Electronic media device usage and screen time among children in a tertiary care hospital in Western Uttar Pradesh, India: A cross-sectional study

Background : Increased use of electronic media devices has become a significant health problem in the paediatric population worldwide. Excessive use of these devices in children is associated with several health-related hazards. Objectives: To describe the media device usage, screen time, and factors associated with their uses among children in a tertiary care hospital in Western Uttar Pradesh, India. Method: A cross-sectional study was conducted in the department of Paediatrics of a tertiary care hospital, in Moradabad, Western Uttar Pradesh, India. All children aged 6 months to 8 years were recruited. A questionnaire in English that was converted into Hindi was used to collect data. Exposure to electronic device usage, average time spent on each device, and factors associated with device usage were analysed.


Introduction
Increased use of electronic media devices has become a significant health problem in the paediatric population worldwide 1 . Excessive use of these devices in children is associated with several health-related hazards, including a negative impact on language development, cognition, social interactions, sleep, learning, behaviour and noncommunicable diseases 2,3 . Several guidelines have been developed in recent years to set limits for screen device use by children. World Health Organisation recommends that children of 3-4 years limit screen time to less than 60 min per day 4 . Indian psychiatry association issued recommendations for media use in children and adolescents up to 18 years of age and advised zero screen time in children less 2 years. Between 2 to 5 years viewing for specific purposes like educational games or teaching aid for a limited period (not longer than 30 minutes per session, and not more than two sessions per day, under supervision -a shared media use), rather than for entertainment was advocated 6 . Most recent guideline issued in 2016 by the American Academy of Paediatrics also recommends a maximum of one hour of screen time per day in children aged between 2-5years 6 . Several studies in western countries have evaluated screen time among pre-school children 7 . However, studies evaluating conformity of screen time in preschool children belonging to low and middle-income countries to these guidelines are sparse 8 . Recent appliances, such as smart phones, tablets etc. can be positioned effortlessly in a child's room, thereby encouraging more media exposure according to the social cognitive theory 9,10 . As shown by a recent study by Common-Sense Media, 2013, young children show increased use of handheld devices such as cell phones mainly due to increase in accessibility and usage of technology 11 . Children are being more and more detached from parents, as parents are being more and more attached to the technology 12 .

Objectives
Present study was undertaken to assess the electronic media device usage, screen time and factors associated with their uses among children of North India.

Method
A descriptive, cross-sectional study was conducted in the department of paediatrics of a tertiary care hospital, in Moradabad, Western Uttar Pradesh, India over a period of one year on children aged 6 months -8 years, belonging to the Moradabad District, Uttar Pradesh.
Sample size: Minimum sample size (n=355) was calculated using the formula n= (Z1-α/2 )2 ×p q / d2. Purposive sampling technique was used for selection of children.
Inclusion criteria: Children aged 6 months to 8 years who visited the paediatric outpatient department (OPD) or the immunisation clinic were enrolled.

Exclusion criteria:
The parents who did not give consent to participate & children with neurological or intellectual disability were excluded from the study.
Study procedure: A questionnaire made in English that was converted into Hindi was used to collect data from respondents. This questionnaire (which was pre-validated on the sample population) included demographic and socio-economic details, availability and usage of electronic screen devices, type of media devices, and time spent on media devices. Data on the availability and usage of electronic devices were gathered using separate questions to be answered "yes" or "no" for individual devices: television, smartphone, tablet, desktop, and laptop. Data on time spent on each device was gathered as the average time per day for each device to be filled by the parent. Yes-or-no questions were used to collect data on the types of programmes viewed, including cartoons, adult programming, movies, educational programming, and nursery rhymes. The age at first exposure was captured by a question with a single choice to be selected from multiple choices of predetermined age ranges. The questionnaires and participant information sheets were filled out by the parents of children who visited the paediatric OPD.

Ethical issues:
The study was approved by the Institutional Ethics Committee of Teerthanker Mahaveer University, Moradabad, Uttar Pradesh, India (No. TMMC&RC/IEC/19-20/045) dated 19.12.2019. Written informed consent was obtained from a parent or legally acceptable caregiver.

Statistical analysis:
The data were entered into the Microsoft Excel sheet and the statistical analysis was performed by SPSS software version 25.0. Categorical variables were present in the form of frequency and percentage. Mean and standard deviation were used for analysing the continuous variables. Fisher's exact test and Chi-Square test were used to analyse the categorical variables. Evaluation of predictive factors was done by multivariate and bivariate regression, which was followed by assessment of the fit of model. p-value < 0.05 was taken as significant.

Results
A total of 384 children were recruited for this study, among whom 8 were sick and 21 were ones whose parents were not willing to give consent. Finally, 355 children were included in the study. Table 1 shows the general characteristics of the study population. Mean age of the study population was 46.1 ± 4.8 months. Usage of screen devices by children showed a distribution parallel to their availability at home. Study also showed that a higher caregiver's screen time per day was associated with a higher child's screen time.
The present study found exposure to an audio-visual media device among 6-to 8-year-old children to be 92.5%. Only 27 (7.5%) children did not have any screen time at all. Table 2 shows the correlation of screen time in different age groups. Screen time and different age groups of children were found to have a significant correlation (p value = 0.0023).
Among shows watched, cartoons were the most popular. A significant (p value = 0.012) correlation was discovered between the types of shows watched and the age group of the children (Table 3).
Factors associated with screen time exceeding one hour per day in children are shown in Table 4. More than one hour of screen time per day was significantly associated with the male gender (p= 0.001) and children living in urban areas (0.022).     2,3 . Therefore, it is likely that the majority of our children are at risk of developing these health hazards.
A study done by Chang HY, et al 18 showed that 65% of children were exposed to TV, compared to 31.3% of children who were exposed to smartphones. In our study, 19.5% of children aged 6 months to 1 year, 51% aged 1 to 3 years and 29.5% over the age of three had their first screen experience. Varadarajan S, et al 17 reported that the first exposure to screens occurred among 60.8% of children between 7 and 12 months, 13.8% between 19 and 23 months, and 8.5% less than 6 months of age. Chang HY, et al 18 showed that children who were exposed to television before 24 months of age comprised 65%. In our study 12.2% of children below 12 months of age were using smartphones for the very first time. The smartphone was the most commonly used audio-visual media device, which was used by 45.6% of children, followed by television (22.8%).
Our findings on the types of screen media device usage by Indian children were comparable to the usage by children from many other countries 13 13 reported that tablets were the most commonly used media device among children. The access to desktops, laptops, and tablets was very limited in this study as compared to studies from western countries 24,25 . This can be attributed to economic differences between developing and developed countries.
In our study, cartoons, educational programmes, entertainment shows, and adult programmes were seen by 34.7%, 24.5%, 24.5%, and 16.3% of the children, respectively. The age group, gender, and place of residence all had a substantial impact on the duration of media device viewing. Our study found that male gender and urban residence were significant predictors of increased screen time (>1 hour) in children that exceeded the recommended limit. Our findings were comparable to those of Anand B, et al 26 . Children aged 2-8 years, female gender, and children from an urban background watched much more television in their study. Higher father's education, according to Rathnasiri A, et al 12 , was a predictor of increased screen time in children.
The study had some limitations. Children attending this hospital cannot reflect the whole situation in western Uttar Pradesh. Future research should include all children belonging to different institute of Uttar Pradesh in order to estimate the electronic media device usage, screen time and factors associated with their uses among children in North India.

Conclusions
The electronic media devices were used by the majority of children, and over 80% used them for more than the recommended daily upper limit of one hour. Smartphones were found to be the most popular electronic media devices. Higher socioeconomic status, maternal employment, nuclear family size, and the firstborn child were significantly associated with electronic device use.