International Journal of

Environmental Research
and Public Health

Article
Determinants of Excessive Screen Time among Children under
Five Years Old in Selangor, Malaysia: A Cross-Sectional Study
Diana Raj 1,2 , Norafiah Mohd Zulkefli 1 , Zalilah Mohd Shariff 3 and Norliza Ahmad 1, *

1 Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia,
Serdang 43400, Malaysia; [email protected] (D.R.); [email protected] (N.M.Z.)
2 Ministry of Health Malaysia, Putrajaya 62590, Malaysia
3 Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia,
Serdang 43400, Malaysia; [email protected]
* Correspondence: [email protected]; Tel.: +60-192710577

Abstract: Excessive screen time interferes with the health and development of children. However,
the screen time situation among Malaysian children remains poorly understood. This study aims to
identify the prevalence and determinants of excessive screen time among children under five years in
Selangor, Malaysia, using the latest World Health Organization guidelines. In this cross-sectional
study, 489 parent–child dyads were randomly selected from nine government health clinics in Petaling
district, Selangor. Total screen time and factors were assessed using validated self-administered
questionnaires and analysed using multiple logistic regression. The overall prevalence of excessive
screen time was 91.4% with a median of 3.00 h. The majority of children utilized television (66%),





 followed by handheld devices (30%) and computers (4%). Determinants of screen time identified
Citation: Raj, D.; Mohd Zulkefli, N.;
were Malay ethnicity, (aOR 3.56, 95% CI 1.65–7.68), parental age of ≥30 years (aOR 3.12, 95% CI
Mohd Shariff, Z.; Ahmad, N. 1.58–6.16), parental screen time >2 h a day (aOR 2.42, 95% CI 1.24–4.73), moderate self-efficacy to
Determinants of Excessive Screen influence a child’s physical activity (aOR 2.29, 95% CI 1.01–5.20) and the positive perception on the
Time among Children under Five influence of screen time on a child’s cognitive wellbeing (aOR 1.15, 95% CI 1.01–1.32). Parents play
Years Old in Selangor, Malaysia: A an important role in determining their child’s screen time. Future interventions should focus on
Cross-Sectional Study. Int. J. Environ. addressing parental determinants to ensure age-appropriate screen time.
Res. Public Health 2022, 19, 3560.
https://doi.org/10.3390/ijerph Keywords: screen time; child; television; parents; Malaysia
19063560

Academic Editors: E. Kipling

Webster, Amanda Staiano and
Michael J. Duncan 1. Introduction

Received: 22 January 2022

Screen time refers to the time spent on screen-based activities including television,
Accepted: 15 March 2022
smart phones, computers, tablets, video games and other handheld or visual devices [1].
Published: 17 March 2022
Currently, the Malaysian Dietary Guidelines for Children and Adolescents (2013) recom-
mends less than two hours of screen time for children in general, with no specific guidelines
Publisher’s Note: MDPI stays neutral
on screen time for children below five years of age [2]. However, in 2019, the World Health
with regard to jurisdictional claims in
Organization (WHO) recommended no screen time for children below the age of two,
published maps and institutional affil-
whilst those aged between two to below five should be limited to one hour per day [3].
iations.
Globally, around 70% to 90% of children aged below the age of five did not meet the
screen time guidelines [4–9]. Although excessive screen time is more prevalent among
children from developed countries than developing countries, the subject will need to be
Copyright: © 2022 by the authors.
interpreted with caution due to the scarcity of studies in the latter. Nonetheless, findings
Licensee MDPI, Basel, Switzerland. from a population-based study in India revealed that the prevalence of screen time among
This article is an open access article children below five was indeed high at 73% [10]. In Malaysia, the National Health and
distributed under the terms and Morbidity Survey (NHMS) conducted in 2016 using the older American Academy of
conditions of the Creative Commons Pediatrics (1999) guidelines revealed that 52.2% of children below five years old exceeded
Attribution (CC BY) license (https:// the two-hour screen-time limit, with 74% of them aged below two years and 32.6% aged
creativecommons.org/licenses/by/ between two to below five years [11]. However, the determinants of excessive screen time
4.0/). among these children were not explored, which could be essential in creating targeted

Int. J. Environ. Res. Public Health 2022, 19, 3560. https://doi.org/10.3390/ijerph19063560 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 3560 2 of 11

intervention programs. This figure is also expected to increase with the use of the latest
WHO guidelines due to stricter recommendations.
Children who exceed the screen time recommendation are classified as having exces-
sive screen time. This phenomenon has been largely exacerbated with the recent Coron-
avirus pandemic and multiple lockdowns imposed by the country. Excessive screen time
has been associated with higher risks of developmental delay, particularly language delay,
reduced physical activity, childhood obesity, hyperactivity-inattention, irritability, low
mood and disrupted cognitive and socioemotional development, leading to poor educa-
tional performance, as well as limiting children using their imagination or exploring the
world around them [10,12–14].
Although studies have been conducted to understand the factors associated with
excessive screen time, it has mainly focused on school-age children [15]. It is insufficient
to generalize evidence derived from older children to children aged below five years old
due to developmental differences, as well as different influences towards their sedentary
behaviours. Moreover, being a multicultural nation, a combination of cultural forces, and
environmental factors provide a complex matrix of parental beliefs and parenting styles
among Malaysian parents, which could also influence their child’s screen time. To the best
of our knowledge, there have been no studies exploring the factors associated with screen
time among children below five years in Malaysia. The aim of this study was to measure
the prevalence of excessive screen time among children below five years old in Selangor,
Malaysia, using the updated WHO 2019 guidelines, and to identify its determinants.

2. Materials and Methods

2.1. Study Sample
A cross-sectional study was conducted in the district of Petaling, Selangor, Malaysia.
Selangor is the most populated state in Malaysia, with the Petaling district home to the
highest number of children below five years old [16]. Data was collected from parent–
child dyads of children below five years old, who were recruited from nine child health
clinics between April and May 2019 using stratified sampling methods with a probability
proportionate to clinic size. Based on the appointment book, a list of children below and
above two years was made to ensure the sample was as representative of the population
as possible. This was in assumption that the attendance of children aged below two will
exceed those between two-five, due to the compulsory immunization schedule which stops
at 18 months. The number of children sampled from each category followed the Malaysian
population ratio of children aged below two and those aged between two to below five,
which was 40% and 60%, respectively. Subsequently, each respondent was selected using a
systematic sampling method, whereby the k interval of 14 was obtained by dividing the
population size with the sample size. The first patient was selected using a random number
generator, giving all respondents an equal chance of being selected. Children with any
physical, mental, or chronic diseases were excluded from the study. The sample size was
calculated using the two proportions method by Lawanga [17], based on previous studies
comparing proportions of excessive screen time per day among children with siblings (63%)
and without siblings (47%) [18]. A minimum sample size of 501 parents–child dyads was
obtained upon adjusting for non-response rate of 30%, with alpha levels set at 0.05 and beta
levels set at 0.20, respectively.

2.2. Study Variables

A validated and reliable questionnaire was used during data collection [19–25], whilst
height and weight measures were obtained from the child’s health record books. This
questionnaire was pretested among 50 parents of children below five years old at one of
the study sites; these samples were not included in the main study.
Int. J. Environ. Res. Public Health 2022, 19, 3560 3 of 11

2.3. Dependent Variable

Screen time: Parental report of the total screen time was adapted from a study by
Bernard et al. [26]. The child’s screen time per weekday and weekend were reported for
three types of devices; (1) television (including but not limited to videos, DVD’s, PlayStation,
Wii, Xbox), (2) computers (desktop and laptop) and (3) other handheld devices (including
but not limited to mobile phones, tablets, iPad’s, Gameboy), before being averaged to
obtain device-specific screen time in hours per day ([weekday × 5 + weekend day × 2]/7).
Total screen time was calculated as the sum of time for all three types of devices. Children
below two years old who had any screen time and children between two to below five years
of age who had more than one hour of screen time were considered as having excessive
screen time [3].

2.4. Independent Variable

Sociodemographic variables, including number of siblings and type of childcare set-
ting (homecare by parents, non-parental homecare and center-based care), were adapted
based on previous studies [18,27]. Body mass index (BMI) z-score was calculated based on
the height (m) and weight (kg) obtained from the child health record book. The physical
household environment was measured using three items, including the number of screen
devices present in the household, whether screen devices (televisions, computers or hand-
held device) were present in the child’s bedroom (yes/no) and the presence or absence
of outdoor play equipment [18,19,28]. Neighbourhood environment was assessed using
three items, including availability of public facility such as park or playground (yes/no)
for physical activity [29]. Perceived safety related to crime and perceived safety related to
pedestrian walking was assessed using an adapted questionnaire from the Neighbourhood
Environment Walkability Scale (NEWS) [20]. Responses ranged from (1) “strongly disagree”
to (5) “strongly agree”. Scores were averaged to obtain thresholds of safety. Each unit
increase in score revealed a lower threshold for both crime and pedestrian walking safety.
Internal consistency for perceived safety related to crime was 0.9, whilst safety related to
pedestrian walking was 0.8.
Parental attitude towards screen time was made up of 8 items adapted from Carson and
Jensen [19] and Asplund et al. [21], with responses ranging from (1) “strongly agree” to (5)
“strongly disagree”. Average score of above 3 was categorized as having positive attitude
while those scoring below 3 were classified as negative attitude. Internal consistency
of items in this study was 0.84. Parents were also asked to indicate their self-efficacy
in influencing their child’s physical activity level ranging from (1) “not confident” to
(5) “very confident”. Scores were summed up to create a ‘self-efficacy to reduce child’s
physical activity score scale’ and averaged to obtain the mean and median. A categorical
variable was then derived by splitting the scores into three groups which were “low”, (25th
percentile or less) “moderate” (between more than 25 to less than 75th percentile) and “high
self-efficacy” (75th percentile or more). These items had an internal consistency of 0.88 [22].
Parenting style was assessed using an adapted version of the Steinberg instrument [23].
Two parenting styles dimensions were measured, namely “involvement” and “strictness”
of parents. The involvement scale consisted of nine items with an internal consistency
of 0.75, whilst the strictness scale was made up of six items, with an internal consistency
of 0.78. Parents responded to the questions on a 5-point scale ranging from (1) “Strongly
disagree” to (5) strongly agree” for all 15 items. For interpretation purposes, parents were
categorized into the four parenting styles which is authoritative, authoritarian, indulgent
and neglectful based on median splits of the “involvement” and “strictness” scale.
Parents’ barriers to reduce screen time were obtained using a 6-item questionnaire
adapted from Carson and Jensen [19] with an internal consistency of 0.78. Items were rated
on a 5-point Likert scale ranging from (1) “Strongly disagree” to (5) strongly agree”. All
responses were averaged to create an overall barrier score, whereby each unit increase in
score reflected more barriers. Parents’ screen related restrictive practices were assessed
on a Likert scale of “1–5” adapted from Pearson et.al with internal consistencies ranging
Int. J. Environ. Res. Public Health 2022, 19, 3560 4 of 11

between 0.81 and 0.83 [24]. Scores were summed with each unit increase in scores indicating
more restrictive practices. Parents’ perception regarding the influence of screen time on
their child’s well-being was assessed based on 11 health aspects that were classified into
physical, cognitive and social wellbeing adapted from Hinkley et al. [25]. Questions were
rated on a “3-point scale” with “positive influence” given a score of “3”, “no influence”
given a score of “2” and “negative influence” given a score of “1”. One unit increase in
parental perception score indicated greater perception of positive influence of screen time
on child’s wellbeing. The internal consistency was 0.81.

2.5. Statistical Analysis

Analysis was conducted using the International Business Machines Statistical Package
for the Social Science version 25.0. Descriptive statistics were used to describe the sample
using frequency (n) and percentage (%) for categorical variable and mean and standard
deviation (SD) or median and interquartile range (IQR) for continuous variables. Pearson’s
chi-square test and simple logistic regression was used to determine the association between
excessive screen time and its associated factors. Potential predictors of excessive screen time
were screened to identify factors associated with excessive screen time in unadjusted models.
A total of 11 independent variables with a p value of less than 0.25 [30], including those
that were statistically significant, were chosen from the bivariate analysis to be included in
the multivariate analysis. Subsequently, multiple logistic regression was conducted using
the ‘Backward’ selection approach. Logistic regression included 95% confidence interval
(95% CI). Significance level was set at alpha less than 5%.

3. Results
Out of the 510 questionnaires distributed to eligible parents, 489 consented and com-
pleted the questionnaire, yielding a response rate of 96%. The overall prevalence of exces-
sive screen time among children below five years old in this study was 91.4%. Children
in this study spent an average of 3 h (IQR 1.36–5.04) per day watching screens, where the
majority spent time watching television (66%), followed by handheld devices (30%) and
computers (4%). The distribution of screen time among children aged below 2 years and
those aged be-tween 24–59 months is illustrated in Figure S1.
The mean age of parents in this study was 32.2 ± 0.2 years. More than half of them
earned a monthly household income of less than Ringgit Malaysia (RM) 5000 (56.6%) and
were employed (78.3%). Gender of the children who participated in the study were of
almost equal percentage, with 51.7% of them being male and were taken care for by their
parents only (56.4%). Table 1 shows the association between sociodemographic, household
and neighbourhood characteristics and screen time of the children. Older parents aged
30 years and above, children from the Malay ethnicity, presence of siblings, and having
outdoor play equipment for the child to play with were associated with excessive children’s
screen time.
Table 2 shows the association between parental factors and screen time, whereby
parents own screen time was significantly associated with their child’s excessive screen
time (p = 0.002).
The results of the multivariate analysis (Table 3) showed that children from the Malay
ethnicity were more likely to have excessive screen time (aOR = 3.56, 95% CI 1.65–7.68)
compared to other ethnicities. Children who had parents aged 30 years and above were
more likely to have excessive screen time (aOR = 3.12, 95% CI 1.58–6.16) as compared to
those who had parents aged less than 30 years. Parental screen time of more than 2 h a
day was the strongest modifiable predictor of excessive screen time among children aged
below five years (aOR = 2.42, 95% CI 1.24–4.73). Children whose parents had moderate
self-efficacy to influence a child’s physical activity were 2.3 times more likely to have
excessive screen time compared to parents who had higher self-efficacy (aOR = 2.29, 95%
CI 1.01–5.20). For one-unit increase in parental perception score of positive influence of
Int. J. Environ. Res. Public Health 2022, 19, 3560 5 of 11

screen time on their child’s cognitive wellbeing, there was a 1.2 unit increase in screen time
(95% CI 1.01–1.32).

Table 1. Association between sociodemographic, household and neighbourhood characteristics and

children screen time (n = 489).

Descriptive Statistics Bivariate Analysis

n (%)
Excessive Screen Low Screen χ2 B
p Value
Variable Time (%) Time (%) (df ) (95% CI)
Parents Age 10.65 (1) 0.001 c
<30 years 148 (30.3) 126 (85.1) 22 (14.9)
≥30 years 341 (69.7) 321 (94.1) 20 (5.9)
Parents Education 0.98
Level 0.001 (1)
Lower Education 164 (33.5) 150 (91.5) 14 (8.5)
Higher Education 325 (66.5) 297 (91.4) 28 (8.6)
Monthly Household 0.30
Income 1.09 (1)
less than RM 5000 277 (56.6) 250 (90.3) 27 (9.7)
RM 5000 and more 212 (43.4) 197 (92.9) 15 (7.1)
Employment status 0.002 (1) 0.97
Employed 383 (78.3) 350 (91.4) 33 (8.6)
Unemployed 106 (21.7) 97 (91.3) 9 (8.7)
Child’s Age 0.03 (1) 0.96
<24 months 258 (52.8) 236 (91.5) 22 (8.5)
24–59 months 231 (47.2) 211 (91.3) 20 (8.7)
Child’s Sex 1.9 (1) 0.17
Male 253 (51.7) 227 (89.7) 26 (10.3)
Female 236 (48.3) 220 (93.2) 16 (6.8)
Ethnicity 10.37 (1) 0.001 c
Malay 419 (85.7) 390 (93.1) 29 (6.9)
Non-Malay 70 (14.3) 57 (81.4) 13 (18.6)
Marital Status a 0.42
Married 483 (98.8) 442 (91.5) 41 (8.5)
Divorced/Widowed/ 6 (1.2) 5 (83.3) 1 (16.7)
Separated
Presence of Siblings 6.05 (1) 0.01 c
No 182 (37.2) 159 (87.4) 23 (12.6)
Yes 307 (62.8) 288 (93.8) 19 (6.2)
Childcare settings 1.26 (2) 0.53
Parental care only 276 (56.4) 249 (90.2) 27 (9.8)
Home based childcare 104 (21.3) 96 (92.3) 8 (7.7)
Childcare centers 109 (22.3) 102 (93.6) 7 (6.4)
BMI z-Score 0.33 (1) 0.57
Not overweight 416 (85.1) 379 (91.1) 37 (8.9)
Overweight/Obese 73 (14.9) 68 (93.2) 5 (6.8)
Total Gadgets at home a 0.99
<3 gadgets 35 (7.2) 32 (91.4) 3 (8.6) -
3 or more gadgets 454 (92.8) 415 (91.4) 39 (8.6)
TV in Bedroom 0.55 (1) 0.46
Yes 74 (15.1) 66 (89.2) 8 (10.8)
No 415 (84.9) 381 (91.8) 34 (8.2)
Outdoor Play
Equipment a 0.03 c
No 29 (5.9) 23 (79.3) 6 (20.7)
Yes 460 (94.1) 424 (92.2) 36 (7.8)
Public facility 0.57
(i.e., park) a
No 44 (9.0) 39 (88.6) 5 (11.4)
Yes 445 (91.0) 408 (91.7) 37 (8.3)
Crime Safety b 3.71 ± 0.04 0.81 (0.57–0.1) 0.23
Pedestrian safety b 3.13 ± 0.03 0.72 (0.45–1.18) 0.19
Values represent mean (SD) for continuous values; frequency and percentage for categorical values; a Fishers
exact test; b simple linear regression; c Significant at p < 0.05.
Int. J. Environ. Res. Public Health 2022, 19, 3560 6 of 11

Table 2. Association between parental factors and children screen time.

Descriptive Statistics Bivariate Analysis

Variable Excessive Screen Low Screen χ2 B
n (%) p Value
Time (%) Time (%) (df ) (95% CI)
Attitude towards screen
0.33 (1) 0.57
time
Negative 306 (37.4) 278 (90.8) 28 (9.2)
Positive 183 (62.6) 169 (92.3) 14 (7.7)
Parenting Style 0 (1) >0.99
Authoritative 163 (33.3) 149 (91.4) 14 (8.6)
Non authoritative 326 (66.7) 298 (91.4) 28 (8.6)
Self-Efficacy 4.89 (2) 0.09
Low SE 101 (20.7) 88 (87.1) 13 (12.9)
Moderate SE 274 (56.0) 257 (93.8) 17 (6.2)
High SE 114 (23.3) 102 (89.5) 12 (10.5)
Parental Screen Time 9.52 (1) 0.002 b
2 h or less 173 (35.4) 149 (86.1) 24 (13.9)
More than 2 h 316 (64.6) 298 (94.3) 18 (5.7)
Perception on
23.03 ± 0.24 1.03 (0.97–1.09) 0.27
wellbeing a
Physical 8.00 ± 4.0 0.99 (0.86–1.14) 0.88
Cognitive 10.0 ± 4.0 1.11 (0.98–1.26) 0.09
Social 6.0 ± 3.0 1.08 (0.92–1.27) 0.34
Barriers a 2.95 ± 0.03 0.83 (0.52–1.34) 0.45
Restrictive practices a 26.6 ± 0.17 1.04 (0.95–1.14) 0.39
Values represent mean (SD)/median [IQR] for continuous values, and frequency and percentage for categorical
values; a Simple linear regression; b Significant at p < 0.05.

Table 3. Determinants of excessive screen time among children below five years of age.

Variable a OR (95% CI) b p Value

aOR (95% CI)
Parent’s Age
<30 years 1 1
≥30 years 2.80 (1.48–5.31) 3.12 (1.58–6.16) 0.001 c
Ethnicity
Non-Malay 1 1
Malay 3.07 (1.51–6.24) 3.56 (1.65–7.68) 0.001 c
Parental Perception on influence of screen
1.13 (0.98–1.26) 1.15 (1.01–1.32) 0.04 c
time on child’s cognitive well-being
Parental Self-Efficacy to influence child’s
physical activity
High 1 1
Low 1.26 (0.55–2.89) 0.96 (0.40–2.31) 0.92
Moderate 2.23 (1.04–4.78) 2.29 (1.01–5.20) 0.047 c
Parent’s screen time
2 h or less 1 1
more than 2 h 2.67 (1.40–5.07) 2.42 (1.24–4.73) 0.01 c
a Simple logistics regression; b Multiple logistic regression; c Significant at p < 0.05; aOR = adjusted Odds Ratio.

4. Discussion
This study was conducted to assess the prevalence of excessive screen time among
children below five years of age and its determinants. Overall results indicate that more
than 90% of children below five years of age in Selangor, Malaysia exceeded the WHO
age-appropriate screen time limit. The prevalence is higher than studies conducted in
developed countries utilising similar guidelines such as Canada (62%) [31]. However,
meaningful comparisons between other countries are difficult due to the lack of uniformity
in guidelines prior to this. In our analysis, we found a positive association between
Int. J. Environ. Res. Public Health 2022, 19, 3560 7 of 11

excessive child’s screen time and parental factors—ethnicity, parental age, parental screen
time, parental self-efficacy to influence child’s physical activity and parent’s perception on
the positive influence of screen time on child’s wellbeing. These findings are consistent
with previous studies [28,32–34].
An interesting finding of this study is the role of ethnicity in a child’s screen time.
Children from the Malay ethnicity were more than three times likely to have excessive
screen time compared to other ethnicities. The fertility rate in 2018 for Malay women of a
childbearing age in Malaysia was 2.4 births per one thousand women, compared to those
of Indian and Chinese ethnicity with 1.3 and 1.1, respectively [35]. With the increased
participation of women in the labour workforce [36], having a large family in addition to
a job, family, and dual working parents, multitasking can be challenging. Furthermore,
adults within 30–45 years have been labelled as the sandwich generation, having to also
include elderly care into their duties. Adhering to the responsibility of providing care for
both children and the elderly, as emphasized by Malay culture, can increase stress among
caregivers [37]. This could explain why screens become a relief in childrearing among
the Malays.
In addition, screen time is also known to be inversely associated with levels of physical
activity [38]. Studies have shown that those of a Malay ethnic background were less likely
to engage in physical activities compared to other ethnicities [39,40]. In addition, the
parenting style and worry about their child’s safety has been shown to be a prominent
factor that influences Malay parents’ decisions. A study among Malaysian pre-schoolers
showed that a significantly higher proportion of Malay parents (49.9; 95% CI 44.2–55.7)
expressed worry about their child’s safety against crime and injury when participating
in physically active play, compared with Chinese parents (30.6; 95% CI 23.6–38.6) [41].
This in turn could be a potential contributor to the increase in Malay children resorting to
sedentary screen time activities indoors.
Children of older parents aged above 30 years were three times more likely to have
excessive screen time compared to those aged below 30 years. This was similar to findings
from a cohort study in Finland [42]. Maternal age has shown to have a significant influ-
ence on the parenting attitude and behaviours of mothers. Older mothers with previous
experience as a parent could also become more focused on other self-actualization activ-
ities beyond the home [43]. These could be reasons why older parents do not prioritize
good screen time parenting behaviours, leading to an increase in screen time among these
children. Furthermore, the majority of older parents in this study had more than one child
and there could be a possibility of needing a coping tool to meet the demands of raising
multiple children [44].
Parents played an important role in modelling behaviours to their children [34]. Stud-
ies have shown that parents who limit their own screen time have seen a significant
reduction in their child’s screen time as well. The Malaysian Communications and Mul-
timedia Commission reported that the percentage of Malaysian adults using the internet
via screens was 88.7%, with the majority spending 5–12 h per day [45]. Intriguingly, the
majority of them used screen time for social purposes instead of work-related activities,
with an increase in online gaming among 42.8% of users. Moreover, a large fraction of them
reported taking part in these activities within the home environment. Predictably, children
below five spend most of their time at home, observing the screen time behaviours of their
parents. This may explain parental screen time being one of the determinants of excessive
screen time among children below five years in this study.
Our finding on the association between parents’ self-efficacy to influence a child’s
physical activity and children’s excessive screen time was consistent with an Australian
study, whereby relatively lower self-efficacy was associated with the likelihood of an
increase in screen time [46]. A local study showed that Malaysian parents tend to display
higher self-efficacy when it comes to nurturing and responsiveness compared to only
moderate self-efficacy towards the establishment of routines and limited settings [47]. This
may explain why establishing routines such as screen time schedules might be a more
Int. J. Environ. Res. Public Health 2022, 19, 3560 8 of 11

difficult task for parents. Self-efficacy was also related to their psychological and emotional
states, whereby anxiety and stress would result in lower self-efficacy [48]. Likewise, more
than half of the participating parents reported having no confidence to influence their
child’s physical activity when they were feeling stressed.
When parents perceive that screen time can contribute to cognitive benefits, they tend
to encourage and not limit the time spent on screens, therefore giving their children more
access to screen devices [13]. However, parental perception on cognitive wellbeing in
this study did not play a significant role compared to previous studies [25,49], suggesting
that there may be other pressing reasons why parents allowed excessive screen time as
discussed above.
This study is among the first to use classifications from the recently published WHO
2019 children screen time guidelines [3]. It contributes to the lack of locally existing research
on excessive screen time among children aged below five years old in Malaysia, using
a wide range of variables. Data obtained in this study serves as a baseline for future
comparable or interventional research in this area. However, potential limitations need to
be noted. The cross-sectional nature of the study limits drawing inferences on cause and
effect. The use of self-administered questionnaires might have also led to inconsistency
with actual experience. Moreover, parental reports of their child’s screen time might be
subjected to recall bias of their child’s actual screen time. Parents may also be influenced
by social desirability, both in terms of their child’s screen time behaviour as well as to
present themselves in ways that they believe are expected of them as parents. This could
lead to under or over-reporting. Furthermore, given that this study was performed among
parents who completed their children’s health schedules in a particular district, findings
from this study need to be interpreted with caution in view of the limited generalizability to
other populations.

5. Conclusions
The main determinants for excessive screen time among children under-five years old
were ethnicity, parental age and other parental factors such as parent’s screen time, parent’s
self-efficacy to influence a child’s physical activity and parent’s perception of the influence
of screen time on a child’s well-being. Interventions that aim to address these factors may
foster healthy screen time habits in children.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/ijerph19063560/s1, Figure S1: Distribution of screen time among children below 5 years.
Author Contributions: Conceptualization, D.R., N.M.Z., Z.M.S. and N.A.; Data curation, D.R.,
N.M.Z. and N.A.; Formal analysis, D.R. and N.A.; Funding acquisition, N.A.; Investigation, D.R.;
Methodology, D.R., N.M.Z., Z.M.S. and N.A.; Project administration, N.A.; Resources, N.M.Z. and
N.A.; Software, D.R. and N.A.; Supervision, N.M.Z., Z.M.S. and N.A.; Validation, N.M.Z., Z.M.S. and
N.A.; Visualization, D.R. and N.A.; Writing—original draft, D.R.; Writing—review and editing, D.R.
and N.A. All authors have read and agreed to the published version of the manuscript.
Funding: This study was funded by the PUTRA IPM UNIVERSITY PUTRA MALAYSIA GRANT
(GP-IPM/2018/9640700). The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Committee of Ministry of Health Malaysia (NMRR-19-41-
45681/25 March 2019) as well as Ethics Committee for Research involving Human Subjects, University
Putra Malaysia (JKEUPM-2019-252/3 June 2019).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study with no personal identifying data published.
Data Availability Statement: Data supporting findings of this study are available upon reasonable
request to the corresponding author N.A.
Int. J. Environ. Res. Public Health 2022, 19, 3560 9 of 11

Acknowledgments: We would like to thank the Director General of Health Malaysia for his permis-
sion to publish this article. This work was funded by University Putra Malaysia under the Grant
Putra IPM.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Canadian Paediatric Society; Digital Health Task Force; Ottawa; Ontario. Screen time and young children: Promoting health and
development in a digital world. Paediatr. Child Health 2017, 22, 461–468. [CrossRef] [PubMed]
2. Ministry of Health Malaysia. Malaysian Dietary Guidelines for Children and Adolescents. Nutrition Division Ministry of Health
Malaysia. Putrajaya: Technical Working Group on Nutritional Guidelines. 2013. Available online: http://nutrition.moh.gov.my/
(accessed on 20 April 2020).
3. World Health Organization (WHO). Guidelines on Physical Activity, Sedentary Behaviour and Sleep for Children under 5 Years of Age:
Summary; World Health Organization: Geneva, Switzerland, 2019. Available online: https://www.who.int/publications/i/item/
-guidelines-on-physical-activity-sedentary-behaviour-and-sleep-for-children-under-5-years-of-age (accessed on 22 April 2020).
4. Poitras, V.J.; Gray, C.E.; Janssen, X.; Aubert, S.; Carson, V.; Faulkner, G.; Goldfield, G.S.; Reilly, J.J.; Sampson, M.; Tremblay, M.S.
Systematic review of the relationships between sedentary behaviour and health indicators in the early years (0–4 years). BMC
Public Health 2017, 17, 868. [CrossRef] [PubMed]
5. Carson, V.; Kuzik, N. Demographic correlates of screen time and objectively measured sedentary time and physical activity
among toddlers: A cross-sectional study. BMC Public Health 2017, 17, 187. [CrossRef] [PubMed]
6. Duch, H.; Fisher, E.M.; Ensari, I.; Harrington, A. Screen time use in children under 3 years old: A systematic review of correlates.
Int. J. Behav. Nutr. Phys. Act. 2013, 10, 102. [CrossRef] [PubMed]
7. Goh, S.N.; Teh, L.H.; Tay, W.R.; Anantharaman, S.; Dam, R.M.V.; Tan, C.S.; Chua, H.L.; Wong, P.G.; Riemenschneider, F.M.
Sociodemographic, home environment and parental influences on total and device-specific screen viewing in children aged 2
years and below: An observational study. BMJ Open 2016, 6, e009113. [CrossRef]
8. Tremblay, M.; Barnes, J.; Vanderloo, L. Canadian Kids Need to Move More to Boost Their Brain Health. Alberta Centre for Active Living;
WellSpring: Toronto, ON, Canada, 2018. Available online: https://www.activehealthykids.org/wp-content/uploads/2018/11/
canada-report-card-long-form-2018.pdf (accessed on 5 May 2020).
9. Zimmerman, F.J.; Christakis, D.A.; Meltzoff, A.N. Television and DVD/video viewing in children younger than 2 years. Arch.
Pediatr. Adolesc. Med. 2007, 161, 473–479. [CrossRef] [PubMed]
10. Varadarajan, S.; Venguidesvarane, A.G.; Ramaswamy, K.N.; Rajamohan, M.; Krupa, M.; Christadoss, S.B.W. Prevalence of
excessive screen time and its association with developmental delay in children aged <5 years: A population-based cross-sectional
study in India. PLoS ONE 2021, 16, e0254102. [CrossRef] [PubMed]
11. Institute of Public Health. National Health and Morbidity Survey 2016: Maternal and Child Health (MCH) Volume II: Maternal and Child
Health Findings; Institute for Public Health: Kuala Lumpur, Malaysia, 2016. Available online: http://iku.moh.gov.my/nhms-2016
(accessed on 18 April 2019).
12. Hosokawa, R.; Katsura, T. Association between mobile technology use and child adjustment in early elementary school age. PLoS
ONE 2018, 13, e0199959. [CrossRef] [PubMed]
13. Cheng, S.; Maeda, T.; Yoichi, S.; Yamagata, Z.; Tomiwa, K.; Japan Children’s Study Group. Early Television Exposure and
Children’s Behavioral and Social Outcomes at Age 30 Months. J. Epidemiol. 2010, 20 (Suppl. S2), S482–S489. [CrossRef]
14. Rideout, V.; Hamel, E. The Media Family: Electronic Media in the Lives of Infants, Toddlers, Preschoolers and their Parents; Henry
J. Kaiser Family Foundation: Menlo Park, CA, USA, 2006. Available online: https://www.kff.org/other/the-media-family-
electronic-media-in-the/ (accessed on 20 April 2020).
15. Hinkley, T.; Salmon, J.; Okely, A.D.; Trost, S.G. Correlates of sedentary behaviours in preschool children: A review. Int. J. Behav.
Nutr. Phys. Act. 2010, 7, 66. [CrossRef]
16. Department of Statistics Malaysia. Children Statistics Malaysia. 2017. Available online: https://www.dosm.gov.my/v1/index.
php?r=column/pdfPrev&id=WGlmVnppZ2J6b2hGZHFQMmxWQ2UwUT09 (accessed on 12 November 2018).
17. Lwanga, S.K.; Lemeshow, S.; World Health Organization. Sample Size Determination in Health Studies: A Practical Manual. 1991.
Available online: https://apps.who.int/iris/handle/10665/40062 (accessed on 21 May 2020).
18. Chandra, M.; Jalaludin, B.; Woolfenden, S.; Descallar, J.; Nicholls, L.; Dissanayake, C.; Williams, K.; Murphy, E.; Walter, A.;
Eastwood, J.; et al. Screen time of infants in Sydney, Australia: A birth cohort study. BMJ Open 2016, 6, e012342. [CrossRef]
19. Carson, V.; Janssen, I. Associations between factors within the home setting and screen time among children aged 0–5 years:
A cross-sectional study. BMC Public Health 2012, 12, 539. [CrossRef]
20. Prado, C.V.; Rech, C.R.; Hino, A.A.F.; Reis, R.S. Perception of neighbourhood safety and screen time in adolescents from Curitiba,
Brazil. Rev. Bras. Epidemiol. 2017, 20, 688–701. [CrossRef]
21. Asplund, K.M.; Kair, L.R.; Arain, Y.H.; Cervantes, M.; Oreskovic, N.M.; Zuckerman, K.E. Early Childhood Screen Time and
Parental Attitudes toward Child Television Viewing in a Low-Income Latino Population Attending the Special Supplemental
Nutrition Program for Women, Infants, and Children. Child. Obes. 2015, 11, 590–599. [CrossRef]
Int. J. Environ. Res. Public Health 2022, 19, 3560 10 of 11

22. Smith, B.J.; Grunseit, A.; Hardy, L.L.; King, L.; Wolfenden, L.; Milat, A. Parental influences on child physical activity and screen
viewing time: A population-based study. BMC Public Health 2010, 10, 593. [CrossRef]
23. Veldhuis, L.; Van Grieken, A.; Renders, C.M.; HiraSing, R.A.; Raat, H. Parenting style, the home environment, and screen time of
5-year-old children; the “be active, eat right” study. PLoS ONE 2014, 9, e88486. [CrossRef]
24. Pearson, N.; Salmon, J.; Crawford, D.; Campbell, K.; Timperio, A. Are parental concerns for child TV viewing associated with
child TV viewing and the home sedentary environment? Int. J. Behav. Nutr. Phys. Act. 2011, 8, 102. [CrossRef]
25. Hinkley, T.; Carson, V.; Kalomakaefu, K.; Brown, H. What mums think matters: A mediating model of maternal perceptions of
the impact of screen time on preschoolers’ actual screen time. Prev. Med. Rep. 2017, 6, 339–345. [CrossRef]
26. Bernard, J.Y.; Padmapriya, N.; Chen, B.; Cai, S.; Tan, K.H.; Yap, F.; Shek, L.; Chong, Y.S.; Gluckman, P.D.; Godfrey, K.M.; et al.
Predictors of screen viewing time in young Singaporean children: The GUSTO cohort. Int. J. Behav. Nutr. Phys. Act. 2017, 14, 112.
[CrossRef]
27. Tandon, P.S.; Zhou, C.; Lozano, P.; Christakis, D.A. Preschoolers’ total daily screen time at home and by type of childcare.
J. Pediatr. 2011, 158, 297–300. [CrossRef]
28. Jago, R.; Sebire, S.J.; Edwards, M.J.; Thompson, J.L. Parental TV viewing, parental self-efficacy, media equipment and TV viewing
among preschool children. Eur. J. Pediatr. 2013, 172, 1543–1545. [CrossRef]
29. Downing, K.L.; Hinkley, T.; Hesketh, K.D. Associations of Parental Rules and Socioeconomic Position with Preschool Children’s
Sedentary Behaviour and Screen Time. J. Phys. Act. Health 2015, 12, 515–521. [CrossRef] [PubMed]
30. Hosmer, D.; Lemeshow, S. Applied Logistic Regression, 2nd ed.; John Wiley & Sons: Hoboken, NJ, USA, 2000; ISBN 0-471-35632-8.
31. Pujadas Botey, A.; Bayrampour, H.; Carson, V.; Vinturache, A.; Tough, S. Adherence to Canadian physical activity and sedentary
behaviour guidelines among children 2 to 13 years of age. Prev. Med. Rep. 2016, 3, 14–20. [CrossRef] [PubMed]
32. Chiu, Y.C.; Li, Y.F.; Wu, W.C.; Chiang, T.L. The amount of television that infants and their parents watched influenced children’s
viewing habits when they got older. Acta Paediatr. 2017, 106, 984–990. [CrossRef] [PubMed]
33. Jago, R.; Thompson, J.L.; Sebire, S.J.; Wood, L.; Pool, L.; Zahra, J.; Lawlor, D.A. Cross-sectional associations between the screen-
time of parents and young children: Differences by parent and child gender and day of the week. Int. J. Behav. Nutr. Phys. Act.
2014, 11, 54. [CrossRef] [PubMed]
34. Schoeppe, S.; Vandelanotte, C.; Bere, E.; Lien, N.; Verloigne, M.; Kovacs, E.; Manios, Y.; Bjelland, M.; Vik, F.N.; Lippevelde, W.V.
The influence of parental modelling on children’s physical activity and screen time: Does it differ by gender? Eur. J. Public Health
2016, 27, 152–157. [CrossRef] [PubMed]
35. Jegasothy, R.; Sengupta, P.; Dutta, S.; Jeganathan, R. Climate change and declining fertility rate in Malaysia: The possible
connexions. J. Basic Clin. Physiol. Pharmacol. 2021, 32, 911–924. [CrossRef] [PubMed]
36. World Bank. Labor Force, Female (% of Total Labor Force-Malaysia). Available online: https://data.worldbank.org/indicator/SL.
TLF.TOTL.FE.ZS?locations=MY (accessed on 8 February 2022).
37. Noor, S.; Isa, F.M. Malaysian sandwich generation issues and challenges in elderly parents care. Int. Multidiscip. J. Soc. Sci. 2020,
9, 289–312. [CrossRef]
38. Dutra, G.F.; Kaufmann, C.C.; Pretto, A.D.; Albernaz, E.P. Television viewing habits and their influence on physical activity and
childhood overweight. J. De Pediatr. 2015, 91, 346–351. [CrossRef]
39. Teh, C.H.; Lim, K.K.; Chan, Y.Y.; Lim, K.H.; Azahadi, O.; Akmar, H.; Nadiah, Y.U.; Syafinaz, M.S.; Kee, C.C.; Yeo, P.S.; et al.
The prevalence of physical activity and its associated factors among Malaysian adults: Findings from the National Health and
Morbidity Survey 2011. Public Health 2014, 128, 416–423. [CrossRef] [PubMed]
40. Lee, S.T.; Wong, J.E.; Shanita, S.N.; Ismail, M.N.; Deurenberg, P.; Poh, B.K. Daily physical activity and screen time, but not other
sedentary activities, are associated with measures of obesity during childhood. Int. J. Environ. Res. Public Health 2015, 12, 146–161.
[CrossRef]
41. Lee, S.T.; Wong, J.E.; Ong, W.W.; Ismail, M.N.; Deurenberg, P.; Poh, B.K. Physical Activity Pattern of Malaysian Preschoolers:
Environment, Barriers, and Motivators for Active Play. Asia-Pac. J. Public Health 2016, 28, 21S–34S. [CrossRef]
42. Matarma, T.; Koski, P.; Löyttyniemi, E.; Lagström, H. The factors associated with toddlers’ screen time change in the STEPS Study:
A two-year follow-up. Prev. Med. 2016, 84, 27–33. [CrossRef]
43. Grady, G.; McCarthy, A.M. Work-life integration: Experiences of mid-career professional working mothers. J. Manag. Psychol.
2008, 23, 599–622. [CrossRef]
44. Nikken, P. Parents’ Instrumental use of Media in Childrearing: Relationships with Confidence in Parenting, and Health and
Conduct Problems in Children. J. Child Fam. Stud. 2019, 28, 531–546. [CrossRef]
45. Malaysian Communications and Multimedia Commission. Internet Users Survey 2020. In Malaysian Communications and
Multimedia Commission; Cyberjaya: Selangor, Malaysia, 2021. Available online: https://www.mcmc.gov.my/skmmgovmy/
media/General/pdf/IUS-2020-Report.pdf (accessed on 3 March 2021).
46. Jones, C.J.; Smith, H.; Llewellyn, C. Evaluating the effectiveness of health belief model interventions in improving adherence:
A systematic review. Health Psychol. Rev. 2014, 8, 253–269. [CrossRef]
47. Hashmi, S.I.; Nawi, N.H.M.; Seok, C.B.; Halik, M.H. “Am I A Super Mom”, Malaysian Working Mothers Believes about Their Parenting
Self-Efficacy; UMS: Kota Kinabalu, Malaysia, 2014. Available online: https://www.ums.edu.my/fpp/images/download/
proseding_skik2014/Shazia_Iqbal_Hashmi.pdf (accessed on 16 May 2019).
Int. J. Environ. Res. Public Health 2022, 19, 3560 11 of 11

48. Wittkowski, A.; Garrett, C.; Calam, R.; Weisberg, D. Self-Report Measures of Parental Self-Efficacy: A Systematic Review of the
Current Literature. J. Child Fam. Stud. 2017, 26, 2960–2978. [CrossRef]
49. Hesketh, K.D.; Hinkley, T.; Campbell, K.J. Children’s physical activity and screen time: Qualitative comparison of views of
parents of infants and preschool children. Int. J. Behav. Nutr. Phys. Act. 2012, 9, 2960–2978. [CrossRef]