Excessive screen time and its associated factors among under-5 children in Woliso City Administration, Central Ethiopia: a community-based cross-sectional study

Abstract

Background

Screen time is the daily duration an individual spends watching screen devices. Excessive screen time leads to sedentary behaviours, negatively affecting all developmental health domains. Despite the growing accessibility of screen devices, limited attention has been given both globally and locally, particularly in Ethiopia. This study aimed to assess excessive screen time and its associated factors among under-5 children in Woliso City Administration, Central Ethiopia.

Methods

A community-based cross-sectional study was conducted from 10 January to 29 February 2024. Guardians of under-5 children were selected using systematic random sampling, and data were collected using an interviewer-administered structured questionnaire adapted from previous studies. EpiData V.3.1 and Statistical Product and Service Solutions V.25.0 were used for data entry and analysis. Findings were presented through in-text narrations, tables and graphs. Binary logistic regression analysis tested factors associated with excessive screen time, with adjusted ORs and p values <0.05, illustrating the strength and statistical significance of the association.

Result

Out of 506 study participants, 498 responded. About 75.9% (CI 71.9 to 79.6) of participants had excessive screen time. Significant factors included father’s age ≥30 years (AOR 0.225, CI 0.080 to 0.630), mother’s age ≥30 years (AOR=1.775, CI 1.045 to 3.015), child’s age ≥24 months (AOR 0.464, CI 0.251 to 0.858), parental supervision (AOR 4.329, CI 1.367 to 13.71), parental perception of maximum daily screen time (<60 min: AOR 5.894, CI 2.255 to 15.41; ≥60 min: AOR 4.30, CI 1.577 to 11.743), parental restrictive practice (AOR 0.495, CI 0.354 to 0.691) and availability of screen devices in the bedroom (AOR 1.869, CI 1.069 to 3.629).

Conclusions

Three in four children had excessive screen time. Parental supervision, parental perception of maximum screen time, parental restrictive practice and screen devices in eating, playing or sleeping rooms were modifiable factors influencing screen time. Hence, it is essential to educate parents on limiting children’s screen time per recommended guidelines and regularly supervise young children.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Excessive screen time is highly prevalent in high-income and middle-income countries and contributes to sedentary behaviour and poor developmental outcome in children.

• Demographic, parental and environmental factors are modifiable influences on screen time behaviour.

WHAT THIS STUDY ADDS

• This study is the first evidence from Ethiopia, showing high prevalence of excessive screen time with parental behaviour such as supervision, perception of limits and restrictive practice along with presence of devices in children’s living spaces, significantly shaping screen use.

• By generating data from low-income settings, it fills an important gap in global understanding of screen time patterns.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• These findings establish baseline prevalence and highlight modifiable factors, supporting tailored parental education, clinical counselling and policy initiatives to reduce excessive screen exposure and promote healthier child development.

Introduction

Screen time (ST) is the duration of time that an individual spends with any screen device, including television (TV), computers, tablets, handheld devices or other visual devices.¹ Screen-based entertainment, including watching TV, playing video games and using smartphones and tablets, is extremely common among young children.²

With the widespread availability and accessibility of screen-based entertainment,³ the trend of ST among young children has almost doubled in the past two decades and is emerging as a global public health concern.4,8 Currently, even children from low-income households (HHs) are vastly utilising modern digital technologies.⁹ Globally, around 70%–90% of under-5 children spend more time on screen devices than the recommended ST, with the highest prevalence observed in developed countries.¹⁰ The evidence demonstrates that excessive ST ranges from 10% to 93.7% in high-income countries and 21% to 98% in middle-income countries.¹¹ The prevalence of excessive ST ranged from 39.7% to 91.4% across diverse populations around the world.2,47 10 12

Early childhood is a crucial period for both physical and cognitive development during which habits are shaped and adapted to their family’s lifestyles, including exposure to ST.⁵ Excessive ST during this period is associated with various negative developmental outcomes, such as deficits in attention, behavioural control, language and fine motor skills.2,410 14 21 Excessive ST also affects the five developmental domains, including physical well-being, social competence, emotional maturity, language and cognition, and communication.^{4 22} In addition to its impacts on child development, it has multiple adverse health outcomes, including poor-quality sleep, risk of non-communicable diseases, sedentary behaviours, unhealthy dietary patterns and obesity, aggressive and antisocial behaviours, autism spectrum disease and attention-deficit hyperactivity disorder.2,411 14 22 23 26 However, recent meta-analyses reported that the association between ST and impairments in cognitive functioning is complex, as some of the studies revealed insignificant effects and some others showed significant benefit.³⁰

Evidence shows that various groups of factors, including the child’s demographic traits, parental or caregiver characteristics, home-media environment and neighbourhood environment, influence the child’s ST. From the child’s demographic traits, sex,^{25 29} place of residence,³¹ ethnicity^{10 19} and birth order^{7 31} were identified as factors affecting ST. Parents’ age,^{10 11} education,^{27 30} income,^{3 25 28} ST rule at home,¹¹ self-efficacy,^{10 11 32} types of care,^{11 24 33} parents’ or caregivers’ ST,^{2 7 10 16 19 33} parents’ attitudes towards ST,¹¹ parental perception towards the influence of ST¹⁰ and time spent with the child¹¹ were the parental-related factors influencing the child’s ST. The availability of screen devices in the sleeping, eating and playing rooms was a home-media environment factor that affects the child’s ST.^{25 32} From the neighbourhood environment-related factors, access to parks in the neighbourhood was identified as a factor contributing to a child’s ST.³¹ In addition, the child’s physical activity status was also found to be a factor influencing ST.^{33 34}

Different strategies have been taken to limit the time young children spend in front of screens. For instance, in 2019, the WHO developed a guideline that recommends nil ST for children under 2 years and less than an hour per day for children aged 2–5 years.⁵ The American Academy of Pediatrics recommends no screen exposure until 18 months of age and up to 1 hour per day for children aged between 2 and 4 years.³⁵ Moreover, about 18 countries have implemented recommendations to restrict screen-related activities among young children.⁵

Various studies have identified child ST worldwide, particularly in developed countries. The majority of the previous studies were focused on schoolchildren and adolescents.¹⁰ However, there has been limited evidence regarding ST and its associated factors among under-5 children. Therefore, this study aimed to assess the level of ST among under-5 children and its associated factors in the Woliso City Administration. To the extent of our knowledge, this was a pioneer study that assessed children’s ST in Ethiopia.

Methods

Study design, period and setting

A community-based cross-sectional study was conducted from 10 January to 30 February 2024, in the Woliso City Administration. The city is located 114 km southwest of Addis Ababa, Ethiopia, with four administrative kebeles (lower administrative units): Ayetu, Egersa, Burka Gudina and Hora. According to the 2014 estimation, a total of 118 000 people were living in around 15 476 houses, with 19 389 being under-5 children.

Population selection and eligibility criteria

All under-5 children who were living in Woliso Town were considered the source population. Parents or guardians of under-5 children from each of the selected HHs were study participants in this study.

All parents or guardians of under-5 children from the selected HHS and permanent residents (who lived for at least 6 months) were included in this study. However, children whose families had no screen or digital devices in their houses were excluded from this study.

Patient and public involvement

No patients or members of the public were directly involved in the design, conduct or reporting of this study.

Sample size determination and sampling technique

For the first objective, the sample size was calculated using a single population proportion formula with a 50% population proportion, resulting in 423 participants. To obtain the maximum sample size, we used the second objective, considering three factors (parent’s age, ethnicity and parent’s ST) from a previous study conducted in Malaysia.¹⁰ The highest estimated sample size was 506, including a 10% non-response rate.

Sampling technique

The four administrative kebeles in Woliso City Administration were included in the study. The sample was proportionally allocated to the number of HHs in each kebele (figure 1). A systematic random sampling technique was used to select participants, with every 31st HH chosen. If a selected HH had more than one under-5 child, a lottery method was applied to select the participant. Unavailable guardians were revisited the next day.

Figure 1. A diagrammatic illustration of the sampling technique used to assess excessive screen time and associated factors among under-5 children in Woliso City Administration, Central Ethiopia, 2024. HHs, households.

Study variables

ST was the outcome variable. Independent variables included the child’s sociodemographic characteristics, the parent’s sociodemographic characteristics, childcare, the parent’s media-related factors, physical activity, the home media environment and neighbourhood environment-related factors.

Study measures and study outcomes

Data were collected using an interviewer-administered structured and validated questionnaire with eight parts, adapted from previous literature^{10 36 37} (online supplemental material). Part 1 contained 10 questions on sociodemographic characteristics of parents, while part 2 included six questions on sociodemographic characteristics of children. Part 3 comprised two questions related to child care.¹⁰

Part 4 contains four questions related to ST usage. Two items assess the duration children spent on different devices during weekdays and weekends.¹⁰ The average daily ST was calculated by summing weekday ST (for all screen devices) multiplied by 5 and weekend ST (for all screen devices) multiplied by 2, then dividing by 7. Excessive ST was defined as any ST among children younger than 2 years, and more than 1 hour among children aged 2–5 years.³⁶ Recommended ST was defined as no ST for children younger than 2 years and ≤1 hour for children aged 2–5 years.⁵ The reliability of these items was high, with Cronbach’s alpha values of 0.951. The rest of the two questions in this part are about parental ST,¹⁰ which had a Cronbach’s alpha value of 0.839.

Part 5 measured physical activity with two items on weekday and weekend outdoor playtime. The average outdoor play was calculated as for ST and then dichotomised as <1 hour/day or ≥1 hour/day.³⁸ Reliability was acceptable, with Cronbach’s alpha of 0.74 in a previous study³⁷ and 0.833 in this study.

Part 6 focused on parental factors, including supervision, time spent with children, perception of maximum ST and availability of HH ST rules.³⁷ Parental self-efficacy was assessed using a Likert item ranging from 1 (‘not confident’) to 5 (‘very confident’) adapted from previous study,³⁶ and categorised as low (≤25 th percentile), moderate (25th–75th percentile) and high (≥75 th percentile).^{10 36} It demonstrates good reliability.³⁶ Parental attitude towards ST was measured with eight Likert items (1=‘strongly disagree’ to 5=‘strongly agree’), with average scores >3, indicating a positive attitude and <3 a negative attitude.¹⁰ Its reliability was strong (Cronbach’s alpha=0.84 in previous study,¹⁰ 0.917 in this study). Parents’ perception of effects of ST on a child’s well-being was assessed with eleven Likert items (1=‘negative influence’ to 3=‘positive influence’), for all three classifications (physical well-being, cognitive development and social well-being). All scores were summed up and averaged to create an overall score for each of the three classifications, with higher scores indicating stronger perceived positive influence.¹⁰ The Cronbach’s alpha was 0.81 in a previous study¹⁰ and 0.918 in this study. Parental barriers to reduce ST were measured with six Likert scale questions (1=‘strongly disagree’ to 5=‘strongly agree’). Responses were averaged to create an overall barrier score, whereby the higher score reflects strong barriers to reduce ST.¹⁰ The reliability of these items was 0.78 in a previous study¹⁰ and 0.688 in this study. Parental screen-related restrictive practices were assessed with six Likert items (1=‘strongly disagree’ to 5=‘strongly agree’). All scores were summed up and averaged, where higher scores indicated more restrictive practices.¹⁰ The reliability of this item was 0.81 in a previous study¹⁰ and 0.925 in this study.

Part 7 included four questions on the number of screen devices, TV placement and availability of playthings. Part 8 assessed environmental factors, including two items on availability of public facilities/playgrounds. And also, Likert scale questions ranged from 1=‘strongly disagree’ to 5=‘strongly agree to assess perceived crime safety (6 items) and perceived pedestrian safety (5 items). Scores were averaged with higher scores indicated lower perceived safety¹⁰ for both pedestrian and crime safety. Reliability was strong, for both crime safety and pedestrian safety, with Cronbach’s alpha of 0.9 and 0.8 in previous studies,¹⁰ and 0.861 and 0.677, respectively, in this study.

Data collection technique

Four data collectors (BSc-holder nurses) and a supervisor (MSc-holder nurse) conducted the data collection process. The data collectors approached the participants through house-to-house visits and conducted face-to-face interviews. The questionnaire was translated into Afan Oromo and Amharic (local languages) as per the participants’ preferences. Each interview took a maximum of 30 min. The supervisor and investigators daily monitored the data collection process to check the questionnaires for completeness.

Data quality assurance

The questionnaire was pretested on 5% of the sampled population in Goro town 2 weeks before actual data collection. Based on the pretest results, necessary amendments were made. A 1-day training about a data collection tool, procedure, ethical considerations, the study’s aim and benefit and participants’ rights was given to data collectors and supervisors. The collected data were checked for inconsistency and missing values. In addition, the collected data were cleaned and coded before analysis.

Data processing and analysis

The collected data were entered into EpiData V.3.1 and then exported to SPSS V.25.0 for analysis. The data were cleaned and checked for outliers and missing values before analysis. Descriptive statistics, including means, SD and frequency, were presented in text narrations, frequency tables and graphs. The association between ST and independent variables was tested using a binary logistic regression analysis. All candidate variables (those with a p value of less than 0.25) identified in the bivariate logistic regression analysis were included in the multivariable logistic regression analysis. Multicollinearity was assessed using the variance inflation factor (VIF). Accordingly, the variables with a VIF of less than 10 were considered not correlated. The Hosmer-Lemeshow goodness-of-fit test was applied to select the appropriate model. Finally, the adjusted OR and a p value of less than 0.05 at 95% CI were used to illustrate the strength and significance of the association, respectively.

Results

Parents’ sociodemographic characteristics

A total of 498 parents or guardians of under-5 children participated, which gives a 98.42% response rate. The mean (SD) age of mothers and fathers in this study was 31.09±5.46 and 37.31±6.042 years, respectively. The total number of family members ranges from 2 to 9 (mean (SD) 5.32±1.346). In addition, approximately 274 mothers (55%) and 407 fathers (81.7%) attended college or higher. Nearly half, 217 (43.6%) of mothers were housewives, and 188 (63.7%) of fathers were government employees. The majority, 411 (82.5%) of parents, earn more than 75 000 ETB per year. About 302 (60.6%) of parents had 3–5 rooms in their house (table 1).

Table 1. Sociodemographic characteristics of parents of under-5 children in Woliso City, Central Ethiopia, n=498.

Variables	Category	Frequency	Percent
Number of family members	≤3	34	6.8
	4-6	362	72.7
	≥7	102	20.5
Mother age	Less than 30	186	37.3
	30 and above	312	62.7
Father age	Less than 30	46	9.2
	30 and above	452	90.8
Mother’s education	Can't read and write	7	1.4
	Primary school	45	9.0
	Secondary school	172	34.5
	College and above	274	55.0
Father’s education	Can't read and write	3	0.6
	Primary school	40	8.0
	Secondary school	48	9.7
	College and above	407	81.7
Mother’s occupation	Housewife	217	43.6
	Merchant	88	17.7
	Government employer	188	37.7
	Labour worker	5	1.0
Father’s occupation	Merchant	114	22.9
	Government employer	317	63.7
	Driver	38	7.6
	Labour worker	21	4.2
	Other*	8	1.6
Number of room	≤2	119	23.9
	3-5	302	60.6
	≥6	77	15.5
Annual income	<75 000 ETB	87	17.5
	≥75 000 ETB	411	82.5

^*Priest, pastor, prophet.

Child’s sociodemographic characteristics

The mean (SD) age of under-5 children in this study was 31.94±17.86 months and, more than half, 344 (69.1%), of the children were ≥2 years old. More than half, 265 (53.2%), are females. Around one-fourth, 125 (25.1%), of the children in this study were firstborn children, and 65 (13.5%) of the children had no siblings. The majority, 447 (89.8%) of them, are from the Oromo ethnic group, and slightly more than half, 277 (55.6%), were Protestant (table 2).

Table 2. Sociodemographic characteristics of under-5 children in Woliso City, Central Ethiopia, n=498.

Variables	Category	Frequency	Percent
Age	<24 months	154	30.9
	≥24 months	344	69.1
Sex	Male	233	46.8
	Female	265	53.2
Birth order	1	125	25.1
	≥2	373	74.9
Presence of sibling	Yes	431	86.5
	No	67	13.5
Religion	Orthodox	177	35.6
	Protestant	277	55.6
	Muslim	44	8.8
Ethnicity	Oromo	447	89.8
	Amhara	21	4.2
	Gurage	30	6.0

Child care

The primary caregivers of under-5 children were mothers 322 (64.7%), nannies 142 (28.5%), others (sisters or aunts) 20 (4%) and grandmothers 14 (2.8%), respectively. Regarding child care settings, about half, 246 (49.4%), of under-5 children were cared for at home by parents, 138 (27.7%) were cared for at a child care centre, and 114 (22.9%) were cared for at home by someone other than parents.

Parent’s media-related factors

About 234 (47.0%) and 323 (64.9%) of mothers and fathers spent more than 2 hours per day on screen devices, respectively. The mean (SD) ST of mothers and fathers was 167.64±108.43 and 262.98±172.54 min per day, respectively. Around three-fourths, 376 (75.5%) of mothers spent more than 2 hours per day with their children, with a mean (SD) spent time of 255.65±123.66 min/day. Likewise, only 109 (21.9%) of fathers spent more than 2 hours/day with their children, with a mean (SD) spent time of 104.28%±85.71% (table 3).

Table 3. Distribution of parent’s screen time and time they spent with their under-5 children in Woliso City, Central Ethiopia, n=498.

Variables	Category	Frequency	Percent
Mother’s ST	≤2 hours	264	53.01
	>2 hours	234	46.99
Father’s ST	≤2 hours	175	35.1
	>2 hours	323	64.9
Average time mother spent with child	≤2 hours	122	24.5
	>2 hours	376	75.5
Average time father spent with child	≤2 hours	389	78.1
	>2 hours	109	21.9

ST, screen time.

The study shows that only 209 (42.0%) of parents supervised their children at least 5 days/week when they were using screen devices, and 12.9% (64) never supervised their children (figure 2).

Figure 2. Distribution of parental supervision of under-5 children while using screen devices per week in Woliso City, Central Ethiopia, n=498.

Only 28 (5.60%) of parents perceived that their children should not be exposed to screen devices, while 235 (47.2%) of parents perceived that the maximum daily ST for under-5 children is more than 1 hour/day (figure 3).

Figure 3. Distribution of parent’s perception towards maximum daily ST of their under-5 children in Woliso City, Central Ethiopia, n=498. ST, screen time.

Nearly three-fourths, or 365 (73.3%), of parents had HH rules regarding their child’s ST. Of those who had ST rules, 122 (24.5%) had rules that restricted the amount of time their child could spend on screen, 72 (14.5%) and 68 (13.7%) had rules that restricted the child to watching only under adult supervision and prevented them from sitting near the TV, respectively. In addition, 46 (9.2%) had rules that allowed only children’s channels, and 46 (11.4%) had rules that prevented any media gadgets an hour before sleep.

In this study, 219 (43.8%) parents of under-5 children had low self-efficacy to say no to their child’s ST, while 213 (42.8%) and 67 (13.4%) had high and moderate self-efficacy. In addition, only 215 (43.2%) of parents had negative attitudes towards their child’s ST.

The mean (SD) of parents’ perceptions of the effect of ST on physical well-being, cognitive development and social well-being was 6.56±2.439, 7.76±3.083 and 5.686±2.268, respectively. The mean (SD) of parents’ barriers to reducing their child’s ST and parents’ restrictive practices were 3.666±0.914 and 23.982±6.886, respectively.

Child’s physical activity status

It was reported that 215 (43.2%) of the children in this study had an outdoor playing time of less than an hour/day, and 283 (56.8%) had ≥1 hour of outside playtime. Their outdoor playtime was between 0 and 540 min/day, with a mean of 119.396±94.89. The mean physical activity increased from 110.0±94.631 min/day on weekdays to 142.86±117.414 on weekends.

Home media environment

The majority, 472 (94.8%) of participants, possessed at least three screen gadgets in their home. The most widely available screen devices in the area were 99.4% mobile phones, 99% TVs, 44.8% computers and 14.3% tablets. Around 235 (47.2%) of parents place the screen devices in the room where children sleep, eat or play. Of these parents, 176 (74.9%) left the TV switched on for more than 2 hours/day. The majority, 442 (88.8%), of parents provided their children with outdoor playthings (table 4).

Table 4. Home media environment in Woliso City, Central Ethiopia, n=498.

Variables	Category	Frequency	Percent
Total gadget	<3	26	5.2
	≥3	472	94.8
Screen devices in sleeping, eating or playing room	Yes	235	47.2
	No	263	52.8
TV switch on duration in sleeping, eating, playing room (n=235)	≤2 hours	59	25.1
	>2 hours	176	74.9
Providing outdoor playing thing	Yes	442	88.8
	No	56	11.2

Neighbourhood environment

Almost one-fourth, or 133 (26.7%), of parents reported the availability of a public facility, playground or garden in their nearby environment. About 53 (39.8%) of public facilities, playgrounds or gardens were located within a 10 min walk, 39.1% and 21.1% of them 11–29 min and 30 min, respectively.

Additionally, the mean (SD) score for perceived crime safety in the neighbourhood was 3.167±1.174. Similarly, the mean (SD) score for perceived pedestrian safety in the neighbourhood was 3.504±0.976.

Status of excessive ST

According to this study, 378 (75.9%) (CI 71.9 to 79.6) of the under-5 children had an excessive ST. Of these, 130 (26.1%) were among children less than 24 months old, whereas 248 (49.8%) were among children 24 months and older.

The ST of under-5 children ranged from 0 to 451.43 min/day, with a mean (SD) of 103.64±86.86 min/day. For children less than 24 months old, the ST ranged from 0 to 394.29 with a mean (SD) of 57.287±69.66/day, whereas for children 24 months and older, it ranged from 0 to 451.43 with a mean (SD) of 124.394±85.875 per day.

The mean (SD) ST of under-5 children was increased from 97.30±87.93 min/day on the weekdays to 119.50±109.91 min/day on the weekends. The mean ST of boys was 112.57±90.375, which was higher than the mean ST of girls (95.79±83.06). Regarding the birth order, the mean ST was 123.36±97.58 among first-born children and 97.03±82.06 among second-born or above-born children.

Factors associated with ST

Table 5 illustrates the bivariate and multivariate analysis outputs of factors associated with ST among under-5 children. In the bivariate analysis, the age of the mother, the age of the father, the age of the child, the mother’s ST, the physical activity of the child, parental supervision, perception of maximum ST, presence of HH ST rules, parent’s self-efficacy, parent’s attitude towards ST, parental perception of the effect of ST on the child’s well-being, barriers to reducing ST, parental restrictive practice, place of screen devices and presence of public facilities were declared to be candidates for multivariable logistic regression, assuming a p value less than 0.25. However, two variables (parental attitude and the child’s physical activity) were removed from the multivariable analysis due to their higher VIF.

Table 5. Bivariate and multivariable analysis results of factors associated with screen time among under-5 children in Woliso City, Central Ethiopia, 2024 (n=498).

Variables	ST		COR (95% CI)	P value	AOR (95% CI)	P value
	Excessive	Recommended
Age of mother
<30 years	132 (70.97	54 (29.03	1		1
≥30 years	246 (78.8)	66 (21.2)	1.525 (1.005 to 2.314)	0.047	1.775 (1.045 to 3.015)	0.034
Age of father
<30 years	39 (84.78)	7 (15.22)	1		1
≥30 years	339 (75)	113 (25)	0.538 (0.234 to 1.238)	0.145	0.225 (0.080 to 0.630)	0.005
Age of the child
<24 months	130 (84.42)	24 (15.58)	1		1
≥24 months	248 (72.1)	96 (27.7)	0.477 (0.291 to 0.782)	0.003	0.464 (0.251 to 0.858)	0.014
Mothers’ ST
≤2 hours	189 (71.6)	75 (28.4)	1		1
>2 hours	189 (80.8)	45 (19.2)	1.667 (1.094 to 2.539)	0.017	1.060 (0.632 to 1.777)	0.825
Parental supervision during ST
Never	59 (92.2)	5 (7.8)	4.977 (1.906 to 12.99)	0.001	4.329 (1.367 to 13.71)	0.013
Seldom	103 (81.7)	23 (18.3)	1.889 (1.100 to 3.244)	0.021	1.409 (0.691 to 2.873)	0.346
S. times	69 (69.7)	30 (30.3)	0.970 (0.576 to 1.634)	0.909	0.796 (0.410 to 1.546)	0.501
Often	147 (70.3)	62 (29.7)	1		1
Parental perception of maximum daily ST
0 min	15 (53.6)	13 (46.4)	1
<60 min	185 (78.7)	50 (21.3)	3.207 (1.433 to 7.178)	0.005	5.894 (2.255 to 15.41)	0.001
≥1 hour	178 (75.7)	57 (24.3)	2.706 (1.216 to 6.025)	0.015	4.300 (1.577 to 11.73)	0.004
Presence of household ST rule
Yes	263 (72.1)	102 (27.9)	1
No	115 (86.5)	18 (13.5)	2.478 (1.434 to 4.281)	0.001	1.069 (0.530 to 2.155)	0.851
Parental SE to say ‘no’ for ST
Low	178 (81.7)	40 (18.3)	1.998 (1.275 to 3.132)	0.003	0.863 (0.463 to 1.610)	0.643
Moderate	53 (79.1)	14 (20.9)	1.700 (0.881 to 3.278)	0.113	1.200 (0.523 to 2.757)	0.667
High	147 (69.0)	66 (31.0)	1		1
Parental perception on effect of ST on physical well-being			21.241 (1.128 to 1.365)	< 0.001	00.836 (0.488 to 1.431)	0.513
Parental perception on effect of ST on child’s cognitive development			21.239 (1.150 to 1.336)	< 0.001	11.620 (0.907 to 2.893)	0.103
Parental perception on effect of ST on social well-being			21.316 (1.190 to 1.455)	<0.001	11.291 (0.739 to 2.255)	0.37
Barrier to reduce ST			1.298 (1.037 to 1.625)	0.023	1.216 (0.939 to 1.576)	0.138
Parents’ restrictive practice			0.849 (0.809 to 0.892)	0.001	0.890 (0.841 to 0.941)	0.001
Place screen devices in room where children eats, sleeps or plays
Yes	200 (85.1)	35 (14.9)	2.729 (1.753 to 4.247)	0.001	1.869 (1.069 to 3.269)	0.028
No	178 (67.7)	85 (32.3)	1		1
Availability of public facility such as playground or garden
Yes	111 (83.5)	22 (16.5)	1
No	267 (73.2)	98 (26.8)	0.540 (0.323 to 0.902)	0.018	0.729 (0.387 to 1.375)	0.329

SE, Self Efficacy; ST, screen time.

In multivariable analysis, the father’s age, the mother’s age, the child’s age, parental supervision, parental perception of maximum ST, parental restrictive practice and screen devices in the bedroom were significantly associated with children’s excessive ST. From sociodemographic characteristics, the father’s age ≥30 years and child’s age ≥24 months were negatively associated with ST; however, the mother’s age ≥30 years showed a positive association. The odds of excessive ST were 77.5% (AOR=0.225, CI 0.080 to 0.630) lower among children whose fathers’ age was 30 and above when compared with their under-5 counterparts. Conversely, the odds of having excessive ST were 1.7 times (AOR=1.775, CI 1.045 to 3.015) higher among children whose mothers’ ages were 30 and above when compared with their under 30 counterparts. Children aged 24 months and above were found to have 53.6% (AOR=0.464, CI 0.251 to 0.858) lower odds of having excessive ST than younger children below 24 months.

Parent’s media-related behaviour, such as parental supervision, perception of maximum ST and parental restrictive practice, was significantly associated with a child’s ST. The odds of excessive ST among children who lacked parental supervision during ST were 4.3 times (AOR=4.329, CI 1.367 to 13.71) higher compared with those whose parents supervised more than 5 days/week. Children of parents who perceive the daily maximum ST as less than 60 min and as ≥1 hour had 5.9 times (AOR=5.894, CI 2.255 to 15.41) and 4.3 times (AOR=4.300, CI 1.577 to 11.73) higher odds of having excessive ST, respectively, than those whose parents perceived it as 0 min. Additionally, for a unit increase in parental restrictive practice score, there was a 0.89 unit decrease in the child’s ST (AOR=0.890, CI 0.841 to 0.941).

The availability of screen devices in the room where a child plays, eats or sleeps was the only home media environment factor associated with the ST of under-5 children. The odds of excessive ST were 1.9 times (AOR=1.869, CI 1.069 to 3.269) higher among children who had screen devices in their playing, eating or sleeping rooms.

Discussion

This study assessed ST among under-5 children and its associated factors. Accordingly, 75.9% (95% CI 71.9 to 79.6) of participants had an excessive ST. The factors associated with excessive ST were found to be the father’s age, mother’s age, child’s age, parental supervision, parental perception of daily maximum ST, parental screen-related restrictive practice and putting screen devices in the child’s playing, eating or sleeping room.

In this study, 75.9% of under-5 children in Woliso town had an excessive ST. This finding is congruent with a study conducted in India, which found 73% of excessive ST.⁷ This may be due to the similarity in study setting; hence, both are conducted in the community. In contrast, this prevalence is higher than reports from Ireland (56%)² and Latin American populations (47%),¹⁶ however lower than the figure reported in Malaysia, where 91.4% of children had excessive ST.¹⁰ These variations across countries may be explained by differences in socioeconomic status, access to devices, study settings (community vs institution-based), methodological approaches (eg, survey vs diary) and the guidelines used to define excessive ST. Overall, despite contextual differences, the consistently high prevalence across diverse settings underscores that excessive ST in early childhood is a global issue.

When examined by age group, 84.4% (95% CI 77.7 to 89.8) of children under 24 months in Woliso had excessive ST, which is comparable with report from Portugal (85.5%)³⁹ and higher than the 73.3% reported in India for the same age group.⁷ Among children aged 24 months and older, 72.1% (95% CI 67.0 to 76.8) had excessive ST, comparable with report observed in India, which reported 73%,⁷ however higher than the 57.8% reported in Portugal.³⁹

This study found a negative association between ST and a child’s age. Children ≥24 months old were about 53.6% less likely to have an excessive ST compared with children less than 24 months old. This might be due to the difference in the daily recommended ST for different age groups, which is 0 min for less than 24-month-old children and less than an hour for those aged 24 months and above.⁵ This means that even having 1 min of ST is considered excessive ST among children less than 2 years old, while for children above 2 years old, it has to be more than 60 min to be considered excessive. Another possible reason might be that younger children may have a stronger attraction to screens due to the bright colours, sounds and interactive features that can captivate their interaction. Older children may have developed other interests and activities that compete with ST.

Children whose mothers were 30 years old or older were nearly twofold more likely to have an excessive ST compared with children whose mothers were less than 30 years old. This was similar to the finding from Malaysia.¹⁰ The majority of mothers in this age group had a higher number of family members and was less restrictive towards the media usage of their children. These findings suggest a potential necessity for coping strategies to manage the challenges of parenting and HH responsibilities, potentially leading to a reduction in ST restrictions. Hence, the phenomenon among this specific population needs deep exploration using phenomenological studies.

The father’s age was also found to be significantly associated with the child’s ST. Accordingly, children of fathers aged 30 years and older had a 77.5% lower likelihood of an excessive ST compared with their counterparts. This could be related to the fact that older fathers have parenting experience, maturity and more knowledge about the potential negative effects of excessive ST that can help them set limits on ST through stricter monitoring and regulation of ST behaviour.

Inadequate parental supervision during the ST was found to be significantly associated with the child’s ST. Children who never had parental supervision during ST were fourfold more likely to have an excessive ST compared with those whose parents supervised them more than five times per week. Lack of parental supervision may lead to a lack of boundaries and guidance on when and how to use screen devices, which can lead to children spending excessive time on screen devices and engaging in activities that are not suitable for their age.

A significant association was discovered between ST and parental perceptions of maximum ST. For instance, children whose parents perceived the maximum daily ST as an hour and above were four times more likely to have excessive ST compared with children whose parents perceived that no ST was acceptable. A possible explanation could be that as parental perception of maximum ST increases, they may be more permissive to ST and less likely to set strict limits or monitor their children’s ST usage closely, which could lead to children spending more time on screens.

A negative association was found between the parental restrictive practices score and ST. Accordingly, for a unit increase in parental restrictive practice score, there was a 0.89 unit decrease in ST. Parents who engage in more restrictive practices regarding screen usage are likely to have a greater impact on reducing their children’s ST. When parents actively enforce rules and restrictions, children may have fewer opportunities to engage in screen activities.

Placing screen devices in the room where a child plays, eats or sleeps also increases the likelihood of having excessive ST. This finding is consistent with a study conducted in Colombia, which found that having a TV in the bedroom was linked to a higher likelihood of excessive ST.³¹ Additionally, a study conducted in Ireland found that children who have a TV in the dining room were more than two times more likely to have an excessive ST.² This might be related to the easy accessibility of screen devices at all times. In addition, if screen devices are readily available in areas where children spend time, they may be less inclined to engage in other activities, which can result in children defaulting to screens as their primary form of entertainment.

Strengths and limitations of the study

To the best of our knowledge, this is a pioneer study in Ethiopia that identified ST among under-5 children. Thus, it can be used as a baseline for future studies. Its community-based approach could enable divergent recruitment of participants and assure sample representativeness. Moreover, a face-to-face interview could ensure data completeness by minimising ambiguity and reducing certain sorts of recall bias. However, the ST of the children in this study could be subjected to parental recall bias, which might lead to underestimation or overestimation. As the study is cross-sectional, we cannot formulate a cause-and-effect relationship.

Conclusion

About three in four children in the study area had an excessive ST. Despite the detrimental effect of ST on the health and development of children, significant numbers of under-5 children are engaging in excessive ST. Several modifiable and unmodifiable factors were identified as influencers of ST. Among the unmodifiable factors, the age of the father and the age of the child were negatively associated with ST, and the age of the mother was positively associated with ST among under-5 children. Parental supervision, parental perception of maximum ST, parental restrictive practice and TV in the bedroom were the modifiable factors significantly associated with the child’s ST. Thus, concerned bodies need to educate the families regarding limiting their young child’s ST based on the recommended guidelines and recommendations, supervising their young children regularly while they are using screen devices, and not placing screen devices in rooms where the children can easily access them. It is also necessary to integrate ST education into paediatric wellness programmes and parent education programmes at health facilities. We recommend researchers in the field assess the phenomenon using interventional and follow-up studies to identify strategies to adopt healthy ST habits and mitigate recall bias, respectively.

Implication for practice

As a clinical implication, this study is important for parental supervision and parental engagement to monitor their children’s ST. The finding identified that parental supervision, parental perception of daily maximum ST and parental screen-related restrictive practices were significantly influencing factors in children’s ST. Healthcare providers can use this information to educate parents on the impact of their involvement in regulating ST for their children. For instance, healthcare professionals can emphasise the need for parents to actively supervise and monitor their children’s ST activities to reduce excessive use. They can also advise on setting appropriate daily maximum ST limits and implementing effective screen-related restrictive practices. Furthermore, healthcare providers can tailor their recommendations based on parental age.

This was the first study conducted in Ethiopia that addressed the information gap on ST among under-5 children. It offers valuable insights into the prevalence and factors associated with excessive ST among under-5 children. The results emphasise the importance of targeted interventions that empower parents to establish a balanced and supportive ST environment for their children. Furthermore, this study contributes to the emerging body of literature on ST behaviours in young children, aiding in the development of evidence-based strategies to tackle this significant public health concern.

Data availability statement

Data are available upon reasonable request.