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* Department of Psychology, Iowa State University, Ames, Iowa
National Institute on Media and the Family, Minneapolis, Minnesota
Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
|| Department of Pediatrics, Hennepin County Medical Center, Minneapolis, Minnesota
¶ HealthPartners Research Foundation, Minneapolis, Minnesota
# Department of Epidemiology, University of Minnesota, Minneapolis, Minnesota
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Design. A cross-sectional survey mailed to all members of the Minnesota chapter of the AAP.
Participants. A total of 365 pediatricians completed the survey.
Measures. The 58-item survey assessed familiarity with, agreement with, and implementation of each of 3 AAP recommendations, to limit children's media time, to discourage television (TV) viewing among children <2 years of age, and to encourage alternative entertainment for children. Pediatricians were also asked about the perceived effectiveness of and barriers to guideline implementation. In addition, pediatricians were asked to report their own TV viewing habits and their opinions about how much media affect children's health and behavior.
Results. Most pediatricians were familiar with and also agreed with the 3 AAP recommendations. Their agreement may stem from the fact that pediatricians almost universally believe that children's media use negatively affects children in many different areas, including children's aggressive behavior, eating habits, physical activity levels, risk for obesity, high-risk behaviors, and school performance. Pediatricians were most likely to have encouraged alternative entertainment and were least likely to have discouraged TV viewing for children <2 years of age. The majority of pediatricians provided all 3 recommendations to parents at least sometimes. Most pediatricians reported that their recommendations were at least a little effective when they did make them. The most frequent barrier pediatricians reported facing was a lack of parental motivation or support for the recommendations, with approximately one-third of pediatricians also citing a lack of time and a sense of futility in affecting patients' media habits as barriers. Finally, pediatricians who watched the greatest amounts of TV were significantly more likely than those who watched less to think that the AAP recommendation to limit children's total media time to no more than 1 to 2 hours per day is unrealistic, whereas those who watched less were more likely to agree with the recommendation.
Conclusions. Results suggest that the efforts of the AAP in reaching pediatricians have been largely successful, with the majority of pediatricians in Minnesota being aware of and agreeing with the 3 major recommendations suggested by the AAP policy statement on children, adolescents, and television. However, implementation of the recommendations could be improved, especially because pediatricians usually think that the recommendations are at least a little effective when made. Strategies for overcoming barriers to making recommendations need to be addressed, including the sense of futility in affecting media use that some pediatricians may feel.
Key Words: media effects • television • recommendations • medical training
Abbreviations: AAP, American Academy of Pediatrics • TV, television
For 20 years, the American Academy of Pediatrics (AAP) has expressed concerns about the amount of time children and adolescents spend watching television (TV).1 In addition, media use has increased in the past decade, with video games, the Internet, and audio and video music formats. American children and adolescents average >21 hours of weekly TV viewing; when video games and other media are included, weekly screen times increase to as much as 35 to 55 hours.2–6 It has been estimated that young people view 10 000 acts of violence each year and nearly 15 000 scenes with sexual references, with <15% dealing at all with topics such as abstinence, birth control, or sexually transmitted infections and/or pregnancy and only 1% having a primary emphasis on sexual risks.7–10 Mass media are second only to school sex education as the vehicle for acquiring information about sexuality.11 Moreover, a recent content analysis of TV programming revealed that alcohol, tobacco, and illicit drugs are presented in 70% of prime time network dramatic programming.12
Concern about media exposure is based on a large body of research that demonstrates the multiple negative effects of media on children's and adolescents' health, including effects on violent or aggressive behavior, substance use, early initiation of sexual activity, obesity, poor body image, and decreased school performance.13–17 In the domain of violence alone, >1000 studies have established a connection between media violence and aggressive behavior among children.18–23 A recent study documented that the negative effects of TV viewing are not restricted to the short term for children and adolescents but increases in violent behavior persist even into adulthood.24 Other studies have confirmed associations between media exposure and adolescent high-risk behaviors, such as substance use and early initiation of sexual activity.25 Media also exert a significant displacement effect. Two to 3 hours of media time translates into less physical activity, with a concomitant increase in obesity, a decrease in reading, and a reduction in interaction with peers.26
Through research policy statements and the launching in 1997 of the Media Matters national public education campaign, the AAP has tried to educate its 57 000 members regarding the effects of media and to provide a means to influence families and their children. The most recent policy statement on media was issued in February 2001 and was titled "Children, Adolescents, and Television,"27 with specific recommendations for pediatricians to incorporate media education and advocacy into their anticipatory guidance and parental education. Recommendations include the following. (1) Parents should discourage TV viewing for children <2 years of age and should encourage more interactive activities that promote proper brain development, such as talking, playing, singing, and reading together. (2) Parents should limit children's media time (with entertainment media) to no more than 1 to 2 hours of quality programming per day for older children. (3) Parents should monitor programming, view with their children and adolescents, and encourage alternative forms of entertainment, such as reading, athletics, hobbies, and creative play. The present study attempted to evaluate how effective and successful the national AAP efforts have been in increasing awareness of media effects among AAP members in Minnesota and to determine to what degree pediatricians have incorporated these guidelines into their practices.
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METHODS |
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2 years of age and encourage more interactive activities that promote proper brain development, such as talking, playing, singing, and reading together, and (3) encourage alternative entertainment for children, including reading, athletics, hobbies, and creative play. Pediatricians were asked a series of questions regarding these recommendations, including (1) how familiar they were with each of these recommendations, on a 4-point, verbally anchored, Likert scale (not at all familiar, a little familiar, somewhat familiar, or very familiar); (2) whether they agreed or disagreed with each recommendation, on a 3-point, verbally anchored, Likert scale (I agree with this recommendation, it's a good idea but it is unrealistic, or I disagree with this recommendation); (3) how often they had made each recommendation to parents/caregivers as part of anticipatory guidance during well-child care visits, on a 5-point, verbally anchored, Likert scale (almost always, often, sometimes, rarely, or never); and (4) how effective they think their efforts are when they do make each recommendation, on a 4-point, verbally anchored, Likert scale (very effective, somewhat effective, a little effective, or not at all effective). Pediatricians were asked about potential barriers to making recommendations regarding media use and about their familiarity with and use of the AAP media history form and AAP brochures. A series of items also asked pediatricians how much they think media use affects several child outcomes at 4 different ages (infant/toddler, preschool age, school age, and adolescence), on a 3-point, verbally anchored, Likert scale (not at all, a little, or a lot). Finally, pediatricians were asked a series of questions for determination of demographic data and assessment of their own media use and exercise habits.
Procedure
The study was conducted with survey methods developed by Berdie et al,28 involving mailing with follow-up surveys. These procedures included the following steps. (1) The initial questionnaire and a cover letter signed by AAP officials were sent via first-class mail. A preaddressed, postage-paid, return envelope was also enclosed. (2) Practitioners who did not respond to the initial mailing were sent a postcard reminder 
2 weeks after the initial mailing. (3) Those who still did not respond were sent an additional mail follow-up reminder 2 weeks after the postcard, with another copy of the questionnaire and a postage-paid envelope. (4) All members with valid e-mail addresses were sent an additional reminder to complete their surveys 1 month later. Data collection occurred between July and October 2002.
Data Analyses
The data reported below are primarily descriptive, describing the percentages of pediatricians who indicated each response on the survey. The data are accurate to ±4% with a 95% confidence level when generalizing to Minnesota pediatricians as a group. In addition to descriptive statistics, 
2 analyses were performed to determine whether there were systematic differences between male and female pediatricians. 2 analyses were also conducted to determine whether there were systematic differences between pediatricians who themselves watch more versus less TV (weekly viewing divided by tertiles, as described below).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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2 = 16.4, df = 3, P < .01). Female pediatricians were also more likely to agree with the recommendation to limit children's total media time to 1 to 2 hours (2 = 8.0, df = 2, P < .05).
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2 = 8.1, df = 3, P < .05). However, even those who were at all familiar with the media history form were not likely to have asked parents to complete it during the past year (often: 1%; rarely: 11%; never: 88%). Similarly, very few pediatricians provided any of the AAP brochures on media use (eg, Smart Parent's Guide to Kids' TV, Television and the Family, and The Internet and Your Family) to their patients (often: 1%; sometimes: 8%; rarely: 12%; never: 79%).
Pediatricians were asked how often during the past year they made each of the 3 AAP recommendations to parents or caregivers as part of anticipatory guidance during well-child visits (Table 3). Pediatricians were most likely to have encouraged alternative entertainment (recommendation 3) and least likely to have discouraged TV viewing for children <2 years of age (recommendation 2). However, a majority of pediatricians provided all 3 recommendations to parents at least sometimes (77%, 61%, and 88% for the 3 recommendations, respectively). Female pediatricians were significantly more likely to have reported providing each of the 3 recommendations to parents or patients (lowest 2 = 9.7, df = 4, P < .05). Pediatricians were also asked to what age groups they typically made media recommendations. Sixteen percent of pediatricians reported typically making the recommendations to parents of infants, 53% to parents of toddlers, 81% to parents of school-aged children, and 61% to parents of adolescents, with only 14% reporting that they did not typically make recommendations.
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Table 4 indicates how frequently pediatricians thought various barriers impeded their ability to make recommendations regarding media use to parents or patients. The most frequent barrier the pediatricians faced was lack of parental motivation or support for the recommendations (51% said this was always or often a barrier). Approximately one-third of pediatricians cited a lack of time with the patient or parent (34% stated always or often), as well as a sense of futility in affecting patients' media habits (31% stated always or often). Even given this sense of futility that many pediatricians reported, a lack of physician or staff support for the recommendations was the least reported barrier (76% stated rarely or never). Furthermore, pediatricians appeared to have an array of suggestions for alternatives to electronic media when making recommendations (64% reported that this was rarely or never a barrier). Female pediatricians were more likely than male pediatricians to report lack of time with the patient and lack of parental support for the recommendations as barriers (lowest 2 = 10.9, df = 4, P < .05).
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2 = 6.0, df = 2, P < .05).
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2 = 7.7, df = 2, P < .05).
For adolescents, the findings were similar. Almost all pediatricians thought that media use negatively affects academic achievement (98%), eating habits (99%), overall physical activity levels (100%), overweight/obesity (99%), aggression (99%), high-risk behaviors such as smoking or drinking (98%), and high-risk sexual attitudes and behaviors (98%). Female pediatricians were more likely than male pediatricians to think that TV affects adolescents' academic achievement, eating habits, overall physical activity, overweight/obesity, aggression, and high-risk sexual behaviors (lowest 2 = 5.9, df = 2, P < .05).
Pediatricians' Media Practices
Pediatricians reported personally watching an average of 9.9 hours of TV per week (SD: 7.5). They also reported exercising for 30 minutes an average of 3.2 times per week (SD: 1.9).
One-third of the pediatricians (34%) reported using media in their waiting rooms for entertainment purposes, and 28% reported using media in their waiting rooms for patient or family education purposes. Male pediatricians were more likely than female pediatricians to report using media for patient education (36% and 20%, respectively; 2 = 10.9, df = 1, P < .001).
Interestingly, pediatricians' personal TV-viewing habits appeared to be related to their opinions. Pediatricians were divided into 3 groups (tertiles) on the basis of the amount of time they watched TV each week. Pediatricians who watched the greatest amounts of TV were significantly more likely than those who watched less to think that the AAP recommendation to limit children's total media time to no more than 1 to 2 hours per day is unrealistic, whereas those who watched less (bottom 2 tertiles) were more likely to agree with the recommendation (2 = 11.9, df = 4, P < .05). Physicians who watched the greatest amounts of TV themselves were also more likely to report a lack of physician/staff support for the recommendations as a barrier than were physicians who watched less TV (2 = 16.0, df = 8, P < .05). They were also more likely to report a lack of suggestions for alternatives as a barrier (2 = 18.6, df = 8, P < .05).
Pediatricians' TV watching was related to many of their beliefs about the effects media may have on children. The more pediatricians watched TV each week, the less likely they were to report that media affect infants' brain development (2 = 13.1, df = 4, P < .05), preschool-aged children's eating habits (2 = 9.7, df = 4, P < .05), preschool-aged children's aggression (2 = 11.3, df = 4, P < .05), schoolchildren's academic performance (2 = 20.8, df = 4, P < .001), schoolchildren's eating habits (2 = 11.8, df = 4, P < .05), schoolchildren's physical activity levels (2 = 8.6, df = 4, P < .05), adolescents' academic performance (2 = 14.0, df = 4, P < .01), adolescents' eating habits (2 = 19.6, df = 4, P < .001), adolescents' aggression (2 = 9.3, df = 4, P < .05), and adolescents' high-risk behaviors (2 = 11.6, df = 4, P < .05).
A majority of pediatricians reported some interest in receiving training for patient media use reduction through continuing medical education (high interest: 15%; moderate interest: 43%; low interest: 42%). Pediatricians who were most interested in receiving training were also significantly more familiar with the AAP recommendations, agreed with them more, made them to parents or patients more often, thought that the media have greater effects on children, tended to be younger and to be generalists, and were more likely to be female (lowest 2 = 7.9, df = 2, P < .05).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The efforts of the AAP were directed not only at member education but also at influencing children and families by providing a structure for pediatricians to provide recommendations to patients and parents. The results are more mixed on this account. Three of 4 pediatricians (76%) almost always or often recommend that parents encourage alternatives to screen-based entertainment for their children, but only one-half (51%) regularly recommend that children's total screen time be limited to no more than 1 to 2 hours per day, and only one-third (33%) regularly discourage TV viewing for children <2 years of age. These results are somewhat surprising, given that, when pediatricians do make the recommendations, they generally think that they are at least a little effective (although many think that they are very or somewhat effective). Some might argue that a recommendation that is only a little effective is not worth making, but it must be remembered that, in many facets of behavioral health, small effects can have large consequences for public health. For example, the effect of calcium intake on bone mass has an effect size of only 1%, and the effect size of daily aspirin use in the reduction of the risk of heart attacks is <1%.29,30 These effect sizes are quite large when one realizes that, if the recommendations are made to 1 million people, then 10 000 of them might be made healthier. Therefore, health care professionals are used to making recommendations that may have only a little effect, because a little effect may be all that is needed to improve health outcomes.
The low rate of making recommendations is also somewhat surprising because there are few regular perceived barriers to making recommendations. However, lack of parental motivation or support for the recommendations is the barrier most often faced and is likely to be a particularly difficult barrier to surmount.
Given the general familiarity with the AAP recommendations and the frequency of making the recommendations (even if irregularly), it is surprising that pediatricians appear unaware of the more global Media Matters campaign and the specific media resources that are available, such as the media history form. It is unclear from this study why so few pediatricians are aware of the media history form or why so few use it or other AAP brochures.
Female pediatricians are significantly more aware of the guidelines and incorporate them into their practice during anticipatory guidance and parental education. In addition, it is interesting that pediatricians who report watching more TV are more likely to find the recommendations unrealistic, incorporate them less into their practice, and generally find less perceived support for the recommendations from their office/clinic staff.
In their study of pediatric residency programs, Rich and Bar-on31 found that less than one-third of accredited programs educate pediatricians-in-training about the influences of media on children and adolescents. However, they also found that pediatric program directors who had been formally trained in media effects on health were significantly more likely to include media education for their residents. Furthermore, they noted that, if we expect pediatricians to include evaluation of and anticipatory guidance about media use during children's health maintenance visits, then these skills must be taught and practiced in their residency training. It is perhaps significant that more than three-quarters of pediatricians have pediatrician trainees in their clinics/practices. Perhaps even without a formal curriculum, pediatricians' knowledge, attitudes, and practices (ie, whether they make recommendations to parents) will be passed on to future generations.
A strength of this study is that it was a state-based survey. However, the response rate of 41% may limit generalization. Response rates are often low when busy health care practitioners are sampled, and the rates observed in our study are similar to those of other physician surveys32,33 and higher than the response rate of 19% in a recent survey of pediatricians.34 Furthermore, it is unclear at this time how representative Minnesota pediatricians are of pediatricians nationally. We recommend replication of this study in other states.
It is possible that the high rates of awareness and agreement with the AAP recommendations are the result of a social desirability response bias. However, if pediatricians were highly motivated to provide socially acceptable responses, then we would expect that similarly high percentages of pediatricians would report being familiar with the media history form, would report making recommendations to patients, and would provide brochures. However, this pattern was not found. Therefore, social desirability does not seem to have affected the responses broadly. If this study is replicated, it may be appropriate to insert a false recommendation (eg, children <7 years of age should not view media violence at all) to test for a social desirability bias.
This study also did not measure awareness of and agreement with the recommendation that parents remove TV sets from children's bedrooms. This is particularly important because of the recent evidence of the wide range of negative effects that appear to be related to bedroom TVs6,35 and because this may be an issue that pediatricians can very quickly ask about and recommend a change. Given the increasing prevalence of bedroom TVs even for preschool-aged children, this issue is likely to become more important in the future.2,6,36
Overall, our findings are encouraging, considering the almost universal awareness of and agreement with the recommendations. As part of the recommendations published in 2001,27 pediatricians were challenged to lead efforts within their communities to establish coalitions to promote media advocacy and education. In addition, it is possible to conceptualize an approach that would use the office as a setting for direct interventions to reduce media use. To address the sense of futility identified by some respondents in this survey, pediatricians may need to be shown that interventions designed to reduce TV watching and media use can have clinically significant effects. A recent randomized, controlled study documented the ability to reduce body mass index values with the initiation of a 6-month curriculum, at the elementary school level, designed to reduce children's TV viewing.37 Furthermore, the same intervention reduced aggressive behavior, as measured with peer ratings, and observed verbal aggression.38 These results are particularly notable because the intervention was designed to influence only the amount of screen time and not the content of the media watched/played. Certainly, more research in this area is needed. However, the early results clearly suggest that recommendations to limit the total amount of screen time are not misplaced and may have important effects on several aspects of children's health outcomes. Pediatricians are in a privileged position to have positive effects, and the advocacy of the AAP in these respects appears to be valid and should be continued.
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ACKNOWLEDGMENTS |
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We thank Amanda Rian for her help with data collection and 2 anonymous reviewers for their helpful comments.
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FOOTNOTES |
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Address correspondence to Douglas A. Gentile, PhD, Department of Psychology, Iowa State University, W112 Lagomarcino Hall, Ames, IA 50011-3180. E-mail: dgentile{at}iastate.edu
Drs Oberg and Hogan are members of the AAP. The views expressed herein are those of the authors only.
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REFERENCES |
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