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Impact of information and communication technology on child health: ICT

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REVIEW ARTICLE

Impact of information and communication technology on child health

Eugenia HC Woo, Peter White and Christopher WK Lai
1
Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong

Abstract: This article provides a general framework for understanding the use of information and communication technology in education and
discusses the impact of computer usage on students’ health and development. Potential beneficial and harmful effects of computer use by children
are discussed. Early epidemiological and laboratory studies have indicated that children are at least of similar risk of developing musculoskeletal and
vision problems as adults, and musculoskeletal and visual health problems developed in childhood are likely to persist into adulthood. This article,
therefore, aims to provide a reflection on the deficits of existing policy and recommendations for child-specific guidelines in computer use.
Key words: children; computers; health-related problems; information and communication technology.

Background
Over the past two decades, information and communication tech-
nology (ICT) has developed at a rapid pace. The use of computers
and other electronic communication devices has become a part of
everyday life. Many young people spend increasingly more time
engaging in using these devices in school, work and leisure activi-
ties. No doubt, ICT has fundamentally changed the practices and
procedures of all forms of endeavour within business, education
and governance.
Information and communication technology in
education
Information and communication technology has broken down the
traditional boundaries of teaching and learning and brought enor-
mous change to the education sector.1 It is believed that ICT and
the Internet are the way forward in education to enable students
to become skilled citizens for the knowledge economy. Govern-
ments throughout the world have been promoting the use of ICT
in education vigorously over the past few decades. For instance,
one-to-one laptop programmes are expanding rapidly across the
world with large-scale initiatives such as Microsoft’s Anytime
Key Points
• Impact of computer usage on students’ health and development.
• Musculoskeletal and visual health problems developed in child-
hood are likely to persist into adulthood.
• Reflection on the deficits of existing policy and recommendations
for child-specific guidelines in computer use.
Correspondence: Dr Peter White, Department of Health Technology and
Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong
Kong. Fax: +852 2362 4365; email: peter.white@polyu.edu.hk
Conflict of interest: None declared.
Accepted for publication 28 February 2016.
Learning and the One Laptop per Child programme.2 The purpose
of one-to-one computing is to let students learn anytime and any-
where with a portable computer. Through the growing popularity
of electronic books, more and more people use electronic devices
for reading, and some primary and secondary schools have
replaced their traditional textbooks with electronic teaching
materials. Therefore, it has become a global trend to employ ICT
as a medium for teaching and learning both inside and outside
the classroom.3
Children’s computer use
According to a report by Computer Industry Almanac, computers
in use reached over 1.6 billion units worldwide at year-end 2011
and are expected to grow to 2.45 billion by 2016. In fact, the avail-
ability of computers, both at school and at home has resulted in
very high computer usage. At school, students are asked to
perform different computer tasks including word processing,
searching for information on the Internet and using educational
software. They also use their home computers for homework,
communication and playing games. Two-thirds of USA high school
students aged 16–18 years reported using their tablet computers
for more than 4 h per day.4 Hong Kong students aged 12–16 years
reported an average of 2.5 h per day.5 However, even very young
children have been recorded as using computers. More than one
quarter of 4- to 6-year-olds in the USA use a computer for an
average of 64 min in a typical day,6 and over half of 5 years old in
Australia use a computer each week.7
Potential Beneficial and Harmful Effects of
Information and Communication Technology
Educational motivation and engagement
The use of ICT in education provides learning motivation and
engagement for students.8 Students are intrinsically motivated
to learn because of the effective construction of learning envi-
ronments and activities. 9 ICT tools such as videos, television

590 Journal of Paediatrics and Child Health 52 (2016) 590–594

© 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
EHC Woo et al.
and multimedia computer software that combine text, sound
and colourful, moving images can be used to engage students
in the learning process. Computers with Internet connection
can also increase students’ motivation as they combine the me-
dia richness and interactivity of other ICTs with the opportunity
to connect with real people and to participate in real world
events.10
Recent research has confirmed that ICT can enhance students’
motivation, interest and academic achievement when compared
with traditional educational settings.11 The intrinsic features of
ICT, such as immediate feedback, animation, sound, active interac-
tion and individualization are more capable to motivate students to
learn than other media.12 It has also been noted that computers
provide opportunities for students to engage in self-directed learn-
ing activities, which further promote academic motivation.13
When students’ interests were aroused by motivation, Azita14
found that their learning in difficult subjects like Science and
Mathematics became easier.
Because of the introduction of computers at home and in school,
there has been a growing concern that extended computer work
will place young computer users at risk of developing cumulative
musculoskeletal disorders (MSDs) and computer vision syndrome
(CVS).15 A recent study confirmed that computer-related health
disorders such as stress, CVS, MSDs and carpal tunnel syndrome
(CTS) occur simultaneously among prolonged computer users,
such as employees and students.16
Musculoskeletal problems and disorders
Among computer users, the most common health-related com-
plaints involve the neck, shoulders and back.17 Sitting at a desk
and working on a computer for extended periods of time can stress
the trapezius muscle, causing soreness and even headaches. Trape-
zius myalgia can be caused by working for long periods sitting at a
desk working on a computer keyboard. This is also common for
those who have poor posture and work in an area that is not
ergonomically designed, for example, when a computer screen is
misaligned. If the trapezius is not in the correct position, the muscle
can lengthen or shorten and affect blood and oxygen flow. This will
bring about muscle fatigue and discomfort, leading to pain as well
as MSDs.
In addition, intensive mouse and keyboard use have been asso-
ciated with increased risk of upper extremity MSDs, such as CTS.18
CTS is caused by compression of the median nerve as it passes
under the carpal tunnel in the wrist.19 Typical symptoms of CTS
include pain, numbness and tingling in the thumb, index finger,
middle finger and half of the ring finger. These symptoms are
particularly strong at night or when the hand is kept in the same
position for extended periods of time.20
Numerous studies have indicated that computer use is associ-
ated with MSDs in children. Harris and Straker21 reported that
60% of children complained of discomfort while using their lap-
tops and a similar proportion experienced discomfort while carry-
ing them. It was evident that children adopted a wide range of
postures during laptop use, with the desk-sitting posture account-
ing for only one-third of usage time. Breen et al.22 also observed
that children using computers at school adopted poor postures.
Additionally, school computers may be shared by two or more
children, particularly in the younger age groups. This implies that
Journal of Paediatrics and Child Health 52 (2016) 590–594
© 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
ICT and child health
the screen may be angled to one or more viewers, which has been
shown to affect neck-shoulder muscle activity and is related to
greater risk of developing MSDs.23
Another study has shown that a higher level of exposure to
computer work results in higher risk of CTS. Ali and
Sathiyasekaran24 reported that longer years of exposure as a
computer professional and longer hours of computer use per
day were risk factors for CTS. However, this study only focused
on health problems for adult computer users, but there is
sufficient evidence to warrant concern about the potential health
risks posed to children and adolescents using different types of
electronic devices.
Vision problems
According to the American Optometric Association,25 a person
who exceeds 2 h of computer use a day is at risk of CVS. CVS is
caused by staring at a computer screen for long periods of time
without taking a break, which leads to decreased blinking reflex
and tightening of the inner eye muscles. Typical symptoms of
CVS include eye irritation, such as red, itchy, watery or dry eyes;
eye fatigue, including heaviness of the eyelids or forehead; and dif-
ficulty in focusing the eyes. Other symptoms of CVS are headaches,
neck ache, back ache and muscle spasms. These symptoms can be
further aggravated by improper lighting conditions or air moving
past the eyes.
Despite the large amount of literature available regarding mus-
culoskeletal problems in young computer users, surprisingly little
attention has been paid to the vision problems faced by children
when using computers. A preliminary field study involving
Scottish school children showed that those who did use a com-
puter were 1.4 times more likely to fail a visual acuity screening
test.26 Kinge et al.27 also claimed that intensive near-work could
initiate myopia or lead to its progression in young adults, espe-
cially with regard to the time spent on near-work. Extensive
viewing of near objects may strain the visual system and result
in structural change of the eye, in particular refractive changes
causing myopia.28 On the other hand, no research has yet
confirmed that the use of computers will lead to, or worsen,
short-sightedness among students.
Lifelong health problems
Epidemiological studies in western countries have reported simi-
lar figures for MSDs and CVS between children and working
adults.15 When children are exposed to health risk factors of
ICT, it is possible that the harm may accelerate the subsequent
onset of ICT-related injury.29 The development group for the
European guidelines for prevention in low back pain pointed
out that poor lifestyle habits and prolonged sitting during school
age on non-ergonomic furniture might induce low back pain.30
A longitudinal study showed that low back pain during childhood
was a risk factor for continuing muscle pain in adulthood.31 In
another longitudinal study on a group of children in the age
range of 8–14 years, symptoms of ICT-related back pain and
headache persisted into their late 20s.32 It is, therefore, necessary
to teach children to develop good postures and better computer
work habits.14
591
ICT and child health
Direct Methods for Detecting Child Health
Problems
Posture and muscle activity by electromyography
The first detailed comparisons of posture and muscle activity of
children when reading books and using computers were con-
ducted in Australia.33 The findings showed that the greatest devia-
tion from the resting posture occurred when reading books, while
the greatest electromyographic activity in the cervical erector
spinae and upper trapezius muscles were observed when using a
laptop computer. However, they did not consider the high display
conditions commonly observed in children. The main limitation of
their study was that the children did not interact fully with the IT,
as the tasks involved in computer use only involved reading, with-
out any typing or mouse clicking activites.
Recent studies have focused on variations of posture and muscle
activity in children performing interactive tasks that involve read-
ing books and writing on paper, or reading from a computer mon-
itor and inputting data using a mouse or keyboard.34,35 However,
observations only spanned a short period of time, which may not
have been long enough for participants to reach a steady-state per-
formance. Moreover, changes in posture are likely to occur over
longer time, as muscle extensibility changes and the accumulated
effects of central and peripheral fatigue develop. Prolonged muscle
and joint loading are well-known risk factors for the development
of MSDs in adults and may be even more significant in children.36
Therefore, the long-term effects of computer-related activities on
children’s health are warranted.
Median nerve characteristics by ultrasonography
The diagnosis of CTS is based on combinations of characteristic
symptoms and signs and electro-diagnostic studies.37 Although
electro-diagnostic studies are highly specific,38 the false negativity
falls between 10% to 20%.39 Electro-diagnostic studies can identify
the level of the lesion or injury but do not provide any information
about the median nerve and its surrounding structures. Nowadays,
imaging studies have been proposed as an alternative to electro-
diagnostic studies in the diagnosis of CTS. Magnetic resonance imag-
ing, although relatively expensive, time consuming and not gener-
ally available, has been shown to be valuable in the diagnosis of
CTS.40 Because of its advantages of being portable, non-invasive,
non-ionising, inexpensive and easy-to-use, ultrasound imaging has
been used to quantify the cross-sectional area of the median nerve
as a criterion in the diagnosis of CTS.41,42 It has been successfully
applied to study the changes of nerve functions and activities.43
Blink rate patterns by videography
Blink reflex is one of the fastest reflexes in the body and is present
at birth. However, blink rate varies with different activities. For ex-
ample, the blink rate is faster when we are active and is slower
when we are sedate or concentrating. Patel et al.44 observed that
the mean blink rate during conversation was 18.4 blinks per min
but dropped to 3.6 during computer use. Tsubota and Nakamori45
also reported that mean blink rate was 22 blinks per min under re-
laxed conditions, 10 blinks while reading a book at a table and only
seven blinks while viewing text on a computer. Their results sup-
ported the fact that blink rates decreased when using computers.
592
© 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
EHC Woo et al.
In many studies, blink rates were measured by analysing captured
watcher’s facial videos. However, these external camcorder-based
analyses limit the facial movements. Further research is suggested
using a high quality video camera to improve accuracy.
Implications on Policy and Recommendations
In many countries, health authorities provide guidelines for the use
of computers, such as workstation configuration standards. Such
guidelines include the international standard European ISO-9241,
and national standards such as Australian AS-3590.2, Canadian
Can/CSA-Z412-M89 and American ANSI/HFES-100, and Hong Kong
Occupational Safety and Health (Display Screen Equipment) Regulation
(Cap. 509B). In the past couple of decades, research and related guide-
lines have focused primarily on desktop and to a lesser extent, on lap-
top computers. Given the rapid pace of ICT advancement, it is difficult
to keep these standards up-to-date. Newer forms of ICT such as tablet
computers may not be adequately addressed in existing guidelines. In
addition, published guidelines tend to consider the adult population
only.28 For example, a key separation of 19 mm is typical for most
keyboards and considered suitable for most adults, which is based
on the recommendations of ISO 9241-410; however, this may be too
wide for other users, such as children.
Besides, existing guidelines are oriented towards work tasks and
work environments, but computing tasks performed by children
are different from the adult work tasks. For example, students may
frequently have to look at a teacher and/or display board as well
as the computer.28 Moreover, classrooms are traditionally designed
for reading and writing. The classroom space and computer worksta-
tion dimensions may not be suitable for computer use. Several
recent studies, therefore, have reported the inappropriateness of
user-workstation dimensions in classrooms and poor ergonomic
computer workstation design for child use at school.46,47
There is ample evidence to show that children are using com-
puters at school, which are not suitable for their build.48 Because
neck, upper back and lower back pains are associated with poorly
designed school furniture,49 children, therefore, are at greater risk
of muscle fatigue and discomfort when using computers in school.
The impact would be even more far-reaching if students started
using computers in primary schools.
With regard to the negative impact on ICT use in education, rec-
ommendations for child-specific guidelines in computer use are of
the utmost importance. Most children do not receive information
about correct sitting behaviour, so they require sufficient education
and instructions on these issues. Ergonomic training programmes
should be implemented in the school curriculum in order to help
raise students’ awareness of good posture when using computers.
In addition, school furniture and workstations should be designed
so as to be adjustable. It is important that appropriate training should
be provided to enable them to adjust their furniture to the most
comfortable position for their task and individual preference.50
Conclusion
The use of ICT in education induces both positive and negative im-
pact on young users. As children and adolescents are at the age of
physical and behavioural development, excessive use of computers
by students both at home and in school has raised health concerns
Journal of Paediatrics and Child Health 52 (2016) 590–594
EHC Woo et al.
among parents, educators and health-care professionals.
Therefore, in order to minimise the risk of adverse displacement
of physical activity, a revision of existing child-specific policy and
guidelines for computer use are strongly recommended.
Acknowledgement
This study was supported by funding from the Department of
Health Technology and Informatics, The Hong Kong Polytechnic
University.
Multiple Choice Questions
1 What is this paper about?
a) To provide a reflection on the deficits of existing policy and
recommendations for child-specific guidelines in computer use.
b) To provide a comprehensive framework for understanding
the use of information and communication technology in
education.
c) To provide an in depth discussion of the impact of computer
usage on students’ health and development.
d) To provide a comprehensive description of the potential ben-
eficial and harmful effects of computer use.
e) To provide a comprehensive review of the epidemiological
and laboratory studies on computer use by children.
a) is the correct answer. The aim of this paper is to provide a reflec-
tion on the deficits of existing policy and recommendations for
child-specific guidelines in computer use. b) is incorrect: this paper
would like to provide a general framework for understanding the
use of information and communication technology in education.
c) is incorrect: this paper would like to provide a brief discussion
of the impact of computer usage on students’ health and develop-
ment. d) is incorrect: this paper would like to provide a brief
description of the potential beneficial and harmful effects of
computer use. e) is incorrect: this paper would like to provide a
condensed, up to date, review of current research on computer
use by children.
2 Which of the following is a limitation of the current research on
children’s health problems?
a) Research subjects did not interact with computer use
which did not involve reading, typing or mouse clicking
activity.
b) Researchers observed the subjects over a long period of time,
which may be time consuming.
c) Little research has been conducted on the long-term effects of
computer-related activities on children’s health.
d) Small and non-probability sample of convenience.
e) Measurements and intervention were made without blinding
of the researchers to the subjects.
c) is the correct answer. The limitation of the current research
on children’s health problems is that little research has been
conducted on the long-term effects of computer-related activi-
ties on children’s health. a) is incorrect: research subjects did
not interact fully with the computer use that only involved
reading, without any typing or mouse clicking activity. b) is in-
correct: researchers only observed the subjects over a short pe-
riod of time, which may not be long enough for participants to
Journal of Paediatrics and Child Health 52 (2016) 590–594
© 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
ICT and child health
reach a steady-state performance. d) is incorrect: many previ-
ous studies had a large sample size using a simple random sam-
pling. e) is incorrect: many previous studies had randomly
assigned participants and had a standardised protocol by the
researchers.
3 What do the authors suggest as further improvement of
children’s computer usage?
a) Future research regarding short-term effects of computer-re-
lated activities on children’s health is warranted.
b) Parents should be aware of their children’s musculoskeletal
and visual complaints.
c) Parents should control their children’s computer use.
d) Governments throughout the world should not promote the
use of information and communication technology in
education.
e) A revision of existing child-specific policy and guidelines for
computer use is recommended.
e) is the correct answer. A revision of existing child-specific policy
and guidelines for computer use is recommended by the authors
for further improvement on children’s computer usage. a) is incor-
rect: future research regarding long-term effects of computer-
related activities on children’s health is warranted. b) is incorrect:
education on teaching children to develop good postures and better
computer work habits is recommended. c) is incorrect: parents
should teach their children about the safe and healthy use of com-
puter use rather than parental controls. d) is incorrect: it has be-
come a global trend to employ information and communication
technology as a medium for teaching and learning both inside and
outside the classroom.
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