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PEDIATRICS Vol. 107 No. 1 January 2001, pp. 156-162
From the * Division of Adolescent/Young Adult Medicine,
Children's Hospital, Harvard Medical School, Boston, Massachusetts;
and the Department of Pediatrics, Ronald McDonald Children's
Hospital, Loyola University Stritch School of Medicine, Chicago,
Illinois.
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ABSTRACT |
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Abstract
Methods
Results
Discussion
References
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Objective. Substantial research has associated exposure to entertainment media with increased levels of interpersonal violence, risky sexual behavior, body image distortion, substance abuse, and obesity. The objective of this study was to determine what pediatric residency programs are teaching trainees about media and the influence of media on the physical and mental health of children and adolescents.
Design. Survey of residency curricula, consisting of 17 items about children's exposure to media, including television, movies, popular music, computer/video games and the Internet, the effects of this exposure on specific health risks, and associations between program characteristics and media education in the residency curriculum.
Participants. Directors of the 209 accredited pediatric residency programs in the United States.
Results. Two hundred four programs (97.6%) responded. Fifty-eight programs (28.4%) offered formal education on 1 or more types of media; 60 programs (29.4%) discussed the influences of media when teaching about specific health conditions. Residents in 96 programs (47.1%) were encouraged to discuss media use with patients and parents; 13 programs (6.4%) taught media literacy as an intervention. Among program characteristics, only media training received by program directors was significantly associated with inclusion of media in residency curricula.
Conclusions. Despite increasing awareness of media influence on child health, less than one-third of US pediatric residency programs teach about media exposure. Developing a pediatric media curriculum and training pediatric residency directors or designated faculty may be a resource-effective means of improving health for children growing up in a media-saturated environment. Key words: media, television, health risk, obesity, pediatric training.
Over the past several decades, researchers and clinicians
have been increasingly concerned by a large and growing body of evidence that has established significant associations between media
exposure and a variety of health risk behaviors in children and
adolescents.1-3 Investigators have found media influences
on: 1) violence,4-16 2) risky sexual
behaviors,17-21 3) body concept, dieting, and disordered
eating,22-29 4) substance use attitudes and
behaviors,30-42 and 5) obesity.43-49 In
1978, an American Academy of Pediatrics (AAP) task force published "The Future of Pediatric Education,"50 which directed
the focus of training in pediatrics toward areas of new morbidity in
general pediatrics, developmental and behavioral pediatrics, and
adolescent medicine, areas where media can have significant influence
on behavior-based health risks. The AAP established early leadership on
media as a health issue, forming the Task Force on Children and
Television in 1983. The following year, the task force issued their
first report to pediatricians, "Children, Adolescents, and
Television."51 Smith et al surveyed 144 pediatric
program chairpersons in the mid-1980s and found that only 14.2% of the
120 responding programs taught their residents about the effects of
television on the developing child.52 Since the late
1980s, the AAP has issued 11 policy statements regarding various health
effects of media exposure on children and adolescents, reviewing the
research and making clinical recommendations.53-63 In
1996, the American Medical Association (AMA) published the Physician Guide to Media Violence.64 In 1997, the AAP implemented Media Matters, an initiative to educate
its members65 and to provide clinical tools such as the
Media History form66 to assess and mitigate media effects
on child health. Media Matters has held 2-day media training
opportunities for its members in the Northeast and Texas; more are
planned for the Midwest and California. In addition, media information
is provided under the Media Matters section of the AAP Web
site and a package of media education materials is available to any AAP
member on request. Although these initiatives have been
well-received, they have affected only the practices of
pediatricians who have availed themselves of the educational
opportunity presented by Media Matters. If the majority of
pediatricians are to follow recommendations to include evaluation of
and anticipatory guidance about media exposure as part of a child's
health maintenance visit, these skills should be taught and practiced
during their postgraduate medical training. The objective of this study
was to investigate what pediatric residency programs are teaching their
residents regarding the recognition, intervention, and prevention of
media effects on the health of children and adolescents.
Survey Design
We designed a 17-item survey instrument to determine the
quantity and nature of media education being provided as part of graduate medical training for pediatric residents. The survey explored
specific areas of concern about the health effects of media exposure
that have been established by research and addressed by clinical policy
statements and practice guidelines. To encourage completion, responses
were primarily in the form of checkboxes, denoting the presence of a
specific curricular component, with limited numerical or verbal short
answers.
The survey was designed to collect several types of data about
residency programs and their training curricula. One section explored
general characteristics of the residency program: region of the
country, number of pediatric residents trained, existence of a primary
care as well as a categorical track, inclusion of medicine-pediatrics
and/or family practice residents in the program, types of inpatient and
outpatient clinical settings, and geographic locations (urban,
suburban, rural) of training environments. The survey asked the
residency program director whether s/he was a member of the AAP, was
aware of the Media Matters initiative, and whether s/he had
attended a Media Matters training workshop. A second section
of the survey assessed teaching about children's exposure to
television, movies, popular music, computer/video games and the
Internet. It asked whether issues specific to each type of media were
taught and what content areas, health concerns, and interventions were
discussed. Several questions focusing on television (amount of
exposure, violence, effects of commercials, ability to distinguish
fantasy from reality, sexism, and pro-social effects) were designed to
elicit comparable information to that of the 1986 survey of pediatric
residency programs' education about television.52 The
survey inquired about who gave the lectures (pediatric faculty, psychology or psychiatry faculty, chief residents or other residents, other) to whom (PL-1, 2, 3 or all) and in what settings (continuity conference, noon conference, grand rounds, other). It asked whether programs encouraged residents to discuss children's media use with
parents and whether faculty observed residents for these discussions.
The third section evaluated whether residents were taught about
specific medical conditions and health risk behaviors that have been
associated with media exposure, and whether media effects on these
behaviors were included as part of the condition-specific content.
Finally, programs that did not teach about media were asked about
barriers to teaching the health effects of media exposure as part of
the residency program, whether they desired to have curricular
materials for media education, and whether they were likely to use such
materials if provided.
Survey Distribution and Collection
The survey, a cover letter explaining the study, and a stamped,
self-addressed envelope were mailed to the 209 pediatric residency programs in the United States and Puerto Rico accredited for the academic year 1999-2000.67 As an incentive, curricular
materials for teaching media issues to pediatric residents were offered
to those who completed the survey. Initial surveys were mailed in the
second week of May 1999. Nonrespondents were mailed or faxed duplicate
surveys 6 weeks later. This was repeated again for those who had not
responded 3 months after the initial mailing. Reminder phone calls to
directors of programs whom had not responded were placed in August and
September 1999. All completed surveys were received between May 20 and
October 6, 1999.
Data Analysis
Descriptive characteristics summarized the US pediatric
residency programs' survey responses. Pearson
Completed surveys were received from 204 of the 209 programs, a
response rate of 97.6%. The residency program director completed 68.6% (140) of the surveys and the remainder were completed by associate program directors, residency curriculum directors, or chief
residents. Although 95.1% (194) of the survey respondents were members
of the AAP, only 29.9% (61) were aware of the Media Matters
initiative and 2.9% (6) had attended Media Matters
training. The responding residency programs (Table
1) ranged in size from 10 to 122 pediatric residents, 2 out of 3 offered medicine-pediatrics combined
programs, and nearly 1 in 8 had primary care training tracks.
Representing 44 states, Puerto Rico, and the District of Columbia,
their training settings were predominantly urban, but approximately
half included suburban and 1/6 offered rural training sites.
TABLE 1
METHODS
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Abstract
Methods
Results
Discussion
References
2 tests were used to compare frequencies of
the television variables measured in this study and in
1986.52 Residency program characteristics, geographic
location, and directors' awareness of and training in media issues
were analyzed for associations with the presence and nature of media
education in the residency curriculum, using Pearson
2 tests or 2-tailed Fisher's Exact tests as
appropriate. All analyses were performed using SPSS version 9.0 (SPSS,
Inc, Chicago, 1998).
RESULTS
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Abstract
Methods
Results
Discussion
References
Characteristics of Pediatric Residency Programs (N = 204)
Fifty-eight programs (28.4%) included formal education for their pediatric residents regarding the risks to children posed by exposure to television, movies, computer/video games, the Internet, and/or popular music (Table 2). Forty programs taught about just 1 type of media, predominantly television, and only 4 programs taught about all 5 types of media covered in the survey.
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Formal lectures on television exposure were provided by 26.6% (54 programs) as compared with 14.2% of the 120 programs surveyed in 1986 (P < .025). The percentages of programs that addressed specific content on television use and effects on child health in 1986 and 1999 are indicated in Table 3. Other content areas volunteered by respondents to this survey included the educational uses of television and use of the videocassette recorder and filters to control television content (1 program), the effects of television-watching on literacy (1 program) and the effects of television-watching on school performance (1 program). Among programs that included lectures on television, the lectures were required in 85.2% of the programs and were presented by pediatric faculty members in 92.6% of the programs.
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Education about interventions on media influence is indicated in Table 4. Ninety-six programs (47.1%) encouraged residents to discuss their patients' media use with the patients and parents; faculty members observed residents conducting these discussions at 25 programs (11.8%). Twenty programs (9.8%) taught their residents to recognize the signs and symptoms of media exposure in children (inattention, difficulty in completing tasks, and irritability, particularly when asked to cease media use). Thirteen programs (6.4%) taught media literacy as an intervention. Less than one-fifth of the programs taught their residents interventions on children's television consumption that have been most prominently recommended in policy statements, such as limiting viewing time (18.1%), co-viewing television with parents (17.2%), and no television in children's bedrooms (11.8%). As indicated in Table 4, other recommended interventions on children's media use were covered by 5% or fewer programs.
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A large majority of pediatric residency programs taught their residents about the various health conditions and risk behaviors that research has found to be associated with media use. However, the influence of media exposure on any of those risks was included in less than one-fourth of the programs' education about these conditions (Fig 1). In 70.6% (144) of the residency programs, media were not mentioned as an influencing factor on any of the health conditions or risk behaviors that the survey examined; 3.4% (7) discussed media exposure as a risk factor in all 10.
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Only Media Matters training of the program director was significantly associated with the inclusion of media education (general and specific to various media) in the residency curriculum (Table 5). There were no significant associations between media education and the size, region, or training settings of programs, the presence of medicine-pediatrics or family practice residents, or program directors' membership in the AAP or awareness of the Media Matters initiative.
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Among the 146 pediatric residency programs that did not teach the health risks of media exposure, the most frequently cited reasons for not including formal media education were lack of a media curriculum (63.7%) and absence of faculty qualified to teach about media (34.2%), as well as the substitution of informal discussion for formal training in media (51.4%). When these programs were offered curricular materials with which to teach about media and health effects, 93.2% said they desired such materials and 82.9% stated that they were likely to incorporate them into their residency training curricula. Twenty-two programs (15.1%) had already planned to include media education in their future curricula.
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DISCUSSION |
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Results
Discussion
References
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Despite considerable research evidence and a commitment to advocacy by the AAP, less than one-third of accredited US residency programs currently educate pediatricians-in-training about the influences of media on the physical and mental health of children and adolescents. The current survey followed-up and built on a 1986 study of pediatric education on television's health effects52 and is, to our knowledge, the first survey to evaluate pediatric residency training in the wide array of media to which contemporary children are exposed. Small increases in television education since 1986 are offset by scant attention paid to the growing influence of other media such as computer/video games and the Internet. Although almost half of all US residency programs encourage discussion of media use with patients and parents, there is little training in assessment and intervention on the health effects of media. However, residency program directors who have received formal media training are significantly more likely to include the health effects of media in their residency curricula. The majority of residencies that do not include media issues in their training at this time recognize the need and desire the curricular tools with which to implement such education for their residents.
One hundred fifty years ago, the Industrial Revolution dramatically
changed the world, creating rapid advances in productivity, knowledge,
and social change
and generating a host of unanticipated, but serious
public health problems ranging from industrial accidents to
environmental pollution. We are currently in the midst of a similar
sociotechnological watershed, the Information Revolution. It, too, is
producing great advances and presenting significant threats to public
health. For children, adolescents and young adults, morbidity and
mortality from many infectious diseases and congenital disorders have
steadily decreased, while behavior-based conditions such as violence,
substance abuse, obesity and sexually transmitted diseases such as
human immunodeficiency virus (HIV) have replaced them as the most
prevalent health risks.68
Children, specifically those <8 years old whose abstract reasoning skills have not developed, cannot discriminate between fantasy and reality and are particularly vulnerable to the influence of messages conveyed through entertainment media.69-73 Children's exposure to media, including television, movies, music, computer/video games, and the Internet, is constantly increasing. A 1999 study by the Kaiser Family Foundation found that the average child between 8 and 18 years old spent 6 hours and 43 minutes each day with television, video or computer games, popular music, or other media, more time than they spent in school, with parents, or engaged in any activity other than sleep.74 Having more contact time with children and adolescents, media has the potential to replace parents, teachers, and peers as educators, role models, and the primary source of information about the world and how one behaves in it.
Violence, in the form of accidents, homicide, and suicide, is a major cause of mortality for children and adolescents.68 Appropriately, more than two-thirds of pediatric programs provide their residents formal training in violence. However, only one-fifth discuss the media's influence on violent behavior. Consistent and strong associations between media exposure and increased aggression have been found in population-based studies of violence epidemiology,4 cross-sectional studies,5 experimental9-11 and natural laboratory research.12 Although media are not the sole or even the predominant influence on violent behavior, the 0.3 correlation between television exposure and aggressive behavior found on meta-analysis8 is larger than that of condom nonuse and sexually transmitted HIV (0.2), lead exposure and lower IQ (0.15), passive tobacco smoke and lung cancer (0.15) ,or calcium intake and bone mass (0.1),75 associations on which clinicians routinely base preventive medicine.
Although relationships between media exposure and other health risks are not yet as thoroughly investigated, current research evidence supports similar associations. While >80% of pediatric training programs teach their residents about risky sexual behavior, only one-eighth discuss the effects of media on young people's sexual expectations, attitudes, and behaviors.17,18,21 Over 85% of US pediatric programs educate their residents about eating disorders, but less than 1 in 5 of these programs explore the influences that media have on young people's physical ideals and weight loss behaviors.26-28 More than 70% of pediatric residencies educate their trainees about the health risks of substance use, but few teach about the powerful influence of the media,39-42,76,77 particularly advertising.30-39 As the most common chronic health condition of young Americans, it is appropriate that three-fourths of US pediatric programs teach their trainees about obesity. However, <17% discuss the strong dose-response effect between the amount of obesity and the hours of television watched.43,44 The evidence linking media exposure to these health outcomes is well-documented and accepted by many pediatricians. Given this fact, it is troubling that so few pediatric training programs examine the potent risk factors of media exposure.
This study represents the status of pediatric postgraduate medical training in nearly all of the US accredited programs as of mid-1999. Limitations of this study include social desirability bias, which may have resulted in overreporting of media education in programs, particularly on the part of those training directors that completed surveys after the August 1999 publication of the AAP policy statement on media education.63 On the other hand, because residents are taught by a variety of faculty members, some of whom may educate residents due to personal interest in and concern about the influences of media use on child health, program directors may not be fully aware of the extent of media education that their residents receive. In addition, interpretation of the term formal media education may have varied between respondents. Finally, although the survey asked about Media Matters as the only media training designed specifically for pediatricians, there are other forms of media education that respondents might have received.
The goal of residency education is to produce a complete pediatrician, who has developed the fund of knowledge and body of technical skills necessary to treat a variety of acute and chronic diseases, who promotes child health through well-child examinations and anticipatory guidance, and who engages in life-long learning and skill-building as a child health professional. Previously, the requirements for residency education have been explicit with respect to medical training, but less specific in regard to psychosocial risk factors such as media exposure. With the publication of "The Future of Pediatric Education (FOPE) II" in January 2000,78 the pediatric community emphasized the growing importance of societal and psychosocial factors to disease prevention and health promotion. The influence of media on the health-related attitudes and behaviors of young people can represent a considerable threat to their well-being. Pediatricians who will be caring for children and adolescents growing up in the media-saturated world of the Information Age need to be trained in anticipatory guidance regarding media risks, in recognition of media influence on the health of individual patients, and in effective interventions. Just as pediatricians have included health risk avoidance using nonmedical tools such as bicycle helmets and seat belts, media effects need to be included as part of the health maintenance visit. The AAP policy statements, particularly those in the comprehensive statement on media education,63 should guide anticipatory guidance and interventions. These include the thoughtful and deliberate use of media by children, which includes parental involvement and guidance about media use as well as the development of media literacy so that young people are immunized against deleterious media effects. A protective intervention that can be learned by anyone, even very young children, media literacy is a developed awareness of how media work and the ways in which media can alter reality to influence one's thoughts and behaviors. Media literacy will also allow children and adolescents to use media, particularly more interactive media such as computer games, the Internet, and the growing area of interactive video, in more pro-social and pro-health ways. Media are powerful, but not inherently malignant. These powerful communications tools pose potential risks, but can be focused to improve child health through education and empowerment of children and parents. In the Information Age, pediatricians will need to actively consider the positive uses of media in health promotion, clinical practice, and the lives of our patients.
Current pediatric residency training in the media influences on child
health lags behind an ever-increasing and broadening need. Beyond
television, pediatric education needs to respond to the rapidly
expanding use and social importance of other media such as
computer/video games and the Internet. It is encouraging that, although
the number was small, pediatric program directors who were formally
trained in media effects on health were significantly more likely to
include a broad range of media education for their residents. Those who
did not include media education in their training noted that lack of a
formal curriculum and absence of qualified faculty were predominant
reasons. In addition, they overwhelmingly requested and intended to use
curricular materials to address these deficits. These findings suggest
a solutiondevelop a media education curriculum for
pediatricians-in-training and provide formal faculty training in the
teaching of media issues. The package of Media Matters
information and materials sent to each program director who responded
to this survey may serve as the first step in the process of building
awareness of media exposure as a potential health risk in the training
programs for pediatricians. When pediatric training programs have
the knowledge and tools to educate their residents in the health risks
of media exposure, graduating cohorts of new pediatricians will be
better prepared to care for their patients' medical and
psychosocial needs, promoting health, and preventing the new
morbidities of the Information Age.
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ACKNOWLEDGMENTS |
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The American Academy of Pediatrics supported direct costs of this study.
We thank Kathryn Pollenz for her tireless data collection and Noel DiCarlo and Lara Hauslaib for assisting her, Maria Luoni for establishing the database, and the American Academy of Pediatrics Division of Public Education, particularly Jennifer Stone and Lisa Reisberg, for providing Media Matters educational materials to respondents.
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FOOTNOTES |
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Received for publication Aug 22, 2000; accepted Oct 13, 2000.
Reprint requests to (M.R.) Division of Adolescent/Young Adult Medicine, Children's Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: michael.rich{at}tch.harvard.edu
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics; AMA, American Medical Association; HIV, human immunodeficiency virus.
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REFERENCES |
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United States, 1989-1993.
MMWR Morb Mortal
Wkly Rep.
1994;
43:577 [Medline]This article has been cited by other articles:
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  A. B. Jordan and T. N. Robinson Children, Television Viewing, and Weight Status: Summary and Recommendations from an Expert Panel Meeting The ANNALS of the American Academy of Political and Social Science, January 1, 2008; 615(1): 119 - 132. [Abstract] [PDF]
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 M. E. Schmidt and M. Rich Media and Child Health: Pediatric Care and Anticipatory Guidance for the Information Age. Pediatr. Rev., August 1, 2006; 27(8): 289 - 298. [Full Text] [PDF]
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 R D Goldman and A Macpherson Internet health information use and e-mail access by parents attending a paediatric emergency department Emerg. Med. J., May 1, 2006; 23(5): 345 - 348. [Abstract] [Full Text] [PDF]
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 D. A. Gentile, C. Oberg, N. E. Sherwood, M. Story, D. A. Walsh, and M. Hogan Well-Child Visits in the Video Age: Pediatricians and the American Academy of Pediatrics' Guidelines for Children's Media Use Pediatrics, November 1, 2004; 114(5): 1235 - 1241. [Abstract] [Full Text] [PDF]
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T. L. Cheng, R. A. Brenner, J. L. Wright, H. C. Sachs, P. Moyer, and M. R. Rao Children's Violent Television Viewing: Are Parents Monitoring? Pediatrics, July 1, 2004; 114(1): 94 - 99. [Abstract] [Full Text] [PDF]
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 K. Kaliebe and A. Sondheimer The Media: Relationships to Psychiatry and Children: A Seminar Acad Psychiatry, September 1, 2002; 26(3): 205 - 215. [Abstract] [Full Text] [PDF]
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) and
media influence on those behaviors (
).