A community-based cross-sectional study was conducted from January 10, 2024, through February 29, 2024, in Woliso City Administration. The city is in Oromia Regional State, about 114 km southwest of Addis Ababa, the capital city of Ethiopia. Ethiopia is rapidly shifting from an agrarian lifestyle to urbanization [38]. The country is also undergoing a digital revolution as a result of the national initiative “Digital Ethiopia,” which is playing a crucial role in access to digital devices and increased usage [39]. As a result, about 85.4 million and 28.6 million people are actively using mobile phones and the internet, respectively [40]. In particular, about 94.8% of parents in Woliso City had screen devices, of which 99.4% were mobile phones [16].

Regarding ST and the physical environment, about 54.5% of Ethiopian children and adolescents adhere to the sedentary recreational ST guidelines, whereas only 43% of children and adolescents have access to physical activity settings [41,42]. In Woliso City, only 26.7% of parents reported having available playgrounds, and about 56.8% of children had outdoor playtime of more than 1 hour [16].

Generally, the study setting (Woliso City) has 4 administrative kebeles (lower administrative units)—namely Ayetu, Egersa, Burka Gudina, and Hora—with an estimated 15,476 households. As of 2014, the estimated total population of the city was 118,000, including 19,389 children under the age of 5 years.

All mothers of under-five children living in the Woliso City Administration were the source population. All mothers of under-five children who were permanent residents of the city and willing to participate were included in the study. However, mothers who did not have a screen device or whose children were blind were excluded from the study.

The sample size needed for this study was determined using the single-population proportion formula, considering a 95% CI level, a 5% margin of error, and a 50% proportion of occurrence. After adding a 10% nonresponse rate, a sample size of 423 was obtained and allocated proportionally across kebeles. A systematic random sampling technique was used, targeting every 36th household. The first household was selected by lottery method. In each selected household, mothers or guardians of under-five children were approached and invited to participate. Data collectors explained the study objectives, obtained informed consent, and administered the questionnaire to eligible respondents.

Four data collectors and 1 supervisor conducted the data collection using a validated, structured, and pretested interviewer-administered questionnaire adapted from a previous study [37], after translating it into the local languages (Afan Oromo and Amharic). The questionnaire contained sociodemographic information, child-related factors, parental factors, parental barriers to reducing ST, home environment–related questions, and neighborhood environment–related questions.

Sociodemographic factors include information related to family size, age of the mother, age of the father, marital status, educational status of both parents, occupation of both parents, religion, ethnicity, number of rooms in the house, and monthly income.

Regarding child-related factors, the questionnaire included age, sex, number of children, ST in minutes, and childcare facility. A child’s average daily ST, reported by parents, was calculated by multiplying weekday ST by 5 and weekend ST by 2, then dividing the sum by 7 [6].

For parent-related factors, the questionnaire assessed both parents’ average daily ST. Parental self-efficacy in reducing their child’s ST was evaluated using a single question rated on a 5-point scale, ranging from “not at all confident” to “very confident.” Then the scores were divided into 3 categories based on percentiles [8,37]. Parents’ attitudes toward ST were evaluated by an 8-item questionnaire on a 5-point Likert scale, ranging from 1 (“strongly disagree”) to 5 (“strongly agree”), where scores above 32 indicated a positive attitude [8,10,37]. Additionally, parental perceptions were assessed using 11 questions that examined the effects of ST on their child’s physical, cognitive, and social well-being [43]. They rated the influence as 1 (“negative impact”), 2 (“no impact”), or 3 (“positive impact”), with higher scores indicating a more positive effect on their child’s specific well-being [37]. Parenting style was assessed using an adapted version of the Steinberg instrument, a widely used tool for measuring parenting style [44]. Two dimensions were measured: involvement (9 items) and strictness (6 items) on a 5-point scale from 1 (“strongly disagree”) to 5 (“strongly agree”). Based on the Baumrind classification, parents were categorized into 4 groups according to the median split of involvement and strictness [45]. Furthermore, parental restrictive practices on ST were assessed by 6 sedentary-related restrictive practice questions on a 5-point Likert scale, in which higher scores reflected more restrictive practices [46].

Home environment–related factors include information on the number of screen devices, the presence of screen devices in the child’s eating, playing, or sleeping rooms, and the presence of outdoor playthings. The neighborhood environment–related factors include questions about the availability of public facilities or a garden, perceived safety from crime, and perceived pedestrian safety.

Lastly, the outcome variable of this study, parental barriers to reducing a child’s excessive ST, was assessed using 6 items adapted from validated instruments [8,37]. Each item was rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). Item scores were averaged to produce a continuous barrier score ranging from 1 to 6, with higher values indicating stronger perceived barriers [8,37]. Internal consistency was confirmed with Cronbach α of 0.82, demonstrating good reliability.

The data quality was meticulously ensured from the collection to the analysis stages. The standardized questionnaire was translated into Afan Oromo and Amharic, and then back into English. The researchers and the supervisor conducted regular checks for inconsistencies or missing data, and the data were coded and cleaned before analysis. Moreover, comprehensive training was provided to data collectors and supervisors on data collection tools, procedures, ethics, study aims, and participants’ rights.

EpiData (version 3.1; EpiData Association) was used for data entry and SPSS (version 20.0; IBM Corp) was used for analysis. All normality assumptions were tested and met for the continuous variables. Descriptive statistics were presented as frequency tables and in-text narratives. Dummy tables were created for all categorical variables, and bivariate linear regression analysis was conducted. All independent variables with P<.25 in the bivariate analysis were entered into the multiple linear regression model. Key assumptions were assessed and met: linearity was checked using scatterplots, homoscedasticity by examining residual plots, normality of residuals with histograms and the Shapiro-Wilk test, and multicollinearity using variance inflation factors (all <2). Statistical significance was set at P<.05, and unstandardized β coefficients with 95% CIs were reported.

The study was conducted in accordance with the Declaration of Helsinki. Accordingly, an ethical approval letter (reference number: IRB/23117/2023) was first obtained from the Arba Minch University Institutional Research Ethics Review Board Office. Then, a letter of support was submitted to the Woliso Town Administration to facilitate cooperation during data collection. After explicitly explaining the study’s aim, benefits, and risks, written informed consent was obtained from each participant. To maintain the confidentiality of participants’ information, personal identifiers, including names and house numbers, were anonymized.

A total of 423 parents took part in this study, resulting in a 100% response rate. The majority of participants were married (n=412, 97.4%), and three-quarters had a moderate (4-6) number of total family members (n=321, 75.9%). The mean ages of mothers and fathers were 31.29 (SD 5.511) and 37.32 (SD 5.939) years, respectively. Approximately half of the mothers (n=223, 52.7%) and the majority of fathers (n=343, 81.1%) completed college or higher education. In terms of employment, 188 (44.4%) mothers were unemployed, while most fathers, 415 (98.1%), were employed. Most participants were identified as Oromo, totaling 374 (88.4%) and 236 (55.8%) of participants reported following the Protestant religion. Around one-third (n=144, 34.0%) of participants earned less than 11,000 Ethiopian Birr (ETB 1=US $0.02 as of February 29, 2024), and one-quarter of participants lived in homes with 2 or fewer rooms (Table 1).

In this study, the mean age of under-five children was 29.1 (SD 14.818) months. More than half of the children were male (n=233, 55.1%), and approximately one-fifth were an only child (n=97, 22.9%). Nearly half, 223 (52.7%), of the children received home care from their parents (Table 2). Additionally, the mean ST of under-five children in this study was 2.268 (SD 1.425) hours per day.

The mean ST of mothers and fathers was 2.39 (SD 1.27) and 3.16 (SD 1.72) hours per day, respectively. In this study, approximately 190 (44.9%) of mothers had low self-efficacy to say no to their child’s ST. In addition, about one-third (n=129, 30.5%) of participants held a positive attitude toward their child’s ST. Regarding parenting style, approximately 165 (39.0%) participants were identified as neglectful (Table 3). The mean scores for parental perceptions of the effects of ST on children’s physical, cognitive, and social well-being were 6.95 (SD 2.31), 8.09 (SD 2.65), and 5.73 (SD 1.92), respectively. Moreover, the mean score of parental restrictive practice concerning ST was 19.74 (SD 6.45).

A significant majority of participants (n=401, 94.8%) had at least 3 screen devices in their homes, and approximately 197 (46.6%) parents placed a TV in the room where their child plays, eats, or sleeps. Additionally, 345 (81.6%) parents provided outdoor play equipment for their children, while only 122 (28.8%) parents reported the availability of public facilities, gardens, or playgrounds in their neighborhood (Table 4). Moreover, the mean scores for perceived safety concerning crime and pedestrian issues were 17.50 (SD 6.76) and 17.37 (SD 4.94), respectively.

The overall mean score of barriers toward reducing their child’s ST was 4.28 (SD 1.04), with the most common challenges including the need for time to complete household chores, poor weather conditions, and the fact that their child enjoys screen-based activities (Table 5).

The bivariate linear relationships between barrier to reducing ST and all independent variables, including sociodemographic, child-related, parental, home environment, and neighborhood environment factors, were illustrated in Table 6.

In the bivariate analysis, educational status of mothers and the availability of screen devices in the child’s bedroom were identified as having a negative association with parental barriers to reducing ST. Accordingly, mothers of under-five children who had primary education (β=−0.416, 95% CI −0.772 to −0.060; P=.02), mothers of under-five children with college education or above (β=−0.243, 95% CI −0.457 to −0.030; P=.03), and not having screen devices in the bedroom (β=−0.325, 95% CI −0.523 to −0.127; P=.001) were associated with fewer barriers.

On the other hand, factors found to be positively associated with parental barriers to reducing ST included marital separation (β=1.184, 95% CI 0.565 to 1.802; P<.001), child’s ST (β=0.650, 95% CI 0.618-0.683; P=.02), mother’s ST (β=0.097, 95% CI 0.019-0.174; P=.02), moderate maternal self-efficacy to say no to ST (β=0.361, 95% CI 0.050-0.671; P=.02), low maternal self-efficacy to say no to ST (β=0.381, 95% CI 0.169-0.593; P<.001), positive maternal attitude (β=0.451, 95% CI 0.232-0.670; P<.001), perception of the influence of ST on the child’s cognitive well-being (β=0.046, 95% CI 0.009-0.084; P=.02), restrictive practices regarding ST (β=0.087, 95% CI 0.074-0.101; P<.001), providing outdoor playthings (β=1.523, 95% CI 1.256-1.791; P<.001), presence of public facilities such as gardens and playgrounds (β=1.739, 95% CI 1.594-1.884; P<.001), perceived crime safety (β=0.035, 95% CI 0.021-0.049; P<.001), and perceived pedestrian safety (β=0.032, 95% CI 0.012-0.052; P=.002).

In the simple linear regression analysis, 22 variables with a P<.25 were identified and included in the multiple linear regression models. All assumptions for multiple linear regression were met, and the explanatory variables in the final models explained about 89.4% of the variation in barriers to reducing ST (R²=0.894 and adjusted R²=0.892). The multiple linear regression analysis revealed that educational status of the mother, the child’s ST, attitude, perceptions of the effect of ST on cognitive well-being, restrictive practices regarding ST, and the availability of public facilities were significantly associated with barriers to reducing their under-five children’s ST.

In this study, mothers of under-five children with only a primary school education faced fewer barriers compared to those with a secondary school education (adjusted β=−0.130, 95% CI −0.255 to −0.004; P=.04). Additionally, participants with a positive attitude toward child ST were more likely to encounter higher barriers in reducing ST than those with a negative attitude (adjusted β=0.382, 95% CI 0.264-0.499; P<.001). For each unit increase in perceptions of the effect of ST on a child’s cognitive well-being, the mean score of barriers was increased by 0.021 (adjusted β=0.021, 95% CI 0.009-0.034; P=.001). Moreover, for a 1-unit increase in restrictive practices regarding ST, the mean score of barriers decreased by 0.011 (adjusted β=−0.011, 95% CI −0.004 to −0.018; P=.001). The only child-related factor that was significantly associated with parental barriers was the child’s ST. Accordingly, parents whose children spent more hours on screens faced greater barriers to reducing ST (adjusted β=0.369, 95% CI 0.328-0.409; P<.001). Lastly, parents who indicated a lack of public facilities, gardens, or playgrounds in their area were more likely to experience higher barriers to reducing ST than their counterparts (adjusted β=0.849, 95% CI 0.759-0.940; P<.001) (Table 7).

This study assessed barriers to reducing ST and its associated factors among mothers of under-five children in the Woliso City Administration. Accordingly, the study found that the mean barrier score was 4.28 (SD 1.04). Factors significantly associated with barriers to reducing ST included mother’s educational status, child’s ST, attitudes, perceptions of the effect of ST on cognitive well-being, restrictive practices regarding ST, and the availability of public facilities.

In this study, the mean score for barriers was found to be 4.28 (SD 1.04), which is notably higher than the mean score 3.51 (SD 0.83) reported in a previous Malaysian study [37]. The variation in scores could be attributed to differences in study populations, as this study focused solely on mothers, while the Malaysian study included both parents [37]. Research indicates that mothers often bear a larger share of managing children’s routines and ST [47], and a recent systematic review also confirms that maternal caregiving roles remain central in moderating child ST [48]. Additionally, the difference in study settings may account for this variation. The nature of community-based studies, which reach a diverse population, often allows them to capture a broader range of everyday challenges and barriers experienced by parents. Socioeconomic status [37], cultural norms, and parenting practices [49] also likely contribute to these differences.

According to this study, mothers of under-five children with only a primary school education faced fewer parental barriers to reducing their children’s ST compared with those with a secondary school education. This finding may be because mothers with higher education levels may have greater access to resources, support systems, and outdoor employment status, which can influence their ability to manage their children’s ST effectively. This finding is congruent with research indicating that higher educational attainment often correlates with increased awareness of the potential negative impacts of ST, leading to more restrictive practices and fewer perceived barriers [50].

Additionally, mothers with a positive attitude toward ST were more likely to encounter higher barriers in reducing ST. This finding is supported by a study from Australia [49] and Malaysia [37]. Research indicates that parents’ positive attitudes toward ST can lead to more permissive practices and a lower perceived need to restrict ST, thereby increasing the barriers they face in attempting to reduce it [49]. Conversely, parents with negative attitudes are more likely to implement stricter controls and face fewer barriers. Recent reviews also highlight similar findings, noting that parental attitudes and self-efficacy strongly influence barriers to ST reduction [49].

Furthermore, our study reported that there was a positive association between parental perceptions of the effects of ST on their child’s cognitive well-being and barriers. This finding is supported by research indicating that parents who perceive ST as having a positive impact on cognitive development may face greater barriers [49]. When parents perceived ST to be beneficial to their child or themselves, it became a barrier for them to place necessary restrictions on ST activity [50,51]. This aligns with updated evidence showing that parental confusion and mixed perceptions about ST benefits remain a major barrier [48].

Apart from that, parental restrictive practices regarding ST were negatively associated with barriers to reducing ST. Parents who monitor and employ greater restrictions on ST may face fewer challenges in managing their child’s ST due to the consistent enforcement of ST rules [49,52]. This finding is congruent with recent intervention studies that report that restrictive practices are effective strategies for reducing barriers [53].

Furthermore, our study reported that mothers whose children spent more time on screens faced greater barriers to reducing ST. This was supported by previous studies [8,37,54]. Increased ST can lead to more ingrained habits and screen addiction [3], making it extremely hard for parents to enforce restrictions, which can increase parental barriers [55].

Finally, our study reported that parents who indicated a lack of public facilities, gardens, or playgrounds in their area faced greater barriers to reducing ST. The absence of accessible outdoor spaces limits children’s opportunity for physical activity, making it more challenging for parents to encourage alternatives to ST, thereby increasing barriers to reducing ST [56]. The UNESCO MGIEP (United Nations Educational, Scientific, and Cultural Organization—Mahatma Gandhi Institute of Education for Peace and Sustainable Development) highlighted that equitable access to green spaces is crucial for promoting healthy behaviors and reducing ST among children [57]. Additionally, community programs aimed at reducing ST were less successful in neighborhoods with limited green spaces, as children had fewer options for outdoor play [56].

These findings should be understood within Ethiopia’s social environment, where childcare facilities such as kindergartens and nursery schools are limited, and playgrounds and safe outdoor spaces are scarce. Such contextual realities restrict opportunities for alternative activities and create barriers to reducing screen use. The broader social environment, including limited facilities and cultural caregiving practices, remains crucial for interpreting and designing locally tailored interventions.

To the best of our knowledge, this is a pioneering study in Ethiopia that identified barriers to reducing ST. Thus, it can be used as a baseline for future studies. Its community-based design ensured that diverse real-life challenges were captured. Comprehensive data collection through a validated questionnaire and a multilingual approach (Afan Oromo and Amharic) facilitated accurate responses. However, several limitations should be noted. First, the cross-sectional design limits causal inference. Second, reliance on self-reported ST may introduce recall bias, as parents may not accurately remember or estimate their child’s daily screen use. Third, social desirability bias may have influenced responses, with some parents underreporting ST or overstating restrictive practices to align with perceived norms. The reliance on maternal reports of their partner’s ST is also a limitation. Fourth, although we adjusted for multiple covariates, residual confounding cannot be ruled out, as unmeasured factors (eg, parental mental health) may also influence barriers. These limitations should be considered when interpreting the findings, and future longitudinal studies using objective measures of ST are recommended.

The findings from this study underscore the need for targeted interventions to reduce ST among young children. Health care providers, educators, and policymakers should prioritize enhancing access to public facilities, gardens, and playgrounds as alternatives to ST. Additionally, implementing educational programs for parents can raise awareness of the negative impacts of excessive ST and provide strategies for effective management. Community-based initiatives that create screen-free zones and organize family-friendly events can foster environments that support healthy screen habits. Health care professionals should integrate ST management guidelines into routine pediatric care, offering parents consistent support and personalized recommendations. Providing parents with practical tools and resources for monitoring and restricting ST can help to overcome identified barriers and promote healthier screen habits among children.

For the scientific community, this study highlights the importance of further research on the barriers and predictors of parental efforts to reduce ST in various cultural and socioeconomic settings. It encourages the development and testing of community-based initiatives and interventions that create supportive environments for reducing children’s ST. Additionally, it advocates for policies that enhance access to public facilities, gardens, and playgrounds to promote healthy child development. By addressing a significant research gap, this pioneering study in Ethiopia provides valuable insights and potential solutions for both clinical practice and the scientific community, ultimately contributing to the global effort to manage and reduce children’s ST.

Most mothers with a child aged younger than 5 years experienced 4 barriers in their efforts to reduce ST. In addition, this study identified several associated factors with barriers to reducing ST, including maternal education, parental attitudes, restrictive practices, perceptions of ST’s cognitive effects, the child’s ST, and lack of public facilities such as gardens and playgrounds. Based on these findings, we recommend that relevant bodies enhance access to public facilities and playgrounds to provide alternatives to screen use, implement educational programs for parents to raise awareness about the negative impacts of excessive ST, and develop community-based initiatives that support screen-free activities. Interventions should also address parental attitudes and misconceptions, promote balanced and evidence-based perspectives, and support consistent restrictive practices such as monitoring and removing screens from children’s bedrooms. Furthermore, community-based initiatives that encourage screen-free activities can complement household efforts, and integrating ST management guidelines into routine pediatric care will ensure that parents receive culturally appropriate support. Together, these measures can reduce barriers and foster healthier screen habits among young children.