Screen time and its correlates among children aged 3–10 years during COVID-19 pandemic in Nepal: a community-based cross-sectional study

Study design and study population

This is a community-based descriptive cross-sectional study done among schoolchildren aged 3–10 years in Bhaktapur district in Nepal during March 2021. This was just before the COVID-19 second wave in Nepal, as during the intervening period, children mostly had physical classes in school.16 The minimum sample size was 606, calculated using the formula: n=((z² p(1−p))/e²)×design effect, where z=1.96 at the 95% confidence level, p=0.5 (the estimated prevalence of high screen time among schoolchildren is taken as 50%, as these data are not yet available for Nepal), e (allowable error)=0.05, design effect=1.5 and adding a 5% non-response rate. We selected household children by applying a multistage sampling technique. Two out of four municipalities (Changunarayan and Suryabinayak Municipality) of the Bhaktapur district were randomly selected in the first stage. Then, 144 wards from the 2011 census (available smallest population unit) were taken as a cluster and formed the sampling frame for the study. The required clusters were obtained by dividing the sample size (606 household children) by 30 (cluster size), 20.2~21 clusters. Thus, 630 (21 clusters×30 samples) were the samples included in this study. All clusters (wards) from selected municipalities were included in the sampling frame. Twenty-one clusters (wards) were determined by systematic random sampling from the sampling frame. Then, 30 household children were selected consecutively for the interview, and children from 3 to 10 years were enrolled as study participants. The enumerators visited two more times those households where responding parents were absent or busy during an initial visit for data collection. Regarding child selection, if there were more than one eligible child, we selected the younger child as a study participant.

Data collection, data entry and statistical analysis

Face-to-face interviews with parents of eligible schoolchildren as the proxy respondent were conducted through household visits. The tool used included sociodemographic variables, access to screen devices, screen time-related variables, strategy to reduce screen time and variables related to its perceived negative impact. The tool was developed according to the study’s objective through an extensive literature review involving ophthalmologists, optometrists and public health researchers, and pretested in a small sample of same-age children at Madhyapur Thimi municipality. Enumerators were trained on the study tool to increase the reliability and repeatability and used the same tool by all enumerators for data collection.

The average screen time of more than 1 hour for children up to 4 years and more than 2 hours for children from 5 to 10 years was considered high screen time.17 18 Socioeconomic status of households was estimated using modified Kuppuswamy’s socioeconomic scale for Nepal.19 Perceived change in children’s vision and amount of food eaten during the pandemic were assessed through a structured questionnaire.

Data were entered in EpiData V.3.1 data entry format provided with checks to avoid errors in data entry. Data were cleaned, categorised and analysed using SPSS V.26.0. The data were presented in mean, median, SD, frequency and percentage, and shown in tables. A χ² test with Bonferroni correction was done to find the association between independent and dependent categorical variables. Wilcoxon signed-rank test was applied in non-normal continuous variables. To determine the correlates, a two-step modelling approach was undertaken. First, a bivariate logistic regression analysis of each explanatory variable and outcome variable was conducted to identify the associations. Second, those variables with p values of <0.1 were included in a multivariate logistic regression analysis to determine the effect adjusted for each potential explanatory variable. Following Bonferroni correction, a p value of <0.002 denoted statistical significance in the final model obtained by dividing 0.05 by the number of variables included in the model (n=18).

Patient and public involvement

Patients or the public were not involved in this research’s design, conduct or reporting.

Change in participants’ behaviour due to COVID-19 pandemic

The mean daily screen time was increased in both gender and age groups. A male child had more screen time than a female child, and regardless of gender, mean daily screen time was higher in the 5–10 years old group than in the lower age groups (figure 1).

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The median screen time of the participants before the pandemic was 1.0 and increased to 2.2 hours during the pandemic. Mean rank screen time before and during the COVID-19 pandemic was 116.6 and 275.8, significantly different (p<0.001). The difference in sleeping and playing time was also considerably different, with a p value of <0.001. The median playing time (excluding the playing using a screen device) decreased during the pandemic compared with before (2 hours vs 1 hour a day) (online supplemental table 1).

The prevalence of high screen time among all participants was 55.2% (95% CI=51.3% to 59.1%), where the prevalence was higher in male (61.8%, 95% CI=58.0% to 65.6%) than female participants (48.6%, 95% CI=44.7% to 52.5%). Among sociodemographic correlates, gender, school type and school level were significantly associated with high screen time. Regarding the children’s access to screen devices, high screen time was significantly associated with access to all types of screen devices except for video game consoles (table 2).

Perceived children’s vision problems due to COVID-19 pandemic

Nearly 3% of caretakers and parents perceived that their children’s vision worsened due to increased screen time during the COVID-19 pandemic. About 9 out of 10 parents reported no change in their children’s eating behaviour during and before the pandemic, as shown in online supplemental table 2.

Parental knowledge, perception, control and strategies employed for reducing children’s high screen time and adverse health effects

More than four in five parents knew about their children’s daily allowable screen time. Regarding the effects of high screen time on children’s health, 97.5% (n=614) said it could cause negative effects. The most common perceived effect was eye problems, followed by sleep disorders (table 3). More than 6 in 10 parents also perceived that high screen time affects their child’s studies.

Scolding the children was the most used strategy by more than 6 of 10 parents to reduce high screen time, whereas 3.0% used the parental screen control smartphone application (table 4). About 9 in 10 parents had not consulted for eye health services to reduce the effect of high screen time on their children’s eye health.

Correlates of high screen time

Participants from private schools were two times (adjusted OR (AOR)=2.4, 95% CI=1.5 to 3.9, p<0.001) more likely to have high screen time than those from public schools. Participants who had a smartphone were about seven times (AOR=6.9, 95% CI=1.5 to 31.3, p=0.013) more likely to have high screen time than those who had no smartphones. Participants who used screen devices for playing games were two times (AOR=2.5, 95% CI=1.3 to 4.9, p=0.008) more likely to have high screen time than those not playing games. Participants whose parents perceived vision problems as the effect of increased screen time were about eight times (AOR=7.8, 95% CI=1.6 to 38.1, p=0.011) more likely to have high screen time than those who did not perceive it to be. Participants whose parents turned off Wi-Fi to curb screen time were, in fact, three times more likely to land up in more screen time (AOR=3.5, 95% CI=0.8 to 15.2, p=0.093), though not statistically significant (table 4). The model was fit (p=0.285) and could explain a 42.0% association of increased screen time with the correlates (Nagelkerke R²=0.420).

Correlates of high screen time among children

Older boys, children of higher socioeconomic groups and those studying in private schools with longer hours of online courses correlated with higher screen time. The screen time increased as age increased, consistent with other literature findings.20–22 29 The screen devices were used mainly for gaming purposes, which may be one of the reasons why boys are using screen devices. This might be because boys have greater freedom in our part of the world. In contrast, children in the USA used screen devices for educational use, and girls’ screen time increased more than boys.30 Since the start of the pandemic, online classes have significantly increased; about 27.9% of students use screen devices for online classes; thus, this may be one reason why senior children use screen devices for more extended periods than junior ones due to more classes. Other important factors could be the knowledge and skill that could be developed through digital media and the internet among children, although we did not explore these factors in this study.29 Children from the family having higher socioeconomic status, having their digital devices and studying in private schools have a higher prevalence of high screen time. In this study, the availability of television, smartphones and laptops increased the chances of increased screen time by more than fourfold to eightfold. Access to media devices at home appeared to determine mobile screen use.29 In this study, 20.5% of parents do not use screen devices in the presence of their children, although it does not have positive associations with low screen time, as seen in other studies.31 32

COVID-19 pandemic and high screen time

This study shows that screen time during this pandemic has doubled more than before the start of the pandemic. As supported by other literature findings, the reciprocal effect was seen in playing time, which also decreased by half during the pandemic.22 This study does not find any difference in sleeping time, though different literature findings showed children were late in bedtime and wake-up time, and total sleeping time also increased.22 33 Children spent less time on physical activity and more time on screen devices during confinement than before the pandemic. Similarly, a study in Chile found an increase in sleeping time by 1.4 hours per day though sleep quality declined (−0.75 hour/day).22 The increase in screen time has also increased the adverse effects among children’s health. Eye problems, impaired study performance and loneliness were the few negative effects parents perceived of long screen time. Parents think that visual impairment has increased due to increased screen time even though less than 1% of children got their eyes checked regularly or 6 monthly. Although we did not measure the refractive error status of the children in this study, a study was done in China that suspected a possible increase in myopia due to screen time of >2 hours. Before COVID-19, high screen time contributed to adverse cognitive and executive function and behaviour outcomes at ages 6–7 years in children born at less than 28 weeks.24 26 Other potential health issues increased during and 3 months before the pandemic, such as obesity, cardiovascular diseases and mental health issues.26

Parents’ strategies to reduce high screen time among their children

Although 83.3% of parents knew they should limit their children’s screen time, this knowledge did not help reduce their children’s screen time. Most parents have used scolding as a strategy for discouraging their children to use screen devices for a long time. Parents may use this common strategy in most low/middle-income countries. Another strategy used by parents was encouraging their children to play or spending more time with their children; it was a much more desirable approach. At the same time, a minority used a parental control application on smartphones and turned off Wi-Fi frequently to limit screen time. Although different strategies are used, none seem beneficial in reducing screen time. Parental control applications used on smartphones are counterintuitive as they increased high screen time by about ninefold. Children feel happy to spend more time with their parents to take them away from screen exposure, as giving a reward works better than punishment in children’s behaviour. Therefore, interventions for parental education seem to be as important as counselling the students.

Formulating the guidelines for screen exposure

Most global studies on high screen time focus on children less than 5 years, although screen time was very high in higher-aged children. This may be due to the availability of clear guidelines from the WHO.17 The literature regarding allowable screen time for children above 5 years is not available except for few country-specific guidelines.17 18 Global and national guidelines for children of all ages, including strategies to decrease screen time and halt the adverse health effects of high screen time, should be developed and implemented to tackle this emerging public health problem.

Conclusion

During the COVID-19 pandemic, one in two schoolchildren aged 3–10 years in Bhaktapur district had higher screen time than allowable for their age who used smartphones to play games. Types of school and having digital screen devices correlated with increased screen time among the children. No strategy used by parents seemed to work to control the high screen time of their children. Children-focused interventions should be explored to reduce high screen time and tested through an intervention study. Conducting awareness programmes through stakeholders’ engagement in mitigating negative health impacts is also recommended.