Introduction

Visual impairment in children refers to all degrees of reduction in vision in childhood, which can significantly affect the development of visual, motor, and cognitive function and potentially lead to long-term adverse psychosocial consequences [1–3]. According to WHO estimates, at the beginning of the VISION 2020 program, about 19 million children under the age of 15 years were visually impaired, and 1.4 million children had irreversible blindness. It was predicted that half of the blindness cases were preventable [4]. The prevalence of blindness in low and middle-income countries, including Bangladesh, ranges from 0.2 to 7.8/10,000 people, and in developed and industrialized countries, the annual incidence is 6/10,000 in the under-15 age group [5]. In school, visual impairment has been shown to adversely affect a child’s educational performance, including reading skills [6–8]. Approximately 90% of visually impaired children do not receive adequate education due to factors including discrimination, stigmatization, and lack of access to appropriate schools [9]. Reports suggest that most VI is preventable or treatable [10–12]. However, there is data that only 4% of rural people have had an eye check once in their lifetime [13]. Understanding the lifestyle and behavioural factors associated with ocular problems, early detection, and effective methods of addressing the factors are essential approaches for preventing visual impairment [14, 15].

The risk factors of visual impairment include watching TV, mobile phone, family history of ocular conditions, and Vitamin Deficiency [16–19]. Vitamin A, or all-trans-retinol, is an essential micronutrient for immunity, the maintenance of mucosal surfaces, and vision; thus, its deficiency is associated with visual impairment [19]. Periodic, high-dose vitamin A supplementation is a proven, low-cost intervention and the estimated number of saving lives of more than 350,000 children each year [20]. However, problematic smartphone use (PSU) has been becoming a challenging health issue for children as it has severe adverse effects on their mental health, emotional stability, self-control, and vision [21, 22]. The number of smartphone users is consistently increasing, reported to be 1 billion in 2014 and 5.5 billion in 2024 and projected to be 6.5 billion in 2029 globally, with a 14.9% annual growth rate [23].

Bangladesh is a low-medium income country in southeast Asia with an estimated number of people of 169.8 million, including 56.9 million children aged 0–17 years [24]. In Bangladesh, mobile phone use is increasing at one of the highest rates in the world. According to the Bangladesh Telecommunication Regulatory Commission (BTRC) report in 2020, around 74% of Bangladesh’s 15–65-year-old population had mobile phones, with gaps between ownership and accessibility, including urban and rural areas, socioeconomic status, and occupation [25]. An overall increase in smartphone use was 8.59% from 2021 to 2024, but there was a decrease in TV ownership [26]. Due to the increase in access to mobile phones and internet, children are expected to have more access to mobile facilities. To develop a successful visual impairment prevention program, it is first necessary to characterize the sociodemographic, lifestyle, and behavioral factors and their association with ocular problems [3]. Besides the vitamin A supplement, it is now prime time to undertake strategic policies considering the findings for limiting children’s smartphone usage, making Bangladesh susceptible to protecting its future generation from the harmful effects of mobile phones.

Some programs exist at the school level, including health programs funded by the Bangladesh government that perform periodic vision screening and Vitamin A supplements for each child [27]. Vitamin A supplement has been a successful program. In 2022, vitamin A supplement was reported to be 92%, a positive indication of preventing vision impairment. Children are primarily unaware and cannot always point out vision deficiency at an early stage, and parents may remain unaware of the gradually developing vision problem. Islam et al. previously reported that 96% of rural people did not have any eye examination in their lifetime and were unaware of their vision condition. Similar to the successful A supplement program, no such outcome related to vision screening has been reported, and the impact of the government/s program on vision screening is not well understood. Alam et al. studied the ocular status, health-seeking behaviors, and barriers to the uptake of eye care services among children of a slum community [28]. The study among 410 children aged 5–16 reported that 36.6% had ocular abnormalities, including 26.7% refractive error, of whom 73% never went to an eye care specialist. Epidemiological data on the risk factors of vision impairment, current symptoms of vision problems, and their associations with self-reported ocular problems in children would be beneficial for informing policy and planning control strategies. The current study aimed to report (i) the association of sociodemographic factors with lifestyle and behavioral factors and self-reported ocular problems and (ii) the association of lifestyle and behavioral factors with self-reported ocular problems among children.

Materials and methods

Results

Table 1 shows the characteristics of the participants. The majority of participants are between 7–11 years old, with the most dominant age group being 7 years old (22.9%). The sample is consisting of 7004 girls (52.5%) and 6337 boys (47.5%). Most of the participants, 93.3%, reside in rural areas, with only 6.7% residing in urban areas, indicating a highly rural sample. Most participants reside in semi-paka houses (57.9%), followed by those who reside in Kacha houses (24.9%). A smaller proportion, 17.2%, reside in Paka houses, indicating a difference in housing conditions.

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Table 1. Descriptive information with number and percentage of children, and the socio-demographic conditions of the children’s family.

https://doi.org/10.1371/journal.pone.0328541.t001

A majority of the fathers have secondary education (57.3%), with lower numbers having primary education (12.1%) or higher education (graduate or higher at 8.0%). Notably, 1.8% of the fathers have no education. A majority of the mothers have secondary education (60.2%), with the second most common category being primary education (23.1%). A lower percentage have graduate education (2.2%).

The majority of the fathers work in agriculture (35.2%), followed by daily labor (25.4%) and business (17.2%). Some are unemployed (0.5%) or unable to work (0.5%).

Nearly all the mothers, 96.4%, are homemakers or house duties, and only a small number is engaged in paid work. The remaining, 3.6%, are in daily labor (0.5%) or business (0.1%). The majority of the respondents belong to the middle-class group (69.3%), followed by the poor (16.5%) and the rich (12.7%). Few are very poor (1.6%), indicating a predominantly middle-income sample.

Table 2 presents data on behavioral factors such as TV watching, mobile phone usage, and reading books, along with self-reported ocular problems and ocular trauma and their associated characteristics, including children’s age, gender, and parents’ sociodemographic factors. The main statistical approach used in this table is the Chi-square test. P for trend tests examine whether there is a significant trend across ordered categories like grade levels and socio-economic status.

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Table 2. The association of sociodemographic factors with lifestyle and behavioral characteristics and self-reported ocular problems in the 13341 children reported using Chi-square tests.

https://doi.org/10.1371/journal.pone.0328541.t002

The coverage of Vitamin A taken was 98.8%. Of the children, 58.7% watched TV, 58.5% used mobile phones, 17.6% used more than one hour, and 25.1% read books 3–6 hours a day. About 60% of children watched TV or computers. The chi-square test revealed that gender was not associated with watching TV (boys 59.1% boys vs. 58.4% girls, p = 0.41). However, watching TV was significantly higher in urban areas (67.1% urban vs. 58.1% rural areas, p < 0.001) and who owned a paka house (71.1% in paka house vs. 42.3% in kacha houses, p < 0.001). The proportion of watching TV or using mobile phones was higher among children whose parents had higher education, had government or private jobs, or those with higher socio-economic status. The proportion of watching TV or using mobile phones for more hours was higher among children whose parents had no education or primary education. Almost every student reads books regularly, but the percentage of more hours spent reading was higher for children in higher grades, in paka houses, and parents with higher education. For example, the proportion of children in grade 1 who read books 3–6 hours per day was 1.7%, and those in grade 5 was 53.8%. Test for the trend option in the Chi-square test revealed a significant trend as they went to the higher grades, p < 0.001 for trend. Ninety-nine (0.7%) children reported that they had problems seeing the blackboard or distance people, with a significant difference between urban (2.2%) and rural areas (0.6%), p < 0.001, and between living in paka houses (1.3%) and kacha or semi-paka houses (0.6), p = 0.006. Mothers’ higher education was associated with more hours of reading books (16.6% in mothers with no formal education vs. 46.6% in graduate mothers, p < 0.001) and a higher proportion of seeing problems (0.3% in mothers with no formal education vs. 3.1% in graduate mothers, p < 0.001) and a higher proportion of headache (0.3% in mothers with no formal education vs. 1.4% in graduate mothers, p = 0.004). Only 59 (0.4%) students had a history of previous eye examination, 32 (0.2%) used spectacle, and four had previous eye surgery.

Table 3 includes Chi-square tests and p-values that help interpret the relationships between different lifestyles and behavioral factors with self-reported ocular conditions, history of eye examination, and spectacle use. Watching TV or a computer or using a mobile phone was not associated with any ocular condition, but more hours of watching TV or using mobiles or reading books were associated with a higher proportion of seeing problems or any ocular trauma. Only five children did not take vitamin A, one of whom had problems seeing the blackboard, had eye examinations, and used spectacles.

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Table 3. The association of lifestyle and behavioral factors with self-reported ocular problems, eye examinations, and spectacles use in the total sample of 13341 children reported using Chi-square tests.

https://doi.org/10.1371/journal.pone.0328541.t003

Table 4 presents data on behavioral factors and their associations with ocular problems and ocular trauma. The main statistical approach used in this table is the relative risk (RR), which assesses the strength of the association. The statistical analysis, based on relative risk, shows that longer durations of TV watching and mobile usage are significantly associated with an increased likelihood of experiencing ocular problems and ocular trauma. Reading books for 3–6 hours daily is also linked to a higher likelihood of seeing problems. The findings demonstrate the potential role of screen time (mobile and TV) on eye health. Compared to children who did not watch TV or computers, children who watched TV or computers for one-hour, relative risk (RR) (95% CI) 4.16 (2.15, 8.07) or more than one hour RR (95% CI) 5.33 (2.62, 10.8) were more likely to have seeing problems. Compared to children who did not use mobile phone, those who used it for one hour RR (95% CI) 4.82 (2.17, 10.7) or more than one hour RR (95% CI) 7.30 (3.06, 17.4) were more likely to have any ocular trauma. Reading more hours was also associated with a higher proportion of seeing problems.

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Table 4. The associations of lifestyle and behavioral factors with self-reported ocular problems in the total sample of 13341 children.

https://doi.org/10.1371/journal.pone.0328541.t004

Discussion

Ocular problems have a significant impact on daily life, including poor cognitive function and learning deficiency. Understanding the ocular problems and practice in the detection of vision impairment and the factors that potentially cause vision impairment are primary approaches for preventing vision impairment [14,15]. The significant findings from this study include: (1) Almost 99% of the children had taken Vitamin A, (2) About 60% of the children watched TV or computer or mobile screens regularly and this percentage was higher in urban areas, (3) a small number of children had previous eye examination, (4) only 0.2% of children used spectacles, (5) those who watched TV or used mobile more than one hour daily had problems seeing blackboard or distance people or had any ocular trauma than children who did not watch TV or did not use mobile phones.

Results from this study indicate that about 60% of children are regularly exposed to screens, with a higher prevalence in urban areas, consistent with the research findings. Studies have consistently stated that urban children usually have greater access to electronic devices, leading to increased screen time than their rural counterparts. For instance, one of the national studies in China documented that excessive recreational screen time (RST) among urban children and adolescents was higher than their rural counterparts. This finding has been attributed to the high availability of electronic devices and the varying lifestyle patterns in urban areas [32]. A recent study reported that teens living in metropolitan areas had higher odds of having four or more hours of screen time on a weekday than their non-metropolitan counterparts [33]. In this regard, a study done among 2–6-year-old children in western India reported an average screen time of 2.7 hours, which was higher among young children [34].

Our study shows that more urban children had more difficulty seeing the blackboard than rural children. A cross-sectional study in India showed a refractive error prevalence rate of 7.61% among urban school children, while it was 5.21% among rural school children. Such difference can be because children in urban settings might run a greater risk of myopia due to some aspects of urban lifestyle, like increased use of computers and mobile phones and lesser time utilization outdoors [35]. Our study reported that children who watched TV for at least one hour were more likely to have seeing problems or ocular trauma than those who did not. These findings demonstrate the potential consequence of long-term screen exposure on children’s visual health. This increased risk of more hours of TV watching stresses the need to monitor screen time to prevent children’s vision problems. These risks could, therefore, be reduced by promoting outdoor activities, reducing screen exposure, and promoting eye examination, thus improving outcomes in eye health. The results of this study concur with global evidence on the strong association between prolonged screen time and vision problems in children. Likewise, a study by Holden et al. [36] reported a strong correlation between increased screen time and the prevalence of myopia among children. The study also noted that prolonged near-work activities, including watching TV, were significant risk factors for vision problems. In a comparative study between urban and rural school-going children regarding refractive errors, myopia showed an urban preponderance of 52% compared with other parts where a rural preponderance of hyperopia was most seen. The present urban predominance of myopia may contribute to the visual problem in viewing distant objects like blackboards [37].

Our study reports an association between mothers’ higher education and a higher proportion of ocular problems. Education has been reported to act as a proxy for the family’s socioeconomic status and geographic area of residence. Thus, the correlation between education and ocular problems may be spurious. Educated mothers can identify health problems in children more quickly easily and seek necessary care. Based on data from 22 developing countries, one study reported a correlation between maternal education and markers of child health, which may imply that educated mothers are more concerned with their children’s health conditions, including eye defects [38]. Higher reporting of visual problems among children of literate mothers could also be associated with better socioeconomic status, health-seeking behavior, and utilization of health services [39, 40]. Although a higher proportion of ocular problems in our study is self-reported, the children of educated mothers could be more aware of children’s conditions than those of uneducated mothers. Our study reported that only a few children had proper eye examinations. Low rates of pediatric eye examinations due to limited healthcare infrastructure and awareness are quite common in low and middle-income countries. For example, in a door-to-door screening of 32857 children aged 5–18 years in an urban slum of Delhi, it was reported that 2.8% of children had previous eye examinations before data collection in 2020 [41]. Yet similar results have been reported among a sub-Saharan population where school-aged children’s access to eye care facilities is very low [42]. Most pediatric ophthalmologists and specialized facilities are based in urban areas, meaning many rural areas have limited availability [43].

Our study showed a strong association of ocular trauma in children with the use of a mobile phone. Although few studies have directly investigated a possible link between mobile phone use and ocular trauma, the literature generally supports this association in the context of screen time contributing to disorders of the eyes among children [44, 45]. Some of the studies showed that extensive smartphone uses leads to significant ocular discomfort and reduced tear stability in children. Studies report that even one hour of continuous screen exposure can induce visual strain in children aged 6–15 [46, 47]. The literature, however, remains scanty regarding direct evidence on specific associations between the use of a mobile phone and ocular trauma. For example, a study from the UK listed various causes of eye injuries but did not identify mobile phone use as a significant factor [48].

Conclusion

The current study shows that the proportion of children taking vitamin A, a government-initiated program, was very high. Although the proportion of children with vision problems, headaches, or any ocular trauma is not high, these incidents were higher in urban areas and who spent more time watching TV or mobile screens. The associations of mothers’ higher education with a higher proportion of vision problems can be considered a proxy for the socioeconomic status and urban areas. Due to the skill shortage, especially of ophthalmologists in rural areas, engaging trained schoolteachers for school-based screening purposes can be a feasible and cost-effective approach to vision care at community levels. Factors associated with the small number of self-reported visual problems suffer from insufficient statistical power, and the conclusion may not reflect the truth. The study has raised concerns and needs further study with greater details.

Supporting information

Acknowledgments

We want to extend our deepest appreciation to all who made this study a success. We want to thank Md Sadequl Islam, the executive director of the ORCD, for his tremendous effort to communicate with all schools, including contacting the administration and the Department of Primary Education. We want to thank Lima Asma, Tarin Sharmin, Jamirul Islam, Mafijur Rahman, Nupur, and Ratul, who participated in the screening program. We are grateful to more than 800 schoolteachers and their staff from 192 schools for their wholehearted cooperation—my thanks to 13341 schoolchildren.