wittek et al. 50 when assessing prevalence rates and predictors of video game addiction in a multicultural sample including native Norwegians and immigrants that the geographical region where an individual is born may play an important role in addictive behavior, and they reported there were more addicted gamers who originated from African, Asian and central American countries compared with gamers born in Europe and North America. Prevalence of gaming disorders was reported in Europe, Asia and North America 14, 31, 50-54 ; while no data exist for prevalence in African countries as well as their association with sleep disorders. Given the lack of knowledge in the field of gaming and sleep disorders in African countries, the purpose of this study is to investigate (i) the prevalence and incidence of online and video gaming in African populations, and (ii) whether gaming is associated with sleep disorders and psychopathological symptoms, including anxiety and depression. The current study furthermore aims to provide information on gamer profiles in Africa, including gender, sociodemographic characteristics, and the association between sleep disorders and different types of devices used for gaming.

1-Ethics committee
This research program was approved by the ethics committee of research on humans of the Université de Montreal, Canada, and by the administrator or dean of the universities at which recruitment took place. All subjects were volunteers and signed a consent form and were recruited through the respective admissions offices. All participants were contacted via the email lists of the admission office, and data were collected within the period of one year and computed in an external database. This database was secured outside the public network and was shared only with the investigators involved in the project.

2-Sample Characteristics
Participants were students aged between 18 and 40 years old (24 ± 2.8 years). The response rate to the online survey was 75%. Characteristics of the sample are detailed in Table 1. The initial population was N = 120.460 participants. After analysis of answers to the questionnaires used to categorize gaming and sleep disorders, and after removing incomplete forms, the final sample included 10.566 participants. Approximately 11.4% of the participants identified themselves as gamers.

3-Data collection
The participants were contacted by email. The online questionnaire which was filled in by the participants included a consent form on the second page, following a description of the study in French and English. Consent was required to participate in this project. The average time to answer all questions was 20 minutes. The questionnaire was configured to be filled in only once by the same email address, and duplicates and incomplete forms were removed. Responses were collected between November 2015 and June 2017.

4-Psychometric properties of questionnaires
This research was performed with a combination of quantitative and self-report questionnaires assessing insomnia and quality of sleep, anxiety and depression, problematic gaming, medical history, sociodemographic and socioeconomic data of participants. The data collected also included global wellbeing, smoking, physical activities and suicidal tendency of participant. For every questionnaire, an additional question was added to estimate decrease of health status across time. The participant was requested to report if they experienced the respective problems (i.e., "Do you have problems to maintain sleep, falling asleep", etc.…) 1 month, 6 months and 12 month before the study. The questionnaires used in this investigation were the following: Insomnia Severity Index (ISI): This questionnaire is widely used to assess insomnia and associated parameters, including lack of sleep and sleep quality. It was developed by Morin and al. in 2001 55,56 . The internal consistency of the ISI was excellent (Cronbach's α = 0.92), and each individual item showed adequate discriminative capacity (r = 0.65-0.84). The area under the receiver operator characteristic curve was 0.87 and suggested that a cut-off score of 14 was optimal (82.4% sensitivity, 82.1% specificity, and 82.2% agreement) for detecting clinical insomnia. An ISI score between 0 and 7 is an insomnia considered clinically nonsignificant, between 8 and 14 as a subthreshold insomnia, between 15 and 21 as a moderate clinical insomnia, and between 22 and 28 like a severe clinical insomnia 55,56 .
A problematic gamer's behavior survey based on Griffiths' calculator's model 57,58 : A short questionnaire developed by researchers involved in this project was used and included the following questions: How many hours do you play per day? How many days you play in the same week? What type of games do you usually play? Do you play for excitement? Do you become restless and excitable if you can't play? Do you try to cut down your playing but you can't? Do you forget social activities, education, family or homework for gaming?
How much money you spent in your gaming? Following , if the participant answered ''yes'' to more than four questions, they were categorized as a problematic gamer. The Hospital Anxiety and Depression Scale (HADS): This is a self-administered scale including 14 items, divided into two subscales of seven items (Anxiety or HADS-A, Depression or HADS-D). It contains no somatic items that can be confused with the symptomatic manifestations of a disease. Each item is scored on a scale of 0 to 3. A score is generated for each of the two sub-scales and for the entire HADS (HADS-T). The scoring is similar for anxiety and depression and following scores there are three categories of symptomatic levels: non-cases or asymptomatic ones (scores ≤ 7); probable or borderline cases (scores 8-10); clearly or clinically symptomatic cases (scores ≥ 11). The duration of administration is approximately five minutes and psychometric properties are detailed in previous studies 59,60 .

5-Statistical Analysis
The normal distribution of the data was analyzed using Kolmogorov-Smirnov's test. To analyse differences between online and video gaming, responses were converted to a dichotomous variable. All participants with an incomplete survey were not included in the analysis. From the initial number, 2114 respondents were excluded.
The final sample employed for analysis was 10.566 participants. Online gaming included games played via online social networks, the internet, smartphones and tablets. Playing classical consoles like Playstation and Xbox was considered as video game. Spearman's rank was used to analyse the relationship between the demographic and socioeconomic data, type of sleep disorders, gender, age, level of education, type of gaming (video or online) and time spent gaming. Mann-Whitney's non-parametric test for independent samples was employed to compare time spent on gaming as a continuous variable between two groups (male and female).
The same test was used to compare video gaming for males and females. The Kruskal Wallis test was used to assess differences in hours of gaming between males and females. The evolution of sleep disorders as a function

RESULTS
The study was conducted in four low-(Cameroon, Gabon, Rwanda, and Senegal) and 5 middle-income countries (South Africa, Nigeria, Morocco, Tunisia, and Ivory Coast). The nine countries chosen in this study were included because they have been ranked in the top 20 more highly developed African countries in terms of technologies use, internet connectivity and potential for the market of gaming and gambling (measured via the increased number of gamers, presence of casinos, expenses for gaming purposes, etc.) in the last four years, according to the most recent annual report of the International Telecommunication Union (ITU 2017), who regularly publish the `"measuring the information society report", which is the world's reference in terms of data related to the development of communications, technologies and connectivity 61 . From an initial sample of gaming/week and use of online or video game. Inside this population, 88.64% (9366 participants) are men and 11.36% (1200 participants) are women. The mean age of the sample was 22.33±2 years old. These results are very interesting because they revealed a disparity in interest of men and women for gaming. In terms of hours of week and according the results of the problematic gamer's survey, men play online and video games 7.8 times more than women; and this trend was the same for all the countries contributing to this study (Table 1) By comparing the sub-sample of gamers using the internet for gaming (i.e., on tablets, smartphones, and computers) with the other sub-sample of gamers using consoles for gaming during the same period of time, the prevalence of sleep disorders was found to be higher for the sub-sample playing online. the more developed a country is in terms of connectivity and technologies (i.e., South Africa, Nigeria, Cameroon and Tunisia).

Relation between socioeconomic status, sleep and gaming
There are several sleep disorders reported by the literature during the last forty years. Each sleep disturbance has his own processing and affects specific layer of population. For example, insomnia is more prevalent in elderly populations than in adolescents 63 . There is also sleepwalking and experiencing nightmares, which are more prevalent with children than with adults 63  observed during the past ten years where it became easier to purchase a smartphone with a telecommunication provider or through an online market place, such as eBay or Amazon, and then downloading free games using application portals, such as the Playstore and Appstore. This may explain why wireless devices including smartphones and tablets are more popular than classical consoles for gaming in these countries.

Relation between technology use, gaming, sleep and education
The mobile gaming market has grown considerably in the last ten years. It is easy to download a mobile game on a wireless device and the majority of these games are free, compared with the expensive price of a single console game which tends to be priced at an average of USD 30. The present research found that gaming and smartphone use were associated with sleep disturbances 39,40 Individually, gaming and using wireless devices are associated with addictive behaviours (i.e. gambling) 11 . Addiction is often associated with mood disorders which are strongly associated with sleep disorders 62,68 . The results of the present study suggest that there appears to be a similar relationship between gaming (specifically online gaming) and the experience of sleep disorders and psychopathological symptoms.
Education plays an important role in the relationship between gaming and sleep disorders because the majority of studies investigating gaming and its consequences on mental health were performed with samples of college and university students 69 . In several studies, the populations affected by gaming addiction are adolescents and young adults 13,31,70 . There is a high prevalence of sleep disorders in students in college and university populations 2,24 . The present study questions the importance of education, in the interplay between problematic gaming and sleep disorders. More investigations are necessary to elucidate if this association exist or not.

Relation between gaming and the prevalence and incidence of diseases
The present research indicates that the more time a person spends gaming, the more general health problems they experience. Respondents to the present research reported that after one year of gaming, they noticed an increase of musculoskeletal diseases, such as back pain (8.33%). Video and online gaming require minimal physical activity. This may explain why there was an association between the experience of musculoskeletal diseases and gaming. After one year of gaming, participants reported more neurological diseases, such as sleep disorders (3.86%). Some researches associated video gaming (specifically action video games) with benefits for attention and spatial memory 15,71 , while many articles reported distraction and mood disorders associated with gaming 14,44,72 . There is still no consensus with regards to the causal links between these variables and more research is needed to assess the (positive and negative) effects of gaming on neurological function. In the present study, the nature of the collected data cannot provide an explanation for why there were 408 respondents who had experienced neurological disorder symptoms and to what extent these were considered to impair them.
It is also important to notice that psychopathologies such as anxiety and depression are not influenced by the duration or the period of gaming. Less than one percent of the population reported anxiety symptoms before or after becoming a problematic gamer. This may indicate that gaming addiction is not necessarily associated with psychopathological symptom experience as has been indicated in the case of pathological gambling by Dufour et al. in 2014. Finally, many other health problems, such as impaired vision (4.31%), appeared within the period of one year's worth of gaming. The cause may be environmental or not in relation to gaming, and its distribution in the population was not statistically significant to be included in the analysis.
Even if biological measures do not confirm the exact number of new cases of diseases, 17.8% of the sample (more than 1880 participants) reported the appearance of diseases they did not have before they had started gaming. Taking into account individuals who did not accurately report their health status, including missing data, it is possible that the number of individuals developing diseases because of gaming may be higher than the current results suggest.

Comparison between Africa, Asia and Europe
Our findings are similar with those reported in Asian countries and Europe. Prevalence of gaming disorders in our african sample is closed to findings in adolescent and student populations in Asian countries, associated with addictive behaviors and a high prevalence of problematic internet use 53 . A number of studies suggested that online gamers with longer weekly gaming hours tend to have more severe depressive and Internet addiction symptoms 73 , as well as sleep disorders 74,75 . In Europe and Asia, problematic gamers also tend to develop somatic and musculoskeletal diseases, due to their poor physical activity and their progressive addiction 53,73,75 .
The present findings did not show a significant association between mood disorder symptoms and gaming, but the current literature reports associations between online and video gaming with anxiety and depression. Our hypothesis is the following: problems associated with excessive gaming may be more of a physical nature in African countries as showed by the present research, whereas research in many other countries (Uk, Turkey, China, Norway, USA) indicates that excessive gaming is associated with mental health problems like sleep disorders, anxiety, depression, and cognitive decline 14,21,42,43,73 . The prevalence is similar for adolescent and students, males and females 14,72,74 . Despite the increase of studies on problematic gaming and technologyrelated disorders around the world, this topic remains understudied in low-income countries and in particular in Wittek and Al in 2016 showed the differences prevalence of gaming disorders regarding the place of birth and was among the first to think about the importance of gaming disorders in Africa 50 , while the prediction of the economic and health impact of gaming in Africa was in parallel made by few authors like Barr and Osiakwan 61,76 . The present study demonstrates prevalence and incidence of gaming disorders in African countries and provides an objective comparison with prevalence in other regions of the world, mainly North America, Europe and Asia (China, Korea and Taiwan) 14,31,[50][51][52][53][54] .

Limitations of the present study
The research design employed had a small number of limitations. The first limitation is the lack of clinical and medical data of participants. Depending on the country, it was not easy to access well-documented and complete medical records because of the complex administration mandatory to obtain this information. The delays in the research process also played an important role in the decision to not include clinical record in the analysis. The second limitation was the languages used in the questionnaire. Many countries where the research was performed have an additional language which citizens use on a daily basis. The questionnaire was available in French and English, but it may have been possible to increase the response rate if the questionnaire was available in other languages, such as arabic (which are the main used language in Tunisia and Morocco) and Kinyarwanda (which are the main language speak in Rwanda in equal proportion of french, english and Swahili). The third limitation was the number of respondents who replied to the questionnaire, because from the initial sample (N=120.460) only 11.4% of participants met the inclusion criteria. This may be due to the fact that several questions focused on gaming, and given the smaller number of gamers, overall participation rates were relatively low. The small percentage of respondents (11.4%) may also be due to a lack of interest for the research and the cultural habits where empirical and biomedical research are not well embedded in culture and inside the African healthcare system 77 . It can also be caused by fatigue effects of individuals being asked to complete surveys and questionnaires more frequently (e.g., questionnaire issuing for marketing, survey made for advertising purpose, questionnaires shared through social media like facebook and whatsapp, survey inside mobile games or AppStore), in addition of the perceived risk of a breach of confidentiality which may decrease people's motivation to participate in research 78 .

Conclusion and futures investigations
This study points to the necessity for the global research community to pay more attention to low-and middleincome countries, in regard to the prevalence and incidence of sleep disorders. This sample of African participants experienced a relatively high rate of sleep disturbances, and it is mainly insomnia which emerged as the main sleep complaints. This study also showed a negative association between gaming (video or online) and the increase of musculoskeletal and neurological diseases as well as various other dysfunctions. Research on Internet addiction and sleep disorders is still in its infancy. There are still data missing on diseases associated with gaming, the sociodemographic and environmental risk factors are not all known, and epidemiological reports on their correlates with metabolic diseases as well as mental disorders are missing specifically for lowand middle-income countries. It is also important to investigate their distribution in the general population, because the majority of studies reported gaming problems for students while children and older people also use the same technologies and may face similar problems. Finally, the current study demonstrated an association between excessive gaming and increased physiological health problems, while the majority of the literature in other countries linked problematic gaming with mental disorders. It appears that the nervous system is more