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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1115-1125

Screen viewing practices and caregivers' knowledge of the health-related effects in children and adolescents in a Nigerian Urban City


1 Department of Paediatrics, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
2 Department of Medical Biochemistry, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria

Date of Submission29-Jul-2021
Date of Acceptance17-May-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. J N Eze
Department of Paediatrics, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital, Ituku- Ozalla, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1706_21

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   Abstract 


Background: Globally, a dramatic increase in the use of television and digital media has been observed among children and adolescents in recent times. The possible health-related effects of frequent and prolonged screen media viewing on these children and adolescents have triggered many concerns among researchers. Aim: The study is aimed to determine the screen media viewing practices and caregivers' level of knowledge about the health-related effects of prolonged screen viewing time on their children. This was a descriptive cross-sectional study among caregiver/child and adolescent dyads on outpatient clinic visits. Subjects and Methods: Respondents (caregivers/children's pairs) were consecutively recruited, and data was obtained using an unambiguous pre-tested semi-structured questionnaire comprising four domains: socio demographic characteristics; screen media viewing characteristics, perception of the health related effects of prolonged viewing time, and measures to limit prolonged screen viewing time in children. Descriptive and inferential statistics were done using Statistical Package for Social Sciences (SPSS) version 22.0 at a level of statistical significance P < 0.05. Results: Of the 205 respondents studied, the majority (67.8%, fathers and 76.1%, mothers) had tertiary education. The daily mean time spent by children watching television/screen media was 2 (± 1.58) hours. Up to 89.3% of the caregivers established good standards for healthy screen-viewing in their homes. However, 52.7% of them had poor knowledge of the health-related problems of increased viewing time. Socio-economic class (P = 0.002) and knowledge level of the parents (P = 0.000) were significant predictors limiting children's screen-viewing time. Conclusion: Increasing screen media viewing is common among the children studied. The majority of the caregivers had poor knowledge of health-related effects of prolonged viewing time despite high educational attainment. There is a need to enlighten caregivers on the possible health effects of excess screen media viewing so as to enable them to institute stringent measures to limit the attendant health consequences on the children.

Keywords: Children, health-related effects, screen media viewing time


How to cite this article:
Ikefuna A N, Uwaezuoke N A, Eze J N, Eke A L, Eke C B. Screen viewing practices and caregivers' knowledge of the health-related effects in children and adolescents in a Nigerian Urban City. Niger J Clin Pract 2022;25:1115-25

How to cite this URL:
Ikefuna A N, Uwaezuoke N A, Eze J N, Eke A L, Eke C B. Screen viewing practices and caregivers' knowledge of the health-related effects in children and adolescents in a Nigerian Urban City. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 8];25:1115-25. Available from: https://www.njcponline.com/text.asp?2022/25/7/1115/351457




   Introduction Top


A dramatic increase in the use of television (TV) and digital media has been observed among children and adolescents in recent years globally. The innovations introduced in the television scriptwriting and production of various television programs both in high and low-middle-income countries have led to children and adolescents' addiction to television and other screen media viewing. The emergence of social media platforms has worsened matters by increasing their quest to maintain social interaction with peers through this medium. This has brought about over-dependence on screen media devices, including smartphones, tablets, television, video games, computers, or wearable technology in their daily activities. Studies have reported increased viewing hours and less indulgence in physical activities in children and adolescents,[1],[2],[3] contrary to the World Health Organization's (WHO) recommendation. The World Health Organization recommends that children and youth aged 5–17 years old accumulate at least 60 minutes of moderate to vigorous-intensity of physical activity daily.[4]

The possible immediate and long-term health-related effects of increased television and video-game viewing on children and adolescents, as observed in various studies, have triggered many concerns among researchers.[1],[2],[3] Complexity in the grading of the duration of the exposure and other factors such as socio-economic status,[2],[5],[6] family structure,[7] parenting practices,[3],[8],[9] and mother's mental health,[6] have influenced outcomes of these studies on the topic.

Daily screen media viewing in excess of two hours has been associated with reduced physical and psychosocial health in children and adolescents.[7],[10] The negative effects on the child's healthy development include weight status, sexual initiation, aggressive feelings and beliefs, consumerism and social isolation, and poor academic performance.[11] Computer use, TV viewing, and the presence of media in children's bedrooms reduce sleep duration and delay bedtimes in children during school days as well as weekends.[12] Also, exposure to media violence has been positively related to imbibed subsequent aggressive behavior, ideas, arousal, and anger among these children. This is particularly important for very young children who developmentally think concretely and are unable to distinguish fantasy from reality, particularly when it is presented as “real life”.[11]

Lower frequency of family meals, presence of a TV in the bedroom, absence of rules guiding TV and other electronic media viewings in homes, and less physical activity were associated with more than two hours per day of screen time.[7] Restrictive screen-viewing parenting practices were also associated with greater child sedentary time and less moderate-to-vigorous physical activity.[3] Children and adolescents' sedentary behaviors defined as low-energy expenditure ≤1.5 Metabolic Equivalent of Tasks (MET) with little physical movements such as sitting, watching TV, and playing video games,[10] are shown to continue into adulthood. Sedentary time spent during childhood is associated with several health consequences as adults.[2],[13],[14],[15],[16],[17] The long-term consequences of excess viewing of media devices include overweight and obesity;[14],[15],[17] elevated blood pressure and lipid levels;[18] as well as neuropsychological disorders such as anxiety, aggression, and depression.[2],[16]

Evidence from available literature suggests that decreasing any form of sedentary electronic device-viewing-time is associated with reductions in body mass index and lower health risk in children and adolescents.[10] The age of 10–11 years is considered to be a key transition phase from a prevention perspective, and good opportunities for future health may be established among children growing into adolescence. A decrease in both maternal and paternal regulation at the age of 11 years significantly predicted more TV and digital video disc (DVD) exposure time or duration among adolescents at the age of 13 years.[8]

Currently, about three-quarters of teenagers own smartphones, which allows them easy access to the internet, streaming TV/videos, and other interactive applications.[18] Studies on sedentary behaviors of children and adolescents and parental practices in our environment in this computer age are limited. It has been recommended that pediatricians could work with families and schools to promote the understanding of risks as well as benefits of electronic screen use on child health and development.[18] Hence, the index study which is aimed at evaluating the screen media-viewing practices and its health-related effects on children and adolescents in Enugu, Nigeria becomes imperative.


   Methods Top


Study location

This cross-sectional study was conducted at the children's outpatients (CHOP) clinics of a tertiary hospital, Enugu State, Southeast Nigeria, between January 15 to February 28, 2020. The hospital is a five hundred-bed reference federal tertiary health facility in Enugu state. The hospital is a referral center for the neighboring southeastern states of Nigeria, including Abia, Anambra, Ebonyi, and Imo states of Nigeria, as well as the north-central geopolitical states of Benue and Kogi, and sometimes parts of southern Cameroon.

The CHOP renders primary, secondary, and tertiary healthcare services to children seen in the general outpatient clinics. It is the first port of call for new patients, except emergency cases, which usually are initially reviewed at the Children's Emergency Room or the Newborn Special Care unit, depending on the age of the child. There is a pharmacy and medical records unit currently undergoing processes for digitalized services attached to the CHOP.

The clinic runs daily with at least four supervising consultants overseeing the services provided each day and at least four trainee (two senior and two junior) residents in attendance. There are about nine nurses on rotation per week; among them are two certified pediatric nurses. Also, two pharmacists and two pharmacy technicians, four medical records officers, one dietician, one public health nurse visitor/counselor, and two other support staff (orderlies) work on weekdays in the CHOP unit.

Study design

This was a descriptive cross-sectional survey among parents/caregivers of children and adolescents attending the Children's outpatient clinics of the hospital.

Study population

All children and adolescents who presented to the Children's outpatients clinics whose parents/caregivers consented to the study were recruited and served as the respondents.

Patients' selection

About 50 children and their parents/caregivers respectively attended the CHOP on each clinic day. All caregivers/parents of children attending the pediatric clinics during the period of the study who consented to the study were recruited and served as respondents. Respondents (parents/caregivers) were selected consecutively from the pediatric outpatient clinics and specialist clinics of the hospital as they presented.

Study questionnaire

Information was obtained from consenting respondents using an unambiguous pre-tested semi-structured interviewer-administered questionnaire. The questionnaire was a collective modification of the tools which had been previously validated and used in similar studies by Oyero et al.,[19] Nagwa et al.,[20] and O'Connor et al.[21] among children and adolescent populations. The questionnaire was administered to the accompanying parent/caregiver, and was pre-tested prior to commencement of the study. Five respondents were used for the pre-test of the study questionnaire, and these respondents were subsequently excluded from the actual study.

The study questionnaire has four subsections as follows

  1. The socio-demographic characteristics, including the biodata of the child, position of the child in the family, parent/s, their educational attainments, and present occupations of parents/caregivers from where the respective social class was subsequently determined using the criteria proposed by Oyedeji.[22] Scores were awarded to each child based on the occupation and highest educational attainment of both parents. Scores of 1 and 2 were grouped as the upper class; a score of 3: middle social class, while scores of 4 and 5 were considered as the lower socio-economic class.
  2. Screen media viewing characteristics: number of days of use of screen media per child per week; how much time (in hours) on the average is spent on the screen each day; age at first exposure to screen media; the length of time that the screen media is on in a given day per household; number of infants pre-recorded children's programs (DVDs, videos, universal serial bus (USB), memory card); the screen media viewing time of the parents per household; type/number of screen viewing media per household; presence of other screen viewing media in the household; presence of TV or other electronic viewing media available in the children's sleeping room.
  3. Caregivers' knowledge of the health-related problems associated with increased TV/screen media viewing time: reduced life expectancy, increased risk of cardiovascular diseases, negative effects on verbal intelligence quotient, the likelihood of anti-social behavior (criminal behavior/aggressiveness), association with excessive weight gain/obesity, impaired neurocognitive development, attempts at mimicking stunts (risk-taking behavior), associated sleep disturbances. Caregivers' level of knowledge was categorized as 'Good' if the caregiver scored 4 or more points out of a total of 8 points on the knowledge domain; and 'Poor' if the caregiver scored less than 4 out of the 8 points.
  4. Measures to limit prolonged or regulate screen media viewing time in children: regulation/decrease in child's screen time; child's reward (positive reinforcement) for adherence to the screen media view time reduction plan; encouragement of outdoor and sporting activities; taking off the screen media from the children's bedrooms; setting good examples on healthy screen media viewing time by the caregiver/parent; as well as the provision of learning alternatives/kits for the children.


Pilot study: A pilot study to ascertain the clarity of the questionnaire was done on 15 subjects/caregivers who were not enrolled in the study.

Ethical approval

Ethical approval for the study was obtained from the Health Research and Ethics Committee of the hospital.

Written informed consent was obtained from each parent/caregiver prior to their selection for the study and subsequent administration of the protocol.

Data analysis

Data obtained were recorded and analyzed using the Statistical Package for Social Sciences (SPSS) version 22.0 (IBM Corp. Armonk, NY, USA). The Kolmogorov-Smirnov test was used to determine the normality of variables. Variables such as the number of televisions in the household, screen viewing time, duration during which the TV was on in the household on a typical day, and the screen media viewing time of the parents per household assumed the Gaussian distribution and were expressed as mean ± standard deviation (SD). Variables such as age at which child was exposed to TV; and the number of infants pre recorded children's program (DVDs, videos/USB/ memory card etc.) in each household assumed the non Gaussian distribution and were reported as median (interquartile range (IQR)). Descriptive statistics were presented in the form of frequency, charts, and percentages. The association between socio-demographic variables and caregivers' level of knowledge about the health-related effects of screen viewing was tested using Chi-square. Further statistics, including Cramer's and multi-variate regression, were applied to determine variables that were truly statistically significant as determinants of control measures adopted by caregivers to limit screen media viewing time. The level of statistical significance was set at P < 0.05.


   Results Top


Participants' basic characteristics

Two hundred and eight respondents (participant/caregiver pair) were recruited for the study; three of them voluntarily withdrew from the study before the completion of their respective questionnaires, giving an overall response of 98.6%. Data from the remaining 205 respondents were analyzed; 110 (53.7%) of the children were females; the male: female ratio was 0.9:1. The majority, (66.8%) of the children were between 5 and 18 years; 41% were in primary school, and 126 (61.5%) belonged to the high socio-economic class; [Table 1].
Table 1: Socio-demographic characteristics of children and caregivers

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Caregivers' basic characteristics

One hundred and forty-three (69.8%) of the children had their mothers as caregivers. Only a few (18) (8.8%) were accompanied by their guardian, and the rest by their father. A greater proportion of the caregivers (40.0%) were between the ages of 31 and 40 years, as shown in [Table 1]. In all, 139 (67.8%) of the fathers and 156 of the mothers (76.1%) had tertiary education. Fathers were mostly self-employed, (91) (44.4%), while a greater proportion of the mothers (90) (43.9%), were government employees.

Participation in television viewing and video game

About 86% of the children have watched TV or played video games within the past seven days. The mean (SD) number of times children watched TV in the last seven days was 4.75 (2.28) times. The mean (SD) screen time was about 2 (1.58) hours; range of 30 minutes–10 hours; [Table 2].
Table 2: Mean and standard deviation of some factors in TV/screen media exposure and practices

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The children started watching TV or other screen media at a median (IQR) age of 1 year; ranging from 9 months to three years. However, some caregivers exposed their children to screen media at infancy, and a few others only allowed the child to start watching TV/video games when the child was 12 years old. The mean (SD) duration during which the TV was on in the household on a typical day was about 5.08 (2.67) hours. Parents spent about 3.16 (1.6) hours per day watching TV/or other screen media.

Eighty-two (40.0%) of the respondents had only one television in their household; only 2.4% of them had five or more televisions in their households. The median (IQR) number of infant pre-recorded children's programs (DVDs, videos/USB/memory card, etc.) owned was 8.5; ranging from 3 to 20.

The majority (146) (71.2%) of the caregivers had television/screen media viewing regulations in their families, while only 66 (32.2%) had regulations for television in the children's room.

Respondent's knowledge of the health-related problems associated with excess screen media viewing

[Figure 1] shows the knowledge of respondents on the health-related problems of increased viewing time. One hundred and seventy-four (84.9%) of them know that children attempt to mimic stunts seen on television/screen media, exposing them to risky behaviors. Similarly, 143 (69.8%) of the respondents know that excessive screen media viewing time may cause sleep problems in children. Only 27 (13.2%) and 35 (17.1%) of the respondents, respectively know that increased viewing time could increase the risk of cardiovascular diseases and reduced life expectancy. Also, 49 (23.9%) respondents know that television/other screen media viewing in early childhood may affect brain development (impaired neurocognitive development).
Figure 1: Knowledge of health-related problems of increased screen media viewing time

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The overall knowledge scores indicating the level of the knowledge of health-related problems associated with increased viewing time among these caregivers show that more than half (108) (52.7%) have poor knowledge, while the remaining 97 (47.3%) have good knowledge.

Measures to regulate/control screen media viewing time

The measures put in place at home in order to control screen media viewing time show that across the various measures, 183 (89.3%) of the respondents set good examples of healthy screen media viewing for the children; and 168 (82.0%) limit child's screen time and also encourage outdoor and sporting activities for children as measures to control. The least control measure that caregivers subscribed to was child reward (positive reinforcement) for adherence to screen media reduction plans and taking away TV from children's rooms; [Figure 2].
Figure 2: Measures to control screen media viewing time

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Relationship between the knowledge scores of the respondents on health-related problems of increased viewing time and the actual ages of the children and their caregivers

There is a significant relationship between the knowledge scores of the respondents on the health-related problems associated with increased viewing time and the actual ages of the children (r = 0.244, P = 0.001). The respondents with older children aged ten years and above tended to have more knowledge of health-related problems of increased viewing time at a rate of 24.4%. In the same vein, the ages of the caregivers had a significant direct relationship with the knowledge of health-related problems of increased viewing time (r = 0.163; P = 0.035). Older caregivers more than 50 years old had more knowledge of health-related problems of increased viewing time at a rate of 16.3%; [Table 3].
Table 3: Correlation between Socio-demographic variables and knowledge scores on health-related

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Relationship between socio-economic class of the respondents and their knowledge of health-related problems of increased viewing time

The socio-economic class of the respondents did not show any significant relationship with their knowledge of health-related problems of increased viewing time (r = -0.013 and P = 0.855). There was no significant association between the level of knowledge and socio-economic classes (P = 0.084); though the Cramer's V-value was 0.180, implying an 18.0% extent of association. This is evident from the percentage distribution where the majority of those with poor knowledge (57.4%) as well as those with good knowledge (66.0%) levels were in the high socio-economic class [Table 4].
Table 4: Association between the caregivers' level of knowledge and socio-economic class

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There was also no significant association between th efather's highest educational level and the knowledge level of health-related problems of increased viewing time (P = 0.566). The Cramer's V-value (0.106) shows a 10.6% extent of association. For the mother's highest educational level there was a 14.6% extent of association with the knowledge level of health-related problems of increased viewing time, though not significant (P > 0.05). This implies that both parents' educational levels did not show any significant association with their knowledge levels of health-related problems of increased viewing time.

Association between the measures to control excessive viewing time and the knowledge levels of health-related problems of increased viewing time

The test of association between the measures to control excessive viewing time and the knowledge levels of health-related problems of increased viewing time is presented in [Table 5].
Table 5: Test of association between Knowledge level and control measures

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The majority (168) (82.0%) of caregivers subscribed to the option of limiting the child's screen time by ensuring that the TV/Video games were on only at times acceptable to them. Overall, 85/97 (87.6%) of those who had good knowledge compared to 83/108 (76. 9%) of those with poor knowledge of health-related effects of increased screen media subscribed to limiting their children's viewing time. Similarly, 163 (79.5%) of caregivers provided learning alternatives to screen media viewing for their children. The proportion of those with good knowledge (82.5%) was comparable to those with poor knowledge (76.9%) with respect to providing alternatives to media viewing. Limiting the child's screen time as well as provision of learning alternatives to TV/video/computer/internet were found not to have any significant association with knowledge levels of health-related problems of increased viewing time (P > 0.05). On the other hand, 148 (72.2%) caregivers will institute child reward (positive reinforcement) for adherence to a screen media viewing reduction plan. About 87.6% of those who had good knowledge when compared to only 58% of those with poor knowledge subscribed to giving positive reinforcement (child reward). Child reward for adherence to TV and other screen media reduction plan was significantly associated with the knowledge levels of health-related problems of increased viewing time (P = 0.001) with a Cramer's V-value of 0.346. This implies a 34.6% extent of association between child reward for adherence and the knowledge level. Similarly, 82.5% of those with good knowledge compared to 62% of those who had poor knowledge took the TV away from children's room. Taking off the TV and other viewing media from the children's bedroom(s) was found to have a significant association with the knowledge levels of health-related problems of increased viewing time (P = 0.003, Cramer's V = 0.237), with a 23.7% extent of association. The majority (93.8%) of caregivers with good knowledge versus 85.2% of those with poor knowledge subscribed to caregivers, setting a good example. There was a 19.5% extent of association between the caregiver/parent setting good examples on healthy screen media viewing time and the knowledge levels of health-related problems of increased viewing time (P = 0.017).

Determinants of control measures on excess viewing time

The regression analysis results presented in [Table 6] show how knowledge level and socio-economic classes (SEC) predicted the various measures put in place by respective households. The measure of limiting a child's screen time was significantly predicted by both knowledge and socio-economic class. These two variables were significant determinants (P = 0.001) of households limiting children's screen time by 18% (R2 = 0.180). Individually, both knowledge level (P = 0.001) and socio-economic class (P = 0.002) were significant predictors of limiting child's screen time.
Table 6: Regression on measures set by caregivers to limit child exposure to screen media

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The measure of giving rewards to children for adhering to screen media reduction plan was also significantly determined by the two variables (knowledge of health-related problems of increased viewing time and socio-economic class) (P = 0.001 and R2 = 0.221); this implies that knowledge level and SEC combined, influenced parents putting in place child rewards by 22.1%. Individually, knowledge of health-related problems of increased viewing time and SEC were significant predictors of the child reward for adherence to TV and other screen media reduction plan; with respective P values of 0.001 and 0.013.

Encouraging outdoor and sporting activities for children was significantly predicted by knowledge of health-related problems of increased viewing time (P = 0.002) as well as the socio-economic classes of the household (P = 0.002). The knowledge levels and SEC significantly determined the measure of encouraging outdoor and sporting activities for children by 16.1% (R2 = 0.161, P = 0.001).

While the measure of taking off the TV and other screen media from the children's room(s) was significantly predicted by the knowledge of health-related problems of increased viewing time in such home (P = 0.000), their socio-economic class was not a significant predictor of these measures (P = 0.326). However, the two variables in combination were significant determinants of taking off the screen media from the children's room(s) by 15.9% (R2 = 0.159); P = 0.001.

With regards to caregivers/parents setting a good example on healthy TV and other screen media viewing, only the knowledge of health-related problems of increased viewing time significantly predicted this measure (P = 0.001) when the knowledge level and SEC were considered singly. However, socio-economic class and knowledge level in combination significantly predicted the measure of setting healthy screen media viewing time by caregivers by 21.3% extent (R2 = 0.213, P = 0.001).

The provision of learning alternatives to TV/videos/computer/internet-viewing practice was significantly predicted by the knowledge of health-related problems of increased viewing time (P = 0.015) as well as the socio-economic classes of the household (P = 0.023). In combination, the knowledge level and SEC were found to significantly determine the measure of provision of learning alternatives to TV/videos/computer/internet by 8.9% extent (R2 = 0.089, P = 0.004).


   Discussion Top


The majority of the children in this study started watching television and other screen media platforms at two years of age, and a few were exposed to media viewing earlier. The average screen media viewing time was two hours. Screen media viewing duration among the children studied was modest, although some children had viewing duration up to ten hours. The mean screen time documented in a similar but large-scale population study of Spanish children aged 6 to 9 years was 1.8 h per day in 2011; this increased by 39% (2.5 h per day) in 2013.[23] Studies have documented that daily TV/video game/computer-viewing in excess of two hours is associated with reduced physical and psychosocial health in children and adolescents.[10],[14],[15],[17] On the other hand, recreational screen time at low levels (<2 hours per day) has been associated with lower health risks in children.[24] Factors such as socio-economic status,[2],[5],[6] family structure,[7] parenting practices,[3],[8] and mother's mental health[6] have influenced the reported outcomes of excess screen media time in available studies. Lower frequency of family meals, presence of a TV in the bedroom, absence of rules about TV viewing, and less physical activity, as well as parents' practices influenced the children's viewing practices.[7],[25] These factors were associated with >2 hours per day of screen time.[7] Caregivers in the index study had a mean screen time of 3.16 hours per day. The difference in the mean screen time between children and adults in the current study may be attributed to parent's exercising control over their children's adherence to screen media viewing. More than 80% of the caregivers in this study encouraged outdoor and sporting activities in their children, thus limiting their screen media time.

The majority of the households had television/screen media viewing regulations in their homes. The total duration of time during which the TV and other screen media in the household were on, was about 5.08 ± 2.67 hours on a typical day. This practice perhaps also checkmates the duration of time children could view the TV. However, only 32.2% of caregivers had viewing regulations for the television in the children's room. Nuutinen et al.[12] observed that the presence of screen media in children's bedrooms is associated with increased viewing time, resulting in reduced sleep duration and delayed bedtimes during school days and on weekends. In addition, it has been found that increased screen time/screen light (particularly blue light and activity from screens before bed) among young people is reducing sleep time, causing emotional arousal, inhibiting melatonin release, and disrupting sleep rhythms,[22],[26] thus predisposing these children to poor mental health and cardiovascular risk associated with sedentary behaviors which may invariably extend into adulthood.[10],[16],[27]

Overall, near-half of the caregivers in the index study had good knowledge about health-related effects of excess screen media viewing. Interestingly, more than two-thirds of them subscribed to the knowledge of screen media viewing being associated with sleep problems in their children. However, they were not abreast with the more important risks such as impaired neurocognitive development, increased risk of cardiovascular disease, and reduced life expectancy. Only about 23.9% of them had the knowledge that screen media viewing in early childhood may affect brain development, and sadly, only a few, 17.1% and 13.2%, respectively subscribed to the knowledge of reduced life expectancy and increased risk of cardiovascular diseases. Overweight and obesity;[14],[15],[17] elevated blood pressure and lipid levels,[28] as well as neuropsychological disorders such as anxiety and depression[2],[16] have also been reported in many studies as long term consequences of sedentary behavior associated with increased TV video game viewing. There is evidence from the available literature that suggests that decreasing any type of sedentary time is associated with reductions in body mass index and lower health risk in children and adolescents.[10] A study has established a strong link between screen-based sedentary behavior with unhealthy dietary TV-watching, which could suppress satiety signals, while fast foods, sweetened beverages, and restaurant advertisements contribute to increased intake of caloriesthrough eating while watching, and by implication, increase in body weights (obesity and overweight),[23] with attendant health risks particularly metabolic syndrome (insulin resistance/type 2 diabetes, hypertension, dyslipidemia, and cardiovascular disease).[29]

Older caregivers and those with older children had more knowledge about the health effects of excess TV viewing than the younger caregivers and those with younger children in the current study. There was no significant association between the socio-economic status of the caregivers and the level of knowledge of adverse effects of screen media viewing. Maternal educational attainment, to a greater extent, related to the caregiver's knowledge score than paternal education, although the differences were not statistically significant. Yalcin et al.[30] had corroborated the same finding in preschoolers, noting that maternal level of education did not affect the viewing time. In contrast to the finding in the present study, some other studies reported that a lower maternal educational level was significantly associated with a higher prevalence of any daily screen viewing behavior.[31],[32] Parental knowledge and parental practices have the potential to act as targets for health promotion strategies that are aimed at either reducing or delaying the habit of increased screen media viewing in children, particularly the younger ones. This is because informed parents could help in monitoring their children, young and older ones alike, as well as their own media use, thus serving as positive role models in limiting family exposure to unhealthy screen media use.

Over 80% of the caregivers set good examples of healthy TV and other screen media use for their children by limiting their own screen time as well as their children's screen time. There was a 19.5% extent of association between the caregiver/parent setting good examples on healthy screen media viewing time and the knowledge levels. These caregivers encouraged outdoor and sporting activities for children as measures to control their television and other screen media viewing time.

Limiting a child's screen time and provision of learning alternatives to TV/video/computer/internet did not significantly associate with knowledge levels of health-related problems of increased viewing time. Child reward (positive reinforcement) for adherence to screen media viewing time reduction plan was the least subscribed measure of control. However, child reward for adherence to the viewing reduction plan was significantly associated with the knowledge levels of health-related problems of increased viewing time. About 87.6% of those with good knowledge subscribed to child reward when compared to 58.3% of those with poor knowledge. This is not surprising considering the norm/cultural practices in the African setting where in most cases, the rule is that of punishment in the form of denials of gift items and in the extreme, spanking for any child who fails to adhere to the parent's/caregivers instructions. Knowledge is, therefore, key to the modification of some of the societal norms. So caregivers who practice child reward in order to positively bring about behavioral change in their children should be commended and encouraged.

In a regression analysis, the knowledge score and the socio-economic class of the caregivers were significant predictors of limiting the child's screen time, the child's reward, and encouragement of outdoor and sporting activities, provision of learning alternatives to TV/videos/computer/internet, setting healthy TV and other screen media viewing time by caregivers as measures to subvert the adverse effects of excess screen media viewing. The overall family climate, including family roles and norms, and parent media use significantly determine their children's screen viewing as media-centric parents tend to have children with more daily screen time and more likelihood of having a TV/screen media in their bedroom.[33] Caregivers of children in the index study were of higher SEC, with higher educational attainments. This may have resulted in fewer viewing times spent on screen media daily by their children. In contrast, Wartella et al.[31] found that children from media-centric families tend to be from lower socio-economic class strata, have lower educational attainment, have fewer developmental resources, and have depressed or single parents, all of which are aspects of the child's social ecology that affect their health and behavioral outcomes.

Knowledge level and socio-economic class were significant determinants of the measure of removal of the TV and other screen media from the children's bedrooms. Whereas the knowledge level significantly predicted this measure, the socio-economic class did not. Pearson et al.[34] had reported that parental concern was positively associated with television viewing among younger and older children as family-based interventions that provide education, support, or encouragement to concerned parents to enact changes to the family environment may be an important approach to reducing screen viewing time in children.

In conclusion, increasing screen media viewing time is common among children and adolescents studied, with the majority of parents/caregivers being well educated but having poor specific knowledge of the health-related effects of increased viewing time in our setting.

Although screen media viewing, when put to good use, has numerous positive impacts on health and development of children and adolescents globally, including improvement in academic performance, enrichment of knowledge and literacy skills, and positive relationships with teachers and peers;[35] paediatricians and other healthcare providers now face the challenges of managing the negative effects of screen use on mental and physical health as well as family life of children,[18] and ought to work with families and schools by promoting understanding of the risks as well as benefits of screen media use. There is a need to further enlighten parents on the specific health-related effects associated with increased screen media-viewing time and encourage them to put reducing measures in place to limit the associated consequences of the practice.

Availability of data and materials

The datasets used/or analyzed during this study are available from the corresponding author on reasonable request.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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