Study setting
COVID-19, the acute respiratory syndrome related to the new coronavirus (SARS-CoV-2) infection, dramatically spread worldwide from China since the end of 2019. It reached Italy, first among European countries, on February 2020. The following further rapid diffusion to other continents on March 11th 2020, led the World Health Organization (WHO) to declare a pandemic. The study took place over a 2-month period, from December 2020 to January 2021. In that time Italy, within the second wave of the pandemic, was divided into three zones - red, orange, yellow- corresponding to three different scenarios of epidemiologic risk [11]. The division of the country into three areas was based on 21 criteria, established by the Italian National Institute of Health. The main indicators included local/regional infection rates and hospital (ordinary and intensive care) occupancy, as well as other factors related to care capacity/outbreak management of the different regional health systems (i.e. availability of health care professionals, effectiveness of the contact tracing system) [12]. Specific strategies to contrast the spread of the disease were taken and tuned, based on the different risk scenarios. Where the overall risk of COVID-19 spread was increased, the movement of people and the economic and social activities were more limited according to the Decrees of the President of the Council of Ministers (DPCM), which varied on a period basis. Teaching and educational activities and services were intermittently carried out in presence for children of infant schools, primary schools and partially of lower secondary schools. For the remaining lower secondary school children and for high school adolescents, distance teaching (online) was the only modality of education which was guaranteed [13].
Selection of study participants
This study was based on a self-report and anonymous questionnaire, which was administered to Italian school-age (6-18 years) children and adolescents during the second wave of the COVID-19 pandemic. The test was conceived and made by pediatricians of the Mother and Child Department of the University of Palermo (Sicily, Italy). Questions were created in Google Forms. They were electronically (email, whatsapp) explained in detail, together with the aims of this study, and directly sent to older children (middle and high school), or indirectly, through the help of teachers, to younger ones (primary school). The forms were addressed in Sicily and in regions of northern Italy (Piedmont, Lombardy). Among around three hundred questionnaires homogeneously distributed between males and females of different age groups, a total of 185 students replied and participated in the study. All participants spontaneously and voluntarily joined the present survey. Lack of partial and/or total completion of the questionnaire was the only exclusion criterion. Their answers were recorded on a web-based Google sheet form, and then analyzed.
Data collection
The questionnaire was designed to understand modalities (frequency, patterns and aims) of smartphone use, its impact (adverse effects) on everyday life, and related parental behaviors among children and adolescents, also in order to reveal the eventual occurrence and degree of addiction, before and during the COVID-19 pandemic. It was made by 4 sections.
The first section was about demographic and socioeconomic characteristics, and included the following variables: age, gender, ethnicity, school year, region of residence, family status, parents’ educational level, occupation and income, age at onset of smartphone use.
The second section concerned COVID-19 related questions: family members’ jobs linked to the epidemic (specific occupation), family members and/or friends infected by SARS-CoV-2 or dead due to COVID-19, degree of concern about the pandemic, implementation of preventive and infection control measures, eventual distance (online) learning and impact of the pandemic on education.
The third section included questions on frequency of smartphone use (i.e. time of smartphone use per day, time between wake up and start of use, frequency of night utilization), and about patterns and effects of their utilization before and during the pandemic, evaluated with the following items: “most frequently used functions”, “aim of use”, “adverse effects” and “parental attitude towards smartphone use”. The most frequently used functions included: “telephone call”, “social network (Instagram, Facebook)”, “game”, “education”, “online chat (Whatsapp)”, “photos”, “videos” and “music”. To analyze the aims of smartphone use, we included the following items: “boredom”, “habit”, “pleasure”, “game”, “communication”, “learning”, “stress relief” and “adaptation to others”. The answers on adverse effects included: “superficial approach to learning”, “distraction”, “mood modification”, “loss of interest”, “isolation”, “sleep disturbances”, “ocular alterations” and “musculoskeletal disorders”. Questions on parental attitude regarding smartphone use included the following items: “surveillance”, “restriction”, “punishment”, “permission” and “explanation”. Participants gave to each of these four items a score, ranging from 1 (never) to 5 (always).
The fourth section was related to the evaluation of eventual occurrence and degree of smartphone addiction, measured by the Italian Smartphone Addiction Scale Short Version (SAS-SV) [14]. It is a well-validated specific questionnaire, which contains 10 questions including daily-life disturbance, positive anticipation, withdrawal, cyberspace-oriented relationship, overuse and tolerance (Table 1).
Table 1. Italian Smartphone Addiction Scale Short Version (modified from De Pasquale et al., 2017) [14].
1
|
Missing planned work due to smartphone use
|
2
|
Having a hard time concentrating in class, while doing assignments, or while working due to smartphone use
|
3
|
Feeling pain in the wrists or at the back of the neck while using a smartphone
|
4
|
Will not be able to stand not having a smartphone
|
5
|
Feeling impatient and fretful when I am not holding my smartphone
|
6
|
Having my smartphone in my mind even when I am not using it
|
7
|
I will never give up using my smartphone even when my daily life is already greatly affected by it
|
8
|
Constantly checking my smartphone so as not to miss conversations between other people on WhatsApp, Facebook or Instagram
|
9
|
Using my smartphone longer than I had intended
|
10
|
The people around me tell me that I use my smartphone too much
|
Participants expressed their opinion for each item over a 6-point scale, ranging from 1 (strongly disagree) to 6 (strongly agree). A different normal range is identified for males and females. Males are considered addicted if scores are higher than 31. High risk of addiction is present with scores between 22 and 31. Females are addicted if scores are higher than 33, and at high risk with scores between 22 and 33 [15].
Statistical analysis
We used R version 4.0.4 (R Foundation for Statistical Computing, Vienna, Austria) for data analysis. Simple descriptive statistics were expressed as frequency and percentage for categorical variables, mean and standard deviation (SD) for continuous variables. Paired-samples t-test was used to compare data on patterns of smartphone use in the study population, before and during the COVID-19 pandemic. A p value lower than 0.05 was considered statistically significant.