Correlates of screen time among 8–19-year-old students in China

Screen-based sedentary behavior (SSB), including many new forms of digital media, is ubiquitous and is an important part of daily activity in the current information era. A longer time spent in SSB was significantly associated with lower fitness, overweight or obesity, depression, inattention, shortened sleep duration, and cardiovascular disease risk factors in children or adolescents [1‐6], independent of meeting or not meeting the recommended level of physical activity [7, 8]. Moreover, the habits of SSB developed in childhood more easily persist into adulthood compared with the habits of moderate or vigorous physical exercise [9]. The “Health Behavior in School-aged Children” project (World Health Organization) indicated that students aged 11–15 years spent more than 2 h per day viewing television (an indicator of SSB) in 30 countries, and screen time (ST) has been growing along with further popularization of new screen devices (e.g., personal computer, tablet, smart phone, etc.) [10]. A study conducted in a city in Eastern China also showed that 51.5% of adolescents spend more than 2 h on ST per day [11].

Limited previous studies have indicated that increased ST was related to male sex, being older, weekends, low parental education, and high media accessibility (such as having a television [TV] or a computer in the bedroom) [12‐15]. Other studies on environmental correlates of SSB, however, have not been very clear, and some of the results were inconsistent (such as the presence of a television set in the bedroom) [16, 17]. Meanwhile, environmental correlates, such as media accessibility and parental social factors (rules or viewing accompanied by parents), play a key role in evidence-based interventions on restricting prolonged ST in school-aged children [16]. To our knowledge, few studies have explored and confirmed the modifiable correlates of prolonged ST, especially for new screen devices, such as cell phones and pads/tablets, in children in developing countries [18].

The aim of the present study was therefore to examine the correlates, including individual and environmental factors, of ST based on a validated self-reported SSB questionnaire in 8–19-year old Chinese girls and boys.

Based on data collected using a validated questionnaire, male sex, junior high school students, weekends, presence of parents/others, and media accessibility were significantly associated with prolonged ST. These results are important for developing a series of effective strategies against prolonged ST in 8–19-year-old students in the future.

The percentage of prolonged weekday and weekend leisure ST (≥2 h/d) were 11.7% and 83.1%, respectively; this was lower for weekdays and greater for weekends compared with the results of another study in Chinese children [25]. The findings that boys have more leisure ST than girls do and that there is more ST on weekends than on weekdays are also consistent with previous studies [10, 25]. Another study indicated that age was positively associated with ST [10]. In our participants, age and grade were nonlinearly associated with ST (leisure ST decreased after 15 years of age/junior high school grade). This might be because there is more pressure in regards to studying and preparing for college entrance examinations in Chinese senior high school students than is seen for senior high school students in Western culture; this may push students to place more attention and time on study-related behavior, resulting in a “crowding-out effect” [26, 27].

In addition, correlations between environmental factors and leisure ST were not significantly changed after additional adjustment for parental education levels. In contrast with previous studies [28], low parental education was not a risk of prolonged ST in students in this study. In China, this might because parents with higher education level (high school or above) do not restrict their children’s SSB as well as because they might have greater media accessibility owing to a higher socioeconomic status [29].

Previous studies have shown that parents viewing TV with their children or parental role modeling of TV viewing were positively associated with the duration of TV viewing [30‐32]. In our results, however, the presence of parents/others was negatively associated with leisure ST. Parents of students in the present study might play a supervisory role while watching TV with their children, rather than merely being present or accompanying their children. The results also potentially indicate that parental rules concerning screen viewing or parental expectations could mediate SSB (especially for TV viewing) in this population [26, 33]. Accordingly, media accessibility, especially having a TV set in the bedroom, seems a more important target than the accompaniment of parents/others for preventing prolonged leisure ST. These results differ from those of Carson et al. [34], who indicated that social environments might be more important than physical environmental factors, such as neighborhoods. Upon further exploration of the data, the presence of a TV set in the bedroom was not associated with leisure ST in our participants. Students with a TV in the bedroom did not have a significantly greater amount of time spent watching TV, but did have a greater amount of time using a phone/tablet and computer. Therefore, this does not appear to be a causal relationship, but rather just a relationship observed between the presence of a TV set in the bedroom and leisure ST. Most students with a TV in the bedroom were older and were more likely to be alone (not accompanied by parents or others) while watching TV. It was deduced that these students might have a greater amount of individual space, independence, and insensitivity to parental control, which could increase leisure ST.

Furthermore, our results indicate that cell phone/tablet-based leisure ST has become a main component of ST, although Jiang et al. reported that playing on a mobile phone was less prevalent before 2014 in Chinese adolescents [25]. In our data, 91.0% students with one type of screen and 96.7% students with two types of screens were the owners of a cell phone/tablet. This observation shows that cell phone/tablet-based leisure ST has dramatically increased in recent years and now comprises the largest proportion of ST, as was observed with Australian children [35]. These results also suggest a call for future studies that focus on exploring the correlates of small/mobile leisure ST because of its potentially different correlates.

This study has some limitations. First, caution should be noted in generalizing our results or inferring any causal relationships, because this was a cross-sectional study performed in the north of Zhejiang Province (a region with a relative high economic status in China), even though the students were from different grades and schools. Second, the presence of parents/others has not been defined clearly; for example, it is unclear whether there were efforts to restrict or encourage students’ SSB; moreover, the study lacked a direct investigation of parents. Previous studies indicated that parental ST, role modeling, and familial rules for SSB were related to leisure ST of students or children [36, 37]. The strength of our study was measuring time spent using cell phones/tablets, which was highly prevalent in Chinese students. Previous studies in this field mainly focused on descriptions of sociodemographic characteristics or correlates of TV viewing and computer use.

Greater media accessibility and less presence of parents/others are associated with prolonged leisure ST in 8–19-year-old Chinese students, based on data collected using our reliable questionnaire. Additional attention should be paid to mobile/small screen-based devices, such as cell phones and pads/tablets, to avoid prolonged leisure ST, especially in boys and/or on weekends. Development of effective strategies for intervention of small/mobile device-based ST will be required in future studies.