# Exercise as it relates to Disease/Use of targeted interventions to reduce recreational screen time in adolescents

A critical appraisal of the research paper 'Intervention to reduce recreational screen-time in adolescents: Outcomes and mediators from the ‘Switch-Off 4 Healthy Minds’ (S4HM) cluster randomized controlled trial' by Mark J. Babic, et al (2016)

## What is the background to this research?

Sedentary behaviour is becoming an increasing issue in young Australian adolescents. Only 1 in 5 (20%) Australian adolescents aged 13-17 met the Australian physical activity guideline. Recreational screen time is the use of devices such as computers, phones and gaming devices that does not promote activity or education. Recreational screen time is a cause of sedentary behaviour as it is normally an activity that is performed below the 1.5 metabolic equivalents (METs) that equates to a person being sedentary.
The research paper being appraised is a study on the effectiveness of the switch off 4 healthy minds (S4HM) intervention and its impact on the recreational screen time of adolescents. The researchers hypothesised that adolescents in the S4HM intervention will report significantly lower levels of recreational screen-time at 6-month post-intervention, compared to those in a wait-list control group.

## Critique of research
### Where is this research from?

This research was collected from 8 catholic secondary school in the Hunter region of New South Wales, Australia. The research conducted was published in the Preventive Medicine Journal in 2016.
The authors of the article come from multiple different universities located in New South Wales, within the authors, there fields of practice relate heavily to the topic being discussed, though many of the authors participating in the research have had little peer reviewed research published in the past.

### What kind of research was this?

The study performed was a parallel group cluster randomised controlled trial. A cluster randomised trial is effective as it able to effectively able to evaluate whether a guideline recommendation is affecting the outcome for the participants. A cluster randomised trial also is also preferred as there is potential for contamination of the study by members of the control group.
The methodology of this research is similar to other studies performed on similar topics using a cluster randomised controlled trial such as a study by Pedersen J et al. (2022)

### What did the research involve?

The study consisted of 322 students, of which 308 responded to follow up assessments. The control group contained 155 students who did not participate in the intervention and continued their normal school curriculum and usual behaviours. The intervention group contained 167 students who were assessed over a six month period where they were participating in the Switch off 4 Healthy Minds program. The program involved participants attending an interactive seminar at the beginning of the 6 months, receiving Ehealth messages online twice weekly and signing behavioural screen time contracts. Parents of the participants were also sent newsletters once monthly.
The methodology of the study is deemed appropriate. The primary outcome of the study, which was the recreational screen time amount, was measured using the adolescent sedentary activity questionnaire (ASAQ). A study by Hardy et al. (2007) deemed that the ASAQ can gather comprehensive amounts of gathering information and the information is of a good to excellent reliability. Secondary outcomes measured included multiple assessments of health (BMI, Weight) which were all measured using equipment and methods adequate to scientific and research standards.
There is one major limitation that is present in the research. That is the completion of the ASAQ by participants as it is completely subjective. This introduces the possibility of recall and social desirability biases amongst the participants which may affect the results of the study.

### What were the basic results?

There was no significant difference found in the recreational screen time of the intervention group compared to the control group at the end of the 6 month period. Both groups observed had significant reductions in screen time from baseline to post-test, S4HM (intervention) = − 50.5 min/day, p < 0.001; Control = − 29.2 min/day, p = 0.030. Though when observing the adjusted between group difference, mean = − 21.3 min/day; p = 0.255, the results are not statistically significant. Of the secondary outcomes the researchers also interpreted that there were no statistically significant group-by-time effects for any of the mental health outcomes, BMI or physical activity.
The results of the study are interpreted positively even though most outcomes are not statistically significant. The researchers identify that the students have found the S4HM intervention to be helpful and an educational tool. The study does not over emphasis the implications of its finding as it simply states the results and indicates the need for future research to be conducted on the recreational screen time of adolescents for more impactful data to be obtained.

## What conclusions can we take from this research?

Recreational screen time in the adolescent population of today is an ever growing issue. Multiple interventions have been trialled but it seems that none are having the needed effect in reducing screen time. This study has not produced statistically significant data so it is somewhat clear that further measures need to be taken in the future to provide interventions that produce statistically significant data. Though the data does show that the intervention had somewhat of an effect on the participants as they themselves deemed that the intervention was appropriate and educational in providing methods to reduce screen time.
The results of this research have similar outcomes to other screen time intervention studies. One recent study from Da Silva Bandeira, et. al in 2019 had similar findings stating that there was no significant differences between the intervention and the control group for reduction of screen time.

## Practical advice

Recommendations for screen time in Australian adolescents aged 13-17:
* No more than two hours of sedentary recreational screen time per day for children and young people aged 5–17 years (not including schoolwork).
Recommendations for physical activity in Australian adolescents aged 13-17:
* Children and young people do at least 60 minutes each day of moderate to vigorous physical activity

## Further information/resources

Australian National Guidelines for Screen Time
Australian National Guidelines for Physical Activity for Young People
Tips to help reduce screen time in children

## References

* 1 2 3 4 5 Babic, M. et al. (2016) Intervention to reduce recreational screen-time in adolescents: Outcomes and mediators from the ‘Switch-Off 4 Healthy Minds’ (S4HM) cluster randomized controlled trial. Preventive Medicine. 2016 Oct;91:50-57. Available from database: https://doi.org/10.1016/j.ypmed.2016.07.014
* ↑ Australian Institute of Health and Welfare, Insufficient Physical Activity [Internet]. Canberra: Australian Government; 2020 [cited 2022 Sep 13]. Available from: https://www.aihw.gov.au/reports/risk-factors/insufficient-physical-activity/contents/insufficient-physical-activity
* 1 2 Heagerty P, DeLong E, Cluster Randomized Trials [Internet]. NIH Pragmatic Trials Collaboratory; 2017 [cited 2022 Sep 13]. Available from: https://rethinkingclinicaltrials.org/chapters/design/experimental-designs-randomization-schemes-top/cluster-randomized-trials/
* ↑ Pedersen J, Rasmussen MGB, Sørensen SO, et al. Effects of Limiting Recreational Screen Media Use on Physical Activity and Sleep in Families With Children: A Cluster Randomized Clinical Trial. JAMA Pediatr. 2022;176(8):741–749. Available from database: 10.1001/jamapediatrics.2022.1519
* ↑ Hardy L, Booth M. (2007) The reliability of the Adolescent Sedentary Activity Questionnaire (ASAQ). Preventive Medicine. 2007 Jul;45(1):71-74. Available from database: 10.1016/j.ypmed.2007.03.014
* ↑ Da Silva Bandeira A, et al. (2019) Psychosocial mediators of screen time reduction after an intervention for students from schools in vulnerable areas: A cluster-randomized controlled trial. Journal of Science and Medicine in Sport. 2020 Mar;23(3);264-269. Available from database: https://doi.org/10.1016/j.jsams.2019.09.004
* ↑ Australian Institute of Family Studies, Too much time on screens? Screen time effects and guidelines for children and young people [Internet]. Canberra: Australian Government; 2021 [cited 2022 Sep 13]. Available from: https://aifs.gov.au/resources/short-articles/too-much-time-screens-screen-time-effects-and-guidelines-children-and#:~:text=no%20more%20than%20two%20hours,years%20(not%20including%20schoolwork).
* ↑ Department of Health and Aged Care, For children and young people (5 to 17 years) [Internet]. Canberra: Australian Government; 2021 [cited 2022 Sep 13]. Available from: https://www.health.gov.au/health-topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians/for-children-and-young-people-5-to-17-years