The Journal of School Nursing2021, Vol. 37(6) 421–430© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519881185journals.sagepub.com/home/jsn
The purpose of the study was to describe adherence to screen time (ST) and physical activity (PA) recommendations among Canadian youth. The present study was based on a representative sample of Canadian students from Grades 7 through 12 (N = 47,203). ST and PA as well as demographic (gender, ethnicity, grade, and province of residence) and individual (alcohol, tobacco and cannabis usage, school connectedness) correlates were self-reported by youth. In total, 49.2% (99% confidence interval [CI] = [46.3%, 52.2%]) of participants respected none of the recommendations, while 40.2% (99% CI [37.0%, 43.3%]) and 20.8% (99% CI [19.2%, 22.4%]) respected PA or ST recommendations, respectively. In terms of the correlates of health-related behavior, White ethnicity, alcohol use, and feeling more connected to school were positively correlated with adherence. Attending school in Quebec and smoking cannabis increased risk of poor compliance. The present findings may help the design of school-based health promotion strategies designed to increase PA and reduce ST.
screen time, physical activity, guidelines, health-related behavior, school connectedness, school nursing
Poor lifestyle habits during adolescence can pave the way for poor heath in adulthood creating a pattern that is costly for both the individual and society. For instance, adolescent sedentary behavior contributes to the development of chronic metabolic disease, reduced fitness, lower self-esteem, and depressive symptoms (Colley et al., 2013; Liu, Wu, & Yao, 2016; Tremblay, Colley, Saunders, Healey, & Owen, 2010). Although all forms of sedentary behavior may present health risks, screen time (ST) may be particularly detrimental because it has been additionally linked to a range of health, socioemotional, and academic impairments (Faught et al., 2017; Herman, Hopman, & Sabiston, 2015; Pagani, Fitzpatrick, Barnett, & Dubow, 2010). Independent of time spent sedentary, the amount of physical activity (PA) youth engage in, has also been linked to better mental and physical health outcomes, especially when the activity is of moderate to high intensity (Biddle & Asare, 2011; Janssen & LeBlanc, 2010).
Unfortunately, research suggests that a large proportion of Canadian youth fail to engage in enough PA and spend too much time with screens (Janssen, Roberts, & Thompson, 2017). Estimates suggest that between 50% and 80% of Canadian youth between the ages of 11 and 17 exceed the recommended maximum of 2 hr of daily ST beyond school work, while 31.2% fail to achieve the minimum daily recommendation of 1 hr per day of PA (Leatherdale & Ahmed, 2011; Leatherdale & Rynard, 2013). The Canadian Society for Exercise Physiology’s most recent guidelines further emphasize the importance of jointly examining youth adherence to ST and PA recommendations (Tremblay et al., 2016). In particular, youth who simultaneously exceed recommendations of ST and fail to meet recommendations of PA may be of specific interest as they are exposed to a “double dose” of risk.
In order to develop effective targeted interventions, it remains important to understand which adolescents are most at risk of engaging in excessive ST and insufficient PA or a combination of both. Earlier data suggest boys are more active than girls (Colley et al., 2013). Ethnicity whether defined in terms of race or immigration status has been found to contribute to health habits in American and European youth. For instance, White American youth have been found to participate in less moderate to vigorous physical activity (MVPA) than Hispanic and Black youth. Other research indicates that European immigrant youth may be at greater risk of becoming overweight or obese (Belcher et al., 2010; Brug et al., 2012; Wang, Gortmaker, & Taveras, 2011). School connectedness reflecting engagement in learning and attachment to teachers and peers has been positively associated with PA involvement and inversely related to youth propensity for early drug use and risky sexual behavior (Bond et al., 2007; McNeely, Nonnemaker, & Blum, 2002). However, research has yet to examine if school connectedness is also related to adolescent patterns of ST. Finally, in the aftermath of the legalization of marijuana in Canada, it remains of interest to examine the extent to which cannabis-using adolescents may represent an at-risk group for poor health behavior.
In the present study, we provide an updated portrait of health behavior in Canadian youth using a nationally representative sample from 2012 to 2013. As a first objective, we describe the weighted distribution of Canadian adolescents meeting ST and PA recommendations across sociodemographic and psychological characteristics. As a second objective, we examine how these characteristics correlate with ST and PA habits.
The design of the present study was cross sectional and involved analysis of secondary data from the Canadian Student Tobacco, Alcohol and Drugs Survey, formerly the Youth Smoking Survey. This national Canadian classroom–based survey was designed to better understand adolescent health-related behavior. This project was approved by the Office of Research Ethics at the University of Waterloo, Health Canada’s Research Ethics Board, and all School board ethics review committees.
Health region smoking rate and school type were used to stratify the population in order to draw a random sample of schools. The final stratified random sample for the 2012/2013 survey included 47,203 students from public, private, or Catholic schools in all Canadian province except for Manitoba, which chose not to participate. Schools in Canada’s northern territories were excluded from the survey for feasibility reasons. Lists of all schools in the participating provinces were provided by the Department of Education of each province. In total, of the 222 school boards approached, 127 (57%) participated. Participation of school boards ranged from 48% in British Columbia to 100% in the Atlantic Provinces, while school participation rates ranged from 38% in Ontario to 96% in Newfoundland (NFL) and Labrador. The overall student participation rate was 72%. In the present study, only students in Grades 7–12 were included, and only respondents with complete data for all covariates and the outcome variable were included in the regression analysis, resulting in a sample of 37,379.
Teachers received instructions on how to administer the questionnaires. Students completed the survey in the classroom within 35 min and were not rewarded for their participation. Provincial site coordinators oversaw school recruitment and data collection in each province.
Dependent variables: Daily ST and PA. Students reported the number of hours per day they spent (1) watching TV shows or videos, (2) playing video/computer games, and (3) surfing the Internet on a computer (not for homework). For each type of media, survey options included: none, less than an hour a day, 1–2 hr a day, more than 2 but less than 5 hr a day, and 5 or more hr a day. Responses were converted into scores for each type of media activity. Our approach involved using the midpoint for each response range, with the exception of “5 or more hr a day,” where a more conservative score of 5 was used. Total ST scores were then dichotomized into ≤2 hr/day or >2 hr/day to reflect Canadian ST recommendations.
Student participation in moderate to vigorous PA was assessed by asking respondents about the number of minutes they engaged in PA that made them “sweat, breathe harder, or be out of breath” during the previous week. After computing a total number of minutes per week for each participant, total scores were converted to hours and dichotomized as either <1 hr/day or ≥1 hr/day to reflect the Canadian recommendations for youth PA.
To better describe different profiles of at-risk health-related behavior, we created four groups of youth based on their ST and PA: (1) adheres to both screen and PA recommendations, (2) adheres to ST recommendations only, (3) adheres to PA recommendations only, and (4) adheres to neither ST nor PA recommendations.
Correlates of health-related behavior. Well-known correlates of both health outcomes were included in the analysis. Demographic variables were province of residence, sex, high school grade, and ethnicity. Province of residence was derived by the research team based on school location. Students self-reported sex as female or male and selected their grade from Grades 7 to 12 or from Secondary I through V for students enrolled in a school in the province of Quebec. Finally, participants indicated ethnicity by selecting from the following options: White, Black, Asian, Aboriginal (First Nations, Métis, Inuit), Latin American/Hispanic, or Other. Each of these variables was dummy coded to reflect the number of levels of each variable.
School connectedness, referring to youth’s sense of closeness and attachment to people at school and the school environment, was computed from the following items: I feel close to people at my school, I feel I am part of my school, I am happy to be at my school, I feel the teachers at my school treat me fairly, I feel safe in my school, and getting good grades is important to me (Bonny, Britto, Klostermann, Hornung, & Slap, 2000). Students evaluated each item on a Likert-type scale from 1 (strongly agree) to 4 (strongly disagree), α = .82.
Finally, three substance use behaviors were assessed. Binge drinking was derived from participants’ response to the following question: In the last 12 months, how often did you have five drinks of alcohol or more on one occasion? Participants reporting any binge drinking in the past 12 months were then scored as 1 and those who didn’t were scored as 0.
Smoking status was dichotomized as 0 for nonsmoker and 1 for current or former smokers having consumed more than 100 cigarettes in their life. Finally, participants answered the following question regarding cannabis use: In the last 12 months, how often did you use marijuana or cannabis (a joint, pot, weed, hash)? Given that the frequency distribution of this variable was skewed, participant responses were scored to reflect 0 (no cannabis use) or 1 (some use).
Descriptive statistics were generated to produce prevalence estimates of meeting guidelines for daily ST and PA overall in Canada, across provinces, and across selected sociodemographic factors. Next, multivariate logistic regression models were estimated to examine the odds of being in each of the following groups: (1) meets ST and PA recommendations; (2) meets PA recommendations only; and (3) meets ST recommendations only, as compared to the odds of meeting neither recommendations. Models were estimated with the following covariates: sex, province: grade, ethnicity, school connectedness, binge drinking, smoking status, and Cannabis use.
All analyses were conducted with bootstrap weights. This allowed us to calculate variances that took into account the sample design, including the fact that the respondents are clustered into schools. Survey weights were calculated in two steps. First, a weight was calculated to account for school selection within each health region and school strata. A second weight was computed to account for student nonresponse. Both weights were calibrated according to the demographics (age, sex, and grade) of each province (Burkhalter, Cumming, Rynard, & Manske, 2013). To reduce the chances of Type 1 error, we adopted a 99% confidence interval (CI) for all our estimates. All analyses were carried out using SAS Version 9.4 and Stata Version 14.0.
Health behaviors stratified by province are presented in Figure 1. In total, 10.2% of Canadian students reported adhering to both health recommendations. Similar patterns were observed across all Canadian provinces, with a minority of youth in each province achieving both ST and PA recommendations. In contrast, nearly half of the sample (49.2%) failed to respect both guidelines. Just over 40% of youth respected PA recommendations, while 20.8% followed ST recommendations only. Finally, youth in the province of Quebec showed the least healthy pattern of behavior, whereas youth in British Colombia reported the healthiest behavior patterns.
As shown in Table 1, girls and Asian Canadians were most likely to adhere to none of the guidelines. A higher proportion of boys than girls met PA recommendations only (38.0 vs. 21.5). In contrast twice as many girls met ST recommendations only (14.8 vs. 6.6).
Youth meeting neither PA nor ST recommendations are used as the reference group for all multinomial logistic regressions. Tables 2–4 show odds of meeting both recommendations, PA recommendations only, or ST recommendations only based on demographic and psychological characteristics. These results are summarized in the following section.
Differences according to geographic location were observed in youth ST and PA habits. Compared to youth in Quebec, youth in all other provinces were more than twice as likely to follow both health recommendations, with odds ranging from odds ratio (OR) = 2.38 (99% CI [1.27, 4.45]) for youth in Nova Scotia to OR = 4.04 (99% CI [2.05, 7.96]) for youth in British Columbia.
Youth in all other surveyed provinces were also more likely than Quebec youth to meet the PA recommendation, with odds ranging from OR = 1.45 (99% CI [1.03, 2.04]) for youth in Prince Edward Island (PEI) to OR = 2.65 (99% CI [1.78, 3.96]) for youth in British Columbia.
Finally, students in New Brunswick (OR = 1.37, 99% CI [1.11, 1.68]), PEI (OR = 1.53, 99% CI [1.19, 1.95]), NFL– Labrador, (OR = 1.40, 99% CI [1.06, 1.85]), and Saskatchewan (OR = 1.36, 99% CI [1.03, 1.78]) were more likely to meet ST recommendations when compared to Quebec youth. Youth in Quebec did not differ from youth in the remaining provinces in meeting ST recommendations.
Boys and girls showed different patterns of risk in their health habits. Compared to girls, boys were more likely to adhere to PA recommendations (OR = 2.02, 99% CI [1.72, 2.38]), while fewer boys than girls adhered to ST recommendations (OR = 0.47, 99% CI [0.39, 0.57]). Boys and girls were equally likely to adhere to both recommendations.
Youth that identified as White showed greater adherence to guidelines than other youth. Black, Asian, Aboriginal, and youth who selected the category Other were less likely to follow both health recommendations than White youth with odds ranging from OR = 0.60, (99% CI [0.40, 0.91]) for Aboriginal youth to OR = 0.32 (99% CI [0.22, 0.47]) for Asian youth.
Compared to White youth, Black (OR = 0.79, 99% CI [0.64, 0.98]), Asian (OR = 0.61, 99% CI [0.48, 0.77]), and Aboriginal (OR = 0.66, 99% CI [0.52, 0.83]) youth were less likely to follow PA guidelines. No differences were detected between White youth and other youth in the odds of following ST recommendations.
Youth who reported stronger school connectedness showed greater adherence to guidelines. Each one-point increase in school connectedness was associated with an increase in the odds of following both recommendations (OR = 2.18, 99% CI [1.91, 2.48]) as well as increases in the odds of following the PA recommendation (OR = 1.45, 99% CI [1.30, 1.61]) and ST recommendation (OR = 1.46, 99% CI [1.26, 1.69]).
Compared to youth who never drank, youth who drank but did not binge, and youth who engaged in binge drinking were more likely to follow both health recommendations (OR = 1.33, 99 % CI [1.08, 1.63]) and (OR = 1.93, 99% CI [1.58, 2.35]), respectively. Youth who drank but did not binge and youth who binged were also more likely to report following PA recommendations only (OR = 1.32, 99% CI [1.12, 1.54]) and (OR = 1.95, 99% CI [1.66, 2.28]), respectively. Finally, youth who reported using cannabis were less likely to follow both health recommendations (OR = 0.66, 99% CI [0.48, 0.89]), whereas youth who reported being smokers or former smokers were more likely to follow ST recommendations only (OR = 1.46, 99% CI [1.10, 1.93]).
According to the present study, only 10% of young Canadians respect daily PA and ST recommendations. Although many young people followed recommendations for either PA or ST, nearly half of our sample failed to follow either recommendation. Our study also identified several sociodemographic and individual-level characteristics associated with adherence to health guidelines. Those most at risk were youth from Quebec and members of non-White ethnic groups. Furthermore, consistent with other research, girls in our sample were more likely to adhere to ST recommendations, while boys were more likely to meet PA recommendations (Minges, Chao, Nam, Grey, & Whittemore, 2015). In terms of psychosocial factors, nondrinking youth, youth who used cannabis, and those who reported being less connected to their schools were most at risk for showing poor compliance with PA and ST recommendations.
The low levels of adherence observed in Quebec are consistent with previous demographic surveys indicating that a high proportion of youth in Quebec fail to meet healthy eating and PA recommendations (Pica, 2012). These differences could reflect the provinces’ unique cultural and historic profile and distinct health and social service priorities and expenditure (Ministère de la santé et des services sociaux, 2003). Others have found that Hispanic and Black youth are likely to spend more time with screens and less time engaged in PA than White youth (Carson, Staiano, & Katzmarzyk, 2015; Sterdt, Liersch, & Walter, 2014). These differences could partially result from differences in how ethnic groups interpret questions related to PA (Warnecke et al., 1997). Another possibility is that ethnic differences in health habits are driven by income differentials (Williams, Priest, & Anderson, 2016). Neighborhood safety concerns and accessibility to structured physical activities could also represent barriers to non-White youth participation in PA (Franzini et al., 2010).
Boys are exposed to more screens during childhood and are more likely to grow up with a television in their bedroom (Gilbert-Diamond, Li, Adachi-Mejia, McClure, & Sargent, 2014; Pagani et al., 2010; Robertson, McAnally, & Hancox, 2013). As a result, the observed gender differences in our study could reflect developmental continuity in ST habits. More research has examined gender differences in PA. For instance, according to a review of research, girls are likely to face complex relationships with PA. On the one hand, many girls acknowledge that sports are enjoyable and can offer psychological and health benefits. On the other hand, girls also report that pressure to appear feminine can interfere with their involvement in some forms of exercise (Spencer, Rehman, & Kirk, 2015). Indeed, girls were more likely to report not wanting to get dirty or sweaty as reasons for not participating in physical activities. These findings suggest that social norms and gender stereotypes can represent barriers to girls’ involvement in PA. Interventions that are sensitive to gendered concerns (e.g., allowing enough time for showering between physical education classes and other classes) may help increase school-based PA involvement in girls.
Previous research has shown that a lack of school connectedness is prospectively associated with weaker academic outcomes, poor mental health, and drug use (Bond et al., 2007). Our study suggests that low school connectedness is also a correlate of excess ST and insufficient PA. One possibility is that students who feel more attached to their schools may also be more involved in school-based extracurricular sports teams and clubs, which could simultaneously increase their frequency of MVPA and decrease time available for screen-based pursuits. Alternatively, unmeasured characteristics of youth such as their mental health could simultaneously account for how connected they feel to school and dispositions toward health habits.
Contrary to expectation, former and current smokers, who were grouped together in the present study, were more likely to meet recommendations for ST. This finding could result from the former smokers in this group being more mindful of their health habits in an attempt to compensate for past behavior. Alternatively, the association could be spuriously influenced by socioeconomic status (Soteriades & DiFranza, 2003). Youth who are more disadvantaged are more likely to initiate smoking in adolescence and may also have less access to screens. The present study also revealed a positive association between drinking and meeting PA recommendations. Associations between youth drinking and health habits may be driven by involvement in athletics. Previous research has found that high athletic self-esteem or self-identifying as a “jock” is related to alcohol initiation and use in adolescence (Fisher, Miles, Austin, Camargo, & Colditz, 2007; Miller et al., 2003). Furthermore, other research using a sample of 13,583 youth provides evidence that athletes, particularly those who participate in multiple sports, are at increased risk of engaging in binge drinking (Veliz, McCabe, & Boyd, 2016).
The present study presents some limitations and strengths. First, data on portable media device use, such as cell phones or tablets, as well as details on the types of contents youth were engaged with (i.e., social media, educational, or violent contents) were not available. Another limitation of the present study is the use of self-reports, which can lead to mis-classification as well as under- or overestimation of behavior, given that they are subject to recall issues and social desirability bias. The present study was strengthened by the use of a large representative sample of Canadian Youth. Although Canada presents some features that distinguish it from the United States and Europe, media use across Canada, the United States, and many European countries are similar among youth (Bucksch et al., 2016). As such, the present findings are likely to be generalizable beyond the Canadian context and be of relevance internationally.
Sedentary behavior and low levels of PA have been identified as important predictors of health outcomes including risk of type 2 diabetes, hypertension, and elevated cholesterol (Colberg et al., 2016; De Moraes et al., 2015; de Rezende, Lopes, Rey-Lopez, Matsudo, & do Carmo Luiz, 2014; Zhai, Zhang, & Zhang, 2015). Furthermore, PA and ST have been linked to important psychological outcomes including academic achievement, illegal drug use, selfesteem, and mental health (Fitzpatrick, Burkhaler, Asbridge, 2019; Herman et al., 2015; Nelson & Gordon-Larsen, 2006; Twenge & Campbell, 2018). Our data therefore suggest that a high proportion of youth are engaging in lifestyle habits that present important risks to later health and well-being. Given that ST continues to rise among children and adolescents (Bucksch et al., 2016; Twenge, Joiner, Rogers, & Martin, 2018), our results further strengthen the importance of considering youth ST in public health initiatives.
The present findings point to the presence of tremendous heterogeneity in guideline engagement among Canadian youth. Future research is therefore needed to better understand how gender, geography, and culture contribute to the health habits of Canadian youth. Better understanding these differences may then benefit the development of targeted interventions aimed at increasing compliance with health recommendations. A new finding of the present research is that school connectedness may represent a health promotive variable when it comes to ST and PA habits. Future research could seek to better understand the potential usefulness of monitoring and leveraging school connectedness, a modifiable variable, to improve adolescent health assessments.
The absence of detailed content data has been acknowledged as a limitation of the present study. Not all types of media usage present the same risks or benefits to youth. For instance, violent media is of concern to youth well-being (Council on Communications, 2016). In contrast, educational and prosocial contents have been shown to benefit academic achievement and social skills (Corbett, Koedinger, & Hadley, 2001; Prot et al., 2014). Better understanding what types of contents youth are engaged with therefore remains an important area for future research.
The increased understanding that obesity and poor health emanate from a confluence of factors and settings has drawn attention to the importance of school environments in health promotion efforts (Active Healthy Kids Canada, 2014; Pate et al., 2006). School nurses can play an integral role in advancing this agenda. Clinically, school nurses can include questions about student ST and PA habits as well as school connectedness during consultations. Indeed, the American Academy of Pediatrics encourages practitioners to include questions about child media diets during well-child visits (Council on Communications and Media, 2013). Furthermore, research suggests that disconnected youth are especially likely to visit the nurse’s office. Since the systematic screening of student ST and PA habits may not be feasible for most school nurses, given high student to nurse ratios, limited nurse time, and competing priorities, the following strategies represent promising avenues for reaching all students. First, school nurses can contribute to the development and delivery of health curriculum in schools and can spearhead sensitization campaigns aimed at educating students, parents, and staff about the consequences of unhealthy patterns of ST and PA. Second, they can advocate for increased opportunities for youth to engage in movement and PA within the school community and can contribute to the creation of school-based policies designed to regulate the use of screens within the school (Quelly, 2014). Finally, school nurses can play a role in the implementation of interventions designed to decrease ST and increase PA (see Bagby & Adams, 2007, for examples of evidence-based guidelines).
In conclusion, the present study provides an accurate portrait of the ST and PA habits of Canadian adolescents. This research also allowed us to identify several demographic and individual-level correlates of ST and PA involvement. As a result, our findings suggest that interventions that consider geographic, cultural, and demographic differences could be useful for increasing compliance with health recommendations.
Data used for this research were taken from Health Canada’s Canadian Student Tobacco, Alcohol and Drugs Survey (formerly the Youth Smoking Survey), which is conducted for Health Canada by the Propel Centre for Population Health Impact at the University of Waterloo. Health Canada has not reviewed, approved, nor endorsed this research. Any views expressed or conclusions drawn herein do not necessarily represent those of Health Canada. Additional information about the survey can be found at https://cstads.ca
Caroline Fitzpatrick and Mark Asbridge contributed to the conception of the article. All authors contributed to the analysis of the data, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Article was drafted by Caroline Fitzpatrick, while the revisions were worked upon by Robin Burkhalter and Mark Asbridge.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: These analyses were supported by grants from the Social Sciences and Humanities Research Council, Nova Scotia Research, and the Canadian Cancer Society (grant #2017-704507) through the Propel Centre for Population Health Impact.
Caroline Fitzpatrick, PhD https://orcid.org/0000-0002-9439-042X
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Caroline Fitzpatrick, PhD, is an assistant professor in the Département de sciences humaines, at Université Sainte-Anne, Church Point, Canada.
Robin Burkhalter, MMath, is a data analyst with the Propel Centre for Population Health Impact at University of Waterloo, Canada.
Mark Asbridge, PhD, is an associate professor at Dalhousie University, Halifax, Canada.
1 Département des sciences humaines, Université Sainte-Anne, Church Point, Nova Scotia, Canada
2 PERFORM Centre, Concordia University, Montreal, Quebec, Canada
3 Center for Education Practice Research, University of Johannesburg, Gauteng, South Africa
4 Propel Centre for Population Health Impact, University of Waterloo, Ontario, Canada
5 Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
6 Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
Corresponding Author:Caroline Fitzpatrick, PhD, Département des sciences humaines, Université Sainte-Anne, Church Point, Nova Scotia, Canada B0W 1M0.Email: caroline.fitzpatrick@usainteanne.ca
