Assessment of digital eye strain and its associated factors among school children in Palestine

Abstract

Background

Digital eyestrain (DES) is a collection of ocular and vision symptoms caused by prolonged use of digital devices that can greatly impact schoolchildren’s daily activities and learning. The main purpose of this study is to assess the prevalence of DES among schoolchildren and the associated risk factors in Palestine.

Methods

From the 1st of April 2024 to the 30th of May 2024, a total of 492 school children who met the criteria for DES screening in the selected schools were included in the study. A quantitative, cross-sectional design was utilized with a self-structured questionnaire. The sample consisted of schoolchildren aged 11 to 18 years. The questionnaire is structured into three sections: (1) Sociodemographic information, (2) Information regarding the digital device used, and (3) DES assessment by using the Computer Vision Syndrome Questionnaire, and the visual acuity was measured using the Snellen chart. The data was analyzed using SPSS version 25 with a 95% CI.

Results

The study analysis showed that 44.1% of school children experience DES. Snellen chart test analysis showed that 28.25% of students had results exceeding a score of six for either the right or left eye. For both eyes combined, (14.63%) of students had examination results greater than six. After conducting univariate analysis, statistically significant risk factors (p-value less than 0.05) affecting the development of DES in our study were posture, smartphone use at bedtime, and duration of device use, watching movies, social networking, and screen brightness. Moreover, females, older students, and those using devices closer than 30 cm or owning multiple devices reported higher eyestrain scores.

Conclusions

The current research found that Palestinian school children significantly experience eyestrain, indicating the influence of digital devices on eye health. The study results emphasize the need for early detection to prevent future eye health complications.

Introduction

The integration of digital devices into the daily routine of school-age children has greatly impacted their daily activities and learning. As these devices have become indispensable tools for learning and entertainment, concerns have increased about their potential harmful effects on children’s health, especially poor eyesight and eyestrain [1]. Digital device use has led to new unhealthy lifestyle habits for both adults and school-age children. These habits may cause vision problems such as digital eyestrain (DES), also known as computer vision syndrome (CVS), a collection of ocular and vision symptoms caused by prolonged use of digital devices [2]. According to the American Optometric Association, the most common symptoms associated with DES are eyestrain, headaches, blurred vision, dry eyes and pain in the neck and shoulders [3].

Researchers have investigated the risks of smartphone use on children’s vision, examining factors such as daily usage time, posture, device type, usage purpose, nighttime use, time spent on various activities (movies, video games, TV, social media, school projects), the distance between the device and the eyes, the number of devices owned, and screen brightness [4]. Studies across various countries have yielded significant findings. An Indian study found that over half of students used smartphones for reading and academic work, with 77% preferring to use a chair rather than lying down [5]. In Saudi Arabia, average daily smartphone use ranged from 4 to 6 h, with men using them more than women (30.2% vs. 27.2%) [4].

The negative impact of digital devices on eye health has been documented in numerous studies. In India, 39–44% of smartphone users reported excessive use, with 18% experiencing eyestrain due to negligent conduct [5]. A study in Saudi Arabia found that 66% of users had vision problems, with smartphone users reporting higher rates of eye pain and dryness (39.7%) compared to non-users [4], which found that students used digital devices for five or more hours daily, primarily for social media, studying, and watching videos. Also, the majority used smartphones and preferred lying on the bed (64.2%).

Digital devices have become integral to both practical and academic aspects of life. According to the Palestinian census, 75% of children aged 10 years and older own mobile phones [6]. Therefore, the current study aims to identify the relationship between prolonged use of digital devices and the occurrence of DES among school-age children in Palestine. It seeks to shed light on the extent to which digital screen exposure contributes to eye discomfort and long-term visual health consequences, thus emphasizing the need for use guidelines and preventive measures in educational and home settings. Specifically, the research objectives include measuring the rate of use of digital devices among school children in Palestine, analyzing the prevalence of DES, investigating factors associated with digital devices that increase the risk of DES - such as time spent with the child, the child’s position, and evaluating the relationship between characteristics socio-demographic, digital device use and visual impairment. This study assumes that there is a relationship between DES and various factors, including the duration of device use, the distance between the device and the eyes, screen brightness, the purpose of using the device, and the number of devices the child owns.

Methods

Research design

A quantitative, cross-sectional design was utilized in this study to identify the prevalence of DES and its associated risk factors among Palestinian school children.

Setting

The research was carried out in private schools located in Palestine. The selection of Ramallah Governorate was based on its central location within Palestine, while Jerusalem was chosen due to its convenient accessibility. Moreover, both Ramallah and Jerusalem are cities that attract residents from various regions of the country. Ramallah, in particular, is considered a microcosm of Palestine as it accommodates citizens from all across the nation. For the academic year 2023–2024, the study encompassed a group of schoolchildren aged between 11 and 18 who were enrolled in private schools in Ramallah and Jerusalem.

Sampling

In Palestine, there are 400,000 schoolchildren aged 11 to 18, according to the Palestinian Central Bureau of Statistics (PCBS), as well as 3,190 schools [6]. Using the prevalence formula, with a confidence level of (95%), and a margin of error of 5%, the sample size was 384 [7], and 20% were added as a non-respondent rate to ensure that the required sample number was achieved. The minimum sample size was 462 students; nevertheless, we gathered 492 samples to guarantee the study’s accuracy. Moreover, their parents consented to participate in the study. A non-probability, convenience method was used in sample selection. Inclusion: All school-aged children aged 11 to 18 enrolled in a private school in the Palestine for the academic year 2023–2024 were included, regardless of regional or economic representation. Exclusion criteria: Children who suffer from vision problems, those who wear medical glasses, or any physical problem, and students absent during data collection and the child who refused to participate in the study.

Instrument/tool

The data collection questionnaire implemented in this study contains three sections. Section A: Included 4 questions on social demographic information, including the child’s age, sex, place of residence, and monthly income of the family.

Section B: Based on the literature, the researcher built 13 questions about factors such as daily usage time, posture, device type, usage purpose, nighttime use, time spent on various activities (movies, video games, TV, social media, school projects), the distance between the device and the eyes, the number of devices owned, and screen brightness. Section C: The self-administered Computer Vision Syndrome Questionnaire (CVS-Q) was used to identify DES and its symptoms, such as eye fatigue, headache, blurred vision, double vision, itching eyes, dryness, tearing, eye redness and pain, excessive blinking, feeling of a foreign body, burning or irritation, difficulty in focusing for near vision, feeling of sight worsening, and sensitivity to light [8]. The CVS-Q questionnaire measures the frequency of the 16 above-mentioned symptoms with the response options of “never,” “occasionally,” and “often or always.” If the participants report having symptoms “occasionally” or “often,” they will be asked to rate the intensity of the symptoms, choosing between the options “moderate” or “intense.” The total score will be calculated using the following formula:

If the total score is ≥ 6, then the participant is considered to have DES [8]. CVS-Q had a verified validity and reliability with a Cronbach’s alpha of 0.86, which made it a valid tool to incorporate into regular screening of ocular and visual health of school children engaged in computer use [9]. The Snellen chart was used to measure visual acuity. A distance of 6 m is represented by 6/6, which is considered normal vision. The denominator is the distance (in meters) at which a person with perfect vision can still read the minor line that the patient can see, while the numerator is the patient’s distance (in meters) from the chart (10). The specificity pattern varied from 44 to 84%, while the sensitivity ranged from 74 to 100% [10].

Data collection

After obtaining approval from the Institutional Review Board (IRB) of the Birzeit University Committee (BZUPNH2323), approval was also obtained in an official letter from the school where the evaluations were conducted by the Ministry of Education and Higher Education in Palestine. Next, the researchers contacted the principals of each selected school. The school principal and teachers served as contact points, making initial contact with parents and sending a cover letter in Arabic explaining the purpose of the study and comprehensive information about the screening process. Children’s consent was obtained verbally before beginning study activities, after providing a comprehensive description of each step in the data collection process. Between April 1 and May 30, 2024, data were collected from school students aged 11–18 years in different schools in Palestine. They were asked to complete a questionnaire created by the researchers that related to their socio-demographic characteristics. As for the second and third parts, we collected data from private schools in Palestine for children aged 11–18 through a questionnaire in which the student answered specific questions to discover their habits of using digital devices. The expected time to answer the questionnaire was between 10 and 15 min. The researchers also responded to any participant who might ask a question related to the questionnaire or any other aspect of the study. The third part of the questionnaire relates to the role of the researcher in evaluating children’s eyes using the Snellen chart. The researchers took this measurement in a private room under the direct supervision of their supervisor, a pediatric nursing professional.

Ethical consideration

The researchers obtained ethical approval from the Institutional Review Board (IRB) of the Faculty of Nursing, Pharmacy, and Health Professions at Birzeit University and an official letter of approval from the Palestinian Ministry of Education. Informed consent to participate in the study was obtained from the participants’ parents without any obligation, as they could withdraw from the study at any time without accountability. On the other hand, we protected the privacy of participants in this study, as the vision examination was performed in a private room. In addition, the information was used for research only, and the anonymity of the results was achieved by keeping the data in a secure location until the end of the study. A privacy sheet was provided for each survey participant. Furthermore, we ensured that the data contained only the study identification number and did not contain personally identifiable information. When the test revealed poor vision in any of the participants, we provided them with advice and referred these students to a specialist.

Data analysis

The data were arranged and statistically analyzed using the Statistical Package for the Social Sciences (SPSS-25). Parametric and non-parametric data were described using frequencies (n) and percentages (%) appropriately. For continuous variables, mean ± standard deviation (±) and T-test and ANOVA test were used appropriately. Any test is considered significant when the P value is less than (0.05). Furthermore, the 95% confidence interval (CI) takes into account the margin of error (5%).

Result

Table 1; demonstrates the demographic characteristic of participants. A total of 492 school students were varied between females and males (N = 167, 33.9% and 325, 66.1%, respectively). Their ages ranged from 11 to 18 years (M = 13.7, SD = 1.99), and most of the students lived in the city (N = 324, 65.9%). The majority of participants was of middle income family (N = 368, 74.8%).

Table 1.

Sociodemographic characteristics of the participants

Demographic data characteristics	Number of participants (N)	Frequency (%)	Mean (SD)
Age (in years )			13.7(1.99)
Less than 13	150	30.5%
13–14	185	37.3%
15 and more	157	31.9%
Gender
Female	167	33.9%
Male	325	66.1%
Place of resident
City	324	65.9%
Village	126	25.6%
Camp	42	8.5%
Monthly income
Low	6	1.2%
Middle	368	74.8%
High	118	24.0%

Table 2 demonstrates the digital device characteristics of the participants. The data showed that the average total hours of using digital devices were 3.4 h (M = 3.4, SD = 1.40); the majority of participants used digital devices for more than two hours (N = 348, 70.7%). The total hours for using digital devices were divided into five categories: (N = 213, 43.3%) of participants spent less than one hour watching TV, (N = 188, 38.2%) spent 1–2 h watching movies and videos, (N = 141, 28.7%) spent less than 1 h playing video games, ( N = 207, 42.1%) spent less than 1 h studying, and (N = 176, 35.8%) spent 1–2 h on social media. The majority of students used the digital devices lying on the bed (N = 316, 64.2%). More than three quarters of the participants chose the smart phone as their main used device (N = 410, 83.3%), while more than one third used the digital devices for social media and chatting (N = 194, 39.4%), about two thirds used the smart phone at bedtime while the light was switched off (N = 291, 59.1%), most participants used the smart phone at a distance of 30–50 cm (N = 360, 73.2%), more than one third of the participants have two devices (N = 183, 37.2%), and almost two thirds of the students use the digital device at moderate brightness (N = 306, 62.2%).

Table 2.

Digital devices characteristics of the participants

Digital device ch.ch.	Number of participants (N)	Frequency (%)	Mean (SD)
Total Hours			3.4(1.40)
How many total hours child is using digital devises in a day?
0 h	00	00%
Less than 1 h	57	11.6%
1–2 h	87	17.7%
More than 2 h	348	70.7%
How many hours child is watching TV?
0 h	107	21.7%
Less than 1 h	213	43.3%
1–2 h	122	24.8%
More than 2 h	50	10.2%
How many hours child is watching movies/video?
0 h	74	15.0%
Less than 1 h	157	31.9%
1–2 h	188	38.2%
More than 2 h	73	14.8%
How many hours child is playing video games?
0 h	95	19.3%
Less than 1 h	141	28.7%
1–2 h	128	26.0%
More than 2 h	128	26.0%
How many hours dose a child use digital devices to study daily?
0 h	107	21.7%
Less than 1 h	207	42.1%
1–2 h	119	24.2%
More than 2 h	59	12.0%
How many hours the child spending on social media?
0 h	49	10.0%
Less than 1 h	122	24.8%
1–2 h	176	35.8%
More than 2 h	145	29.5%
What is you’re the most posture while using digital devices?
Setting on chair	176	35.8%
Lying on bed	316	64.2%
What device do you use the most?
Computer/desktop	29	5.9%
Smartphone	410	83.3%
IPad	36	7.3%
Laptop	17	3.5%
What is the most purpose of using digital devices?
School project/ studying	53	10.8%
Social media / chatting	194	39.4%
Watching movies/ video	87	17.7%
Video games	150	30.5%
Reading books	8	1.6%
Do you use smartphones at bedtime with light switched off?
Yes	291	59.1%
No	201	40.9%
What is the distance between the device and the eyes (in cm)?
Less than 30	121	24.6%
30–50	360	73.2%
More than 50	11	2.2%
How many digital devices do you own?
1 device	157	31.9%
2 devices	183	37.2%
3 devices	115	23.4%
4 devices	37	7.5%
What is the screen brightness level most often used while using a digital device?
Low brightness	97	19.7%
Moderate brightness	306	62.2%
High brightness	89	18.1%

Digital eye strain prevalence

The eyestrain scale indicated that (44.1%) of school students experienced eye strain, whereas (55.9%) did not report any symptoms.

Snellen chart test results

Snellen chart test results analysis showed that the percentage of students with a denominator acuity score exceeding six was 28.25% for the right eye, and the same percentage (28.25%) was observed for the left eye. When considering both eyes together, 14.63% of students had a denominator acuity score greater than six. (Fig. 1)

Fig. 1.

Percentage of students with a Snellen chart denominator acuity result exceeding six for the right eye, left eye, and both eyes combined

Association between CVS-Q means score and participants’ characteristic

The result of the analysis showed a significant relationship between the CVS-Q mean score and the following study variables: Posture while using digital device (T = 2.408, P = 0.016), where the children lying on a bed while using digital device (M = 6.05, SD = 4.33), showed a higher CVS-Q mean score than children sitting on chairs; Using smartphones at bedtime with the light switched off (P = 0.000) showed a higher mean than non-users (M = 6.37, SD = 4.61); Students who used digital devices for 2 h or more (P = 0.000) experienced a higher mean (M = 6.97, SD = 4.95) compared to those students using devices for 1 h or less. Watching movies or videos for more than 2 h (P = 0.000) exhibited a higher mean (M = 7.19, SD = 5.32); Social networking and chatting for more than 2 h daily (P = 0.000) displayed greater means (M = 7.00, SD = 4.71); the purpose of using digital devices (P = 0.015), with a higher mean for using them for watching movies or videos (M = 6.43, SD = 4.55); the child’s gender (P = 0.000), where means were greater in females (M = 6.85, SD = 4.52); the child’s age (P = 0.002): older children (15 years and more) report higher means (M = 6.66, SD = 4.36) than younger children do (less than 13 years); The distance between the device and the eyes (P = 0.009), a distance of less than 30 cm results in higher means (M = 6.72, SD = 4.89) compared to distances of more than 50 cm; owning multiple digital devices (P = 0.006), with those owning 4 devices (M = 6.75, SD = 5.13), experiencing the higher mean; and screen brightness levels (P = 0.004), where high brightness showed higher means (M = 6.61, SD = 5.15).

Regarding the remaining study variables, there was no statistically significant relationship with CVS-Q mean scores (P-value less than 0.05), including the monthly income of the family (P = 0.119), the place of residence (P = 0.323), and the type of device used most frequently (P = 0.996). Moreover, daily study hours using digital devices (P = 0.479), the time spent playing video games (P = 0.177), and the amount of time spent watching TV showed no significant correlation with CVS-Q scores (P = 0.929). (Table 3)

Table 3.

Associations between CVS-Q mean score and participants’ characteristic

Variables	Categories	Mean (SD)	F/T value	P value
Gender	female	6.85(4.52)	F = 1.884	P = 0.000
Age	male	5.11(4.15)
	Less than 13	5.02(4.26)	F = 6.142	P = 0.002
	13–14	5.44(4.31)
	15 and more	6.66(4.36)
Monthly family income	Low	6.16(3.65)	F = 2.142	P = 0.119
	Middle	5.47(4.09)
	High	6.41(5.10)
Place of residence is?	Village	5.33(4.36)	F = 1.132	P = 0.323
	City	5.91(4.28)
	Camp	5.19(4.87)
How many total hours child is using digital devises in a day?	0 h	0	F = 6.789	P = 0.000
	Less than 1 h	4.21(3.13)
	1–2 h	5.04(3.99)
	More than 2 h	6.97(4.95)
How many hours child is watching movies / video?	0 h	4.75(4.22)	F = 7.520	P = 0.000
	Less than 1 h	4.80(4.06)
	1–2 h	6.25(4.00)
	More than 2 h	7.19(5.32)
How many hours does the child use digital devices for social media?	0 h	4.22(3.70)	F = 8.804	P = 0.000
	Less than 1 h	4.68(3.78)
	1–2 h	5.75(4.32)
	More than 2 h	7.00(4.01)
What is the most purpose of using digital devices?	School project/ studying	4.54(3.51)	F = 3.132	P = 0.015
	Social media / chatting	6.21(4.35)
	Watching movies / video	6.43(4.55)
	Video gams	5.04(4.15)
	Reading books	5.37(4.24)
What is the distance between the device and the eyes in cm?	Less than 30	6.72(4.89)	F = 4.727	P = 0.009
	30–50 cm	5.40(4.16)
	More than 50	4.45(2.43)
How many digital devices do you own?	1 device	5.31(4.24)	F = 4.206	P = 0.006
	2 devices	5.18(3.72)
	3 devices	6.73(4.97)
	4 devices	6.75(5.13)
What is screen brightness level most often used while using a digital device?	Low brightness	6.47(4.43)	F = 5.646	P = 0.004
	Moderate brightness	5.19(4.00)
	High brightness	6.61(5.15)
What device do you use most?	Computer/desktop	5.65(4.46)	F = 0.022	P = 0.996
	Smartphone	5.69(4.36)
	IPad	5.77(4.52)
	Laptop	5.94(4.19)
How many hours dose a child use digital devices to study daily?	0 h	5.12(4.29)	F = 0.327	P = 0.479
	Less than 1 h	5.86(4.39)
	1–2 h	5.90(4.55)
	More than 2 h	5.77(3.96)
How many hours child is playing video games?	0 h	5.65(3.72)	F = 1.650	P = 0.177
	Less than 1 h	6.02(4.81)
	1–2 h	5.01(3.91)
	More than 2 h	6.08(4.64)
How many hours a child watching TV?	0 h	5.65(4.15)	F = 0.152	P = 0.929
	Less than 1 h	5.70(4.49)
	1–2 h	5.59(4.22)
	More than 2 h	6.08(4.64)

Note: F; one-way ANOVA, T; independent T-test, SD: standard Deviation; P-value≤ 0.05 indicates significance

There is a mild to moderate positive correlation between the CVS-Q mean score (DES) and the Snellen test mean score. This means that the higher the Snellen test score the child has (vision problem), the more CVS-Q score there is (DES). (Table 4).

Table 4.

, Pearson correlation between CVS-Q mean score and Snellen test mean score

Snellen test	Right eye (r)	Left Eye (r)	Both Eyes (r)
CVS-Q score	0.190**	0.112*	0.136**
P-value	0.000	0.013	0.002
N	492	492	492

** Correlation is significant at the 0.01 level (2-tailed)

* Correlation is significant at the 0.05 level (2-tailed)

Discussion

In our current study, the prevalence of digital eye strain among students was found to be 44.1%. This rate is notably lower compared to neighboring countries such as Jordan (59%), Saudi Arabia (66%), China (70.5%), and the USA (65%) [4, 5, 11, 12]. However, it is significantly higher than the rate reported in India, which stands at (18%) [13]. Several factors may contribute to the prevalence of DES in Palestine. Potential reasons include differences in educational systems, screen time exposure, lifestyle habits, and access to preventive measures. Additionally, environmental factors and awareness levels about eye health might also play a role in these variations. Further research is needed to understand the specific determinants contributing to the high rate of eye strain in Palestine, yet lower than other neighboring countries [14, 15].

The findings indicate a significant relationship between posture and the occurrence of eyestrain, aligning with previous studies. These studies found that children who use digital devices while lying in bed are more likely to develop eyestrain compared to those who use digital devices while sitting in chairs. Additionally, a study conducted in India demonstrated a significant association between students who preferred to lie down and those who experienced eyestrain [5]. Another study examining the connection between posture and visual stress found that using a smartphone in poor posture could lead to various eye problems. The study recommended avoiding reading while lying on your back or stomach [16].

The results of our study revealed a significant relationship between using phones during sleep with lights off and eyestrain. The percentage of use of digital devices at bedtime is 59.1%. Research in Saudi Arabia discovered that more than 98% of participants possess smartphones, and nine out of ten utilize their devices at bedtime [17]. In contrast, a study in Egypt revealed that 48.8% of individuals use smartphones at bedtime [18].

The results of our study indicated that the majority of school children spent more than 2 h daily on digital devices. In comparison, a study from Saudi Arabia reported that children spent between 4 and 6 h per day on digital devices [4]. Additionally, research from Hong Kong showed that children aged ten years and older spent approximately 30 h per week on digital devices [19].

Our study, involving school students, revealed a significant correlation between the use of digital devices for social media and eyestrain. Students who spend more than two hours daily on their phones experience more eyestrain compared to those who spend less time. An American study indicated that individuals across all age groups check their phones an average of 46 times a day. Americans also dedicate approximately five hours daily to browsing the web, using social media, and utilizing apps, including completing work tasks on digital devices. This leads to prolonged screen time, which can harm eye health [20]. Another study showed that prolonged use of digital devices and excessive social media usage can worsen DES [19], particularly while scrolling through social media platforms, which involves intense, close-up visual work that demands constant focusing and refocusing of the eyes. This continuous visual effort, coupled with reduced blinking, may result in symptoms of eyestrain such as headaches, dry eyes, and blurred vision [21].

Our study demonstrated a significant correlation between children who spend more than two hours watching movies and videos and the development of eyestrain. The findings indicate a substantial relationship between the primary purpose of screen use, which is watching movies and videos, and the occurrence of eyestrain. Previous research supports these results, showing that extended periods of screen focus can lead to eye discomfort, dim vision, and headaches [22].

Our study indicated that women are more susceptible to eyestrain. Much research conducted during the COVID-19 pandemic revealed that symptoms of Digital Eye Strain (DES) were more prevalent among females than males [23]. Additionally, another study highlighted that a significant proportion of the global population suffers from untreated vision impairments, with 90% of these individuals residing in low- and middle-income countries. It was found that one in four women is at risk of vision impairment, compared to just one in eight men [24]. These findings underscore the importance of addressing gender disparities in eye health and ensuring equitable access to eye care services globally [25].

The results of the current study showed that there is a statistically significant relationship between children aged 15 and more and eyestrain. A study conducted during the COVID-19 pandemic found that individuals older than 14 years are at a higher risk for developing digital eyestrain. It also showed that symptoms of dry eye diseases were higher in children in the older age group than in the younger age group. Children at higher ages spend more hours using smartphones, which may lead to a higher prevalence of DES in older children [23].

The results of our study indicated a significant connection between smartphone use at a distance of 30–50 cm and the incidence of eyestrain. This finding is particularly noteworthy given that most individuals tend to use their phones within this range. In contrast, research conducted in India suggests that sitting close to a screen can heighten the risk of eyestrain in children [23]. On the other hand, Dr. Malik’s study recommends keeping the phone screen at a distance equivalent to a few arms’ length to reduce eyestrain, following the (1-2-10) rule, which advises keeping the phone at a distance of one foot from the individual [22]. Another study discovered that holding a phone at arm’s length (16–18 inches) could decrease eyestrain by 30–40% [27]. In general, it is recommended to maintain a distance of 50–75 cm between the eyes and the smart device to reduce eyestrain.

According to our research, a significant 7.5% of participants possessed multiple digital devices; this particular group encountered the most pronounced effects of eyestrain. The quantity of devices owned has a substantial impact on eye problems due to increased screen time and the specific usage of screens, especially exposure to light. All this leads to computer vision syndrome, which encompasses a range of eye and vision-related issues that arise from prolonged screen use. Common symptoms include dry eyes, blurred vision, headaches, and discomfort in the neck and shoulders. The prevalence of DES is remarkably high, affecting approximately 50% or more of individuals who use multiple digital devices [15].

The study revealed a correlation between screen brightness levels and the prevalence of eyestrain. An experimental study by Tian et al. investigated the effects of using electronic devices in dark environments at night on visual fatigue. The findings indicated that low screen brightness in dark environments reduced visual fatigue. Conversely, medium and high screen brightness levels increased visual perception sensitivity, as evidenced by pupil data, which is more likely to exacerbate visual fatigue [28].

Limitation and strength

The limitations of our study resulted from our inability to secure authorization to gather data from government schools in compliance with the directives of the Ministry of Education in Palestine. Our study was therefore limited to private schools, where social and economic circumstances differ and could influence the study sample’s heterogeneity, making it challenging to detect a significant association with some study variables. Additionally, political instability in the West Bank limited transportation, which prolonged and complicated the data collection process. Despite efforts to include a diverse sample, some demographic groups or regions within the West Bank were unreachable, limiting the generalizability of the findings to public school children and other socio-economic groups.

This study is the first to evaluate the percentage of DES and associated variables among school children in Palestine. We used a measurement tool (CVS-Q) and a Snellen chart, both of which have outstanding intra- and inter-observer reliability. However, as the study used a screening tool, care should be taken when extrapolating the findings. Once children with DES have been identified using the CVS-Q and the Snellen chart, it is preferred for future research to use an ophthalmological examination by a specialist for confirmation and diagnosis of vision impairment.

Recommendation

1. Creating a daily schedule routine for children to utilize electronic devices can effectively mitigate the risk of eyestrain. It is strongly advised that children limit their device usage to a maximum of (1–2 h) per day, with regular breaks scheduled every 30 min, it is crucial for them to encourage them to shift their focus away from the screen for 30 s and shift their focus onto an object positioned at a minimum distance of 30 feet. By following this method, the child’s eye moisture is effectively maintained, and their focusing system is reset. Encouraging children to adopt this technique as a daily habit is essential for preserving optimal eye health.

2. When using digital devices, it is advisable for children to keep a distance of at least 30–50 cm between their eyes and the devices.

3. Keep the screen brightness at a level that matches the surrounding light. It is crucial to find a suitable brightness level that is comfortable for the eyes.

4. Educate children on the importance of maintaining good posture while using digital devices. Instruct them to sit with their back straight and shoulders back, position their screen so that the top of the monitor is at or just below eye level, and keep their feet flat on the floor, avoiding slouching. Additionally, advise them against using digital devices while lying on their back or stomach.

5. Parents should make regular visual check-ups a priority for their children to safeguard their eye health and safety. These visits are essential for early detection and treatment of any visual issues. Optometrists can offer advice on maintaining healthy eyes, reducing the effects of digital activities on vision, and prescribing glasses or other treatments as necessary, monitoring their vision consistently promotes optimal eyesight.

6. To enhance children’s sleep quality, it is important to avoid using smartphones and tablets before bedtime. The light emitted by these screens can affect the production of melatonin, a hormone necessary for regulating sleep. It is recommended to power down electronic devices early, ideally (1–2) hours before bedtime, and maintain a dark bedroom setting.

7. Promoting reading, engaging in traditional games, and practicing drawing can boost children’s creative and language abilities while helping to limit screen time. Furthermore, participating in outdoor activities can improve eye health and lower the chances of developing myopia, promoting a well-rounded and healthy lifestyle.

Conclusion

Our study revealed a significant prevalence of eyestrain among students in Palestine; the percentage is 44.1%. This result confirms the impact of digital devices, which have become an integral part of modern life, on eye health. The results indicated a significant relationship between eyestrain and various factors, including a child’s age and gender, posture, phone use when sleeping, the number of hours spent on digital devices daily, and the purposes for which these devices were used, such as video games and social media. In addition, the number of devices the student had, screen distance, and brightness have been found to influence eyestrain as well. However, some variables, such as monthly household income, place of residence, type of device most used, use of devices for studying, playing video games, and watching TV, did not significantly affect eyestrain. These results and knowledge of the behaviors that increase eyestrain indicate the importance of early detection of the problem to reduce its burden later in life.

Author contributions

O.H is the principal investigator, conceptualized, designed the study, and wrote the main manuscript and secured ethical approvals, methods, supervised data collection, analysis, interpretation and revised and modified manuscript. K.M data collection, and prepared Tables 1, 2, 3 and 4, S.M visualization, and prepared Figs. 1, N.T investigation, and data collection, D.A software, and validation, A.H data collection. All authors reviewed the manuscript.

Funding

This study did not receive any funding support. The authors are solely accountable for the content and writing of the study.

Data availability

Data is provided within the manuscript or, upon request, by the corresponding author.

Declarations

Ethical approval and consent to participate

Ethical approval for the study was obtained from the Ethical Research Committee at the Faculty of Pharmacy, Nursing and Health Professions, Birzeit University, Palestine (BZUPNH2323). We obtained all necessary administrative permissions from the participating school. We adhered to ethical standards in carrying out research on humans. Informed consent was obtained from the children’s parents and the children themselves as well. The confidentiality of participants was ensured.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.