ABSTRACT
Background:
The duration of time spent on electronic or digital media is defined as screen time. Digital media expansion and COVID-19 pandemic have made children more inclined towards screen time both as a necessity and as a habit.
Materials and Methods:
A cross-sectional study on children, aged two to five years, was conducted for one year (2021–2022). Parents were asked to self-fill a designed questionnaire. Impacts on physical and mental health of children and the necessity of screen time were assessed by paediatrician and psychologist.
Results:
A total of 650 children (354 boys and 296 girls) participated in the study. The mean screen time of parents was 6.4 hours. ± 2.32 and children were 4.95 ± 2.34 hours. 98.75% of children had screen time more than that recommended for age. Children were exposed to screen time at the tender age of three months. COVID-19 increased screen time by more than 1 hour in 92% of children. The most common gadget used was mobile phones (n = 628, 96.6%), followed by television (n = 511, 78.7%). Screen time had a negligible effect (P = 0.611) on the nutritional status of children. However, it had a significant effect on psychosocial behaviour (P = 0.05), ophthalmologic problems (P = 0.03), sleep cycle (P = 0.00), and academic performance (P = 0.002). Fathers’ occupation (P = 0.00), age of onset of screen time (P = 0.00), and parental setting of time limit for screen time (P = 0.009) were significant contributors to increase screen time.
Conclusion:
Findings suggested poor awareness among parents/caregivers regarding the negative impact of high screen time on children. Parents felt that screen time was a part of a normal day-to-day life and was important, particularly in post-COVID era when education was shifted from schools to laptops.
Keywords: Addiction, behaviour, coronavirus, health, screen time, technology
Introduction
The duration of time spent on electronic or digital media is defined as screen time.[1] Online education gained momentum in India after COVID-19, with children as young as two years being subjected to online schooling for hours. India never had a stringent screen time guideline. Parents, teachers, and students themselves were not aware of optimal screen time duration. Change in lifestyle of children has pushed them from outdoor physical activities towards indoor games, particularly mobiles and televisions. Early exposure to screen time is a potent risk factor of screen dependency disorders at a later age[2] India and the world are staring at another epidemic in the form of non-communicable diseases with majority contribution from increased and unregulated screen time. Studies on the impact of screen time on children’s health have shown that excessive screen time is linked with sedentary habits, leading to obesity.[3,4,5] High screen time was found to be associated with mood changes and developmental delay in children.[6,7,8,9,10] American Academy of Paediatrics formulated guidelines in 2016 for screen exposure,[9] followed by Canada in 2017.[11] In China, studies have found that high screen time associated with sedentary habits and behavioural risk factors,[12] thereby cajoling the policymakers there to think about screen time. Very recently in later end of 2021, Indian Academy of Paediatrics formulated guidelines which recommended <1 hour of supervised screen time for children, aged two to five years, with no exposure to screen time less than two years of age.[13] Although one-fourth of world’s children are in India, only 15 studies are there on screen time with only four studies focusing on children less than five years.[14,15,16,17] Only one study is available from Uttar Pradesh.[18] All of them are in pre-COVID era. In the present world where digital media are encroaching in nearly every person’s house irrespective of their socioeconomic status, it is imperative that we need guidelines not just for limiting screen time but also for setting guidelines for screen time for education and recreation. Thus, the present study was conducted with the objectives to document the burden of screen time in children, aged two to five years, to find out the health consequences both physical and psychosocial in those children to assess the need of a separate set of guidelines for screen time for education and recreation and to counsel the parents of children included in our study about the harms of screen time
Material and Method
Study design
Cross-sectional school-based survey.
Study participants
Parents or caregivers of children, aged two to five years, who are willing to participate were included in the study. Sample size: We enrolled 660 students to determine the mean screen time within 95% CI, assuming the mean screen time of 2.8 hours (SD = 1.7 hours) with 5% precision and a design effect of 2.0. (15), where n = sample size, z = 1.96 @ 95% CI, σ = SD (1.7), e = 0.14 (5% of mean), and D.E. = design effect of 2. We had enrolled 10% extra students to account for no consent from parents.
Inclusion exclusion criteria
Students, aged two to five years, whose parents or caregivers are willing to participate were included in the study. Students whose parents or caregivers are not willing to participate were excluded.
Sampling technique
Multistage random sampling was used for enrolling students in the study. A list of all preschools/primary schools in Lucknow was obtained from the office of Basic Shiksha Adhikari. Lucknow was divided into five zones—central, east, west, north, and south. The south zone was randomly selected for the study. From within the selected zone, 20 schools were randomly selected in the second stage. A list of all students, aged two to five years, was made in the selected schools and 33 students were chosen randomly in each school using computer randomization. Consent letters were then sent to the parents of selected students; those willing were included in the study.
Study tool
Prestructured questionnaire was filled by parents/caregivers that gathered information on digital media use in children. Parents were asked to self-report the average time spent by their children on watching TV, playing on a smartphone or tablet, using the computer, playing video games and time spent on playing outside (both on weekdays and weekends). In addition to its sociodemographic information, parental education level, parental marital status, school performances of children, and age of first exposure to screen time were also enquired. The child’s weight and height were used to interpret the nutritional status as overweight, underweight, and malnourished based on WHO growth charts.[19] We have asked questions on early initiation of screen time and its impact on vision as well. The psycho-social impact was assessed by the behaviour of children on refusal of permission of screen time. Besides it, there are questions regarding the effect of screen time on their social interactions with family and peer groups. There was a psychologist counsellor in our team as well who counselled parents included in our study about the harms of using screen time as well as how to change their habit of using screen time.
Statistical analysis
Statistical Package for Social Sciences (SPSS version 20) was used for data analysis. The association between the quantitative variables was carried out with the aid of t-test and analysis of variance (ANOVA). (Approved IEC NUMBER IS 58/20 DATED 09/042/0202 Issued by DRRMLIMS).
Results
a) Socio-demographic profile: A total of 650 children comprising 354 (54.4%) boys and 296 (45.6%) girls were included in the study. A total of 314 (48.3%) mothers, 275 (42.3%) fathers, and 61 (9.4%) caregivers had filled the questionnaire. Qualifications of persons filling the questionnaire are given in Table 1.
Table 1.
Demographic characteristics along with parental knowledge attitude and practice of screen time
| Number (n=650) | Percentage (%) | |
|---|---|---|
| Demographic details | ||
| Relation with child | ||
| Mother | 314 | 48.3 |
| Father | 275 | 42.3 |
| Caregivers | 61 | 9.4 |
| Qualifications | ||
| Illiterate | 1 | 0.2 |
| Just literate | 3 | 0.5 |
| Primary | 20 | 3.1 |
| High school | 42 | 6.5 |
| Intermediate | 79 | 12.2 |
| Graduate | 283 | 43.5 |
| Postgraduate and above | 222 | 34.2 |
| Fathers Occupation | ||
| Government | 111 | 17.2 |
| Private | 202 | 31.3 |
| Self-employed | 328 | 50.9 |
| Unemployed/homemaker | 9 | 0.6 |
| Mothers occupation | ||
| Government | 69 | 10.6 |
| Private | 59 | 9.1 |
| Self-employed | 114 | 17.5 |
| Unemployed/homemaker | 409 | 62.9 |
| Parental knowledge on screen time | ||
| Knowledge of setting time limit on screen usage | ||
| Yes (weekends and weekdays) | 144 | 22.2 |
| On weekdays | 26 | 4 |
| On weekends | 50 | 7.7 |
| No | 430 | 66.2 |
| Knowledge of setting screen free days | ||
| Yes | 61 | 9.4 |
| No | 589 | 90.6 |
| Parental attitude towards excessive screen time | ||
| Not bothered | 79 | 12.2 |
| Yes, bothered | 571 | 87.8 |
| Parents playing online games with their children | ||
| Yes | 211 | 32.4 |
| No | 439 | 67.6 |
| Parental practice* | ||
| Use screen time for education | 323 | 49.6 |
| Consider screen safer compared to outdoor play | 403 | 62 |
| Use screen time for feeding | 430 | 66.1 |
*Multiple responses ticked
The mean parental age was 34.0 ± 6.0 years. The most common occupation of the father was self-employment/business (n = 328, 50.9%), followed by private or corporate jobs (n = 202, 31.3%) and 111 (17.2%) parents were in government service. The majority of mothers were homemakers (n = 409, 62.9%) and only 242 (37.2%) mothers were employed.
b) Awareness about screen time in parents/caregivers:
More than two-thirds of parents/caregivers were unaware of restricting or setting time limit on the screen time of their children. A total of 430 (66.2%) parents/caregivers had set no limit on screen time. Only 61 (9.4%) parents/caregivers were aware of the concept of screen-free days. A total of 571 (87.8%) parents were perturbed by excessive screen time of their children and 62% of parents/caregivers (n = 402) preferred screen time as a safer alternative to playing outdoors and 66.1% of parents/caregivers (n = 430) consented that they use screen time as an aid for feeding children. The mean parental screen time was 6.4 ± 2.3 hours.
c) Burden of screen time in children, aged two to five years:
The burden of screen time in children, aged two to five years, in Lucknow is shown in Tables 1 and 2.
Table 2.
Burden of screen time on children
| Number (n=650) | Percentage | |
|---|---|---|
| Children’s gender | ||
| Males | 354 | 54.4 |
| Females | 296 | 45.6 |
| Access to gadgets* | ||
| IPad/tablets | 180 | 27.6 |
| Game consoles | 36 | 5.5 |
| Mobile phones | 628 | 96.7 |
| Handheld computer games | 18 | 2.9 |
| Desktop/laptops | 174 | 26.9 |
| Television | 511 | 78.7 |
| Night time use of devices* | ||
| IPad/tablets | 113 | 17.3 |
| Mobile phones | 394 | 60.6 |
| Handheld computers games | 12 | 1.8 |
| Computers games | 18 | 2.7 |
| Free time favourable activity of children* | ||
| Watching TV | 357 | 54.9 |
| Playing outdoor games (swimming and riding a bicycle excluded) | 387 | 59.5 |
| Reading | 62 | 9.5 |
| Playing indoors (non-screen games) | 155 | 23.8 |
| Physical activity like swimming, riding a bicycle | 260 | 40 |
| Craft | 209 | 32.2 |
| Imaginary games | 134 | 20.6 |
| Other family outings like picnic, going to zoo, going to movie, malls, restaurants, etc. | 271 | 41.7 |
| Screen time as favourite activity during free time | ||
| Yes | 311 | 47.8 |
| No | 339 | 52.1 |
| Age of onset of screen time | ||
| <1 year | 196 | 30.2 |
| 1–2 years | 307 | 47.2 |
| >2 years | 147 | 22.6 |
| Effect on academic performance | ||
| Excellent | 255 | 39.2 |
| Average | 314 | 48.3 |
| Poor | 81 | 12.5 |
| Age of onset of speaking | ||
| Delayed | 9 | 1.4 |
| Normal | 641 | 98.6 |
*Multiple responses ticked
A total of 642 children (98.7%) had their screen time more than that recommended for their age (i.e., <1 hour as per American Academy of Paediatrics). Mean parental screen time was 6.4 ± 2.3 hours. Similar trend was seen in children. Mean screen time of children was 5.0 ± 2.3 hours. Children were having comparable screen time on weekends and weekdays. Mean screen time on weekdays was 5.0 ± 2.5 and on weekends was 4.9 ± 2.9. The range of screen time was 0 hours to 15 hours. Mobile phones (628; 96.6s%) were most readily available for use, followed by television (511, 78.6%). Most common gadget used was mobile phones (n = 609, mean hours 2.96 ± 1.80) during weekdays and (n = 572, mean 3.4 ± 2.7 hours.) weekends. Detailed analysis of gadget use is provided in Table 3.
Table 3.
Frequency of use of gadgets (based on mean hours spent per day on each device)
| Weekday | Weekend | |||
|---|---|---|---|---|
|
|
|
|||
| Frequency* | Mean±SD | Frequency* | Mean±SD | |
| IPad/tablets | 171 | 2.12±1.18 | 164 | 2.04±0.98 |
| Game consoles | 22 | 1.63±0.84 | 19 | 2.15±1.21 |
| Mobile phones | 609 | 2.96±1.80 | 572 | 3.35±2.70 |
| Handheld computer games | 7 | 1.71±0.48 | 3 | 2±1 |
| Desktop/laptops | 88 | 1.48±1.26 | 77 | 1.39±0.71 |
| Television | 422 | 2.13±1.27 | 385 | 2±1.13 |
*Multiple responses ticked
Most common gadgets used at night before going to bed were again mobile phones (n = 394; 60.6%), followed by iPad (n = 113; 17.3%), computer games (n = 18; 2.7%) and hand-held computer games (n = 12; 1.8%). Watching television was a favourable activity during free time in 357 (54.9%) children. Screen time was the most favourable activity in nearly half of the study population (n = 311; 47.8%). A total of 403 (77.4%) children had their age of onset of screen time below the recommended age group of two years. The earliest age of onset of screen time was three months. Screen time had a significant (P = 0.002) effect on academic performance and an insignificant effect (P = 0.638) on the development of speech. COVID-19 pandemic increased screen time duration by more than 1 hour in 92% of children as shown in Figure 1.
Figure 1.
Impact of COVID-19 on screen time
d) Health consequences both physical and psychosocial in those children.
Our second objective was to find out the health consequences both physical and psychosocial in the study population. Results are shown in Table 4.
Table 4.
Impact of screen time on child’s health
| Number (n=650) | Percentage (%) | |
|---|---|---|
| Nutritional status | ||
| Stunted | 4 | 0.7 |
| Overweight | 26 | 4 |
| Underweight | 18 | 2.7 |
| Normal | 602 | 92.6 |
| Impact of screen time on behaviour of child | ||
| Normal behaviour | 92 | 14.2 |
| Abnormal response | 558 | 85.8 |
| Ophthalmologic problems | ||
| Yes | 205 | 31.6 |
| No | 445 | 68.4 |
| Effect on sleep time | ||
| Yes | 235 | 36.2 |
| No | 415 | 63.8 |
Screen time had an insignificant effect (P = 0.611) on the nutritional status of children. 92.6% (n = 602) of children had normal nutritional status as per WHO growth charts. However, screen time had a significant effect (P = 0.03) on ophthalmologic problems, like the use of glasses, watering, and itching in eyes. Screen time had a significant effect (P = 0.000) on the sleep cycle of children and psychosocial behaviour (P = 0.05) of children. 85.8% (n = 558 children) had abnormal behaviour when screen time was withheld. A most common response was children getting angry (n = 299; 46%), followed by violent behaviour (n = 116; 17.8%), bored (n = 111; 17%), complaining (n = 108; 16.6%), sad (n = 107; 16.5%), frustration (n = 104; 16%), and withdrawn (n = 30; 4.6%).
e) Counsel parents of children about the harms of screen time.
A total of 642 parents whose children had screen time more than recommended were counselled by a psychologist counsellor who accompanied the team visiting schools.
f) Factors affecting screen time in children.
>90% of parents mentioned online schooling and recreation as an important contributor of increased screen time. Fathers’ occupation (P = 0.0001), age of onset of screen time (P = 0.00) 1, online education (P = 0.0001), and parental setting of time limit for screen time (P = 0.009) had significant impact on child’s elevated screen time. Fathers’ occupation was one important contributory factor towards increased screen time of children, aged two to five years. On applying post hoc analysis, we found children whose father were in private job/self-employed had statistically significant screen time. Similarly, age of onset showed statistically significant relation with screen time. The earlier the age of onset of screen time, the higher the screen time. Parents who had set time limit on screen time their children had statistically significant lesser screen time. Other parameters, like parental age, mothers’ occupation, parental qualification, parental use of gadgets with children, gender of children, and accessibility of gadgets, had no statistically significant contribution towards increased screen time.
Discussion
Importance of restriction of screen time usage had never been so important as it is now. Virtually every household irrespective of its socioeconomic status has a smart phone or television. Schools are also using smart boards for imparting education from pre-primary to high school. Besides education, children are exposed to screen time for recreation purpose as well. Very often parents join them in this activity. World over literature is available on unrestricted and unmonitored gadget use, leading to several adverse effects.[20] However, post-COVID-19 use of gadgets for education as well as recreation was justified so much so that parents thought it is a necessity of every child. Contrary to the recommendations from various bodies, 98.7% of our study group had screen hours more than that recommended. Similar findings were observed in various other studies conducted on screen time in children.[16,17,18,20,21] UNICEF too had recognized the need of setting guidelines on screen time particularly during the current pandemic era.[22] They released a set of 10 tips to reduce screen time during COVID-19 pandemic. They emphasized the negative impact of excessive screen time on physical and psychological health. Excessive screen time hampers sleep cycle, causes behavioural addictions, and predisposes to attention-deficit disorders. UNICEF emphasized on the need of counselling parents as they believed parental pattern of gadget use will be reflected in their children. Similar finding was seen in our study. The results of the study have provided evidence of association between screen time and negative impact on psychosocial health, sleep cycle as well as ophthalmologic problems in children and thus the need of setting guidelines at national level. Eye-related problems due to excessive screen time were also observed in other studies[23,24] The present research has exposed a vast caveat which exists as far as parental knowledge and awareness on screen time and its hazards is concerned. These observations are similar to other studies conducted on parental awareness and perception of screen time.[25] Primary care physicians play a significant role in informing parents on screen time usage, guidelines, and hazards. The results of our study further demonstrate that unless we educate adults on screen time, we cannot curtail the aftereffects it has on children. Preschoolers were having mean screen time of over 5 hours which is five times that recommended for their age. There was mostly no restriction on time limit for gadget use, in addition there were no screen free days for over (n = 571, 87.8%) children. More gadget use was seen during weekends as compared to weekdays. Parents stay at home during weekends, yet the screen time increased further reinforces the finding that lack of knowledge of parents regarding the harmful effects of excessive screen time is only worsening the situation. It also shows that apart from education, screen time is used for recreation. Policymakers and primary care physicians must focus both on setting guidelines on screen time along with developing programmes (via electronic, print, and digital) to increase the parental knowledge on harmful effects of screen time. Cause lack of parental awareness is one of the major factors of increased screen time in their children. Screen viewing is having negative impact on psychosocial health of children, leading to abnormal response behaviours which may be regarded as a symbol of screen addiction in children.[25] Ophthalmologic problems, headache, and decreased interaction with peers were another important side effects of excessive screen time. In our study, 98.7% of children had their screen time much more than the recommended hours for their age. Nearly a third of study population had significant ophthalmologic and sleep cycle-related problems which could be attributed to excessive screen time. Parental supervision, both active and passive, is lacking. The results from our study have shown lack of parental awareness regarding the side effects of excessive screen time. Very few of them (33.8%) are aware of the need to set a limit to screen time or have deliberate screen free days. Ninety per cent of parents were not aware of concept of screen free days. 66.1% of parents were using screen time to feed their children or keep them busy without being aware of its harmful effects. Nearly a third of parents felt that their children were addicted to screen time, but they are unaware of any counselling programme for it. Children as young as three months were exposed to screen time. Various health agencies have specified that children less than two years should not be exposed to screen at all.[8,12] Neither the parents were aware of the minimum age to expose a child to screen nor they were aware of the maximum permissible duration of screen time per day. Unregulated screen time has been shown to have negative effects on both physical and mental health of children worldwide.[4,5,6,7,19] Post-pandemic, it is unlikely that increased screen time would decrease.
Conclusion
The present research emphasized the need to have a separate set of guidelines on screen time for children as well as parents. Unregulated screen time is having negative impact on physical and mental health of children.
Data availability
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request;
Abbreviations
AAP: American Academy of Paediatrics
ANOVA: Analysis of variance
IAP: Indian Academy of Paediatrics
COVID-19: (Coronavirus disease 2019).
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Funding received from ICMR. ICMR Adhoc/168/2020/SBSHR dated 11.01.2021.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request;