Public Health 198 (2021) 211e217

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Public Health
journal homepage: www.elsevier.com/locate/puhe

Original Research

Recommendations on screen time, sleep and physical activity:

associations with academic achievement in Swiss adolescents
L. Marciano*, A.L. Camerini

della Svizzera italiana, Via Buffi 13, 6900 Lugano Switzerland
Institute of Public Health, USI Universita

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: This study aimed to investigate how meeting international recommendations for screen time
Received 17 March 2021 (<2 h/day), moderate-to-vigorous physical activity (MVPA; at least 60 min/day) and sleep (8e10 h/night),
Received in revised form as well as media multitasking (MMI) as a form of screen time, impact academic achievement in early
14 June 2021
adolescence.
Accepted 21 July 2021
Study design: A prospective design was used, where self-report measures were collected during the
spring semester and academic achievement at the end of the school year.
Methods: A total of 1208 grade 3 middle school students (Mage ¼ 13.55 years, SDage ¼ 0.60) in 37 Swiss
Keywords:
Adolescence
schools filled out a paper-and-pencil questionnaire including measures of screen time (covering
Sleep watching television, playing video games, Internet use, smartphone use and social media use), MMI,
Screen time sleep time and time for MVPA. To evaluate academic achievement, end-term grades were provided by
Moderate-to-vigorous physical activity the collaborating education administration for Italian, Maths, Science, History, Geography, Music and
Recommendations Visual arts.
Media multitasking Results: After adjustment for covariates, such as gender, socio-economic status, body mass index and
Academic achievement stressful life events, multivariate linear mixed-effect models, nesting participants in schools, showed that
meeting recommendations for screen time (B ¼ 0.12, b ¼ 0.105, P < 0.001) and MVPA (B ¼ 0.09, b ¼ 0.09,
P ¼ 0.001), but not sleep (B ¼ 0.05, P ¼ 0.087), were associated with higher academic achievement.
Considering the number of recommendations met, meeting all three recommendations improved aca-
demic achievement the most (B ¼ 0.24, b ¼ 0.21, P < 0.001), followed by meeting the guidelines for
screen time þ MVPA (B ¼ 0.20, b ¼ 0.15, P < 0.001) and for screen time þ sleep (B ¼ 0.21, b ¼ 0.13,
P < 0.001). In the fully adjusted model, multitasking with two or more media was related to a worse
academic achievement.
Conclusions: Screen time (including MMI), sleep and MVPA impact academic achievement in adoles-
cence; hence, governmental organisations and schools should raise awareness about the positive and
negative effects of following or not recommendations for MVPA, sleep and screen time among adoles-
cents and their parents. In addition, support should be provided to promote sufficient sleep and MVPA
while limiting overall screen time and parallel device use.
© 2021 The Author(s). Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction disorders3 and higher risk for health-related issues and mortality
later in life.4
Academic achievement is essential for mastering diverse Different daily behaviours can affect cognitive development in
developmental goals. It has been related to higher subjective adolescence, such as screen time, moderate-to-vigorous physical
well-being1 and career adaptability.2 Conversely, lower levels activity (MVPA) and sleep. The impact of screen time on children's
of cognitive performance in childhood and adolescence predict and adolescents' well-being, including academic achievement, is a
diminished well-being, including more frequent psychological subject of growing concern. In Switzerland, in 2020, Swiss ado-
lescents spent, on average, almost 2 h and 44 min on the Internet
and 3 h and 47 min on the smartphone during a typical weekday.
* Corresponding author. USI Universita
della Svizzera italiana, LAB (Level 2), Via This time augmented, respectively, to nearly 4 and 5 h during a
Buffi 13, 6900 Lugano Switzerland. Tel.: þ41 58 666 4821; fax: þ41 58 666 4647. typical weekend day, partly because of the ongoing COVID-19
E-mail address: laura.marciano@usi.ch (L. Marciano).

https://doi.org/10.1016/j.puhe.2021.07.027
0033-3506/© 2021 The Author(s). Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
L. Marciano and A.L. Camerini Public Health 198 (2021) 211e217

pandemic.5 Previous studies showed that screen time (here defined associated with general cognition and academic achievement. A
as the total amount of time spent using a smartphone, social media, meta-analysis reported that longer sleep duration is related to
Internet, television or video games) is related to poorer learning increased intelligence quotient and verbal skills in children aged
outcomes and augmented risk of premature cognitive decline,6 6e13 years.27 The role of sleep in learning can be well understood
already at early developmental stages.7,8 for its implications in memory consolidation, during which mem-
According to the ‘time displacement hypothesis’,9 screen time ory traces are reactivated, analysed and included in long-term
interferes with activities such as MVPA and sleep, which are memory.28
beneficial for academic achievement. Indeed, screen time (espe- Given the evidence of the impact of screen time, MVPA and
cially when 2 h/day10) is a sedentary behaviour that takes away sleep on cognitive well-being, different national and international
valuable time for MVPA11 and augments the risk of overweight and guidelines were formulated. According to the World Health Orga-
obesity in children and adolescents. Screen time also interferes nisation and the Federal Office of Sport,29 children and adolescents
with sleep by delaying bedtime, interrupting sleep due to incoming aged between 5 and 17 years should carry out at least 60 min of
notifications and reducing sleep quality due to the continued MVPA daily.4 In addition, adolescents between 14 and 17 years
emotional arousal from screen time before sleep,12,13 leading to should sleep from 8 to 10 h per night, uninterruptedly, as stated by
daytime sleepiness and lower academic achievement.14,15 In a the National Sleep Foundation30 Finally, recreational screen time
prospective cohort study, the use of electronic devices before should be limited to no more than 2 h per day.31 Given that many of
bedtime, especially the use of the smartphone, social media and these guidelines are very recent yet heavily promoted, research is
video games, reduced the academic attainment of adolescents,15 in needed to investigate if they are actually met and, if so, what effects
part by augmenting daytime sleepiness. they have on academic achievement.
Furthermore, the ubiquity of media devices in adolescents' lives A previous study with US children aged between 8 and 11
has led to a substantial increase in media multitasking, commonly years32 found that participants who met all three recommenda-
defined as either concurrently engaging in two or more media ac- tions, or at least the screen time recommendation or both the
tivities or using media during offline activities (e.g. while doing screen time and the sleep recommendations, performed better in
homework).9 Previous research highlighted that media multi- psychometric tasks assessing global cognition. Another study33
tasking correlates with adverse outcomes, including limited with Australian students from grades 12 to 17 years found that
cognitive control capacities and lower academic achievement.16 meeting recommendations for screen time and/or sleep time was
According to the ‘scattered attention hypothesis’,9 adolescents associated with better academic performance in high school stu-
who frequently multitask on several media have more difficulties in dents, whereas the strongest association in middle school partici-
filtering relevant information from their environment due to scat- pants was reported for those who followed all three guidelines. No
tered attention developed during parallel media exposure. Thus, study, to date, has replicated these findings in the European context
they are more easily distracted in online and offline contexts, with and considered media multitasking as an additional risk factor of
negative consequences for their cognitive processes. academic achievement.
On the contrary, MVPA has been shown to be positively asso-
ciated with academic achievement.17 Evidence suggests that MVPA
Study aims
elicits brain plasticity; hence, it is especially beneficial for cognitive
functioning, including reaction time, attention, memory, inhibition,
The present study aims to investigate (1) how many Swiss stu-
as well as multiple domains of academic performance and brain
dents aged 13e14 years meet the (inter)national recommendations
plasticity.18 A meta-analysis examining the association between
for screen time, MVPA and sleep; (2) whether meeting none, one,
MVPA and eight cognitive categories in 4- to 18-year-old subjects
two or all three guidelines predicts better academic achievement;
found that MVPA was positively associated with better functioning
and (3) the role of media multitasking, as an additional measure of
in all domains.19 Another review found that aerobic exercise was
screen time that may impact attention and cognition. The study
positively associated with cognition and academic achievement in
furthermore considers stressful life events as covariates beyond
children aged <19 years.20 Interestingly, moderate-to-vigorous
sociodemographic characteristics.
bursts of PA have been found to foster cognitive functions and
mental health more than low-intensity PA.21 In addition, longitu-
dinal findings highlighted that physical fitness in adolescence Methods
predicts cognitive performance in young adulthood22 as well as
later in life.23 Study design
From a biological point of view, the benefits of MVPA include
increased expression of molecules (e.g. brain-derived neurotrophic The present study used data from the fifth wave of the ongoing
factor) in brain regions important for memory and cognition, longitudinal MEDIATICINO2.0 study, following up students born in
increased cerebral blood flow and metabolism, better neurotrans- 2004/2005 from childhood to adolescence in Italian-speaking
mitter regulation, enhanced connectivity between brain regions Switzerland The study combines students' questionnaire data with
and modulation of genes’ expression.18 This makes MVPA a crucial end-term school grades obtained from the regional education
component of brain resilience.24 administration and matched by a unique identifier.
Sleep is another pivotal factor in learning and brain develop- In autumn 2013, all public elementary schools in Italian-
ment. In youth, inadequate sleep has been associated with negative speaking Switzerland were invited to participate in the study.
health outcomes, including somatic and psychosocial health (e.g. Based on this opt-in technique, 39 of 79 schools agreed. Within
increased body mass index [BMI], overweight and obesity, cardio- these schools, 60 grade 4 classes comprised 1083 students were
vascular risk, somatic complaints, fatigue, depression, anxiety, randomly selected. No inclusion or exclusion criteria were speci-
inattention, more frequent risk-taking behaviours [e.g. substance fied. In autumn 2015, when the cohort entered middle school, 409
use], as well as low academic performance).25 Shorter sleep time additional students were randomly sampled within schools to
and poor sleep quality and without being consistent in sleep and compensate for sampling attrition and to ensure that the study
wake across the week are related to lower grades.26 On the other sample sufficiently represented all school districts within the
hand, good sleep quality and quantity proved to be positively region.
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L. Marciano and A.L. Camerini Public Health 198 (2021) 211e217

Study participation was voluntary. Parents received a letter grades were pulled together to obtain a general end-term grades
before their children entered the cohort, informing them about the score.
research, its aims and procedure. They were also informed about
the possibility that students could opt-out anytime by simply not
completing the questionnaire without any consequences for their Stressful life events
evaluation at school. As the anonymity of the students was fully Stressful life events were measured asking participants if one of
guaranteed, the regional education administration approved the the following seven events happened in the last year: parents'
study. divorce, a parent with a new partner, a parent's loss of his/her job, a
The fifth wave of the MEDIATICINO2.0 study was in 2018 when family member who deceased or had severe disease, the worsening
1419 questionnaires were distributed among grade 3 middle school of a significant relationship (e.g. with a parent, a teacher, or a
students in 37 schools. Of these, 1374 (97%) were returned, of which friend) or any other negative and significant life event.
27 were blank, and 117 included more than 15% of missing data in
the variables of interest. Twenty-two participants were excluded as
Body mass index
they reported outlier values (defined as z-scores > ±3.5).
BMI was calculated from the reported weight and height. BMI
categories were created using the following cut-offs: 3rd
Measures percentile ‘underweight’, >3rd and 75th percentile ‘normal
weight’, >75th and 97th percentile ‘overweight’ and >97th
Screen time percentile ‘obese’.
Screen time includes estimates for five different activities during Sociodemographic covariates included gender, coded as
recreational time (i.e. time spent watching television, playing video 0 ¼ male and 1 ¼ female, and socio-economic status (SES),
games, using the Internet, using a smartphone and social media measured by asking participants to rate the financial situation of
activities). Students were asked to indicate how much time they their family from 0 ‘definitely not wealthy’ to 4 ‘definitely wealthy’.
spend on each activity on a typical school day and on a weekend
day. For each question, students estimated their daily media use on
a scale with nine-time interval: 0 ‘never’, 1 ‘up to 0.5 h’, 2 ‘between Statistical analyses
0.5 and 1 h’, 3 ‘between 1 and 1.5 h’, 4 ‘between 1.5 and 2 h’, 5
‘between 2 and 3 h’, 6 ‘between 3 and 4 h’, 7 ‘between 4 and 5 h’ and As data collection was organised at the school level, participant-
8 ‘5 or more hours’. Daily recreational time for each activity was level associations between self-report predictor variables and ac-
calculated by weighting the interval midpoint for weekdays and ademic achievement were fitted using multivariate linear mixed-
weekend days: ([sum of weekday screen time  5] þ [sum of effects (random intercepts) models, nesting participants' grades
weekend day screen time  2])/7. A total measure of screen time in within schools (N ¼ 37). Using multilevel modelling allows esti-
hours was then obtained by taking a weighted average of all screen- mation of the variance between students within the same school
related activities. and the variance between schools separately. At the first step
(Model 1), we tested the model, including only the random in-
Sleep time tercepts and the covariates. In Model 2, we included participants'
Sleep time was calculated from students' self-report on when screen time, MVPA and sleep recommendations coded as 0 ‘not
they went to bed the day before and when they got up on the day of met’ and 1 ‘met’. Finally, in Model 3, we tested the effect of meeting
questionnaire completion. As questionnaires were completed at one recommendation (screen time or sleep or MVPA) versus two
school, ‘the day before’ measured sleep time before a school day. recommendations (screen time þ sleep, screen time þ MVPA and
Considering that our sample falls in an age range between 13 and 14 MVPA þ sleep) versus all three recommendations, compared with
years, we decided to use the cut-off value of 8 h 30 min for meeting none met (reference level). The MMI was added as a categorical
the recommendation (as a midpoint of the recommendation of variable ranging from 0 (‘no multitasking’) to 4 (‘multitasking with
8e10 h for 14-to-17 year-olds and 9e11 h for 11-to-13 year-olds). four different activities’) in Model 2 and Model 3 as an additional
measure of screen time. In all models, parameter estimates were
Moderate-to-vigorous physical activity calculated with a maximum likelihood algorithm, using the ‘lme4’
MVPA was measured by asking students to indicate on the package in R software.
abovementioned nine-time interval scale how much time, on a
typical school day, they spend doing sports.
Results

Media Multitasking Index Sample characteristics

A Media Multitasking Index (MMI) was calculated by asking
participants how frequently they engaged in a specific media ac- The analytical sample included 1208 students (Mage ¼ 13.55
tivity (i.e. watching TV, using the Internet, sending messages and years, SD ¼ 0.60), of which 628 (52%) were female and 874 (72.4%)
playing video games) with another simultaneous media activity.34 reported to have a good to very good SES. A total of 288 (23.9%)
The response categories ranged from 1 ‘never’ to 4 ‘very often’. were either overweight or obese. More than half (n ¼ 349 [53.7%])
The MMI was then calculated for each activity following Ophir's reported at least one stressful life event. The average end-term
equation.34 The MMI indicates the number of additional media an grade was 4.78 (SD ¼ 0.52). Most students reported to multitask
individual is using while using a primary medium. with one (n ¼ 429 [35.5%]), two (n ¼ 459 [38%]), three (n ¼ 136
[11.3%]) and four (n ¼ 30 [2.5%]) additional media. An overview of
Academic achievement the sample characteristics is reported in Table 1.
Academic achievement was evaluated based on end-term A Bayesian regression imputation method and a predictive
grades in Italian, Maths, Science, History, Geography, Music and mean matching model were used to impute missing values. All
Visual arts provided by the regional educational administration. A continuous variables were normally distributed with skewness and
minimum of 4 is required to pass, whereas the maximum is 6. All kurtosis <±1.
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L. Marciano and A.L. Camerini Public Health 198 (2021) 211e217

Table 1 achievement. Compared with Model 1, both Models 2 and 3

Sample characteristics (N ¼ 1208). explained a significant additional proportion of variance. In Model
Variable n (%) Mean (SD) 2 (R2 ¼ 0.182), spending <2 h/day on the screens predicted better
Sex
academic achievement (B ¼ 0.12, P < .001), followed by doing PA for
Boys 580 (48%) at least 60 min/day (B ¼ 0.09, P ¼ 0.001). In addition, multitasking
Girls 628 (52%) with two or more other media activities negatively predicted aca-
Age (years) 13.55 (0.60) demic achievement in an increasing way (BMMI(2) ¼ 0.13,
Socio-economic status (SES) 2.85 (0.74)
P ¼ 0.006; BMMI(3) ¼ 0.16, P ¼ 0.006; BMMI(4) ¼ 0.18, P ¼ 0.029). In
Not at all good 3 (0.2%)
Not good 45 (3.7%) Model 3 (R2 ¼ 0.192), meeting only one recommendation did not
Adequate 286 (23.7%) predict academic achievement. However, meeting 2, specifically
Good 668 (55.3%) MVPA þ screen time and sleep þ screen time, significantly pre-
Very good 206 (17.1%)
dicted better academic achievement at the end of the school year
BMI (kg/m2) 19.25 (2.68)
Underweight 59 (4.9%)
(B ¼ 0.20, P < 0.001 and B ¼ 0.21, P ¼ 0.001, respectively). Meeting
Normal weight 861 (71.3%) all three recommendations was the best predictor of academic
Overweight 252 (20.9%) achievement (B ¼ 0.24, P < 0.001). Again, multitasking with two or
Obese 36 (3%) more media activities predicted worse academic achievement
Stressful life events
(BMMI(2) ¼ 0.11, P ¼ 0.012; BMMI(3) ¼ 0.15, P ¼ 0.012;
None 559 (46.3%)
One 331 (27.4%) BMMI(4) ¼ 0.20, P ¼ 0.035).
Two or more 318 (26.3%)
Grades (total) 4.78 (0.52)
Italian 4.69 (0.64) Discussion
Maths 4.45 (0.76)
Science 4.79 (0.66)
Visual arts 5.19 (0.49) Academic achievement has been related to (un)healthy behav-
Media Multitasking Index (MMI) iours in adolescence. This has led to the formulation of recom-
No multitasking 154 (12.7%) mendations for screen time, MVPA and sleep, with the aim to
With 1 other media 429 (35.5%)
promote a healthy lifestyle and development from an early age. The
With 2 other media 459 (38%)
With 3 other media 136 (11.3%) results of the present study, on a Swiss cohort of middle school
With 4 other media 30 (2.5%) students aged 13e14 years, adds to those from previous studies in
BMI, body mass index.
other cultural contexts.32,33 More precisely, the study found that
the majority of adolescents met the recommendations for screen
time and MVPA, but only half of them met the recommendations
Recommendations met for sleep. In particular, meeting at least two of the three recom-
mendations leads to better outcomes, especially if the recom-
Among all students, 905 (74.9%) spent less than 2 h/day on mendation involved screen time. Although it should be kept in
screens, 601 (49.8%) slept for at least 8 h 30 min per night and 813 mind that the data for this study stem from adolescents' self-report,
(67.3%) exercised for at least 60 min per day (see Table 2). With prone to estimation bias, this result is in line with similar studies
regard to the number of recommendations met, 90 (7.5%) did not based on children's and adolescents' self-report:32,33 long and
meet any of the recommendations, 134 (11.1%) reported doing at frequent media use may have detrimental effects on attention,
least 60 min of MVPA per day, 28 (2.3%) reported sleeping for at memory, impulse control and, consequentially, academic perfor-
least 8 h 30 min, 140 (11.6%) reported spending no more than 2 h on mance. Spending no more than 2 h per day in front of screens,
screens and 247 (20.4%) reported following the guidelines for sleeping the recommended amount of 8 h and 30 min and exer-
MVPA þ screen time, 52 (4.3%) for MVPA þ sleep and 153 (12.7%) cising at least 1 h per day was associated with better academic
for sleep þ screen time. The remaining 364 students (30.1%) met all achievement. Following the notion of the ‘displacement’ hypothe-
three recommendations (see Fig. 1). sis,9 this demonstrates that reduced screen time should be
substituted with more time for sleep and/or MVPA to be beneficial
for academic achievements as the latter two activities enhance
Main analyses brain plasticity18 and memory consolidation.28
Furthermore, the present study found that multitasking with
The baseline model (Model 1; see Table 3) explained 13.5% of the two or more media activities leads to worse academic achieve-
variance in academic achievement. Being female, having a better ment; hence, media multitasking should also be considered as an
SES, having experienced two or more stressful life events and additional measure of screen time in future research investigating
having a higher BMI were all significant predictors of academic academic achievement. Digital technologies, especially the

Table 2
Average time spent on each behaviour and proportion of students meeting the recommendations.

Behaviour Time spent [Mhours (SDhours)] Recommendation Number of participants meeting the recommendation (%)

Screen time (total) 1 h 30 min (0 h 58 min) <2 h/day 905 (74.9%)

Video games 0 h 53 min (1 h 10 min) 1048((86.8%)
Smartphone 1 h 57 min (1 h 26 min) 432 (35.8%)
Social media 1 h 26 min (1 h 21 min) 935 (77.4%)
Television 1 h 11 min (1 h 3 min) 1037 (85.8%)
Internet 2 h 4 min (1 h 25 min) 727 (60.2%)
Sleep 8 h 17 min (1 h 1 min) 8 h 30 min/night 601 (49.8%)
MVPA 1 h 45 min (0 h 58 min) 1 h/day 813 (67.3%)

MVPA, moderate-to-vigorous physical activity.

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L. Marciano and A.L. Camerini Public Health 198 (2021) 211e217

Fig. 1. Recommendations met by all participants (in percentage). PA, physical activity.

smartphone, provide quick and easy gratifications. Adolescents are screen time may not only reduce the interfering effects of screens
more willing to use them (simultaneously) to seek short gratifica- before bed or while doing homework (e.g. multitasking) but could
tions, particularly when the first, ongoing task is not gratifying also substitute them with cognitively engaging and educating ac-
enough. According to the ‘scattered attention’ hypothesis, the par- tivities, such as reading, including in-person social interactions,
allel use of different media devices impact the capabilities of promoting a healthier lifestyle.
functioning, reasoning and remembering information in the offline In addition to past studies, the present study also considered
context (e.g. classroom and homework),35 with negative conse- sociodemographic characteristics, BMI and stressful life events as
quences for academic achievement. It is likely that adolescents who potential confounders. Being female and having a better socio-
engage in media multitasking (i.e. parallel use of two or more economic background significantly increased academic achieve-
media devices) also engage in multitasking where devices are used ment, while being overweight and experiencing stressful life events
while doing other offline activities (such as homework). Limited were related to decreased academic achievement. Previous studies

Table 3
Hierarchical regression analyses predicting academic achievement.

Predictors Model 1 Model 2 Model 3

B (95% CI) P B (95% CI) b P B (95% CI) b P

Intercept 4.50 (4.37 to 4.64) <0.001 4.37 (4.20 to 0.53) <0.001 4.39 (4.22 to 4.57) <0.001
Gender (female) 0.24 (0.19 to 0.30) <0.001 0.28 (0.22 to 0.33) 0.26 <0.001 0.27 (0.22 to 0.33) 0.26 <0.001
SES 0.08 (0.04 to 0.12) <0.001 0.07 (0.03 to 0.10) 0.09 <0.001 0.07 (0.03 to 10) 0.09 <0.001
Stress events (¼1) 0.00 (0.07 to 0.07) 0.997 0.02 (0.04 to 0.09) 0.02 0.510 0.02 (0.04 to 0.08) 0.02 0.488
Stress events (≥ 2) 0.12 (0.19 to 0.05) <0.001 0.06 (0.13 to 0.01) 0.05 0.070 0.07 (0.13 to 0.00) 0.05 0.061
BMI (underweight) 0.03 (0.02 to 0.09) 0.638 0.08 (0.20 to 0.05) 0.03 0.229 0.08 (0.20 to 0.05) 0.03 0.224
BMI (overweight) 0.10 (0.17 to 0.03) 0.004 0.07 (0.14 to 0.01) ¡0.05 0.032 0.08 (0.15 to 0.01) ¡0.06 0.023
BMI (obese) 0.18 (0.34 to 0.02) 0.029 0.11 (0.27 to 0.05) 0.03 0.172 0.11 (0.27 to 0.05) 0.03 0.193
Recommendations met (ref ¼ 0 “not met”)
Screen time (<2 h/day) 0.13 (0.06 to 0.20) 0.105 <0.001
MVPA (≥60 min/day) 0.10 (0.04 to 0.16) 0.09 <0.001
Sleep (8 h 30 m/night) 0.05 (0.01 to 0.10) 0.04 0.104
MMI (ref ¼ “0”)
With 1 other media 0.02 (0.07 to 0.10) 0.01 0.717 0.02 (0.06 to 0.11) 0.02 0.601
With 2 other media 0.13 (0.21 to 0.03) 0.12 0.006 0.11 (0.20 to 02) ¡0.11 0.012
With 3 other media 0.16 (0.28 to 0.04) 0.09 0.006 0.15 (0.27 to 03) ¡0.09 0.012
With 4 other media 0.23 (0.42 to 0.04) 0.06 0.019 0.20 (0.39 to 01) ¡0.06 0.035
Recommendations met (ref ¼ “none”)
MVPA only 0.11 (0.01 to 0.24) 0.06 0.090
Sleep only 0.13 (0.33 to 0.07) 0.04 0.200
Screen time only 0.02 (0.10 to 0.15) 0.02 0.704
MVPA þ screen time 0.20 (0.08 to 0.32) 0.15 <0.001
MVPA þ sleep 0.04 (0.13 to 0.19) 0.01 0.670
Sleep þ screen time 0.20 (0.07 to 0.33) 0.13 0.001
All met 0.24 (0.13 to 0.36) 0.21 <0.001
Explained variance
R2 0.135 0.182 0.192
R2 change (ref: Model 1) <0.001 <0.001

CI, confidence interval; BMI, body mass index; MVPA, moderate-to-vigorous physical activity; SES, socio-economic status.
Results of the hierarchical regression analyses: Model 1 includes covariates only; Model 2 includes if a recommendation is met and multitasking as additional predictors;
Model 3 includes more information about the combination of recommendations met and multitasking as additional predictors.

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L. Marciano and A.L. Camerini Public Health 198 (2021) 211e217

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