This study used the Korea Youth Risk Behavior Web-Based Survey (KYRBS). KYRBS is a large-scale, nationwide survey covering health-related behaviors of Korean adolescents [17]. The KYRBS is designed to collect data from middle and high school students (grades 7 to 12) aged 12 to 18 years enrolled in public and private schools throughout South Korea. To achieve national representativeness, the survey uses a stratified, multistage cluster sampling approach [18]. Schools are chosen as the primary sampling units based on regional and school-type stratifications, followed by a random selection of classes within these schools [18]. This methodology ensures a balanced representation of students from both urban and rural areas. Administered annually by the Korea Disease Control and Prevention Agency, the survey has consistently maintained an average response rate of 95.7% over the past 15 years. Students voluntarily completed a web-based anonymous questionnaire following a standardized protocol in a computer lab in each school [19].

To ensure the data’s representativeness, sampling weights were determined and applied. The weighting process considers the probability of selection at each stage of sampling (schools and classes), adjusts for nonresponse, and incorporates poststratification adjustments to align with the overall student population distributions by grade, sex, and school type for each survey year. To avoid overrepresentation, extreme weights were capped using interquartile range techniques. These adjustments ensure that the results reliably represent the health behaviors of the adolescent population across South Korea. In this study, an initial cohort of 992,702 respondents completed the questionnaires from 2008 to 2022. Following the exclusion of participants with missing data, the final dataset comprised 836,972 samples (84.3% of the initial raw data). The exclusion of missing data was conducted systematically to maintain dataset robustness and minimize bias.

The study protocol was approved by the Institutional Review Board of the Korea Disease Control and Prevention Agency (2014-06EXP-02-P-A), and all participants provided written informed consent. Additionally, the study complied with the Population Health Promotion Act 19 (117058) as mandated by the Korean government. This study was conducted following the principles of the Declaration of Helsinki.

We aimed to investigate trends in screen time and explore associated risk factors, with a focus on the diverse family structures of adolescents. The COVID-19 pandemic period was defined as 2020-2022, starting with the first observed COVID-19 case in South Korea on January 20, 2020, and aligning with widespread public health measures [20,21]. The prepandemic years were grouped into 6-year intervals, each spanning two consecutive years, as follows: 2008-2009, 2010-2011, 2012-2013, 2014-2015, 2016-2017, and 2018-2019. This classification allows for a clear comparison of trends before and during the pandemic.

Screen time was defined as the average daily time spent on the internet or using smartphones for noneducational purposes. Participants were asked: “What was your average daily internet or smartphone use on weekdays in the past 30 days?” and “What was your average daily internet or smartphone use on weekends in the past 30 days?” The overall average screen time was calculated by combining weekday and weekend use, weighted to reflect their relative proportions within a week [19].

Family structures were categorized into 4 groups: nuclear family, living with relatives, living alone, and orphanage. A nuclear family was defined as adolescents living with one or both parents, regardless of biological relationships. The “living with relatives” category included adolescents residing with extended family members, such as grandparents or uncles or aunts, excluding parents. “Living alone” referred to those managing households independently without the presence of any family members. The “orphanage” category encompassed adolescents living in child welfare facilities. These classifications are based on established definitions in prior studies on family dynamics and adolescent health [22].

A total of 11 covariates were included in the analytical models: sex, BMI group (underweight, normal, overweight, and obese), grade (7th to 9th [middle-school] and 10th to 12th [high-school]), region of residence (urban and rural) [23,24], smoking status, alcoholic consumption, school performance (low, middle-low, middle, middle-high, and high), sexual experience, physical activity frequency (lower activity, moderate activity, and higher activity), sadness and despair, and highest education level of parents (high school or lower and college or higher). BMI was calculated using self-reported height and weight data. Conforming to the 2017 Korean National Growth Charts, BMI was categorized into the following four groups: underweight (<5%), normal (5% to 84 %), overweight (85% to 94%), and obese (≥95%) [19]. School performance was categorized into the following five groups according to the self-reports of students: low (<20%), middle-low (20% to 39%), middle (40% to 59%), middle-high (60% to 79%), and high (≥80%). Physical activity frequency was classified into the following three groups based on the engagement in vigorous aerobic and resistance training more than three days per week: lower activity (neither activity is done for more than three days per week), moderate activity (either one activity), and higher activity (both activities). The definitions of variables were extracted from peer-reviewed literature [19].

We used a weighted linear regression model to compute β coefficient and β difference (β_diff) along with a 95% CI [25]. This strategy was selected for trend analysis and associated factor analysis. In the analysis of screen time trends, the β coefficient expressed the annual trend of screen time among adolescents in prepandemic or pandemic. β_diff was used to indicate the trend difference between the divided year groups based on the onset of the pandemic. In the analysis of screen time-associated factors, the β coefficient represents the correlation between screen time and each biological, social, and familial factor. β_diff was also used to reveal the difference in correlation between the year groups divided by the onset of the pandemic. In addition, the associations between screen time and each variable were recalculated after adjusting for potential influencing factors, including age, sex, BMI group, grade, region of residence, smoking status, alcoholic consumption, school performance, sexual experience, physical activity frequency, sadness and despair, and highest education level of parents. Statistical significance, as applied in all the above analyses, was determined by a 2-sided P value less than .05. Statistical analysis in this study was conducted using SAS software (version 9.4; SAS Institute Inc).

This study stands out as the initial comprehensive long-term trend analysis of adolescent screen time and associated factors across various family structures, encompassing the COVID-19 era (Figure 4). There was an overall increase in screen time from 2008 to 2022. Specifically, throughout the pandemic spanning from 2020 to 2022, there was a substantial increase in adolescent screen time compared to the prepandemic. Among various family structures, students within the orphanage group exhibited the most significant increase in screen time since the pandemic onset. All examined factors exhibited statistically significant alterations in their association with adolescent screen time during the pandemic. Particularly, stratified by family structure, it was consistently observed that women had more vulnerability to increased screen time during the pandemic regardless of family structure. Meanwhile, the nuclear family group showed distinctive screen time-associated factors, including grade, region of residence, physical activity frequency, sadness and despair, and highest education level of parents, which were not present in the other family groups.

Earlier investigations have predominantly focused on the changes in adolescent screen time trends during the COVID-19 pandemic. Studies conducted in countries such as Canada (n=29,027), Germany (n=1711), the United States (n=5412), China (n=1680), and South Korea (n=913,191) consistently reported significant increases in screen time following the onset of the pandemic [14,26-28]. Many of these studies also examined factors influencing screen time, including depression and mental health [10,11]. However, most were limited by relatively small sample sizes, restricted age ranges of participants, or insufficient analysis of trends across specific demographic subgroups, such as those defined by family structure [26-29].

Additionally, while existing studies from Norway (n=4509) and France (n=3720) have explored the association between adolescent screen time and family structure, they often lack diversity in the types of family structures considered and fail to account for the profound shifts introduced by the pandemic [15,16]. These limitations highlight the importance of considering a wider range of family structures and the influence of contextual factors like the pandemic when analyzing screen time trends [27,28].

In contrast, this study addresses these gaps by analyzing a significantly larger sample size (n=836,972) collected over 15 years, allowing for a more robust examination of long-term trends. Furthermore, the stratification of adolescents by diverse family structures—nuclear families, living with relatives, living alone, and orphanages—enables a unique comparative analysis of disparities in screen time trends across these groups. This approach not only provides a more comprehensive understanding of the changes in adolescent screen time but also sheds light on the distinct risk factors associated with different family structures during the pandemic.

The overall elevation in average screen time of adolescents spanning from 2008 to 2022 could be elucidated by the rise in smartphone penetration among adolescents. The prevalence of smartphones among adolescents in South Korea increased by 15.3%, rising from 79.3% in 2015 to 94.6% in 2022 [30]. This upward trend would have played a role in the elevation of screen time among Korean adolescents over the 15 years. Particularly, a substantial increase in screen time with the onset of the pandemic is likely due to the increased duration of indoor activities. During the pandemic, there was an increase in time spent indoors at home and a decrease in outdoor activities, including walking, cycling, and commuting [31]. Students were restricted from the absence of the school community covering a range of cultural, sports, social, and emotional experiences. Instead, there was an increase in internet use time for video watching and gaming with the onset of the pandemic, suggesting an influence on the rapid rise in screen time [32]. Fundamentally, the rise in screen time could be attributed to the shift in the pandemic lifestyles of students: decreased outdoor activities and various web-based engagements.

Across all family structures, a marked increase in screen time was evident following the pandemic. However, there was a specific increase in screen time among students belonging to the orphanage group. This suggests a potential influence of the presence of parents or relatives on screen time during the pandemic. The Royal College of Paediatrics and Child Health emphasized the significance of the roles of guardians in managing adolescent screen time. They recommended careful parental consideration when introducing technology to adolescents and setting individualized regulations for their screen time [16]. This detailed assistance, initially inadequate for the orphanage group, became further deficient during the pandemic due to the obstruction of support from teachers in schools. It is likely to have contributed to the substantial screen time adjustment failure observed in the orphanage group.

We analyzed the association between various biological, social, and familial factors and screen time according to the family structure. Among the diverse family structures, the nuclear family group exhibited several unique screen time-associated factors from the onset of the pandemic that were not observed in other family structures. In particular, the region of residence indicated that students residing in urban regions were less susceptible to increased screen time during the pandemic compared to their counterparts in rural regions. This finding is likely linked to parental abilities associated with the region of residence. Parents have been identified as having heightened concerns related to screen-related risks, such as cyberbullying and exposure to inappropriate or harmful content [33]. The perceived difference in screen time between regions is likely because parents residing in urban regions exhibited higher levels of parenting compared to those living in rural regions [34]. Particularly, the increase in indoor time during the pandemic induced an increase in the time spent with parents, indicating an intensified influence of parenting on adolescents. Therefore, it may be that students residing in urban regions were less vulnerable to increased screen time during the pandemic than students residing in rural regions.

This study offers a reminder of the recent rapid increase in screen time among adolescents. Considering the rise in screen time since the pandemic, it is imperative for clinical professionals and policymakers to promptly propose relevant regulation solutions. As a noticeable increase in screen time has been observed among adolescents belonging to the orphanage group following the pandemic, officials should implement more intensive management strategies for this particular group. Heightened management is also required for women adolescents, who exhibited vulnerability to increased screen time across all family structures during the pandemic. We additionally suggest the development of a customized screen time management strategy tailored to the specific family structures of each adolescent. Providing individualized solutions targeting the risk factors associated with each family structure can contribute to a more effective reduction in screen time. Specifically, focusing on the distinct risk factors (grade, region of residence, physical activity frequency, sadness and despair, and highest education level of parents) within the nuclear family group could prompt targeted management strategies for this particular cohort. Given the physical and mental health and socioemotional well-being concerns associated with excessive screen time [10,35,36], appropriate efforts from clinical, social, and political professionals are needed to normalize the rapidly increased screen time among adolescents since the pandemic. To address this, it is essential to expand international health expenditure for pandemic response and preparedness [37]. Thus, securing long-term and sustainable funding is crucial to address the rise in adolescents’ digital device use and the associated mental health challenges [38].

In particular, investments in digital education programs, enhanced mental health services, and community support networks are vital to mitigate the physical and mental health impacts of increased screen time among adolescents during the pandemic. Additionally, policy and educational initiatives should focus on leveraging the already identified positive aspects of increased screen time during restricted social interactions, such as its potential for information exchange, education, and communication [39]. Pandemic response funds should be prioritized to address these issues and support adolescents in growing up in a healthy digital environment. Appropriate allocation of funds and policy support will play a critical role in addressing the challenges of increased adolescent screen time and alleviating health disparities exacerbated by the pandemic.

This study has several limitations. First, variations in survey questions from 2008 to 2022 affected data comparability. Specifically, while smartphone use time was the focus in 2017 and from 2020 to 2022, other years emphasized internet use time, excluding total screen time such as television viewing. Nevertheless, to the best of our knowledge, this is the first study to analyze long-term data spanning 15 years, providing comprehensive insights into prepandemic and pandemic-era trends in adolescent screen time. Second, the self-response methodology in KYRBS may not fully reflect the characteristics of the actual population. However, KYRBS has been historically acknowledged as a credible dataset [40,41], and the weight-based analysis conducted with over 800,000 survey respondents further enhances the representativeness and validity of the screen time trends observed in this study. Third, this study is limited to Korean adolescents, restricting its representation of global trends. Despite this, the focus on a specific demographic allowed us to examine the nuanced relationships between screen time and family structures in the Korean context, providing insights relevant to similar societies. Finally, the cross-sectional design prevents establishing causal relationships between screen time and associated factors, highlighting the need for longitudinal and comprehensive studies. However, the study emphasizes the need for longitudinal research and offers a foundational understanding of screen time trends and influencing factors across diverse family structures.

This study examined adolescent screen time trends from 2008 to 2022 across various family structures, revealing a consistent increase over time, with the steepest rise observed during the COVID-19 pandemic. Screen time patterns varied significantly by family structure, with orphaned adolescents experiencing the most pronounced increase, while other groups, such as those in nuclear families, also showed distinct trends influenced by factors like parental education and region of residence. These findings underscore the importance of tailored interventions, including family-type–specific workshops, institutional programs, and digital literacy resources, to address the diverse needs of adolescents. Reducing regional disparities and promoting alternative activities are also critical for mitigating the negative impacts of excessive screen time. Future research on broader structural and cultural influences on digital engagement is necessary to develop comprehensive and sustainable strategies for managing adolescent screen time.