Relation between Screen Times Based Behavior, Physical ... · Naseem Ahmed, et al BAO be eigt...

BAOJ Obesity & Weight Loss Management

Naseem Ahmed, et al. BAOJ Obe Weigt Manage 2019, 4: 24: 023

BAOJ Obe Weigt Manage, an open access journal Volume 4; Issue 2; 023

Research

Relation between Screen Time-Based Behavior, Physical Activity and Health Complaints

Naseem Ahmed1*, Kiran Shafiq Khan2, Syed Muhammad Hussain2, Saira Batool Rizvi2, Roha Saeed Memon2 and Muhammad Taha Tariq2

1Departmet of Pathology, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan2Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan

*Corresponding Author: Dr. Naseem Ahmed, Department of Pathology Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan, Tel: +923332226030, E-mail: [email protected]

Sub Date: May17th, 2019, Acc Date: May 21st, 2019, Pub Date: May 21st, 2019

Citation: Naseem Ahmed, Kiran Shafiq Khan, Hussain SM (2019) Relation between Screen Time-Based Behavior, Physical Activity and Health Complaints. BAOJ Obe Weigt Manage 4: 023.

Copyright: © 2019 Naseem Ahmed. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Introduction

In this era of technology and its vast accessibility, smart phones portability, and increase of entertainment content have substantially increased screen time of children. Therefore providing children with screen-based devices have decreased their physical activities, which lead to physical and behavioral disturbances. Studies have also shown a negative association in school performance with internet use and delayed language development with television use in the first 2 years of life.

Objective

The main objective of the study was to study the trends of media and further study the implications of this screen time on their academic performance, physical and mental health.

Methods

Data were collected through interview-based questionnaires in the first week of January 2019 from 170 students of a private school of Karachi from 6th to 10th grade. Participants attempted questionnaires about their media use, sleep time, hours of study, internet use, physical activity, and quality of life. Data was entered and analyzed by SPSS 24.

Results

A response rate of 100% was obtained, with 65.4% respondents being male. Smart phones, followed by television and computers were the most common modalities of media use. Average BMI was 21.6±2, with one-fifth population lying in the obesity grade. This BMI was compared to the studied variables, and found significantly correlated with study time (p=0.001), and internet use (p=0.017). Almost half

of the individuals (48.2%) with low screen time were found to be very active, and a similar number experienced headache (50.5%), low mood (54%), and poor sleep. Three-fourth individuals used earphones during media use; however, hearing problems were expressed by 10.8% students. Hours of media use had a significant effect on sleep time (p=0.002), and a bivariate analysis further verified this. Gender and grade specific analysis revealed no significant findings.

Conclusions

Limitations in screen use is currently a necessity since the screen time has been found to adversely affect a child’s mental and physical well-being. Newer strategies should be formulated, and studies that test the impact of these new interventions on reducing the hours of media use with achieving better outcomes should be conducted.

Key Words: Screen Time; Adverse Effect of Media Use; Mental and Physical Well-Being; School Going Children; Appropriate Intervention


of 12Citation: Naseem Ahmed, Kiran Shafiq Khan, Hussain SM (2019) Relation between Screen Time-Based Behavior, Physical Activity and Health Complaints. BAOJ Obe Weigt Manage 4: 023.

Introduction

With the advancement in technology, screen-based devices are now more readily available to everyone including the children. With the convenience of their portability and an increasing number of content especially entertainment content, smart phones have penetrated in children lives more than they had before. Internet-connected smart phones and electronic devices have been associated with inactive behavior [1]. Physical activity is considered to be the basis in the physical development of infants, children, and teenagers about to enter into adulthood [2]. This compels a new dedication the way pediatricians, teachers and parents show concern towards the media use among children and to lessen its potential health risks and have proper safety guidelines for media use.

Throughout the world the main mode by which screen time is consumed is by Television among children, affecting their physical and mental abilities adversely and increasing the risk of obesity, sleep problems, depression, and irritability [3,4,5]. A study conducted in Texas indicated that adolescents who had a screen time of 2 hours or less had better sleep than the ones who spent 6 or more hours on screen; also the latter had higher percentages of nighttime eating [6].

The quality of sleep is better when babies and young kids have some physical activities during the day [7]. Evidence suggests that in the first 2 years watching Television may be associated with delayed language development. The use of a screen at a young age less than 2 years reduces the time available for active learning and play affect the development of a full range of the eye movement, and also limits the time that young kids can concentrate [8]. A study conducted among Korean adolescents demonstrated that the students who used internet for their academic purposes performed better in their schools, and the performance was highest in students who spent 2 hours using the internet for their academic purposes, the students who used the internet 2 hours a day for their academic purpose demonstrated 2.71 times more school performance compared to none internet user for academic purpose. On the other, the general use of internet was negatively associated with school performance (5 Current studies have shown an association between TV viewing and increased consumption of unhealthy diet e.g. snacks and beverages with high sugar content) (4). Children who had >4hours of personal computer use per day was more prone to poor health [9]. An experimental study showed that children who received an 18-lesson, multiple-component screen-time reduction curriculum delivered by the regular classroom teachers showed reduced television viewing, video game use, and number of meals eaten in front of the television. Intervention participants also significantly slowed their gain in BMI. An analysis of possible mediators suggested that the effects of reduced screen time on changes in BMI were associated with reductions in dietary energy intake but

not increased physical activity measured by an accelerometer [10]. The prevalence of TV and other screen-based devices were more in children’s bedrooms that belonged to lower socioeconomic status than those children of the higher socioeconomic status, and in lower socioeconomic status parents watched TV/DVDs with their children more often than those children of the higher socioeconomic status [11]. Lesser percentage of preschool children fulfill the recommendations of physical activity and many exceed the recommended screen time, limited and supervised screen time was associated with increased physical activity and lesser sedentary and lesser screen time [12,5]. Parent’s and family screen time also influenced child’s screen time, increasing screen time also had a negative effect on ocular health such as burning sensation, redness, fatigue and watery eyes [5]. A study showed Canadian youth with less than 2 hours of screen time per day was more likely associated with higher self-esteem [13].

The prevalence of screen-based sedentary behaviors resume increasing, with almost half of children and youth still exceeding the public health screen-time recommendation of 2 hours per day or less [14,5]. To our knowledge, there are not enough studies analyzing screen time association with physical and mental health in children, particularly in Pakistan. Therefore, our aim is to explore the physical activities, mental health, obesity, and sleep habits associated with screen time among children.

Methods

Study Population and Data Collection

Data were collected on 29-01-2019 from a private school in Karachi. The data included 170 children and was restricted to 8 -14years old children from 6th to 10th grade. Children above the age of 14 and with no screen time were excluded. A cross-sectional study was conducted. The participants provided information on a questionnaire about their media use (the type of media, hours of television, computer/Internet, and smart phone use, Smartphone skills, earphones use), sleep time, hours of study, the internet used for study purpose and for general use, physical activities (hours of physical activity and perceived exertion, posture in which they use media), psychological quality of life (depression, irritability), physical quality of life (headache, hearing, hand pain, hearing problem) and their BMI. The data were collected by 4th year medical students by going to each class explaining each question to the children, to reduce any errors the medical students themselves calculated the BMI of the participants by measuring weight and height at the spot. Internet use for the study was measured in hours. Mean daily internet use was calculated by adding the time spent on weekdays and the time spent on weekends. We separated internet use for study into 7 groups (> 0 and 1 day a week [1 d]; > 1 and 2days a week [2 d]; >2days and 3days a week [3d]; >3days and



4days a week[4d]; >4days and 5days a week[5d]; > 5days and 6days a week[6d]; >6days and 7days a week[7d]) and internet use for general purpose into 7groups (> 0 and 1 day a week [1 d]; > 1 and 2days a week [2 d]; >2days and 3days a week [3d]; >3days and 4days a week[4d]; >4days and 5days a week[5d]; > 5days and 6days a week [6d]; >6days and 7days a week[7d]).

A questionnaire for parents was also made in which participants parents (mother or father) had to provide information regarding their age, occupation (employment status and type of job), education, socioeconomic class(monthly income), other children, screen-based devices use by their children (the type of devices used, screen time spent, the age of the child the devices was introduced, schedule, the time limit set by the parent), class performance, child’s personal habits [proper sleep, food, noticeable behavioral changes, active listener, engagement in activities other than screen time like reading books, outdoor sports, playing with non-electrical toys(action figures, lego, board games etc) converse with family members, doing art and crafts(painting, coloring, drawing)], screen time spent by the parents themselves, satisfaction of their child’s health.

The cooperation rate for the children’s questionnaire was substantial as the children were excited to know their height and weight, out of 170 children that were approached only 2 of them did not provide complete data. As for the parent’s questionnaire the cooperation rate was not substantial because the parent’s questionnaire was to be filled by the parent’s at home and out of 170 questionnaires merely 25 questionnaires were received so the data from the parent’s questionnaire has been excluded from our study.

Data Analysis

Data is entered on MS Excel, and examined by Statistical Package for the Social Sciences (SPSS) version 24. For categorical responses frequencies and percentages are evaluated and for the evaluation of the associations between quantitative variables Chi-square test is used. Statistically significant is considered when the P- value is less than 0.05.

Results

Out of 168 individuals who completed the questionnaire, majority [n=110, 65.4%] were males. Considering responses from individual grades, 24 students from class 6 filled the questionnaire while 37 students from class 7, 32 from class 8, 51 from class 9 and 24 from class 10 submitted completely filled questionnaires. Mean age of the individuals was 14.1 ± 1.7 years with mean weight and height being 48.9 ± 2.3 kg and 5.0 ± 2 feet, respectively. The participants had an average BMI of 21.6 ± 2.

A small number of participants [n=23, 13.6%] never had their BMI z-scores checked before which was found to be below 16 BMI z-score while an equal number of individuals [n=20, 11.8%] were classified to 16-17 and 17-18.5 BMI z-scores each. A majority [n=71, 42.2%] lied in 18.5-25 BMI z-score range. The remaining participants [n=32, 19%] belonged to the obesity class of 25-40 BMI z-score.

A large bulk of individuals on average [n=129, 76.7%] did not take part in any physical activity. However, children with the screen time of less than 2 hours per day [81, 48.2%] found themselves very active. A reasonable number of participants [n=58, 34.5%] used the internet for study purposes whereas an equal number [n=57, 33.9%] used it for general purposes. Considering the source of media and when given the chance to mark more than one option, the majority [n= 105, 62.3%] opted for mobile/ tablet use. However, a good number of people [83, 49.4%] chose TV and video games or computer as an important contributor to their screen time.

A sizeable majority [n=85, 50.5%] experienced headache following their screen time, while the rest [83, 49.4%] were unsure about it. In addition to this, a significant part of our population [n=91, 54%] felt low or depressed after their screen time whereas, an overwhelming majority [n=112, 66.6%] didn’t feel irritable at all. Furthermore, an interesting extrapolation was that a good number of participants [n=95, 56.5%] concurred on having a TV in their rooms and a majority [n=138, 82%] took snacks while watching the TV. Moreover, a vast majority [n=123, 73.2%] used earphones during mobile/tablet use. Most people [n= 150, 89.2%] stated no hearing issues following the use of earphones for a longer duration however, a small number [17, 10%] reported otherwise. With regards to the posture opted for during the screen time, participants [n= 68, 40.4%] found lying on their backs more comfortable. A sizeable majority [n=58, 34.5%] preferred sitting in an upright position whereas, other options were less opted for (30%). An almost equal number of participants [85, 50.4%] experienced pain in their hands after holding mobile phone/tablet and other media gadgets for a long time. Almost all the individuals [n= 160, 95.5%] denied colliding with someone while using a mobile phone.

Out of 21 responses received from the parents, it was found that the majority [n=14, 70%] limited their child’s screen time especially on weekdays. When asked about the strategies that help divert their child’s attention from the screens, a few parents [n=7, 35%] chose to play sports whereas, a smaller number [n=5, 25%] reported that engaging their child to book reading was helpful. A moderately high number of parents [n=14, 70%] think that 2-4 hours of screen time is quite a lot of media use for children. Almost all of them [n=20, 95%] agreed that an increase in screen time affects their child’s sleep. A greater majority [n=17, 85%] reported concerns about their child’s health and diet intake. A similar majority of the parents [n=15, 75%] agreed that their



child has lost weight significantly in the past 3 months. When asked if they have noticed behavioral changes in their child, a majority [n=16, 80%] denied whereas a few [n=4, 20%] parents agreed. Furthermore, more than half of the parents [14, 70%] agreed that their child gets very stubborn when asked to put the device down. A good number of parents [n=14, 70%] think that every second child has a TV in their room and they can use it independently. Nearly half of the respondents [n=12, 60%] think that increased screen time has a dynamic effect on leading children towards obesity.

In (Table 1) we see that on comparison of total sleep time with the child’s total screen time i.e. the hours of media use with the chi-squared test, significant results were obtained (p=0.002). However, an insignificant association was seen when total study time (p=0.312) and self-rated internet use (p=0.066), Smartphone skills (0.761),

physical activity (p=0.278) were compared. Furthermore, reported days of physical activity (p=0.272), internet use for study purposes (p=0.684) as well as for general purposes (p=0.958) were also found to be statistically insignificant when compared with screen time. Other factors considered including headache (p=0.504), pain in hand (p=0.332), irritability after screen time (p=0.249), use of earphones (p=0.181) along with hearing impairment (p=0.912) also gave insignificant results on the comparison. When the kind of media gadget used (p=0.593) with its associated subcategories such as consumption of snacks during watching TV (p=0.342), collision with someone during mobile phone use (p=0.234), usual posture during screen time (p=0.390) were compared, the results obtained were insignificant. Only feeling low or depressed after screen time (p=0.025) showed a statically significant association with the child’s total screen time.

Table 1: Responses of students of class 6-10 compared with total screen time i.e. hours of media use. <2 hours 3-5 hours >6 hours p-value

Total study time <2 hours 23 (62.2%) 8 (21.6%) 6 (16.2%) 0.312>2 hours 61(69.3%) 18 (20.5%) 9 (10.2%)<6 hours 28 (73.7%) 10 (26.3%) 0>6 hours 4 (80%) 1 (20%) 0

Total sleep time <8 hours 27 (84.4%) 4 (12.5%) 1 (3.1%) 0.0028-9 hours 57 (78.1%) 13 (17.8%) 3 (4.1%)>8 hours 16 (55.5%) 10 (34.5%) 3 (10.3%)>10 hours 16 (47.7%) 10 (29.4%) 8 (23.5%)

Self-rated internet use Mild use (1-3 rating) 65 (78.8%) 13 (15.7%) 5 (6%) 0.066Moderate use (4-7

rating)46 (63%) 19 (26%) 8 (11%)

Extreme use (8-10 rating)

5 (41.7%) 5 (41.7%) 2 (16.7%)

Self-rated smartphone skills Mild use (1-3 rating) 31 (75.6%) 6 (14.6%) 4 (9.8%) 0.761Moderate use (4-7

rating)36 (67.6%) 13 (24,5%) 4 (7.5%)

Extreme use (8-10 rating)

49 (66.2%) 18 (24.5%) 7 (9.5%)

Reported days of physical activities

More than 7 days 25 (64.1%) 8 (20.5%) 6 (15.4%) 0.272

Less than 7 days 91 (70.5%) 29 (22.5%) 9 (7%)How physical active are

you?Less Active 8 (61.5%) 3 (23.1%) 2 (15.4%) 0.278

Active 48 (65.5%) 20 (27.8%) 5 (6.8%)Very active 60 (74.1%) 13 (16%) 8 (9.9%)

Internet use for study purposes

1/7days 19 (66.7%) 7 (25.9%) 2 (7.4%) 0.684

2/7days 3 (60%) 1 (20%) 1 (20%)3/7days 39 (67.6%) 13 (22.4%) 6 (10.3%)4/7days 29 (76.3%) 8 (21.1%) 1 (2.6%)



5/7days 11 (52.4%) 7 (33.3%) 3 (14.3%)6/7days 15 (83.3%) 1 (5.6%) 2 (11.1%)

Internet use for general purposes

3/7days 38 (67.9%) 12 (21.7%) 6 (10.7%) 0.958

4/7days 17 (63.4%) 7 (25%) 3 (11.1%)5/7days 42 (73.7%) 11 (19.3%) 4 (7%)6/7days 19 (67.9%) 7 (25%) 2 (7.1%)

What kind of media do you use?

Television 59 (71.1%) 19 (22.9%) 5 (6%) 0.593

Video games/ computer 54 (63.5%) 21 (24.7%) 10 (11.8%)Mobile/ tablet 70 (66.7%) 27 (25.7%) 8 (7.6%)

Others 8 (57.1%) 4 (26.8%) 2 (14.3%)Do you feel headache after

your screen time?Yes 62 (72.9%) 17 (20%) 6 (7.1%) 0.504

No 54 (65.1%) 20 (24.1%) 9 (10.8%)Do you feel low after your

screen time?Yes 68 (76.4%) 16 (16.7%) 7 (7.9%) 0.025

No 48 (62.3%) 21 (27.8%) 8 (10.4%)Do you feel irritable after

your screen time?Yes 34 (60.7%) 16 (28.6%) 6 (10.7%) 0.249

No 82 (73.2%) 21 (18.8%) 9 (8%)Do you have a TV in your

room?Yes 67 (70.2%) 21 (22.3%) 7 (7.4%) 0.899

No 49 (67.1%) 16 (21.7%) 8 (11%)Do you take snacks during

screen time?Yes 94 (68.1%) 33 (23.4%) 11 (8%) 0.342

No 22 (73.2%) 4 (13.3%) 4 (13.3%)Do you use earphones? Yes 83 (16.7%) 26 (21.2%) 14 (11.4%) 0.181

No 33 (73.2%) 11 (24.5%) 1 (2.2%)Have you been feeling any

hearing issues recently?Yes 13 (76.5%) 3 (17.5%) 1 (5.9%) 0.912

No 102 (68.7%) 34 (22.7%) 14 (9.3%)In which posture do you

usually use your phone or watch TV?

Upright sitting position 42 (61.8%) 18 (26.5%) 8 (11.8%) 0.390

Standing position 11 (91.7%) 1 (8.3%) 0Lying on chest 11 (78.9%) 3 (21.4%) 0Lying on back 42 (61.8%) 18 (26.5%) 8 (11.8%)

Do you feel any pain in hands?

Yes 57 (67.1%) 21 (24.7%) 7 (8.2%) 0.332

No 59 (72.6%) 16 (18.3%) 8 (9.8%)Have you ever collided with someone while using your

phone?

Yes 4 (50%) 2 (25%) 2 (25%) 0.234

No 112 (70%) 35 (21.9%) 13 (8.1%)



To further describe these correlations, bivariate analysis was done. Linear correlations derived showed that pain in hand and irritability after screen time was inversely associated with time duration of media

use, whereas, headache, low mood or depression, total sleep and study time showed a direct correlation with screen time as shown in Table 2.

Table 2: Correlation of headache, pain in hand, feeling low/depressed, irritability, total sleep and study time with hours of media use/ screen time.

Independent variable Dependent variable Correlation coefficient p-value (2-tailed)Hours of media use /screen time Headache after screen time -0.079 0.308Hours of media use /screen time Pain in hands 0.041 0.596Hours of media use /screen time Feel low/ depressed after screen time -0.190 0.014Hours of media use /screen time Irritability 0.129 0.097Hours of media use /screen time Total sleep time -0.058 0.452Hours of media use /screen time Total study time -0.046 0.551Hours of media use /screen time Physical activity -0.121 0.118

When the K-independent sample test was applied and the effect of gender on the responses was analyzed, we found that total study time had more, although an insignificant association with screen time in females compared with males (Table 3). The overall association was, however, significant (p=0.002). When total sleep time was assessed, a statistically insignificant association was found (p=0.375), more in males (p=0.80). Furthermore, insignificant overall and gender-based results were obtained when total screen time (p=0.873), kind of media used (p=0.52), collision with someone during mobile phone use (p=0.09), headache (p=0.264) and irritability (p=0.162), were analyzed.

Internet use for general purposes was found to have an insignificant association (p=0.673) while its use for study purposes had a significant overall association (p=0.001). It could not be derived if either gender influenced this significance because of inability to analyze the responses from females. Similarly, when compared, self-rated internet use had an insignificant association (p=0.115) while self-rated Smartphone skills showed a significant overall association (p=0.022), with males (p=0.197) showing a comparatively greater trend towards achieving statistical significance.

Table 3: Gender-based analysis to assess the effects of either gender on the overall responsesGender association with following

variablesOverall

(p-value)

Male

(p-value)

Female

(p-value)

Remarks

Total study time 0.002 0.804 0.352 <0.05 p value indicate a significant difference between the median of variables

Total sleep time 0.375 0.80 0.608 >0.05 p value indicate no significant difference between the median of variables

Total media / screen time 0.873 0.803 0.225 >0.05 p value indicate no significant difference between the median of variables

Self-rated internet use 0.115 0.248 0.631 >0.05 p value indicate no significant difference between the median of variables

Self-rated smartphone skills 0.022 0.197 0.321 <0.05 p value indicate a significant difference between the median of variables

Reported days of physical activities 0.403 0.608 Insufficient data to perform

the test

>0.05 p value indicate no significant difference between the median of variables

How physical active are you? 0.722 Insufficient data to perform the test

0.497 >0.05 p value indicate no significant difference between the median of variables

Internet use for study purposes 0.001 Insufficient data to perform the test

0.563 <0.05 p value indicate a significant difference between the median of variables

Internet use for general purposes 0.673 Insufficient data to perform the test




What kind of media do you use? 0.52 0.146 0.221 >0.05 p value indicate no significant difference between the median of variables

Do you feel headache after your screen time?

0.264 0.08 0.041 >0.05 p value indicate no significant difference between the median of variables

Do you feel low after your screen time?

0.393 Insufficient data to perform the test

Insufficient data to perform

the test


Do you feel irritable after your screen time?


Do you have TV in your room? 0.462 Insufficient data to perform the test

Insufficient data to perform

the test


Do you take snacks during screen time?

0.552 Insufficient data to perform the test


Do you use earphones? 0.188 Insufficient data to perform the test


Have you been feeling any hearing issues recently?

0.16 No Insufficient data to perform

the test


In which posture do you usually use your phone or watch TV?

0.435 0.726 Insufficient data to perform

the test


Do you feel pain in your hands? 0.102 0.124 Insufficient data to perform

the test


Have you ever collided with someone while using your phone?


In table 4, we see that when bivariate analysis was performed, BMI z-score showed an inverse correlation with gender (p=0.018), while total study time (p=0.001), total sleep time (p=0.254), and low mood/ depression after screen time (p=0.574) showed a negative (direct)

correlation. When correlated, total screen time (p=0.108), kind of media used (p=0.298), physical activity (p=0.02), headache (p=0.004), and irritability (p=0.288) after screen time showed a direct correlation with gender.

Table 4: Correlation of BMI, total study and sleep time, media use, physical activity, headache, low feelings/ depression and irritable after screen time with gender.

Correlation coefficient p-value

BMI 0.523 0.018Study time -0.678 0.001Sleep time -0.268 0.254

Total screen time 0.37 0.108Physical activity 0.514 0.02

Kind of media used 0.245 0.298Headache 0.612 0.004

Depression -0.138 0.574Irritability 0.250 0.288



Considering self-rated physical activity (p=0.722) including reported days of physical activity (p=0.403) and other factors such as usual posture during screen time (p=0.435), consumption of snacks while watching TV (p=0.552), low mood/ depression after screen time (p=0.393), pain in hand (p=0.102), use of earphones (p=0.188) and hearing issues (p=0.16), insignificant results were obtained which were not affected by gender-based analysis. However, for all these variables, failure to perform the test on the gender with insufficient response data limited the efficiency of these analyses.

According to K-independent sample test, when the variables considered were correlated with the BMI z-scores, total screen time (p=0.068) and subcategories of time spent on playing video games or computer use (p=0.77) showed no association with children’s BMI z-score. Total study time (P=0.001) and self-rated Smartphone skills were statistically significant (p=0.001) whereas, children’s physical activity was not found to have any significant association with BMI z-score. Internet use for general and study purposes possessed significance (p=0.017) when compared with BMI z-score. We found that several dependent factors such as headache, feeling low after screen time, hearing problems and pain in hand after long use of media

did not show any statically significance with BMI z-score (p=0.206). A screen in the bedroom was positively associated with children’s total screen time (p=0.17) however, no association was found with BMI z-score. Parental limiting has a positive inverse association with child’s total screen time (p<0.05).

In order to assess the individual contribution of students from each grade of the school included in the study to the overall significant and insignificant results obtained, we further extended our K-independent sample test. (Table 5) summarizes the results obtained on a comparison of responses with the BMI z-scores of students from each class. We see that total study time and total sleep time both had insignificant association with BMI z-scores of all the children, however, least an insignificant correlation was found between total sleep time and BMI of students from class 7 (p=0.08). Similarly, insignificant results were obtained when total screen time, self-rated internet use and physical activity, kind of media used, internet use for general purposes, possession of TV in one’s room, consumption of snacks and use of earphones during screen time and the usual posture preferred during media use were compared with the BMI z-scores of children from each class.

Table 5: Comparison of variables with BMIs of children of each grade included in our population.Class 6

(24 students)

p-value

Class 7 (37 students)

p-value


p-value


p-value


p-value

Remarks

Total study time 0.528 0.308 0.639 0.586 0.732 Not significantTotal sleep time 0.795 0.081 0.653 0.79 0.480 Not significant

Total media / screen time 0.081 0.791 0.159 0.406 0.096 Not significantSelf-rated internet use 0.231 0.676 0.959 0.085 0.324 Not significant

Self-rated smartphone skills 0.028 0.166 0.095 0.460 0.092 Significant association found

with BMI of children of 6th grade

onlyReported days of physical

activities 0.139 0.010 0.199 0.918 0.307 Significant

association found with BMI of

children of 7th grade only

How physical active are you? 0.228 0.814 0.913 Insufficient data to perform the

test

Insufficient data to perform the

test

Not significant

Internet use for study purposes

0.577 0.032 0.740 0.087 0.592 Significant association found


onlyInternet use for general

purposes0.494 0.162 0.636 0.166 0.577 Not significant



What kind of media you use? 0.325 0.142 0.425 0.73 0.221 Not significantDo you feel headache after

your screen time? 0.426 0.013 0.268 0.342 0.029 Significant

association found with BMI of

children of 7th and 10thgrade

Do you feel irritable after your screen time?



onlyDo you have TV in your

room? 0.248 Insufficient

data to perform the test

0.521 0.55 Insufficient data to perform the

test

Not significant

Do you take snacks during screen time?

0.095 0.433 0.357 0.875 0.100 Not significant

Do you use earphones? 0.744 0.615 0.357 0.839 0.507 Not significantHave you been feeling any

hearing issue recently? Insufficient data to

perform the test0.499 Insufficient

data to perform the

test


test


test

No Significant association found


onlyIn which posture do you

usually use your phone or watch TV?

0.655 1.00 0.293 0.805 0.541 Not significant

Have you ever collided with someone while using your

phone?


with BMI of children of 6th and

7th grade only

Self-rated Smartphone skills were found to have a significant association with BMI z-scores of students from class 6 (p=0.028) and insignificant association with the rest. Similarly, reported days of physical activity was found to be significantly correlated with BMI z-scores of class 7 students only (p=0.010) with the most the insignificant association was seen in class 9 students (P=0.918) and a major drop seen in class 10 students (p=0.307). A significant association of internet use for study purposes was found with BMI z-scores of class 7 students (p=0.032), the nearest insignificant value being that obtained with students of grade 9 (p=0.087). Regarding the hearing issue, responses of class 7 students could only be analyzed (p=0.499) due to lack of data from students of other classes. When asked if one collides with someone during mobile phone use, statistically significant results were achieved for the students of class 6 (p=0.039) and class 7 (p=0.034) only.

Discussion

The primary findings of our study were related to the effects that screen time has on the children. In this regard, multiple aspects of the child’s daily life were considered which when compared with the screen use, gave important results. Our study shows that mobile phones or tablets are gadgets that contribute to the greatest part of

a child’s screen time. This could be explained by the fact that mobile phones are one of the handheld technologies that in addition to being an important communication tool provide quicker and easier access to entertainment media. We found that the media use, be it for general or study purposes, was associated with physical inactivity. This may be due to another finding of our study, which showed that children preferred lying on their backs or sitting upright when using media and this sedentary approach if prolonged reduces the duration of individual’s physical activity. Thus, the amount of time that should ideally be dedicated to exercises and fitness is now diverted to sedentary screen use. This association was also reported in a study on Spanish adolescents (15), however, a bunch of other studies provides contradicting results [16] [17]. These studies argue that the physical inactivity may be due to the time spent in other sedentary pursuits and not necessarily media use [18]. We also found that children preferred snacking during screen time. This raises major health concerns as screen time snacking usually consists of unhealthy food items which when consumed at odd times of the day, alters individual’s normal dietary habits [19]. This together with the physical inactivity seen with the prolonged media use can be a potential risk for obesity and the development of metabolic syndrome in the young [20]. In addition to physical well-being, considering the adverse effects of screen use on



one’s mental health, we found that headache, irritability, and depression were experienced by many. Our study outcomes consolidate the results from previous studies. It has been reported that high levels of screen exposure increase the risk of migraine headaches in young adults [21]. Similarly, evidence supports screen time as a cause of depression that can be severe enough to lead to suicide [22].

An interesting part of our study was to record the concerns and attitudes of parents towards their child’s screen time. Parents agreed that increasing hours of media use shows adverse effects on their child’s sleep schedule and physical and mental health. Thus, they adopted strategies to limit their child’s total screen time, one of which was diverting their child’s attention towards other, albeit healthier tasks. The efficacy of the parental limitations on a child’s screen time was assessed in a previous pilot study where parents were trained for skills that could help them decrease their child’s screen time. On implementation, parents could successfully achieve screen time goals and thus, were satisfied with the intervention [23].

On comparison of outcomes with independent factors of an individual’s time duration of media use, gender and BMI z-score, interesting results were obtained. We found that total sleep time was significantly affected by the hours of media use. This association can be consolidated by a systematic literature review which reports screen time as the cause of altered sleep habits (shortened duration or delayed bedtime) [24]. In addition to this, depression is a serious side effect of screen time was also found to have a significant correlation with the duration of media use. An increase in screen time with an associated decrease in non-screen activities was shown to have possibly given rise to depression and suicide [22]. These associations were further supported by direct linear correlations obtained with the bivariate analysis which also reported a direct relationship of screen time with headache consistent with a previous study [21].

Fewer outcomes were found to be affected significantly by the individual’s gender and the BMI z-score recorded, however, greater trends towards insignificance were seen. In this regard, total study time, self-rated Smartphone skills and the internet use for study purposes were significantly impacted by the gender of the individual, however, other associations showed insignificant trends. Our results show consistency with the outcomes of a study which revealed gender-based variations in the use of web applications [25]. It was seen that males, in contrast to females, dedicated internet use to multiple purposes, with information gathering being one. However, females used it mainly for communication [25]. Even with an insignificant overall association, gender differences seemed to have an impact on the outcomes. This may be due to the fact that males and females play different societal roles which could possibly affect their individual screen time. Consequently, outcomes concerning the effects of

screen time are bound to vary between the two groups. Males rated themselves more skilled than females when the use of Smart phones was considered and was found to dedicate a comparatively greater amount of time to internet use whereas females were more likely to get irritated by screen time. Consistencies with the study that reported greater self-rated technology skills in males can be seen [26]. Internet use, be it general or for study purposes showed a significant association with BMI z-score. This is consistent with the results of a study that highlight greater rates of internet addiction in obese individuals in contrast to their healthy peers, indicating a relationship between extensive internet use or addiction and BMI [27]. A similar significant association was seen on the comparison of total study time and self-rated Smartphone skills with BMI z-score, whereas, to our surprise, the rest of the outcomes showed associations rendered insignificant.

Since this the study includes children from only one private school in Karachi, similar studies should be conducted in other schools of Karachi and of Pakistan, be it private or public-sector schools. In this regard, students from multiple socioeconomic backgrounds and academic statuses should be encountered to compare and contrast the screen time effects in various populations. Future studies should consider the population sample size larger enough to yield efficient results. The lack of parental data seen in our study can be taken care of in future studies by interacting with them directly. A clear explanation of the study type and goals could possibly motivate them to participate and provide the data. Fewer than the minimally required responses from a certain gender or from students of a certain class led to the failure to analyze them. Thus the primary goal behind the gender-based analysis i.e. to find differences of outcomes between males and females, and the class-based analysis i.e. to compare responses from students of each grade could not be achieved. Once sufficient data from Pakistan and other Eastern countries are obtained, a comparison of outcomes between East and West can be made. Due to mean differences in socioeconomic statuses and academic environments, variations in the access and limitations to media use, the total screen time is bound to differ between students from the two groups with otherwise similar characteristics. Thus, an assessment of the effects of screen time on outcomes in a large-scale setup, interesting correlations could be derived. Further studies considering outcomes in children who do not own a screen or have a hard time gaining access to one of such devices, and face serious restrictions on media use by the adults in the family, could add to our knowledge in this regard.

Our study has certain limitations. Since we specifically recruited a small number of students from a single school of Karachi, accurate incidence data for screen time together with its effects on children from various cultural and social backgrounds with different socioeconomic and academic statuses could not be achieved. Similarly, children with none or limited access to screens were not a part of this study and



so the associations of outcomes with screen time in this population could not be assessed. The questionnaire for parents was also given to the children who had the responsibility to deliver and get it filled by them. Considering this second part of our study on the attitudes and concerns of parents for their child’s total screen time and health statuses, a meager amount of responses was obtained. This could possibly be due to the fact that their children were unable to lay enough emphasis on the importance of this study who themselves participated for the excitement to know their current height and weight. Even with the amount of parental data obtained, the restrictions on screen time due to concerns about the child’s health were assessed; however, limitations due to expenses from an extended internet use were not. Unequal and unchecked responses of each gender from each grade led to disproportionate population distribution and reduced efficiency of the results based on the comparison of outcomes between population groups. Nonetheless, to our knowledge, this study is the first to provide valuable information about screen time and its effects on mental and physical well-being in Pakistan.

Conclusions

This study aimed at assessing the effects of increasing screen time on an individual’s mental and physical well-being, and it was evident from the results that the screen time had direct correlations with the child’s adverse mental and physical health. Statistically significant correlations between students’ responses and their BMI z-scores were recorded, whereas, the association with gender showed insignificant trends. Increasing screen time is a growing public health problem which necessitates prompt and appropriate interventions designed to efficiently limit the hours of media use. Parents should be trained at the hands-on sessions for skill sets focused on clinically effective ways of monitoring and restricting the use of media in children. In addition to this, newer interventions should be devised and trialed for their efficacy as an alternative, when the strategies primarily implemented fail to report outcomes. Awareness sessions for children regarding the adverse associations of screen time continue to be an effective conservative strategy in solving this problem. These efforts should be continued and further extended to achieve results at the population level. Furthermore, a team of pediatric and public health researchers and practitioners is needed for a detailed discussion and guidance on how to go about the solutions to the problem of extended screen use.

Future Recommendation

This study elaborate the relation of screen time with behavior changes, physical activity and mental health but much screen time is also associated with future cardio-metabolic risk factors, psychological wellbeing, and poor academic performance among children. Despite a good environment outside children spend their more time in front of

TV which make them indolent and annoyed person. It is recommended to held multiple awareness section for parents regarding screen time usage to improve overall physical activity among children, as well as children’s environmental and social knowledge and competence, feelings of self-worth, efficacy and resilience, and reductions in anxiety [28]. Further research is needed to evaluate more risk factor associated with screen time that can put child life at an alarming stage.

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