In our current study, the prevalence of digital eye strain among students was found to be 44.1%. This rate is notably lower compared to neighboring countries such as Jordan (59%), Saudi Arabia (66%), China (70.5%), and the USA (65%) [4, 5, 11, 12]. However, it is significantly higher than the rate reported in India, which stands at (18%) [13]. Several factors may contribute to the prevalence of DES in Palestine. Potential reasons include differences in educational systems, screen time exposure, lifestyle habits, and access to preventive measures. Additionally, environmental factors and awareness levels about eye health might also play a role in these variations. Further research is needed to understand the specific determinants contributing to the high rate of eye strain in Palestine, yet lower than other neighboring countries [14, 15].

The findings indicate a significant relationship between posture and the occurrence of eyestrain, aligning with previous studies. These studies found that children who use digital devices while lying in bed are more likely to develop eyestrain compared to those who use digital devices while sitting in chairs. Additionally, a study conducted in India demonstrated a significant association between students who preferred to lie down and those who experienced eyestrain [5]. Another study examining the connection between posture and visual stress found that using a smartphone in poor posture could lead to various eye problems. The study recommended avoiding reading while lying on your back or stomach [16].

The results of our study revealed a significant relationship between using phones during sleep with lights off and eyestrain. The percentage of use of digital devices at bedtime is 59.1%. Research in Saudi Arabia discovered that more than 98% of participants possess smartphones, and nine out of ten utilize their devices at bedtime [17]. In contrast, a study in Egypt revealed that 48.8% of individuals use smartphones at bedtime [18].

The results of our study indicated that the majority of school children spent more than 2 h daily on digital devices. In comparison, a study from Saudi Arabia reported that children spent between 4 and 6 h per day on digital devices [4]. Additionally, research from Hong Kong showed that children aged ten years and older spent approximately 30 h per week on digital devices [19].

Our study, involving school students, revealed a significant correlation between the use of digital devices for social media and eyestrain. Students who spend more than two hours daily on their phones experience more eyestrain compared to those who spend less time. An American study indicated that individuals across all age groups check their phones an average of 46 times a day. Americans also dedicate approximately five hours daily to browsing the web, using social media, and utilizing apps, including completing work tasks on digital devices. This leads to prolonged screen time, which can harm eye health [20]. Another study showed that prolonged use of digital devices and excessive social media usage can worsen DES [19], particularly while scrolling through social media platforms, which involves intense, close-up visual work that demands constant focusing and refocusing of the eyes. This continuous visual effort, coupled with reduced blinking, may result in symptoms of eyestrain such as headaches, dry eyes, and blurred vision [21].

Our study demonstrated a significant correlation between children who spend more than two hours watching movies and videos and the development of eyestrain. The findings indicate a substantial relationship between the primary purpose of screen use, which is watching movies and videos, and the occurrence of eyestrain. Previous research supports these results, showing that extended periods of screen focus can lead to eye discomfort, dim vision, and headaches [22].

Our study indicated that women are more susceptible to eyestrain. Much research conducted during the COVID-19 pandemic revealed that symptoms of Digital Eye Strain (DES) were more prevalent among females than males [23]. Additionally, another study highlighted that a significant proportion of the global population suffers from untreated vision impairments, with 90% of these individuals residing in low- and middle-income countries. It was found that one in four women is at risk of vision impairment, compared to just one in eight men [24]. These findings underscore the importance of addressing gender disparities in eye health and ensuring equitable access to eye care services globally [25].

The results of the current study showed that there is a statistically significant relationship between children aged 15 and more and eyestrain. A study conducted during the COVID-19 pandemic found that individuals older than 14 years are at a higher risk for developing digital eyestrain. It also showed that symptoms of dry eye diseases were higher in children in the older age group than in the younger age group. Children at higher ages spend more hours using smartphones, which may lead to a higher prevalence of DES in older children [23].

The results of our study indicated a significant connection between smartphone use at a distance of 30–50 cm and the incidence of eyestrain. This finding is particularly noteworthy given that most individuals tend to use their phones within this range. In contrast, research conducted in India suggests that sitting close to a screen can heighten the risk of eyestrain in children [23]. On the other hand, Dr. Malik’s study recommends keeping the phone screen at a distance equivalent to a few arms’ length to reduce eyestrain, following the (1-2-10) rule, which advises keeping the phone at a distance of one foot from the individual [22]. Another study discovered that holding a phone at arm’s length (16–18 inches) could decrease eyestrain by 30–40% [27]. In general, it is recommended to maintain a distance of 50–75 cm between the eyes and the smart device to reduce eyestrain.

According to our research, a significant 7.5% of participants possessed multiple digital devices; this particular group encountered the most pronounced effects of eyestrain. The quantity of devices owned has a substantial impact on eye problems due to increased screen time and the specific usage of screens, especially exposure to light. All this leads to computer vision syndrome, which encompasses a range of eye and vision-related issues that arise from prolonged screen use. Common symptoms include dry eyes, blurred vision, headaches, and discomfort in the neck and shoulders. The prevalence of DES is remarkably high, affecting approximately 50% or more of individuals who use multiple digital devices [15].

The study revealed a correlation between screen brightness levels and the prevalence of eyestrain. An experimental study by Tian et al. investigated the effects of using electronic devices in dark environments at night on visual fatigue. The findings indicated that low screen brightness in dark environments reduced visual fatigue. Conversely, medium and high screen brightness levels increased visual perception sensitivity, as evidenced by pupil data, which is more likely to exacerbate visual fatigue [28].

Limitation and strength

The limitations of our study resulted from our inability to secure authorization to gather data from government schools in compliance with the directives of the Ministry of Education in Palestine. Our study was therefore limited to private schools, where social and economic circumstances differ and could influence the study sample’s heterogeneity, making it challenging to detect a significant association with some study variables. Additionally, political instability in the West Bank limited transportation, which prolonged and complicated the data collection process. Despite efforts to include a diverse sample, some demographic groups or regions within the West Bank were unreachable, limiting the generalizability of the findings to public school children and other socio-economic groups.

This study is the first to evaluate the percentage of DES and associated variables among school children in Palestine. We used a measurement tool (CVS-Q) and a Snellen chart, both of which have outstanding intra- and inter-observer reliability. However, as the study used a screening tool, care should be taken when extrapolating the findings. Once children with DES have been identified using the CVS-Q and the Snellen chart, it is preferred for future research to use an ophthalmological examination by a specialist for confirmation and diagnosis of vision impairment.

Recommendation 1.

Creating a daily schedule routine for children to utilize electronic devices can effectively mitigate the risk of eyestrain. It is strongly advised that children limit their device usage to a maximum of (1–2 h) per day, with regular breaks scheduled every 30 min, it is crucial for them to encourage them to shift their focus away from the screen for 30 s and shift their focus onto an object positioned at a minimum distance of 30 feet. By following this method, the child’s eye moisture is effectively maintained, and their focusing system is reset. Encouraging children to adopt this technique as a daily habit is essential for preserving optimal eye health.

2.

When using digital devices, it is advisable for children to keep a distance of at least 30–50 cm between their eyes and the devices.

3.

Keep the screen brightness at a level that matches the surrounding light. It is crucial to find a suitable brightness level that is comfortable for the eyes.

4.

Educate children on the importance of maintaining good posture while using digital devices. Instruct them to sit with their back straight and shoulders back, position their screen so that the top of the monitor is at or just below eye level, and keep their feet flat on the floor, avoiding slouching. Additionally, advise them against using digital devices while lying on their back or stomach.

5.

Parents should make regular visual check-ups a priority for their children to safeguard their eye health and safety. These visits are essential for early detection and treatment of any visual issues. Optometrists can offer advice on maintaining healthy eyes, reducing the effects of digital activities on vision, and prescribing glasses or other treatments as necessary, monitoring their vision consistently promotes optimal eyesight.

6.

To enhance children’s sleep quality, it is important to avoid using smartphones and tablets before bedtime. The light emitted by these screens can affect the production of melatonin, a hormone necessary for regulating sleep. It is recommended to power down electronic devices early, ideally (1–2) hours before bedtime, and maintain a dark bedroom setting.

7.

Promoting reading, engaging in traditional games, and practicing drawing can boost children’s creative and language abilities while helping to limit screen time. Furthermore, participating in outdoor activities can improve eye health and lower the chances of developing myopia, promoting a well-rounded and healthy lifestyle.