Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11929 Reducing gadget use intensity in preschool-aged children through storytelling and coloring therapy Umi Kalsum,1 Andi Lis Arming Gandini,1 Sutrisno Sutrisno,1 Emmy Putri Wahyuni,1,2 Rosalin Ariefah Putri,3 Nyimas Heny Purwati2 1Department of Nursing, Poltekkes Kemenkes Kalimantan Timur, Samarinda; 2Faculty of Nursing, Universitas Muhammadiyah Jakarta, Jakarta; 3Department of Midwifery, Poltekkes Kemenkes Kalimantan Timur, Samarinda, Indonesia Abstract The use of gadgets in the current era of globalization has become a concerning trend, especially among preschool children, leading to addiction and detrimental effects on their physical, psy- chological, and emotional health. It has also resulted in increased social isolation and hindered development. The impact of this trend is significantly influenced by the roles of parents, family, and the surrounding environment. This study aimed to determine the effectiveness of health education using modules on the bene- fits of storytelling and coloring therapy in enhancing parents’ knowledge, attitudes, and behaviors regarding prudent gadget use in preschool children. The research design was a pre-post quasi- experiment without a control group. The population comprised parents with preschool children attending 11 public kindergartens in Samarinda City. A total sampling method was utilized, resulting in 303 respondents. Health education intervention occurred after the pre-test, followed by one month of assistance and a subsequent post-test. The research instrument was a questionnaire adapted from the theory of planned behavior, assessing parents’ knowl- edge, attitudes, and behaviors related to providing gadgets to chil- dren. Data analysis included univariate and bivariate analyses using the Wilcoxon test. The results indicate a significant influ- ence of health education using modules on the benefits of story- telling and coloring therapy on parents’ wise gadget use in preschool children (p-value < 0.005). Thus, health education for parents on prudent gadget use in preschoolers is highly recom- mended, particularly during parent meetings at school. Introduction Children are at a stage of rapid growth and development, necessitating proper nutrition, stimulation, a conducive environ- ment, and access to health services.1,2 Among these, toddlers and preschoolers are particularly vulnerable to health issues.3 During the preschool years, children are in the initiative versus guilt phase, characterized by burgeoning curiosity and imagination, leading them to ask numerous questions about their surroundings that they don’t yet understand.4 In this golden age, children absorb information quickly, becoming adept imitators and laying the groundwork for their character, personality, and cognitive abili- ties.5 While technology has become indispensable in contempo- rary life, its rapid advancement has significantly impacted various spheres, including education.6 Gadgets, in particular, have gained immense popularity, with both adults and children utilizing them. Many gadget manufacturers target children as their primary mar- ket, resulting in children becoming active consumers of such devices.7 Studies indicate that approximately one-third of preschoolers globally have access to digital devices, with a major- ity exceeding recommended screen time.8-10 Nathan, Muthupalaniappen, and Muhammad (2022) found that the preva- lence of digital device use among preschoolers was 95.9%, pri- marily smartphones (94.2%). Despite this high usage, most chil- Correspondence: Umi Kalsum, Department of Nursing, Poltekkes Kemenkes Kalimantan Timur, Wolter Monginsidi Street No. 38, Samarinda Ulu sub-district, Samarinda City, Indonesia. E-mail: umi2508@gmail.com Key word: coloring; family empowerment; gadget addiction; preschool- ers; storytelling. Contributions: UK, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ALAG, conceptualization, investigation, methodology, vali- dation, and writing – original draft, review and editing; SS, conceptual- ization, investigation, methodology, validation, and writing – original draft, review and editing; EPW, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; RAP, methodology, visualization, writing – review and editing; SS resources, investigation, and writing –review and editing; NHP formal analysis, validation, writing – review and editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, Poltekkes Kemenkes Kalimantan Timur, based on ethical certificate DL.02.03/4.3/10432/2022. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research was supported by a research grant from [DIPA Poltekkes Kemenkes Kalimantan Timur] with contract number [LB.02.01/4.3/01573/2022]”. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 8 October 2023. Accepted: 14 March 2024. Early access: 12 April 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11929 doi:10.4081/hls.2024.11929 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 448] [Healthcare in Low-resource Settings 2024;12:11929] Non -co mmerc ial us e o nly dren (95%) did not own the devices, and usage was supervised (95.7%) to prevent exposure to inappropriate content (70.5%). Notably, digital devices were mainly used for educational (37.4%) and entertainment purposes (36%), primarily through videos (30.9%) and games (30.2%). Alarmingly, a significant portion of children (21.5% on weekdays and 50.3% on weekends) spent more than 1-2 hours on digital devices.9 In Indonesia, a substantial proportion (79.5%) of children and adolescents are gadget users, primarily for information retrieval, entertainment, and online communication.11 Moreover, a survey by Indonesia Hottest Insight in 2013 revealed that about 40% of Indonesian children are active internet users.12 Despite parents’ awareness of the detrimental effects of excessive screen time, including poor posture, sleep disturbances, eye strain, reduced physical activity, exposure to inappropriate content, addiction, and diminished parent-child interaction, adherence to screen time guidelines remains low.13 One of the adverse consequences of excessive gadget use is dependency and addiction, leading to developmental issues in chil- dren.6 Additionally, limited communication and interaction between parents and children due to gadget use can hinder speech development in toddlers.14 It’s crucial to acknowledge that the ages of 1-5 years represent the most sensitive period of child develop- ment, underscoring the importance of cautious gadget use during early childhood.15 Parents play a pivotal role in fostering effective communication and continuously anticipating and addressing their children’s negative habits.16 Research has consistently demonstrated the negative impacts of gadget use on preschoolers, including speech delays, attention deficits, learning difficulties, anxiety, mental health problems, and character assassination.17,18 Conversely, activities like coloring and storytelling have been shown to enhance imagination, fine motor skills, and knowledge in preschoolers.19,20 Thus, encouraging par- ents to engage in storytelling and coloring activities with their chil- dren can help mitigate the negative effects of excessive gadget use. Parental involvement is paramount in regulating children’s gadget usage. This study aimed to assess the impact of health education, focusing on the benefits of storytelling and coloring therapy, on parents’ behavior regarding gadget use in preschoolers. By pro- moting alternative activities and empowering parents with knowl- edge, attitudes, and behaviors conducive to prudent gadget use, this research endeavors to steer children away from excessive gad- get dependency and toward healthier developmental pathways. Materials and Methods The research design employed in this study was quantitative, utilizing a quasi-experimental design, specifically a pre-post test non-equivalent group without a control group. Study participants The study population consisted of parents with preschool chil- dren. Samples were drawn from all parents with preschool-aged children at 11 kindergartens in Samarinda City who met the inclu- sion criteria. These included parents of preschool children aged 3- 7 years whose children were capable of using gadgets and who themselves owned gadgets. The exclusion criteria were preschool children unable to monitor gadget use. The sampling used the total sampling method, resulting in 303 respondents selected from 11 public kindergartens in Samarinda City, Indonesia. Variable, instrument and data collection Independent variables comprised the effect of health education using modules on the benefits of storytelling and coloring therapy. Dependent variables encompassed parents’ knowledge, attitudes, and behaviors regarding prudent gadget use with children. A ques- tionnaire was utilized to assess knowledge about preventing and managing gadget use in preschoolers (consisting of 8 questions), parents’ attitudes toward gadget use in children (12 questions), and parental and child behavioral practices in gadget use (5 questions). The instrument was adapted from Lani’s (2019) research, with validity and reliability tests yielding satisfactory results (knowl- edge questionnaire: r=0.540-0.933, attitude questionnaire: r=0.643-0.780, behavior questionnaire: r=0.519-0.740), indicating validity and reliability. The Cronbach alpha value exceeded 0.6, indicating instrument reliability.21 Data analysis Univariate and bivariate analyses were conducted using the IBM SPSS Statistics 26 computer program. Bivariate analysis uti- lized the Wilcoxon test due to non-normally distributed data, with a significance level set at 95%. Ethical clearance Ethical approval for the research was obtained from the Health Research Ethics Commission, Poltekkes Kemenkes Kalimantan Timur, under ethical certificate DL.02.03/4.3/10432/2022. Throughout the research process, adherence to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence, was observed, with the study subjects being parents with preschool children. Results Table 1 presents data on the characteristics of parents. The majority of mothers (51.2%) have graduated from high school, while a similar proportion of fathers (51.8%) have attained the same level of education. Furthermore, a significant portion of mothers (74.6%) are not employed, whereas a considerable pro- Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of respondents Indicator Mom Father F % F % Education Not in School 2 0.7 4 1.3 Elementary School 18 5.9 13 4.3 Junior High School 34 11.2 31 10.2 Senior High School 155 51.2 157 51.8 Higher Education 94 31.0 98 32.3 Work Doesn't work 226 74.6 0 0.0 Employee 32 10.6 147 48.5 Civil servant 13 4.3 27 8.9 Self-employed 32 10.6 107 35.3 Laborer/Farmer/Fisherman 0 0.0 22 7.3 Family income < IDR 1,500,000 23 7.6 IDR 1,500,000-3,000,000 114 37.6 IDR 3,000,000-5,000,000 99 32.7 > IDR 5,000,000 65 21.5 [Healthcare in Low-resource Settings 2024;12:11929] [page 449] Non -co mmerc ial us e o nly portion of fathers work in the private sector. Additionally, approx- imately 37.6% of respondents reported incomes ranging between IDR 1,500,000 and 3,000,000. Based on Table 2, the data regarding children’s dependence on gadget use reveals that the majority of children (57.4%) exhibit a dependency on gadgets, while nearly half of the children (42.6%) do not show such dependence. Regarding the types of gadget use activities among children, the data indicates that playing games is predominantly observed (57.4%), while listening to songs is most- ly not observed (71.3%). Moreover, the data suggests that watch- ing cartoons is nearly universal (85.1%), indicating that children primarily engage in watching cartoons when using gadgets. Based on the results of the Wilcoxon test presented in Table 3, it is evident that there is a significant difference in knowledge, atti- tude, and behavior before and after the intervention with health education, focusing on the benefits of storytelling and coloring therapy for children. Discussion Level of gadget dependency Gadgets are small devices or tools widely utilized by various age groups, offering numerous benefits and often regarded as inno- vative items. They cater to diverse needs, serving users ranging from adults to children. While adults typically use gadgets for 1 to 4 hours per session, often multiple times a day, preschool children have specific time limits and usage patterns distinct from adults.22 Consequently, negative effects such as gadget addiction can mani- fest quickly due to prolonged use.23 Increased gadget usage can lead to heightened levels of gadget addiction, which, in turn, heightens the risk of attention deficit disorder and hyperactivity. Gadget addiction disrupts the normal release of dopamine, a neu- rotransmitter associated with the brain’s reward system, emotions, motivation, and perception of rewards. Excessive gadget usage triggers excessive dopamine release, fostering a cycle of addiction where users continually seek gratification through gadget activi- ties.24,25 The consequences of gadget addiction can adversely affect brain development, particularly the maturity of the Pre Frontal Cortex (PFC), responsible for executive functions like impulse control, decision-making, and concentration.26 Studies indicate that excessive gadget use, particularly at a young age, can impede the PFC’s normal development, leading to diminished impulse control and concentration skills.27 Therefore, it’s crucial to recog- nize the potential risks of gadget addiction and prudently limit gad- get usage, especially in children. Effective supervision and scheduling are vital to ensuring gadget use remains moderate and doesn’t interfere with healthy brain development. Moreover, offer- ing alternative, stimulating activities such as sports, outdoor play, reading, and social interaction can foster balanced brain develop- ment and mitigate the risk of gadget addiction.24,28 This study corroborates Nurfitri Rahmawati’s research (2020), which highlights that daily gadget usage often indicates high dependency levels, with many children experiencing negative impacts associated with gadgets.29 Excessive screen time among young children has been linked to various harmful consequences, including screen dependency, as evidenced by research indicating a troubling prevalence of media-related dependency among ado- lescents and preschoolers.30 Types of gadget use activities in children In reality, when children become excessively engrossed in their gadget world, they often overlook fundamental needs such as learning and proper socialization in life.31 Many children derive great enjoyment from using smartphones in their daily activities at home, school, and during playtime, leading some to develop a sense of coolness associated with gadget use. Some children even prioritize their gadgets over obeying parental instructions and may react negatively when asked to disengage. This behavior exempli- fies a form of gadget addiction among children. Providing gadgets to children without adult supervision or guidance can indeed lead to various negative impacts.32 The study highlights some of the adverse effects of excessive gadget use on children’s physical and mental health. From vision impairments to severe mental disorders, the consequences can be significant. Moreover, if children are left unsupervised while using gadgets, their condition may deteriorate further. While engaging in play is acceptable, it’s crucial to ensure that children don’t become excessively immersed in gaming to the point where it adversely affects their well-being. Parents’ knowledge in preventing gadget use Having good knowledge forms a solid foundation for making informed decisions and taking appropriate actions regarding gad- get use in children.33,34 Parents’ attitudes towards gadget usage vary. Some parents are comfortable with their children using gad- gets for over an hour a day, viewing them as suitable play tools for preschool-age children. Additionally, many parents see gadgets as an engaging entertainment medium for their children. Some par- ents even support their children’s gaming skills by downloading specific applications. However, a minority of parents permit gad- Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 2. Dependence and types activities of gadget use in children. Indicator F % Gadget use Dependency 174 57.4 Not dependent 129 42.6 Playing Games Yes 174 57.4 Not 129 42.6 Listening to Songs Yes 87 28.7 Not 216 71.3 Watching cartoons Yes 258 85.1 Not 45 14.9 Table 3. Results of bivariate analysis using the Wilcoxon Test before and after intervention. Indicator F Min-Max p Knowledge 0.001 Before 303 1-8 After 303 2-7 Attitude 0.010 Before 303 27-44 After 303 26-44 Behavior 0.001 Before 303 9-20 After 303 10-20 [page 450] [Healthcare in Low-resource Settings 2024;12:11929] Non -co mmerc ial us e o nly get use at the dinner table, believing it enhances their children’s appetite while eating. Furthermore, parents may resort to giving gadgets to their children when they are occupied with work.21 Parrents’ attitude in preventing gadget use Parents, as the primary caregivers spending considerable time with their children at home, bear the responsibility of regulating and supervising their children’s gadget usage. This entails select- ing appropriate content for their children, ensuring it aligns with their age and is free from harmful elements such as pornography or violence, and enforcing time limits on gadget use. Each parent employs distinct parenting styles and approaches, collectively termed as parenting.35,36 The role of parents holds immense signif- icance in shaping the future quality and contribution of children to the nation and society.37,38 Therefore, parents must exert optimal efforts in educating and nurturing their children, guaranteeing their rights are fulfilled both physically and mentally.39 Parental involvement during children’s gadget use forms part of digital par- enting strategies aimed at preventing gadget addiction.40 Parental methods of assisting children with gadget usage vary, including supervising their internet access, providing guidance on responsi- ble gadget use, and diverting their attention from gadgets by allo- cating dedicated time for interactive play.41 Parents’ behavior in preventing gadget use Parents often hold the belief that providing gadgets to their children will keep them entertained indoors, favoring gadget use over outdoor play with friends.42,43 However, this mindset may indicate a lack of awareness regarding age-appropriate child devel- opment. Allowing children unrestricted access to gadgets can be perceived as a convenient solution for keeping them occupied. Nevertheless, without proper supervision and limitations, exces- sive gadget use can impede children’s social and physical growth.21 Researchers suggest that imposing time limits is an effective strategy to curb gadget dependency. While initially challenging, children gradually adapt to new rules within a week. Implementing such restrictions aims not to inconvenience children but rather to encourage engagement in alternative activities and outdoor pur- suits. By regulating gadget usage duration, children are more inclined to explore other beneficial activities such as playing with peers, participating in sports, engaging in artistic endeavors, or reading books.44 Moreover, time constraints facilitate improved time management skills, mitigate gadget addiction, and minimize the adverse effects of excessive technology exposure. Conclusions Considering the evidence, targeted health education interven- tions are demonstrably effective in shaping parental attitudes and practices regarding gadget use in preschoolers. Consequently, edu- cational institutions must place emphasis on incorporating mod- ules that extol the benefits of storytelling and coloring therapy into the curriculum of parent meetings at schools. Such an initiative would ensure that schools are at the forefront of equipping parents with essential knowledge and strategies to guide gadget use amongst their children. This measure is pivotal for cultivating a more conducive digital environment that supports the well-being and development of preschool-aged children. References 1. Hasinuddin M, Noviana U, Fitriah F. Family Support System as an Effort to Optimize Coping Mechanism of Preschool Children During Hospitalization. J Ners 2019;14:199–204. 2. Khasanah U, Efendi F, Has EMM, et al. 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