Parental perceptions, attitudes and knowledge on European preschool children’s total screen time: the ToyBox-study

Abstract

Background

Preschool children spend a significant proportion of their waking hours being sedentary. Parents play a critical role in developing and shaping their children’s lifestyle behaviours, particularly in the early years of life. This study aims to assess parental perceptions, attitudes and knowledge of their preschool children’s sedentary behaviours and the association with children’s television (TV)/video/DVDs viewing and total screen time.

Methods

Data were obtained from a sample of 4836 children (3.5–5.5 years), participating in the multi-centre ToyBox-study at baseline (T0) and at 1-year follow-up (T1) periods. Data on children’s sedentary behaviours were collected via a standardized proxy-administered primary caregiver’s questionnaire.

Results

Regarding total screen time, 66.6% of the children at T0 and 71.8% at T1 in the control group exceeded the recommendations, whereas the proportion in the intervention group varied from 69.7% at T0 to 72.5% at T1. The odds of exceeding total screen time recommendations were significantly higher when parental perceptions towards limiting the total screen time were negative [(both T0 and T1 and in the intervention and control groups (P < 0.05)]. Similarly, the odds of exceeding TV/video/DVDs viewing recommendations were significantly higher (both T0 and T1 is observed in both groups) when parental knowledge of recommendation were absent.

Conclusions

Preschool children whose caregivers stated rules limiting their sedentary screen time were less likely to spend a high amount of time watching TV/video/DVDs. Interventions to increase parental practices may be a promising approach to decrease total screen time of preschool children but studies are needed to confirm this.

Introduction

Childhood is a critical window of opportunity to influence lifestyle behaviours and health at early ages and their tracking into adulthood. Early childhood is a critical period to prevent obesity as key obesity-related behaviours like sedentary time develop during this stage. In fact, promoting a healthy diet and encouraging physical activity (PA) are some of the best options that can be made for personal well-being.¹ Preschool children spent a significant proportion of their time being sedentary² which is shown to be increasing with age.^3–5 Total screen time is the major contributor to the total sedentary screen time in children.⁶ Evidence shows that a high proportion of preschool children exceed recommendations for this specific age group i.e. maximum of 1 h day⁻¹.^7–9 Previous results of the ToyBox-study showed that 70% of preschool children from six European countries exceeded this recommendation^10,11 compared with low parental education levels who are at greater risk of exceeding the recommendations.¹²

Given that most of the time spend on watching television (TV) is done in the home environment,¹³ parents have an important role in their children’s screen-viewing habits. Hence, working with parents, as part of public health interventions, is essential to minimize their children’s sedentary screen time as family rules seem to be effective in reducing screen time.¹⁴ Some European studies reported that children from families with an authoritative parenting style of screen time were more likely to comply with screen time recommendations.^15,16 Parental knowledge of screen time recommendations for preschool children could be important to establish rules at home. However, there is limited research in this matter. A study in children of 2 years of age and below reported that parents with knowledge of screen time recommendations influenced their children’s habits i.e. children spent less time in front of a screen.¹⁷

To the authors’ knowledge, there are no studies in European preschool children that evaluated the longitudinal relationship between parental perceptions, attitudes and knowledge and its impact on children’s TV/video/DVDs viewing or total screen time. So, the objectives were: (i) to examine the cross-sectional association of parental perceptions, attitudes and knowledge of screen time recommendations with their children’s total screen time both at baseline and follow-up and (ii) to track parenting attitudes, perceptions and knowledge and children’s total screen time recommendations between T0 and T1and its association with children’s TV/video/DVDs viewing and total screen time at follow-up.

Methods

Study design

The ToyBox-study (www.toybox-study.eu) is a multicomponent, kindergarten-based, family-involved intervention with a cluster-randomized design aiming to prevent obesity in preschool children. It was conducted in six European countries namely Belgium, Bulgaria, Germany, Greece, Poland and Spain. The detailed protocol is described elsewhere.^18,19 In total, 309 kindergartens and 7056 children aged 3.5–5.5 years were recruited at baseline (T0) and 5529 children continued at follow-up (T1).²⁰ The ToyBox-intervention aimed to promote preschool children’s water consumption, healthy snacking, PA and limit/interrupt their sedentary screen time by improving the children’s physical and social environment both at the kindergarten and at home. For the purposes of this study, 4836 (69% of the T0 sample) preschool children were included with complete information from the parental questionnaire (i.e. Primary Caregivers’ Questionnaire) at T0 and T1. Data collection was carried out between May–June 2012 (T0) and May–June 2013 (T1). The selected kindergartens were randomly assigned as intervention or control at a 2:1 ratio. The ToyBox-study adhered to the Declaration of Helsinki and the conventions of the Council of Europe on human rights and biomedicine. In all countries, ethical approval was obtained from their respective ethical committees and local authorities. Parents provided a consent form for their child or children to participate.

Socioeconomic variables

Maternal education level (years of education) was recorded in five categories: (i) <7 years, (ii) 7–12 years, (iii) 13–14 years, (iv) 15–16 years and (v) >16 years of education. Re-categorized into the following categories for the purposes of this analysis: <7 years to 12 years, between 13 and 16 years and >16 years of education. The selection of this indicator was based on evidence as the most suitable proxy indicator of socioeconomic status in children.²¹

Anthropometric measures

Body weight was measured in underwear and without shoes using an electronic scale (Type SECA 861 or SECA 813) and body height was measured with a telescopic height instrument (Type SECA 225 or SECA 214) to the nearest 0.1 cm. Body mass index (BMI) was calculated as weight (kg) divided by squared height (m²). BMI z-scores (z-BMI) were computed and were used to classify children as having normal weight, overweight and obesity according to Cole et al.²² The intra- and inter-observer reliability for weight and height was excellent (greater than 99 and 98%, respectively) in all participating countries.²³

Parental perceptions and attitudes

Parental perceptions and attitudes were collected via a standardized proxy-administered parental questionnaire. Parents/caregivers were asked to answer the following statements: ‘Q1. My child’s TV viewing levels are within the appropriate recommendations’, ‘Q2. I think it is necessary to limit the screen-viewing activities for my child’ and ‘Q3. My child is allowed to watch TV for as long as he/she wants’. Original response categories can be found elsewhere²⁴ and re-categorized into the following three categories: ‘Disagree’, ‘Neither agree nor disagree’ and ‘Agree’.

For the purposes of the analysis and considering possible changes in parental perceptions, attitudes and knowledge between T0 and T1, nine groups were established reflecting differential combinations of the above questions (Q1, Q2 and Q3) as stated in table 2.

Lastly, parental knowledge about TV viewing recommendations was assessed through the question ‘Q4. I think that the recommendation for TV viewing for 4–6 years old children is’. Original response categories can be found elsewhere²⁴ and then were re-categorized into four categories: (i) ‘≤1 h day⁻¹’, (ii) ‘>1–≤3 h day⁻¹’, (iii) ‘>3 h day⁻¹’ and (iv) ‘I don’t know’. For the purpose of the longitudinal analysis, 10 possible combinations of Q4 were established as stated in table 2.

Sedentary behaviours

Data on children’s sedentary behaviours were collected via the standardized proxy-administered parental questionnaire. Parents indicated the frequency that their children watched TV/videos/DVDs and played computer/video games on a scale of: ‘never’, ‘<30 min day⁻¹’, ‘30 min day⁻¹ to 1 h day⁻¹’, ‘1–2 h day⁻¹’, ‘3–4 h day⁻¹’, ‘5–6 h day⁻¹’, ‘7–8 h day⁻¹’, ‘8 h day⁻¹’ and ‘>8 h day⁻¹’. Average hours per day of TV/video/DVD viewing and personal computer/video games were computed separately for weekdays and weekend days. To obtain the daily TV/video/DVDs viewing and personal computer/video games separately, average minutes per day, both for week and weekend days were summed up and divided by 7 days. To obtain the total daily screen time, the average minutes per day both TV/video/DVDs viewing and personal computer/video games were summed. Both variables (TV/video/DVDs viewing and total screen time) were further re-categorized into two groups including ≤1 h day⁻¹ (if children followed the recommendations) and >1 h day⁻¹ (if children did not follow the recommendations). These categories were based on the Australian, Canadian and recently from World Health Organization sedentary behaviour recommendations stating that preschool children should limit their screen time to maximum 1 h day⁻¹.^8,25,26

Statistical analysis

Statistical analyses were performed using the Statistical Package for the Social Sciences (version 21.0; SPSS, Inc.) except for the multilevel logistic regression model that was conducted using Stata/SE 13 (Stata Corp LP, College Station, TX, USA). Analyses were done for the whole sample, as there were no differences by sex, tested using a t-test for continuous variables and a chi-squared test for categorical variables. Analysis was performed separately by control and intervention group.

For the longitudinal analysis, analysis of covariance (ANCOVA) was used and marginal means and standard errors (SE) indicated differences in TV/video/DVDs viewing and total screen time by parental perceptions, attitudes and knowledge respective combinations indicated above. The analysis was adjusted for maternal education, z-BMI scores in T1, sex, age and centre. Finally, a multilevel logistic regression (level: centre) was performed. TV/video/DVD viewing or total screen time was considered as dependent variables and parental perceptions, attitudes and knowledge respective combinations as independent variables. Age, gender, z-BMI scores and maternal education at T1 were included as covariates into the analysis. All statistical tests and corresponding P-values lower than 0.05 were considered statistically significant.

Results

Table 1 provides information on age, gender, BMI categories, z-BMI scores, maternal education, country, TV/video/DVD viewing and total screen time both at T0 and T1 periods. According to BMI cut-offs, 8.9% of the total sample at T0 had obesity or overweight, whilst 9.4% of the total sample had obesity or overweight at T1. Regarding total screen time in the control group, 66.6% exceeded the recommendations at T0 and 71.8% at T1.

Table 1

Sample characteristics of included participants (n = 4836)

	T0			T1		P value
	Mean (SD)			Mean (SD)
Age	4.74 (0.4)			5.72 (0.4)		<0.001
	n (%)			n (%)
Sex
Boys	3827 (51.8)			3827 (51.8)		0.361
Girls	3562 (48.2)			3562 (48.2)
BMI statusa
Normal weight	4179 (56.5)			4136 (56.0)		<0.001
Overweight	514 (7.0)			516 (7.0)
Obesity	143 (1.9)			181 (2.4)		<0.001
z-BMI scores	0.20 (1.0)			0.27 (1.0)
	n (%)
Maternal education (years)
<7–12	1383 (18.7)					0.109
13–16	3055 (41.3)
>16	2607 (35.3)
Country
Belgium	1263 (17.1)					0.625
Bulgaria	917 (12.4)
Germany	1276 (17.3)
Greece	1768 (23.9)
Poland	1345 (18.2)
Spain	820 (11.1)
	Intervention group		Control group
	T0	T1		T0	T1
	n (%)	n (%)		n (%)	n (%)
TV/video/DVDs viewingb
≤1 h day−1	1045 (32.4)	1009 (31.05)		628 (36.1)	558 (32.2)	0.035
>1 h day−1	2178 (67.6)	2193 (68.5)		1110 (63.9)	1173 (46.9)
Total screen timeb
≤1 h day−1	966 (30.3)	874 (27.5)		574 (33.4)	482 (28.2)	0.011
>1 h day−1	2227 (69.7)	2301 (72.5)		1144 (66.6)	1229 (71.8)

a

BMI status according to Cole’s cut-off.²³

b

Recommendations on healthy eating and PA guidelines for early childhood settings in Australian, Canadian and World Health Organization.^7,8,26

BMI, body mass index; z-BMI, body mass index z-score; T0, baseline period; T1, follow-up period.

Derived from the ANCOVA analysis, figure 1 presents marginal means and SE of TV/video/DVD viewing and total screen time (minutes day⁻¹) according to perceptions, attitudes and knowledge of the parents both at T0 and T1. In general, preschool children with positive parental perceptions towards the independent variables and knowledge on recommendations spent less time in front of any screen both at T0 and T1 as opposed to less strict parenting practices and limited or no knowledge of recommendations.

Figure 1

ANCOVA between TV/video/DVDs viewing and total screen time (minutes/day) and parental perceptions, attitudes and knowledge both at T0 and T1. Abbreviations: T0, baseline period; T1, follow-up period; SE, standard error; TV, television; h, hour. ANCOVA was adjusted for maternal education, z-BMI scores, sex, age, and centre in T0 and T1, respectively.

Table 2 presents mean time of TV/video/DVDs viewing and total screen time according to combinations of changes for parental perceptions, attitudes and knowledge between T0 and T1, in both control and intervention groups. Children whose parents agreed with the statement [37.6 and 40.1% (intervention and control group, respectively)] that their children’s viewing levels were within the appropriate recommendations at both time points had significantly lower TV/video/DVDs viewing time in comparison with children whose parents did not agree. When asked if they thought that it was necessary to limit their children’s total screen time, only 8.2 and 11.4% (intervention and control group, respectively) of parents agreed. Those preschool children whose parents thought that it was not necessary to limit the total screen time at both T0 and T1, had significantly higher total screen time than those whose parents thought that it was necessary to limit it. The majority of the parents (80.90% intervention group and 83.87% control group) disagreed to allow their children watching TV for as long as they wish. Children with parents who do not allow them to watch TV for as long as they wish showed significantly lower TV/video/DVDs viewing time in comparison with those children whose parents had no rules about TV/video/DVDs viewing. Regarding the parental knowledge about TV/video/DVDs viewing recommendations, 66.45% (intervention group) and 67.57% (control group) of parents knew about it at both T0 and T1. This knowledge resulted in significantly lower TV/video/DVDs viewing time of their children as compared with those children whose parents were not aware of the recommendations.

Table 2

Analysis of covariance and multilevel logistic regression analysis by combinations of change for parental perceptions, attitudes and knowledge between at both time points (T0 and T1), in both intervention and control group, and its effects on TV viewing and screen time at T1

			Intervention group			Control group
T0		T1	n (%)	Mean (CI)a	OR (95% CI)b	n (%)	Mean (CI)a	OR (95% CI)b
Q1. My child’s TV viewing levels are within the appropriate recommendations
Q.1.1	Disagree	Disagree	163 (5.6)	148.5 (139.68; 157.44)	6.85 (3.86; 12.14)	71 (4.5)	154.8 (141.01; 168.66)	8.52 (5.57; 10.57)
Q.1.2	Disagree	Neither agree nor disagree	133 (4.5)	119.0 (109.13; 128.88)	3.38 (2.01; 5.67	70 (4.4)	116.3 (102.51; 130.11)	5.27 (2.48; 11.19)
Q.1.3	Disagree	Agree	89 (3.1)	84.4 (72.17; 96.65)	1.83 (1.07; 3.10)	46 (2.9)	89.4 (72.32; 106.39)	2.03 (0.97; 4.25)
Q.1.4	Neither agree nor disagree	Disagree	127 (4.3)	140.9 (130.83; 151.05)	6.39 (3.33; 12.24)	58 (3.7)	132.1 (117.17; 147.12)	9.51 (3.59; 25.18)
Q.1.5	Neither agree nor disagree	Neither agree nor disagree	575 (19.6)	109.2 (104.51; 113.95)	3.11 (2.37; 4.07)	300 (19.1)	104.8 (98.07; 111.53)	3.11(2.14; 4.50)
Q.1.6	Neither agree nor disagree	Agree	330 (11.3)	81.7 (75.43; 87.98)	1.34 (1.01; 1.79)	175 (11.1)	85.8 (77.14; 94.59)	1.76 (1.18; 2.63)
Q.1.7	Agree	Disagree	80 (2.7)	122.8 (109.73; 135.85)	8.33 (3.66; 18.95)	48 (3.0)	123.9 (106.73; 141.18)	9.38 (3.15; 27.93)
Q.1.8	Agree	Neither agree nor disagree	329 (11.2)	110.1 (103.74; 116.33)	3.01 (2.16; 4.19)	174 (11.2)	100.1 (91.24; 108.88)	2.76 (1.79; 4.27)
Q.1.9	Agree	Agree	1102 (37.6)	69.0 (65.54; 72.45)	Ref	631 (40.1)	70.5 (65.93; 75.16)	Ref
Q2. I think it is necessary to limit the screen-viewing activities for my child
Q.2.1	Disagree	Disagree	1447 (46.3)	119.5 (115.27; 123.74)	2.44 (2.27; 4.19)	762 (44.8)	114.5 (108.55; 120.42)	4.41 (2.11; 5.67)
Q.2.2	Disagree	Neither agree nor disagree	140 (4.4)	123.0 (109.28; 136.79)	0.85 (0.55; 1.32)	88 (5.2)	107.1 (89.63; 124.65)	0.83 (0.48; 1.41)
Q.2.3	Disagree	Agree	217 (6.9)	111.3 (100.34; 122.19)	0.59 (0.41; 0.83)	113 (6.6)	120.1 (104.53; 135.67)	0.95 (0.52; 1.67)
Q.2.4	Neither agree nor disagree	Disagree	124 (3.2)	94.3 (79.66; 108.89)	0.64 (0.41; 1.01)	57 (3.4)	128.0 (105.87; 150.67)	1.39 (0.66; 2.87)
Q.2.5	Neither agree nor disagree	Neither agree nor disagree	230 (7.3)	132.4 (121.79; 142.94)	0.95 (0.66; 1.37)	135 (7.9)	128.3 (113.94; 142.64)	1.30 (0.78; 2.17)
Q.2.6	Neither agree nor disagree	Agree	240 (7.7)	131.3 (121.02; 141.64)	1.12 (0.78; 1.56)	111 (6.5)	140.9 (125.28; 156.66)	1.20 (0.70; 2.05)
Q.2.7	Agree	Disagree	215 (6.9)	98.4 (87.39; 109.34)	1.65 (0.96; 2.91)	110 (6.5)	95.3 (79.65; 111.08)	0.67 (0.42; 1.08)
Q.2.8	Agree	Neither agree nor disagree	254 (8.1)	139.5 (129.51; 123.74)	1.10 (0.78; 1.56)	130 (7.6)	123.2 (108.99; 137.41)	0.77 (0.49; 1.19)
Q.2.9	Agree	Agree	256 (8.3)	91.3 (81.19; 101.43)	Ref	194 (11.4)	95.4 (82.19; 100.03)	Ref
Q3. My child is allowed to watch TV for as long as he/she wants
Q.3.1	Disagree	Disagree	2533 (80.9)	86.9 (84.57; 89.37)	Ref	1430 (83.8)	83.9 (80.80; 87.06)	Ref
Q.3.2	Disagree	Neither agree nor disagree	142 (4.5)	129.8 (119.51; 140.23)	1.38 (1.06; 4.18)	68 (3.9)	116.4 (102.31; 130.47)	1.50 (1.01; 5.40)
Q.3.3	Disagree	Agree	53 (1.6)	99.7 (82.74; 116.78)	0.80 (0.41; 1.55)	42 (2.4)	119.9 (101.19; 138.61)	1.10 (0.51; 2.38)
Q.3.4	Neither agree nor disagree	Disagree	142 (4.5)	107.1 (96.82; 117.38)	1.26 (0.79; 2.00)	57(3.3)	114.6 (98.60; 130.65)	6.98 (2.09; 23.34)
Q.3.5	Neither agree nor disagree	Neither agree nor disagree	89 (2.8)	120.2 (107.51; 132.97)	1.49 (0.81; 2.73)	34 (1.9)	146.3 (125.21; 167.33)	4.61 (1.03; 20.56)
Q.3.6	Neither agree nor disagree	Agree	21 (0.6)	118.7 (93.04; 121.30)	2.13 (0.61; 7.41)	10 (0.6)	90.4 (51.97; 128.76)	1.41 (0.26; 7.53)
Q.3.7	Agree	Disagree	78 (2.5)	107.5 (93.82; 121.30)	1.40 (0.75; 2.59)	36 (2.1)	109.5 (90.03; 128.98)	1.51 (0.63; 1.34)
Q.3.8	Agree	Neither agree nor disagree	39 (1.2)	137.5 (119.06; 156.98)	1.83 (0.63; 5.33)	15 (0.8)	125.2 (94.38; 156.07)	0.41 (0.13; 1.34)
Q.3.9	Agree	Agree	34 (1.1)	177.7 (156.21; 199.26)	4.85 (1.08; 10.11)	13 (0.7)	183.7 (151.79; 215.67)	1.92 (0.98; 4.51)
Q4. I think that the recommendation for TV viewing for pre-school children is
Q.4.1	≤1 h day−1	≤1 h day−1	1989 (66.4)	76.0 (73.43; 78.56)	Ref	1095 (67.4)	73.9 (70.51; 77.29)	Ref
Q.4.2	≤1 h day−1	>1–3 h day−1	328 (10.9)	123.0 (116.76; 129.29)	5.30 (3.51; 8.01)	184 (11.3)	114.3 (106.13; 122.44)	6.62 (3.78; 11.61)
Q.4.3	≤1 h day−1	>3 h day−1	11 (0.4)	157.1 (123.98; 190.32)	1.40 (0.36; 5.37)	5 (0.3)	112.1 (63.79; 160.53)	1.39 (0.85; 5.45)
Q.4.4	>1–3 h day−1	≤1 h day−1	267 (8.9)	110.5 (103.63; 117.38)	0.66 (0.51; 0.89)	114 (7.0)	111.2 (100.67; 121.68)	0.47 (0.38; 0.91)
Q.4.5	>1–3 h day−1	>1–3 h day−1	270 (9.0)	141.7 (134.71; 148.66)	7.20 (0.19; 12.39)	156 (9.6)	143.9 (134.68; 153.14)	11.44 (0.90; 26.68)
Q.4.6	>1–3 h day−1	>3 h day−1	17 (0.5)	260.3 (231.83; 288.78)	1.98 (0.67; 3.01)	14 (0.8)	214.5 (185.54; 243.47)	1.49 (0.88; 6.51)
Q.4.7	>3 h day−1	≤1 h day−1	29 (0.9)	88.1 (66.88; 109.26)	1.61 (0.66; 3.95)	11 (0.6)	95.2 (61.01; 129.37)	5.14 (0.63; 41.68)
Q.4.8	>3 h day−1	>1–3 h day−1	35 (1.2)	144.8 (125.63; 164.01)	4.27 (0.99; 13.09)	17 (1.1)	128.5 (101.44; 155.51)	3.31 (0.72; 15.05)
Q.4.9	>3 h day−1	>3 h day−1	17 (0.5)	200.6 (171.20; 230.10)	5.00 (0.63; 22.87)	8 (0.4)	224.3 (186.05; 262.53)	1.83 (1.11; 3.45)
Q.4.10	I don’t know	I don’t know	30 (1.0)	93.5 (72.33; 114.67)	1.65 (1.10; 4.01)	19 (1.2)	112.7 (87.22; 138.28)	1.59 (1.03; 2.33)

T0, baseline period; T1, follow-up period; OR, odds ratio; CI, confidence intervals; Ref, reference category, based on the healthiest option; h, hour.

a

ANCOVA was adjusted for maternal education, z-BMI in T1, sex, age and centre. Results are show in minutes per day of TV/video/DVDs (Q1, Q3 and Q4) or total screen time (Q2).

b

Multilevel logistic regression was adjusted for z-BMI at both T0 and T1, sex, age, maternal education and centre. All models of the multilevel logistic regression include random effects (country) to account for the study design. Statistically significant values are in bold.

Results from multilevel logistic regression analysis are also shown in table 2. The odds of exceeding the TV/video/DVDs viewing recommendations were significantly higher when parents disagreed with the statement (Q1) at both time points, and both intervention and control groups. The highest probability was found when parents agreed at T0 and disagreed at T1 for both intervention and control group (Q.1.7).

When parents asked if it was necessary to limit the total screen time for the children (Q2), the odds of exceeding the total screen time recommendations in preschool children were significantly higher when parents disagreed at both T0 and T1 for both intervention and control group (Q.2.1). Only in the intervention group, the odds of exceeding the total screen time recommendations were less if the parents did not set limit in the total screen time at T0 and yes at T1 (Q.2.3), compared with those who agreed to limit the total screen time at both time points.

Regarding the question if parents allowed watching TV/video/DVDs for as long as their children wished (Q3), the preschool children had significantly higher probability to exceed the recommendations when parents disagrees at T0 and neither agrees nor disagrees at T1 (Q.3.2), both intervention and control group. Only in the intervention group, the odds of exceeding the TV/video/DVDs viewing recommendations were significantly higher when parents agreed at both T0 and T1 (Q.3.9).

Finally, parents were asked about their knowledge on recommendations for TV/video/DVDs viewing for 4–6 years old children (Q4). The odds of complying with the recommendations were higher in those preschool children whose parents thought that the recommendations were ≤1 h day at T0 and >1 h to 3 h day⁻¹ at T1 (Q.4.2), both in the intervention and control groups. However, the odds of exceeding the TV/video/DVDs viewing recommendations were significantly lower in those preschool children whose parents thought that the recommendations were >1 –3 h day⁻¹ at T0 and ≤1 h day⁻¹ at T1 (Q.4.4), both in the intervention and control group. Only in the control group, the odds of exceeding TV/video/DVDs viewing recommendations were significantly higher when parents thought that the recommendations were >3 h day⁻¹ at both T0 and T1 (Q.4.9). Lastly, when parents did not know the recommendations, at both T0 and T1, preschool children were more likely to exceed the recommendations than those preschool children whose parents knew the recommendations.

Discussion

The novelty of this study includes examining the effect of paternal perceptions, attitudes and knowledge of TV/video/DVDs or total screen time on their children’s adherence to screen time recommendations, across a period of one year of follow-up in a large sample of European preschool children using the same harmonized methodology. The current results suggest that parental attitudes could boost or not a nurturing environment for TV/video/DVDs viewing and subsequently influence their children’s screen habits. For instance, more restricting rules or being conscious about screen time recommendations were associated with low TV/video/DVDs time in this sample of European preschool children.

Although TVs still appear to be the most common form of screen devices amongst children up to the age of six, playing computer/video games, tablets, and smartphones have become widely available. The combination of total screen time is an essential tool to assess overall sedentary screen time. In our sample, a high proportion of children did not meet individual total screen time recommendations at T0 and T1. The current findings are consistent with research from other countries that have previously reported high exposure to TV, computer and videos at young ages. For example, a Canadian study reported that 25% of children aged 2–5 watched >2 h of TV daily.²⁷ Another study observed that >80% of the Australian school children did not met their specific age recommendation of spending <2 h day⁻¹ using electronic media.²⁸ In European children (2–9 years), approximately a third of the children failed to meet recommendations²⁹ and in European adolescents, the proportion of them that watched TV more than 2 h day⁻¹, was 58% in males and 53% in females.³⁰

Our study found strong and consistent associations between child’s total screen time and parental rule setting practices. Parental limits and rules about TV or total screen time predicted less TV/video/DVDs viewing time in our sample. In preschool children from Netherlands, children from families with an authoritative parenting style had lower probability of exceeding screen time recommendations compared with families with a neglectful style indicating higher adherence to recommendations in children with established family screen time rules.¹⁵ Another study by Jago et al.³¹ reported that a greater proportion of children with permissive parents watched TV > 4 h day⁻¹ compared with children with authoritarian parents. An Australian study of preschool children reported that children whose parents limited TV viewing had significantly less time in total screen time.³² For all these reasons, improving parenting practices may be a promising approach to incorporate health promotion strategies aiming to reduce or delay the screen time in very young children.

There is consistent evidence showing that parental rules are associated with lower levels of total screen time.^33,34 Jago et al.³⁵, in a systematic review, identified seven types of rules as part of the parenting practices: (i) limits on total time; (ii) limits on time of day; (iii) content restriction; (iv) rules for no viewing during mealtimes; (v) rules for only allowing viewing when supervised by a parent; (vi) contingent screen time in which TV can only occur when other tasks, such as homework or exercise, have been completed and (vii) a no TV policy. Moreover, parental knowledge of the recommendations may impact parental decisions to set screen time rules for their children. In this sense, it is important to note that research assessing the relationship between parental knowledge of screen-viewing recommendations and total screen time in preschool children is scarce. Only a study carried out in Singapore¹⁷ researched the association between parental knowledge of screen-viewing recommendations and levels of screen viewing in young children. Findings showed that greater parental knowledge was associated with lower levels of screen viewing in children aged 2 years and below.

In our sample, significant differences between differential combinations of change in respect to parental perceptions, attitudes and knowledge between T0 and T1 and its effect on TV/video/DVDs and total screen time were observed. In this sense, conscious parental perceptions, attitudes and knowledge of recommendations and its effect on TV and total screen time can help to develop effective interventions for specific behaviours that are directly associated with non-communicable chronic diseases.³⁴

There are several limitations to our findings. First, generalizability of the findings is limited to the specific age group studied. Information on sedentary behaviours was collected via parental self-reported questionnaires, which are prone to over- or under-reporting. However, this questionnaire was developed/adapted and validated for the purposes of the study.³⁶ Nevertheless, this study has many strengths including the use of a large, culturally and socioeconomically diverse sample of preschool children from six different countries across Europe. The novelty of the results and the longitudinal design of the current analyses are also strengths, which increase the value of the results, especially at preschool ages.

Acknowledgements

The authors gratefully acknowledge the children and parents who participated in the ToyBox-study. They also acknowledge to the Seventh Framework Programme of the European Commission.

Funding

The project is funded by the Seventh Framework Programme (CORDIS FP7) of the European Commission under grant agreement number 245200. The content of this article reflects only the authors’ views, and the European Community is not liable for any use that may be made of the information contained therein.

Conflicts of interest: None declared.

Key points

• Preschool children whose parents have rules limiting sedentary screen time were less likely to spend high amount of time watching of TV/video/DVDs.

• Family rules related to screen time and higher parent’s knowledge about children’s TV viewing times recommendations can decrease preschool children’s total screen time.

• Improving parenting practices may be promising approaches in future interventions to decrease screen time.