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doi:10.1111/jpc.13181
REVIEW ARTICLE
Impact of information and communication technology on child health Eugenia HC Woo, Peter White and Christopher WK Lai 1
Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
Abstract: This article provides a general framework for understanding the use of information and communication technology in education and discusses the impact of computer usage on students’ health and development. Potential beneficial and harmful effects of computer use by children are discussed. Early epidemiological and laboratory studies have indicated that children are at least of similar risk of developing musculoskeletal and vision problems as adults, and musculoskeletal and visual health problems developed in childhood are likely to persist into adulthood. This article, therefore, aims to provide a reflection on the deficits of existing policy and recommendations for child-specific guidelines in computer use. Key words: children; computers; health-related problems; information and communication technology.
Background Over the past two decades, information and communication technology (ICT) has developed at a rapid pace. The use of computers and other electronic communication devices has become a part of everyday life. Many young people spend increasingly more time engaging in using these devices in school, work and leisure activities. No doubt, ICT has fundamentally changed the practices and procedures of all forms of endeavour within business, education and governance.
Information and communication technology in education Information and communication technology has broken down the traditional boundaries of teaching and learning and brought enormous change to the education sector.1 It is believed that ICT and the Internet are the way forward in education to enable students to become skilled citizens for the knowledge economy. Governments throughout the world have been promoting the use of ICT in education vigorously over the past few decades. For instance, one-to-one laptop programmes are expanding rapidly across the world with large-scale initiatives such as Microsoft’s Anytime Key Points • Impact of computer usage on students’ health and development. • Musculoskeletal and visual health problems developed in childhood are likely to persist into adulthood. • Reflection on the deficits of existing policy and recommendations for child-specific guidelines in computer use.
Learning and the One Laptop per Child programme.2 The purpose of one-to-one computing is to let students learn anytime and anywhere with a portable computer. Through the growing popularity of electronic books, more and more people use electronic devices for reading, and some primary and secondary schools have replaced their traditional textbooks with electronic teaching materials. Therefore, it has become a global trend to employ ICT as a medium for teaching and learning both inside and outside the classroom.3
Children’s computer use According to a report by Computer Industry Almanac, computers in use reached over 1.6 billion units worldwide at year-end 2011 and are expected to grow to 2.45 billion by 2016. In fact, the availability of computers, both at school and at home has resulted in very high computer usage. At school, students are asked to perform different computer tasks including word processing, searching for information on the Internet and using educational software. They also use their home computers for homework, communication and playing games. Two-thirds of USA high school students aged 16–18 years reported using their tablet computers for more than 4 h per day.4 Hong Kong students aged 12–16 years reported an average of 2.5 h per day.5 However, even very young children have been recorded as using computers. More than one quarter of 4- to 6-year-olds in the USA use a computer for an average of 64 min in a typical day,6 and over half of 5 years old in Australia use a computer each week.7
Potential Beneficial and Harmful Effects of Information and Communication Technology Correspondence: Dr Peter White, Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. Fax: +852 2362 4365; email:
[email protected] Conflict of interest: None declared. Accepted for publication 28 February 2016.
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Educational motivation and engagement The use of ICT in education provides learning motivation and engagement for students.8 Students are intrinsically motivated to learn because of the effective construction of learning environments and activities. 9 ICT tools such as videos, television Journal of Paediatrics and Child Health 52 (2016) 590–594 © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
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and multimedia computer software that combine text, sound and colourful, moving images can be used to engage students in the learning process. Computers with Internet connection can also increase students’ motivation as they combine the media richness and interactivity of other ICTs with the opportunity to connect with real people and to participate in real world events.10 Recent research has confirmed that ICT can enhance students’ motivation, interest and academic achievement when compared with traditional educational settings.11 The intrinsic features of ICT, such as immediate feedback, animation, sound, active interaction and individualization are more capable to motivate students to learn than other media.12 It has also been noted that computers provide opportunities for students to engage in self-directed learning activities, which further promote academic motivation.13 When students’ interests were aroused by motivation, Azita14 found that their learning in difficult subjects like Science and Mathematics became easier. Because of the introduction of computers at home and in school, there has been a growing concern that extended computer work will place young computer users at risk of developing cumulative musculoskeletal disorders (MSDs) and computer vision syndrome (CVS).15 A recent study confirmed that computer-related health disorders such as stress, CVS, MSDs and carpal tunnel syndrome (CTS) occur simultaneously among prolonged computer users, such as employees and students.16
Musculoskeletal problems and disorders Among computer users, the most common health-related complaints involve the neck, shoulders and back.17 Sitting at a desk and working on a computer for extended periods of time can stress the trapezius muscle, causing soreness and even headaches. Trapezius myalgia can be caused by working for long periods sitting at a desk working on a computer keyboard. This is also common for those who have poor posture and work in an area that is not ergonomically designed, for example, when a computer screen is misaligned. If the trapezius is not in the correct position, the muscle can lengthen or shorten and affect blood and oxygen flow. This will bring about muscle fatigue and discomfort, leading to pain as well as MSDs. In addition, intensive mouse and keyboard use have been associated with increased risk of upper extremity MSDs, such as CTS.18 CTS is caused by compression of the median nerve as it passes under the carpal tunnel in the wrist.19 Typical symptoms of CTS include pain, numbness and tingling in the thumb, index finger, middle finger and half of the ring finger. These symptoms are particularly strong at night or when the hand is kept in the same position for extended periods of time.20 Numerous studies have indicated that computer use is associated with MSDs in children. Harris and Straker21 reported that 60% of children complained of discomfort while using their laptops and a similar proportion experienced discomfort while carrying them. It was evident that children adopted a wide range of postures during laptop use, with the desk-sitting posture accounting for only one-third of usage time. Breen et al.22 also observed that children using computers at school adopted poor postures. Additionally, school computers may be shared by two or more children, particularly in the younger age groups. This implies that Journal of Paediatrics and Child Health 52 (2016) 590–594 © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
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the screen may be angled to one or more viewers, which has been shown to affect neck-shoulder muscle activity and is related to greater risk of developing MSDs.23 Another study has shown that a higher level of exposure to computer work results in higher risk of CTS. Ali and Sathiyasekaran24 reported that longer years of exposure as a computer professional and longer hours of computer use per day were risk factors for CTS. However, this study only focused on health problems for adult computer users, but there is sufficient evidence to warrant concern about the potential health risks posed to children and adolescents using different types of electronic devices.
Vision problems According to the American Optometric Association,25 a person who exceeds 2 h of computer use a day is at risk of CVS. CVS is caused by staring at a computer screen for long periods of time without taking a break, which leads to decreased blinking reflex and tightening of the inner eye muscles. Typical symptoms of CVS include eye irritation, such as red, itchy, watery or dry eyes; eye fatigue, including heaviness of the eyelids or forehead; and difficulty in focusing the eyes. Other symptoms of CVS are headaches, neck ache, back ache and muscle spasms. These symptoms can be further aggravated by improper lighting conditions or air moving past the eyes. Despite the large amount of literature available regarding musculoskeletal problems in young computer users, surprisingly little attention has been paid to the vision problems faced by children when using computers. A preliminary field study involving Scottish school children showed that those who did use a computer were 1.4 times more likely to fail a visual acuity screening test.26 Kinge et al.27 also claimed that intensive near-work could initiate myopia or lead to its progression in young adults, especially with regard to the time spent on near-work. Extensive viewing of near objects may strain the visual system and result in structural change of the eye, in particular refractive changes causing myopia.28 On the other hand, no research has yet confirmed that the use of computers will lead to, or worsen, short-sightedness among students.
Lifelong health problems Epidemiological studies in western countries have reported similar figures for MSDs and CVS between children and working adults.15 When children are exposed to health risk factors of ICT, it is possible that the harm may accelerate the subsequent onset of ICT-related injury.29 The development group for the European guidelines for prevention in low back pain pointed out that poor lifestyle habits and prolonged sitting during school age on non-ergonomic furniture might induce low back pain.30 A longitudinal study showed that low back pain during childhood was a risk factor for continuing muscle pain in adulthood.31 In another longitudinal study on a group of children in the age range of 8–14 years, symptoms of ICT-related back pain and headache persisted into their late 20s.32 It is, therefore, necessary to teach children to develop good postures and better computer work habits.14 591
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Direct Methods for Detecting Child Health Problems Posture and muscle activity by electromyography The first detailed comparisons of posture and muscle activity of children when reading books and using computers were conducted in Australia.33 The findings showed that the greatest deviation from the resting posture occurred when reading books, while the greatest electromyographic activity in the cervical erector spinae and upper trapezius muscles were observed when using a laptop computer. However, they did not consider the high display conditions commonly observed in children. The main limitation of their study was that the children did not interact fully with the IT, as the tasks involved in computer use only involved reading, without any typing or mouse clicking activites. Recent studies have focused on variations of posture and muscle activity in children performing interactive tasks that involve reading books and writing on paper, or reading from a computer monitor and inputting data using a mouse or keyboard.34,35 However, observations only spanned a short period of time, which may not have been long enough for participants to reach a steady-state performance. Moreover, changes in posture are likely to occur over longer time, as muscle extensibility changes and the accumulated effects of central and peripheral fatigue develop. Prolonged muscle and joint loading are well-known risk factors for the development of MSDs in adults and may be even more significant in children.36 Therefore, the long-term effects of computer-related activities on children’s health are warranted.
Median nerve characteristics by ultrasonography The diagnosis of CTS is based on combinations of characteristic symptoms and signs and electro-diagnostic studies.37 Although electro-diagnostic studies are highly specific,38 the false negativity falls between 10% to 20%.39 Electro-diagnostic studies can identify the level of the lesion or injury but do not provide any information about the median nerve and its surrounding structures. Nowadays, imaging studies have been proposed as an alternative to electrodiagnostic studies in the diagnosis of CTS. Magnetic resonance imaging, although relatively expensive, time consuming and not generally available, has been shown to be valuable in the diagnosis of CTS.40 Because of its advantages of being portable, non-invasive, non-ionising, inexpensive and easy-to-use, ultrasound imaging has been used to quantify the cross-sectional area of the median nerve as a criterion in the diagnosis of CTS.41,42 It has been successfully applied to study the changes of nerve functions and activities.43
Blink rate patterns by videography Blink reflex is one of the fastest reflexes in the body and is present at birth. However, blink rate varies with different activities. For example, the blink rate is faster when we are active and is slower when we are sedate or concentrating. Patel et al.44 observed that the mean blink rate during conversation was 18.4 blinks per min but dropped to 3.6 during computer use. Tsubota and Nakamori45 also reported that mean blink rate was 22 blinks per min under relaxed conditions, 10 blinks while reading a book at a table and only seven blinks while viewing text on a computer. Their results supported the fact that blink rates decreased when using computers. 592
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In many studies, blink rates were measured by analysing captured watcher’s facial videos. However, these external camcorder-based analyses limit the facial movements. Further research is suggested using a high quality video camera to improve accuracy.
Implications on Policy and Recommendations In many countries, health authorities provide guidelines for the use of computers, such as workstation configuration standards. Such guidelines include the international standard European ISO-9241, and national standards such as Australian AS-3590.2, Canadian Can/CSA-Z412-M89 and American ANSI/HFES-100, and Hong Kong Occupational Safety and Health (Display Screen Equipment) Regulation (Cap. 509B). In the past couple of decades, research and related guidelines have focused primarily on desktop and to a lesser extent, on laptop computers. Given the rapid pace of ICT advancement, it is difficult to keep these standards up-to-date. Newer forms of ICT such as tablet computers may not be adequately addressed in existing guidelines. In addition, published guidelines tend to consider the adult population only.28 For example, a key separation of 19 mm is typical for most keyboards and considered suitable for most adults, which is based on the recommendations of ISO 9241-410; however, this may be too wide for other users, such as children. Besides, existing guidelines are oriented towards work tasks and work environments, but computing tasks performed by children are different from the adult work tasks. For example, students may frequently have to look at a teacher and/or display board as well as the computer.28 Moreover, classrooms are traditionally designed for reading and writing. The classroom space and computer workstation dimensions may not be suitable for computer use. Several recent studies, therefore, have reported the inappropriateness of user-workstation dimensions in classrooms and poor ergonomic computer workstation design for child use at school.46,47 There is ample evidence to show that children are using computers at school, which are not suitable for their build.48 Because neck, upper back and lower back pains are associated with poorly designed school furniture,49 children, therefore, are at greater risk of muscle fatigue and discomfort when using computers in school. The impact would be even more far-reaching if students started using computers in primary schools. With regard to the negative impact on ICT use in education, recommendations for child-specific guidelines in computer use are of the utmost importance. Most children do not receive information about correct sitting behaviour, so they require sufficient education and instructions on these issues. Ergonomic training programmes should be implemented in the school curriculum in order to help raise students’ awareness of good posture when using computers. In addition, school furniture and workstations should be designed so as to be adjustable. It is important that appropriate training should be provided to enable them to adjust their furniture to the most comfortable position for their task and individual preference.50
Conclusion The use of ICT in education induces both positive and negative impact on young users. As children and adolescents are at the age of physical and behavioural development, excessive use of computers by students both at home and in school has raised health concerns Journal of Paediatrics and Child Health 52 (2016) 590–594 © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
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among parents, educators and health-care professionals. Therefore, in order to minimise the risk of adverse displacement of physical activity, a revision of existing child-specific policy and guidelines for computer use are strongly recommended.
Acknowledgement This study was supported by funding from the Department of Health Technology and Informatics, The Hong Kong Polytechnic University.
Multiple Choice Questions 1 What is this paper about? a) To provide a reflection on the deficits of existing policy and recommendations for child-specific guidelines in computer use. b) To provide a comprehensive framework for understanding the use of information and communication technology in education. c) To provide an in depth discussion of the impact of computer usage on students’ health and development. d) To provide a comprehensive description of the potential beneficial and harmful effects of computer use. e) To provide a comprehensive review of the epidemiological and laboratory studies on computer use by children. a) is the correct answer. The aim of this paper is to provide a reflection on the deficits of existing policy and recommendations for child-specific guidelines in computer use. b) is incorrect: this paper would like to provide a general framework for understanding the use of information and communication technology in education. c) is incorrect: this paper would like to provide a brief discussion of the impact of computer usage on students’ health and development. d) is incorrect: this paper would like to provide a brief description of the potential beneficial and harmful effects of computer use. e) is incorrect: this paper would like to provide a condensed, up to date, review of current research on computer use by children. 2 Which of the following is a limitation of the current research on children’s health problems? a) Research subjects did not interact with computer use which did not involve reading, typing or mouse clicking activity. b) Researchers observed the subjects over a long period of time, which may be time consuming. c) Little research has been conducted on the long-term effects of computer-related activities on children’s health. d) Small and non-probability sample of convenience. e) Measurements and intervention were made without blinding of the researchers to the subjects. c) is the correct answer. The limitation of the current research on children’s health problems is that little research has been conducted on the long-term effects of computer-related activities on children’s health. a) is incorrect: research subjects did not interact fully with the computer use that only involved reading, without any typing or mouse clicking activity. b) is incorrect: researchers only observed the subjects over a short period of time, which may not be long enough for participants to
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reach a steady-state performance. d) is incorrect: many previous studies had a large sample size using a simple random sampling. e) is incorrect: many previous studies had randomly assigned participants and had a standardised protocol by the researchers. 3 What do the authors suggest as further improvement of children’s computer usage? a) Future research regarding short-term effects of computer-related activities on children’s health is warranted. b) Parents should be aware of their children’s musculoskeletal and visual complaints. c) Parents should control their children’s computer use. d) Governments throughout the world should not promote the use of information and communication technology in education. e) A revision of existing child-specific policy and guidelines for computer use is recommended. e) is the correct answer. A revision of existing child-specific policy and guidelines for computer use is recommended by the authors for further improvement on children’s computer usage. a) is incorrect: future research regarding long-term effects of computerrelated activities on children’s health is warranted. b) is incorrect: education on teaching children to develop good postures and better computer work habits is recommended. c) is incorrect: parents should teach their children about the safe and healthy use of computer use rather than parental controls. d) is incorrect: it has become a global trend to employ information and communication technology as a medium for teaching and learning both inside and outside the classroom.
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