Influence of length of use of the Information and Communication Technologies on the health of school-age children

Abstract

Introduction: The use of the Internet is becoming increasingly important in enabling children and adults to fully participate in society, whether it is learning new skills or connecting with friends and family. Consequently, children's opportunities are increasingly dependent on the Internet. The advance of technological innovations has resulted in more and more ICT devices being available to children, contributing to the deterioration of children and adolescents' health. Methods: The study was designed as an epidemiological, cross-sectional, descriptive-analytical, comparative study. The study was conducted from October 18, 2021, to January 16, 2022, using an online questionnaire accessible through the Microsoft Forms platform. Respondents were able to access the questionnaire via a link or QR code located on the child's consent form for participation in the study, which was previously signed by a parent/guardian. Results: The results of the study showed that school-age children were the most frequent users of smartphones and watches TV, with male respondents spending more time using almost all ICT devices, with the exception of tablets, which were used more frequently by female respondents. The analysis of pain intensity in the use of information and communication technologies revealed that respondents most frequently experienced mild pain, especially in the neck/shoulders and lower extremities. The frequency of eye problems after using ICT devices was found to be occasional, with the most pronounced symptoms being fatigue, tearing, and eyestrain, as well as headaches in one in five respondents. Conclusion: Increasing frequency of ICT device use was associated with higher pain intensity in all anatomic regions. A 1-hour increase in weekly ICT device use also increased the likelihood of pain intensity in all anatomic regions, including eye symptoms and headaches. High exposure to ICT is of concern because it leads to adverse health outcomes for children.

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Journal of Health Sciences
Amra Mačak Hadžiomerović,
et al
.: Influence of ICT on health of children Journal of Health Sciences XXXX;X(X):1-7 www.jhsci.ba
RESEARCH ARTICLE Open Access
Influence of length of use of the Information and
Communication Technologies on the health of school-age
children
Amra Mačak Hadžiomerović1*, Miloš Lazić2, Jasmina Mahmutović3, Bakir Katana1, Naim Salkić1, Žarko Mitrić4,
Adisa Pašalić5, Hadžan Konjo3, Fuad Julardžija6
1Department of Physiotherapy, Faculty of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina, 2PhD Candidate, Faculty
of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina, 3Department of nursing, Faculty of Health Studies, University
of Sarajevo, Sarajevo, Bosnia and Herzegovina, 4Outpatient Clinic for Physical Medicine and Rehabilitation “Mitrić” Loznica, Serbia, 5
Secondary Dental School Sarajevo, Bosnia and Herzegovina, 6Department of Radiology Technologies, Faculty of Health Studies, University of
Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Introduction: The use of the internet is becoming increasingly important in enabling children and adults to fully partici-
pate in society, whether it is learning new skills or connecting with friends and family. Consequently, children’s opportuni-
ties are increasingly dependent on the internet. The advance of technological innovations has resulted in more and more
Information and communications technology (ICT) devices being available to children, contributing to the deterioration
of children and adolescents’ health.
Methods: The study was designed as an epidemiological, cross-sectional, descriptive-analytical, comparative study. The
study was conducted from October 18, 2021, to January 16, 2022, using an online questionnaire accessible through the
Microsoft Forms platform. Respondents were able to access the questionnaire through a link or QR code located on the
child’s consent form for participation in the study, which was previously signed by a parent/guardian.
Results: The results of the study showed that school-age children were the most frequent users of smartphones and
watches TV, with male respondents spending more time using almost all ICT devices, with the exception of tablets, which
were used more frequently by female respondents. The analysis of pain intensity in the use of information and commu-
nication technologies revealed that respondents most frequently experienced mild pain, especially in the neck/shoulders
and lower extremities. The frequency of eye problems after using ICT devices was found to be occasional, with the most
pronounced symptoms being fatigue, tearing, and eyestrain, as well as headaches in one in five respondents.
Conclusion: Increasing frequency of ICT device use was associated with higher pain intensity in all anatomic regions.
A 1-h increase in weekly ICT device use also increased the likelihood of pain intensity in all anatomic regions, includ-
ing eye symptoms and headaches. High exposure to ICT is of concern because it leads to adverse health outcomes for
children.
Keywords: Information and communication technology; children; musculoskeletal pain; eyes; headache
INTRODUCTION
Information and communications technology (ICT) refers to
any technology used to handle telecommunications, electronic
media, intelligent surveillance systems, audiovisual processing
and transmission systems, and network-based control and
monitoring functions. ICT implies the use of computers to
store, download, transmit, and process data or information (1).
*Corresponding author: Amra Mačak Hadžiomerović, Department of
Physiotherapy, Faculty of Health Studies, University of Sarajevo, Stjepana
Tomića 1, 71000 Sarajevo, Bosnia and Herzegovina.
E-mail: amra.macak_h@fzs.unsa.ba
Submitted: 23 February 2023/Accepted: 29 March 2023
DOI: https://doi.org/10.17532/jhsci.2023.2120
e widespread use of ICT devices by children, youth, and
adults has become an evolutionary phenomenon that sig-
nicantly permeates the eld of education (2). Internet use
is becoming increasingly important in enabling children
and adults to participate fully in society, whether in learn-
ing new skills or in connecting with friends and family. As
a result, children’s opportunities increasingly depend on the
internet (3). e advance of technological innovations has
led to more and more ICT devices being available to chil-
dren. Social networks and the internet are very attractive to
today’s younger generations (4).
Two-thirds of students in Colombia, the Dominican
Republic, Mexico and Peru have access to smartphones at
home. Over 80% of students in Australia, Austria, Belgium,
81,9(56,7<2)6$5$-(92
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© 2023 Hadžiomerović, et al.; licensee University of Sarajevo - Faculty of Health Studies. This is an Open Access arti-
cle distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/
by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.

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.: Influence of ICT on health of children Journal of Health Sciences XXXX;X(X)1-7
Denmark, Iceland, Luxembourg, the Netherlands, and
Portugal have access to laptops at home, while access is
below 40% in Beijing, Shanghai, Jiangsu, Guangdong
(China), the Dominican Republic, and Peru (5).
e availability and use of ICT devices have expanded,
leading to excessive use, especially among young people
with an average daily usage of 7.5h per day (6).
According to a 2018 study conducted by Limelight
Networks, children in the United States play video games
for an average of 6.44h each week, which is longer than the
global average of 5.96h (7).
It was found that the amount of time adolescents spend in
front of ICT device screens increases signicantly between
the ages of 10 and 14, but with signicant dierences
between genders. For boys, it increases by 41.6minutes per
day and for girls by 22.7minutes per day (8). In America,
as many as 89% of adolescents aged 13–17 own a smart-
phone, more than double the rate of 6years ago (9).
ICT device use poses a risk for musculoskeletal pain, as an
increase in daily use for a single hour increases the likeli-
hood of pain or discomfort from 4% to 7%. e increase
in risk can be considered clinically signicant because ado-
lescents spend up to several hours a day on a smartphone,
computer, or TV (10).
Evidence shows that adolescents adopt non-physiological
postures during prolonged smartphone use, with the neck
exed, shoulders hunched, elbows bent, forearms supi-
nated, upper and lower back contorted, and hips, knees,
and ankles constantly exed (11).
Neck and back pain, including headaches, are the leading
cause of disability worldwide, with an increasing prevalence
in school-aged children (12). e prevalence of thoracic
spine pain caused by ICT devices among adolescents is
20.0% in Australia, 13.2% in Portugal, 36% in southern
Denmark (13), and 59.0% in Canada (14), while in south-
ern Brazil, in the city of Rio Grande, it is 26.2% and 36.9%
in Pelotas (15).
Eye strain is the most common eye problem associated with
long-term use of ICT devices, characterized by symptoms
such as dry eyes, itching, foreign body sensation, tearing,
blurred vision, and headache. Ma et al. (2021) found a
rapid increase in myopia (nearsightedness) in students aged
7–12years in Shanghai during a 4-month isolation at home
due to the COVID-19 pandemic, which nearly tripled in
just 6months (16).
It is estimated that the prevalence of eye problems in school-
aged children ranges from 25% to 93%. Higher prevalence
rates of vision problems have been observed in adolescents
who continuously use digital devices for more than 2h. In
a study conducted in private schools in Western India, the
prevalence of eye strain was 17.9%. During online classes,
36.9% of children used digital devices for more than 5h
per day, whereas this percentage was 1.8% before school
hours (17).
e aim of this work was to determine the duration of
daily use of information and communication technologies
in school-aged children and to investigate the intensity of
pain, eye health, and headaches during use.
METHODS
e study was designed as an epidemiological, cross-sec-
tional, descriptive-analytic, and comparative study
that included all respondents who met the criteria for
inclusion in the study. In accordance with the inclusion
criteria, the study included 549 respondents of early
adolescence, that is, students of sixth, seventh, eighth,
and ninth grades of elementary schools in the territory
of Republika Srpska (Bosnia and Herzegovina). Of
the total number, 266 were male and 283 were female
respondents. e survey was conducted in all four geo-
graphical regions of Republika Srpska, namely: Banja
Luka; Doboj-Bijeljina; Istočno Sarajevo-Zvornik; and
Trebinje-Foča.
As provided for in the Ethical Guidelines for Research
with Children (Council for Children of Bosnia and
Herzegovina - 2006), the research was conducted after
receiving the decision of the College Senate on the accep-
tance of the Commission’s report dated September 29,
2021 (number: 01-14-179/21), the approval of the
Ministry of Education and Culture of the Government
of Republika Srpska dated October 18, 2021 (number:
07.041/059-2318/21), the consent of the administrations
of the relevant elementary schools in Republika Srpska and
the written consent of the parents/guardians of the children
participating in the study. e survey was conducted in the
period from October 18, 2021, to January 16, 2022, in
the form of an online questionnaire accessible through the
Microsoft Forms platform.
e instrument used for the research was the Technology
Use Questionnaire, which was adapted to our research.
Respondents could access the questionnaire through the
link and code QR on the consent form for the child’s
participation in the study, which was previously signed
by a parent/guardian. e link could also be received
through the schools’ e-mail address provided by the
Republika Srpska Pedagogical Institute to provide
schools with the consent forms required for participa-
tion in the study. After each completion of the ques-
tionnaire, the researcher received an e-mail notication
of the successful completion of the questionnaire by the
respondent, whose identity also remained anonymous to
the researcher.
e results of the study are presented in the form of tables,
using classical methods of descriptive and analytical sta-
tistics, depending on the type of data and measurement
scale. Adequate methods of classical descriptive and analyt-
ical statistics were used to describe the sample, depending
on the type of data: absolute frequency (N) and relative
frequency (%).
Results are presented in contingency tables (numbers
with two decimal places). e signicance level was set at
p = 0.05.
RESULTS
e study included 549 respondents of adolescent age. All
respondents were between the ages of 10 and 16. Of the
total number of respondents, 266(48.5%) were male and
283(51.5%) were female.

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TABLE 1. Average time of using the ICT devices per gender
ICT devices X SD Min Max p‑value
Television (hours/weekly)
Male 12.63 11.09 0.00 62.00 p=0.060
Female 10.98 9.39 0.00 60.50
Total 11.78 10.27 0.00 62.00
Laptop (hours/weekly)
Male 3.48 8.82 0.00 62.00 p=0.264
Female 2.75 6.45 0.00 60.50
Total 3.10 7.69 0.00 62.00
Tablet (hours/weekly)
Male 1.19 4.36 0.00 55.50 p=0.127
Female 1.85 5.68 0.00 60.50
Total 1.53 5.09 0.00 60.50
Smart phone (hours/weekly)
Male 24.74 16.61 0.00 62.00 p=0.307
Female 23.34 15.43 0.00 62.00
Total 24.02 16.01 0.00 62.00
Total time of the ICT use per
week
Male 42.04 27.62 3.00 209.00 p=0.165
Female 38.92 24.86 2.00 181.50
Total 40.43 26.25 2.00 209.00
TABLE 2. Average intensity of pain in different segments of body per
gender
Anatomical regions X SD Min Max p‑value
Neck/shoulders
Male 1.55 2.12 0.00 10.00 p=0.020
Female 1.97 2.17 0.00 10.00
Total 1.77 2.16 0.00 10.00
Upper back
Male 1.22 2.14 0.00 10.00 p=0.261
Female 1.42 2.15 0.00 10.00
Total 1.32 2.14 0.00 10.00
Lower back
Male 1.00 1.97 0.00 10.00 p=0.086
Female 1.31 2.20 0.00 10.00
Total 1.16 2.10 0.00 10.00
Arms
Male 1.13 2.12 0.00 10.00 p=0.450
Female 1.00 1.84 0.00 10.00
Total 1.07 1.98 0.00 10.00
Wrist/hand
Male 0.83 1.84 0.00 10.00 p=0.479
Female 0.95 1.87 0.00 9.00
Total 0.89 1.86 0.00 10.00
Lower extremities
Male 1.54 2.29 0.00 10.00 p=0.628
Female 1.45 2.19 0.00 10.00
Total 1.49 2.24 0.00 10.00
e statistical analysis in Table1 shows that male respon-
dents spend more time using ICT devices than female
respondents, but with no statistically signicant dierence.
Using Student t-test, it was found that male respondents
spend more time watching TV, on average 12.63 ± 11.09h
per week; on average, they use laptops 3.48 ± 8.82h per
week and smartphones 24.74 ± 16.61h per week. On the
other hand, female respondents spend more time using tab-
lets, with an average usage time of 1.85 ± 5.68h per week.
Overall, the weekly use of ICT devices was slightly longer for
male respondents (with an average use of 42.04 ± 27.62h)
than for female respondents, who used ICT devices for an
average of 38.92 ± 24.86 h per week. Weekly use of ICT
devices by respondents of both genders ranged from 0 to 62h.
Table2 shows a statistically signicant dierence in neck/
shoulder pain intensity according to gender using the
Student t-test, which found that pain intensity was higher
in female respondents, with an average of 1.97 ± 2.17, than
in male respondents, with an average pain intensity of 1.55
± 2.12 (t = 5.413; p < 0.020).
e mean pain intensity in the upper back region was 1.22
± 2.14 for male respondents and 1.42 ± 2.15 for female
respondents.
For the lower back region, the average pain intensity was
1.00 ± 1.97 for male respondents and 1.31 ± 2.20 for
female respondents.
For pain in the arms, the average pain intensity was 1.13
± 2.12 for male respondents and 1.00 ± 1.84 for female
respondents.
Of all segments, pain in the wrist/hand was the least severe
at 0.83 ± 1.84 for male respondents and 0.95 ± 1.87 for
female respondents.
Lower extremity pain had the highest intensity, 1.54
± 2.29 for male respondents and 1.45 ± 2.19 for female
respondents.
As per Chart 1, eye fatigue and headache were to some
extent more common among respondents from rural areas,
while all other symptoms were slightly more common
among respondents from urban areas, although the dier-
ences were not statistically signicant.
Of the total number of respondents, eye fatigue was the
most prominent eye symptom during or after ICT use-even
among 179 (32.6%) respondents, followed by headache
among 105(19.1%) respondents.
Tears in the eyes occurred in (16.4%) of respondents,
while eye discomfort (irritation, heaviness) occurred in
79(14.4%) of respondents.
e least common eye symptom was dry eye (2.2%).
As per Chart 2, correlation analysis of pain intensity
during the last month of the statistically signicant vari-
ables related to time of ICT device use indicates that a
1-h increase in weekly laptop use increases the probabil-
ity of upper back pain intensity by 15.1% (rho =0.111;
p < 0.01), while an increase in weekly smartphone use by
1h increased the likelihood of pain intensity in the upper
back by 23.0% (rho = 0.230; p < 0.01), neck/shoulders by
18.2% (rho = 0.182; p < 0.01), legs by 17.6% (rho = 0.176;
p < 0.01), lower back by 10.9% (rho = 0.109; p < 0.05), and
hands by 8.8% (rho = 0.088; p < 0.05).
Regarding tablet use, a 1-h weekly increase in use also
increased the odds of wrist/hand pain intensity by 16.2%
(rho = 0.162; p < 0.01), in the upper back by 10.8%
(rho = 0.108; p < 0.05) and in the lower back by 9.3%
(rho = 0.093; p < 0.05). Increasing the total time of weekly
ICT device use by 1h increased the odds of pain inten-
sity in the upper back by 22.2% (rho = 0.222; p < 0.01),
legs by 13.3% (rho = 0.133; p < 0.01), neck/shoulder by

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.: Influence of ICT on health of children Journal of Health Sciences XXXX;X(X)1-7
12.4% (rho = 0.124; p < 0.01), and wrist/hand by 11.4%
(rho = 0.114; p < 0.01).
Correlation analysis of eye symptoms and headache of statis-
tically signicant variables related to time of ICT device use,
according to Chart 3, shows that increasing the time of weekly
tablet use by 1h increases the likelihood of headache by 8.9%
(rho = 0.089; p < 0.05). Increasing weekly smartphone use by
1h increases the odds of headache by 14.2% (rho = 0.142;
p < 0.01), of visual disturbance by 12.4% (rho = 0.124;
p < 0.01), for double vision by 12.3% (rho = 0.123; p < 0.01),
and for itchy eyes by 9.8% (rho = 0.098; p < 0.05).
Increasing the total time of weekly ICT device use by 1h
increased the odds of headache by 15.2% (rho = 0.152;
p < 0.01).
CHART 1. Presentation of eye symptoms during or after using the ICT devices per regions.
CHART 2. Correlation analysis of the pain intensity during the last month of statistically signicant variables in relation to the time of used ICT devices.

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Amra Mačak Hadžiomerović,
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.: Influence of ICT on health of children Journal of Health Sciences XXXX;X(X):1-7 www.jhsci.ba
DISCUSSION
e study included 549 respondents of adolescent age. All
respondents were between the ages of 10 and 16. Of the
total number of respondents, 266(48.5%) were male and
283(51.5%) were female.
A cross-sectional study by Torsheim and associates of 31,022
respondents aged 11–15years from the Scandinavian coun-
tries of Denmark, Sweden, Finland, Norway, Iceland, and
Greenland found that average daily computer use was
1.53 h in Denmark (male respondents 1.61 h, female
1.45h), 1.74h in Sweden (male 1.75h, females 1.73h), in
Finland 1.55h (male respondents 1.54h, females 1.55h),
in Norway 1.69 h (male respondents 1.58 h, females
1.80 h), in Iceland 1.79 h (male respondents 1.87 h,
females 1.72h), and in Greenland 1.3h (male respondents
1.17h, females 1.43h). e average daily viewing time TV
was 2.68h in Denmark (male respondents 2.61h, female
2.75h), 2.23h in Sweden (male respondents 2.30h, female
2.17h), 2.17h in Finland (male respondents 2.21h, female
2.13 h), 2.42 h in Norway (male respondents 2.41 h,
female 2.42h), in Iceland 2.39h (male respondents 2.56h,
female 2.22h), and in Greenland 2.61h (male respondents
2.62h, female 2.60h) (18), which means that respondents
in all Scandinavian countries use computers and watch tele-
vision more frequently than respondents in our study.
In a cross-sectional study of a sample of 969 respondents
aged 13–19 years, Silva et al. examined the association
between activities on screens of ICT devices and the pres-
ence of pain in the past 7days. e study authors found
that the average pain intensity per body segment ranged
from 3.6 ± 1.8 in the neck to 4.4 ± 2.3 in the knee. e
results of the study showed that female respondents were
signicantly more likely to report pain in all body segments
(OR ranging from 1.64 to 2.58), except for the region of
the ankles and feet (13). is means signicantly higher
pain intensity in all body regions compared to the results
of our study, noting that female respondents in our study
had higher pain intensity in almost all body regions except
for the regions of the arms and lower extremities, while
the results of Silva et al. study showed that female respon-
dents had signicantly higher odds of reporting pain in all
body segments except for the ankles and feet. e study by
Aartun et al. examined pain intensity in adolescents aged
11–13years and found that the average pain intensity in
the neck and upper back was 3.1, whereas it was 2.7 in
the lower back (19), suggesting that respondents in their
study had higher pain intensity in the aforementioned body
regions than was the case in the results of our study, not-
withstanding the fact that the results were not exclusive to
the gender of the respondents.
Khalaj et al. examined vision problems and their association
with computer use in a sample of 642 respondents aged 11
to 18years. e authors found that eye strain occurred in
81.9% of respondents, eye pain in 50.5% of respondents,
eye redness in 43.3% of respondents, headache in 40.2% of
respondents, and blurred vision in 37.4% of respondents,
while dry eyes were the least common in 7.8% of respon-
dents (20). Review of these results showed that respondents
in our study had a signicantly lower percentage of head-
ache and eye symptoms.
A cross-sectional study from Pakistan involving 385 ado-
lescents aimed to determine the incidence of eye strain
from working on ICT devices and its association with time
spent in front of ICT device screens. e research results
showed that the most common symptoms were headache
(47.3%), tired eyes (33.7%), blurred vision (25%), eye-
strain (22.3%), irritated or painful eyes (15%), and dry
eyes (9.6%) (21), indicating that eye fatigue was the only
symptom consistent with the nding of our study, while all
other symptoms were signicantly more common among
respondents from Pakistan.
A study from Portugal aimed to investigate and compare
the association between time spent in ICT device screen
activities and the presence of pain in all body regions
during the past 7days. e study included 969 respondents
aged 13–19years. e research results showed that the odds
CHART 3. Correlation analysis of eye symptoms and headache of statistically signicant variables in relation to the time of used ICT devices.

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.: Influence of ICT on health of children Journal of Health Sciences XXXX;X(X)1-7
ratio (OR) for neck pain in the past 7days was (OR =1.19)
among respondents who used a cell phone for <1h a day
and (OR =1.92) among respondents who used a cell phone
more than 5 h a day, (OR =1.59) among respondents
who used a computer <1h a day, and (OR =2.16) among
respondents who used a computer more than 4h a day.
For upper back pain, this ratio was (OR =1.08) for respon-
dents who used a cell phone <1h a day and (OR =2.74) for
respondents who used a cell phone more than 5h a day;
(OR =0.97) for respondents who used a computer <1 h
a day and (OR =1.54) for respondents who used a com-
puter more than 4h a day. For low back pain, this ratio was
(OR =1.25) for respondents who used a cell phone <1h per
day and (OR =3.20) for respondents who used a cell phone
more than 5h per day; (OR =2.34) for respondents who
used a computer <1h per day and (OR =3.02) for respon-
dents who used a computer more than 4h per day. For pain
in the hands, this ratio was (OR =1.36) for respondents
who used a cell phone <1h per day and (OR =2.56) for
respondents who used a cell phone more than 5h per day.
For leg pain, this ratio was (OR =1.0) among respondents
who used mobile phones <1h per day and (OR = 2.69)
among respondents who used mobile phones more than
5h per day (13). Respondents who used cell phones and
computers more frequently had higher pain intensity in
all body regions compared with respondents who used cell
phones and computers less frequently, which is consistent
with our study in which the likelihood of pain intensity in
all body regions increased with an increase in cell phone
and computer (laptop) use of 1h per week.
A study by Falkenberg and associates examined eye dis-
comfort, headaches, and musculoskeletal symptoms asso-
ciated with tablet and smartphone use by healthy adoles-
cents with normal vision. Fifty-seventh-grade adolescents
aged 11–13years participated in the study. e authors
found that headaches had a signicant positive correla-
tion with eye strain and associations with neck, shoulder,
back, and arm pain with smartphone use. Headaches were
also associated with eye strain and neck and shoulder pain
when using tablets (22). It is important to emphasize that
respondents showed positive correlations of headaches
due to smartphone and tablet use, whereas the results of
our study showed that the likelihood of various eye symp-
toms and headaches increased with a 1-h weekly increase
in ICT use.
CONCLUSION
School-age children are most likely to use smartphones
and watch TV. Male respondents spend more time using
almost all ICT devices, with the exception of tablets, which
are used more often by female respondents. e analysis
of pain intensity when using information and communi-
cation technologies revealed that respondents most often
experienced mild pain, especially in the neck/shoulder
and lower extremities. e pain that occurred was of a
non-specic character, recorded on the basis of the sub-
ject’s self-assessment. e frequency of eye problems after
using ICT devices was found to be occasional, with the
most pronounced symptoms being fatigue, tearing, and
eyestrain, as well as headaches in one in ve respondents.
With an increase in the time of ICT use by 1h per week,
the likelihood of pain intensity also increased in all body
regions, including eye symptoms and headaches.
Limitations of the Study
Because the survey was conducted during the COVID 19
pandemic, it was not possible to reach respondents directly.
Nevertheless, the entire research was conducted in the form
of an online survey on the Microsoft Forms platform.
CONFLICTS OF INTEREST
e authors declare that they have no competing interests.
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