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Screen Time Associated with Health Behaviors and Outcomes in Adolescents

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Screen Time Associated with Health Behaviors and Outcomes in Adolescents Screen Time Associated with Health Behaviors and Outcomes in Adolescents Vincent Busch, MSc; Lieke Ananda Manders, MSc; Johannes Rob Josephus de Leeuw, PhD Objectives: To study the associations problems and being overweight. Conclu- of screen time (Internet / video games / sions: Screen time was of significant im- television) with health-related behaviors portance to adolescent health. Behavioral and outcomes in adolescents. Methods: interrelatedness caused significant con- Regression analyses were performed to founding in the studied relations when assess the associations of screen time behaviors were analyzed separately com- with several health-related behaviors and pared to a multi-behavioral approach, outcomes in 2425 Dutch adolescents. Re- which speaks for more multi-behavioral sults: Screen time was associated with analyses in future studies. bullying, being bullied, less physical ac- Key words: screen time, health behav- tivity, skipping school, alcohol use and ior, overweight, psychosocial problems, unhealthy eating habits. Compulsive and adolescent excessive screen times were associated Am J Health Behav. 2013;37(6):819-830 respectively with several psychosocial DOI: http://dx.doi.org/10.5993/AJHB.37.6.11 ith the advance of technology, time spent conduct disorder.10-12 In particular, self-efficacy is on television, Internet and video games is an aspect receiving increasing attention among in- Wincreasing among today’s youth.1-3 Televi- terventions in the field of adolescent health promo- sion viewing, Internet use and video game play- tion, because it is believed to be a mediating vari- ing are collectively called ‘Screen Time’. As early able in the causal path of unhealthy behavior and as 1983, it was claimed video game playing could psychosocial problems in adolescents.13,14 become an addiction like any other behavioral ad- Furthermore, some literature suggests that un- diction and the same was argued for excessive In- healthy behaviors are associated with and influ- ternet use several years later.4,5 Although a formal encing each other instead of existing independent- medical diagnosis for video game addiction or In- ly. This raises interest for the probable associa- ternet addiction is (still) lacking in current medical tions of screen time behaviors in relation to each practice, discussions are on-going to add them to other and their possible associations with other the future Diagnostic and Statistical Manual of Mental unhealthy behaviors and health outcomes, which Disorders (DSM).2,5 In general, unhealthy screen has relevance for future health promotion inter- time behavior is characterized by 2 aspects: (1) ventions.15-19 whether or not one spends an excessive amount of This study investigates how a range of known un- time on it; and (2) whether or not the behavior is healthy behaviors and health outcomes are associ- considered “compulsive.” ated with several, relatively ‘new’ unhealthy screen The evidence increases that excessive and/or time behaviors, in a sample of Dutch high school compulsive screen time behavior holds the poten- students. In this study these unhealthy behaviors tial to be harmful to one’s health;3,6,7 recent studies consist of marijuana use, alcohol use, smoking, un- support for this belief, eg, in relation to obesity8,9 safe sex, skipping school, bullying, poor nutritional and several psychosocial and psychiatric prob- behavior and less physical exercise, in accordance lems, such as depression, lower self-efficacy and with the Health Behavior in School-aged Children study (HBSC).20 The health outcomes consist of students’ psychosocial problems, being overweight, Vincent Busch, Doctoral Student, Julius Center for Health Sci- and General Self-Efficacy (GSE).21 To demonstrate ences and Primary Care, University Medical Center Utrecht, the confounding effects of the interrelatedness of Utrecht, the Netherlands. Lieke A. Manders, University Me- the screen time behaviors in their relations with dical Center Utrecht, Utrecht, the Netherlands. Rob J.J. de other unhealthy behaviors and health outcomes, Leeuw, Senior Researcher, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, these associations are presented with and without the Netherlands. correcting for (possible) confounding by the remain- Correspondence Vincent Busch; [email protected] ing screen time behavior variables. Am J Health Behav.™ 2013;37(6):819-830 819 Screen Time Associated with Health Behaviors and Outcomes in Adolescents Thus, we quantify the associations of different the Internet or playing video games as well as the screen time behaviors with a range of unhealthy compulsiveness of these behaviors was measured. behaviors as well as the noted health outcomes, Spending more than 2 hours/day on screen time while preventing the introduction of bias due to behaviors was defined as “excessive” use, in accor- the screen time behaviors’ interrelatedness and dance with current standards in the literature.6,23 demonstrating the importance of multi-behavioral The compulsiveness of someone’s screen time be- analyses in adolescent health behavior research. havior was measured by the Compulsive Internet Use Scale (CIUS) for compulsive Internet use24 and METHODS by the Videogame Addiction Test (VAT) for compul- Samples sive video game playing.25 Both the VAT and CIUS Data were collected from 5 Dutch high schools consist of 14 questions with a 5-point Likert scale, as part of the Utrecht Healthy School (UHS) study used to evaluate compulsive behavior, respectively (N = 2425),22 the UHS pilot study school and its 4 for compulsive video game playing (CVP) and com- sister schools from the UHS itself. These schools pulsive Internet use (CIU). A score higher than 3.0 were part of a convenience sample of schools that points indicates compulsive behavior. These bi- were recruited for the UHS. All 5 schools partici- nary measures for compulsive and excessive use pated out of intrinsic motivation and were not were used in all presented analyses, because these provided with funds or other incentives to partici- are considered indicators of “problem behavior.” pate. All were all assisted with the questionnaire Definitions of the unhealthy behaviors and procedures by the research team. All are situated student demographics. Questionnaire items in suburban areas of middle-to-large cities in the and operationalization were largely similar to the Netherlands. Therefore, all 5 schools should be Dutch HBSC questionnaire and covered several categorized as in-between rural and urban. health outcomes and a range of different health behaviors and socio-demographics20 “Recent be- Survey Procedures havior” was defined as behavior in the month prior The UHS questionnaire was completed indepen- to completing the questionnaire. Questions on re- dently by participants in classroom settings at the cent behavior were asked with regard to alcohol start of the school year in September. Survey pro- and marijuana use, smoking, bullying and unsafe cedures allowed students to participate voluntarily sex. These measures dichotomous, ie, (0 = did not and anonymously. Prior to the survey, students recently exert a behavior, 1 = did exert a behavior were informed of the questionnaire’s purpose and recently). These questions on unhealthy behav- content by means of a newsletter. These points iors were posed as in the HBSC, which means that were repeated at the time of the survey by a mes- binge drinking was regarded as more than 5 alco- sage presented on the questionnaire and by the holic beverages on a single occasion, and skipping classroom teachers. The only students not com- school as >3 hours of disallowed absence from pleting the survey were ones not present at the time school in the recent month.20 of the survey (due to conflicting course schedules, Also measured, but not a standard part of the according to their teachers) or ones absent on the international HBSC survey, were questions re- day of the survey; the surveys were unannounced, garding bullying and being bullied, based on the so this should have not been a source of bias. Tak- Olweus Bully Score and the Olweus Bully Victim ing into account these 2 reasons for being absent, Score.26 These scores distinguish bullies and bul- the response rate was over 95%. Data cleaning was lied children from non-bullies and non-bullied performed in such a way that when 50% or more of children with a cut-off of “2 to 3 times a month” the data were missing the participant was deleted (0 = not bullied/bullying, 1 = bullied/bullying). from the study; also, when answers were contra- In previous research Solberg and Olweus demon- dictory and/or unreliable on account of at least 3 strated these measures’ validity and reliability for main questionnaire topics (eg, nutrition, alcohol adolescents. They stated that these scores allow for use, physical activity) the entire questionnaire was prevalence estimates of bullying and being bullied deleted from analyses. Data cleaning resulted in to be obtained conveniently, that they have a rea- usable questionnaires of over 95% of the partici- sonably well-defined meaning, and that they are pants. No forms of data imputation were applied. easily and unambiguously understood by users and researchers. Thereafter, Kyriakides, Kaloyirou Measures and Lindsay27 assessed its validity and reliability, Screen time. Watching television, using the concluding it to be a psychometrically sound mea- computer/Internet and playing video games will sure for bullying prevalence among adolescents. be referred to as “screen time behaviors.” Inter- Furthermore, healthy physical exercise pat- net use was defined as use of Internet for non- terns were defined as the following dichotomous school-related purposes. Video game playing was measure: at least one hour of moderately intensive defined as (online) gaming on a game console such physical activity every day, where at least twice a as the X-Box or PlayStation. Game use did not in- week the activity is aimed at improving or main- clude games with monetary awards or gambling. taining physical fitness22 (0 = sufficing, 1 = not Both the time spent on watching television, using sufficing).
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