Eye injury is the second leading cause of impaired vision in the United States, with an estimated 2.4 million eye injuries occurring per year.1,2 Nearly 35% of annual injuries occur in individuals younger than 18 years of age.2 Overall, ocular trauma is the leading cause of monocular visual disability and non-congenital unilateral blindness in children.2 Survey data from the American Academy of Ophthalmology (AAO) showed that nearly 90% of patients with eye injuries were not wearing safety spectacles at the time of injury (unpublished data, 2010). Similarly, a study examining only serious eye injuries that resulted in permanent functional or structural damage showed that only 2% of patients had worn eye protection when the injury occurred.3 It has been suggested that almost 90% of eye injuries could be prevented by better education, appropriate protective eyewear use, and avoidance of risk factors.4
The role of mass media has been examined in the context of childhood injury and as a potential tool to convey safety practices. Children in the United States watch an average of 3 to 5 hours of television per day.5,6 Television programming has been shown to influence children’s behaviors with respect to aggression, nutrition, sexuality, smoking, and safety.7–12 This influence on viewers’ behavior has been suggested to be a result of observational learning processes, whereby the modeled behavior encourages a new behavior or inhibits a previously learned behavior in the viewer.13 Televised safety models have been shown to increase children’s ability to identify hazardous scenarios. Potts et al. identified that safety models demonstrating an injury scenario followed by a scene with safety behavior resulted in a decreased willingness to participate in risk activities, whereas models not portraying an injury did not improve risk-taking behavior.13
Several studies examining unintentional, injury-related content in children’s television programs and films have found that recommended safety behaviors were not portrayed accurately.6,14–16 Additionally, popular media portrayals of unsafe risk-associated behaviors rarely resulted in depicted injuries, and injuries that did occur were generally mild or modest.17,18 Previously, we examined the depiction of eye protection in popular adult television programs.19 To our knowledge, no studies have been published characterizing the depiction of eye protection in popular children’s television programs.
Patients and Methods
The methodology of this study closely models those described by Glazier et al., with differences delineated below.19 We selected 30 episodes from children’s animated and live-action programs that aired on national broadcast and cable television channels from January 1, 2010, to December 31, 2010. Programs were chosen using television ratings data obtained from Nielsen. For broadcast and cable television, the top 50 programs by viewership for ages 2 to 12 years were examined. Programs excluded were feature films or television specials that contained fewer than 10 episodes telecasted in the time period or programs that were telecasted in a non-English language. Variety programs, reality television, and sporting events were not included in this study. To accurately approximate television programs viewed by children, all forms of programming (live-action, animated, computer-generated imagery, etc.) were included and there was no exclusion based on program content (eg, reality versus fantasy, past versus present). Twelve broadcast and three cable program series met the inclusion criteria. Of these program series, the three broadcast television series and the three cable television series with the highest average viewership values were selected for analysis. From these six program series, each episode was given a numerical identifier and five episodes were selected using an online random integer generator (M. Haahr, http://www.random.org/integers). All episodes were obtained through the “iTunes Store” and viewed in their entirety with exclusion of show credits. Additionally, no special features or expanded content were included as to approximate their portrayal on television.
To record events associated with ocular risk, a data collection form was created and used. The form was updated from a previous version and was developed using safety guidelines from national organizations (AAO, Centers for Disease Control [CDC], and Occupational Safety and Health Administration [OSHA]).19 Event recording was guided by published reports that evaluated the depiction of seat-belt and helmet use in popular movies.14,16,19 Two reviewers independently evaluated the 30-episode study set. To ensure appropriate coding, reviewers were able to replay segments of content and any disagreements in exposure assessment were resolved with review of material leading to consensus.
A scene was defined as a segment of the program in which the action and narrative formed an independent portion of the overall program. An exposure-scene was defined as a television character in the program participating in an activity that would require protective eyewear based on recommendations of national organizations (AAO, CDC, and OSHA).19–21 Furthermore, an exposure-scene was defined to begin with the initiation of a risk-associated activity and end with permanent cutaway or completion of the risk activity. Characters directly involved with the activity were included as an exposure (eg, all players on a baseball field) but bystanders were excluded (eg, fans in the bleachers of a baseball game).
Protective eyewear use was recorded for characters engaged in activities related to: impact (eg, hammering and power drill use), open vehicle (eg, motorcycle and open cockpit plane), moderate-high risk sports (eg, baseball and paintball), low-risk sports (eg, karate and swimming), dust (eg, chiseling), biologic (eg, blood and tissue), chemical (eg, use of household chemicals), heat (eg, welding and frying), and optical radiation (eg, laser use). If an activity qualified in two categories, the event would count for each category. Character type was recorded in two ways: human versus non-human (eg, alien and humanized animal) and animated versus live-action. The incident of any eye injury was recorded. Eye protection was assumed to be appropriate unless inadequacy was readily apparent (eg, sunglasses for welding and safety glasses worn on forehead) or the protective eyewear was only used for partial duration of the exposure-scene. Activities that posed eye risks that were emergent in nature or unanticipated by characters were not coded as exposure-scenes (eg, a character hit with a ball from an unknown origin off-screen). This was to ensure reviewers only coded events where characters willfully engaged in eye-risk activities.
The programs meeting inclusion criteria for the study set were three broadcast televised programs on PBS (The Cat in the Hat Knows a Lot About That, Curious George, and Dinosaur Train) and three cable televised programs from Nickelodeon (iCarly, SpongeBob SquarePants, and Victorious). Two of the programs (iCarly and Victorious) were live-action and the other four programs were animated. From the 30 episodes viewed, there were 244 exposure-scenes and 19 depictions of adequate protective eyewear. There was a median of 5.5 (mean = 8.1) exposure-scenes per episode, with 26 of 30 (87%) episodes containing at least one exposure-scene. Comparison of the independent coding results between the two reviewers yielded an agreement on 233 exposure-scenes (233 of 244 or 95.5%). There were 11 exposure-scenes that were not initially recorded by both reviewers. After review of the scenes and discussion, all 11 exposure-scenes were determined to qualify as exposures and included in all analyses.
There were six eye injuries depicted in the episode set. One chemical injury occurred in iCarly in which a character was sprayed in the eye with a cleaning detergent. Three unanticipated biologic injuries occurred in SpongeBob SquarePants as two characters were sprayed in the eye with mustard and one character was sprayed with ink from a squid. There was an impact injury and a chemical injury in Victorious during a fight scene in which one character was hit with a rock and the other was sprayed in the eye with chlorine gas. In all six depictions of ocular injuries, the characters either remarked that there was contact with their eye and/or demonstrated that their eye had been injured (eye redness or tearing). There were no serious consequences because injuries seemingly resolved after the scene cut away.
In contrast to ocular injury depictions, we examined eye protection. Table 1 presents the total number of exposure-scenes and those that depicted adequate protective eyewear for each of the selected programs. Depiction of protective eyewear use occurred in 8% (19 of 244) of the exposure-scenes. At least one depiction of protective eyewear use occurred in 4 of 6 programs. For the broadcast programs, there were 136 exposures with a median of 7 (mean = 9.1) exposure-scenes per episode. For the cable programs, there were 108 exposures with a median of 3 (mean = 7.2) exposure-scenes per episode. Of the 19 depictions of protective eyewear, 15 were from broadcast programs (79%), with 13 of those from one program, The Cat in the Hat Knows a Lot About That.
Table 1: No. of Risk Exposures With Depiction of Protective Eyewear by Program
The proportion of eyewear depiction to exposure-scenes with respect to the risk activity is summarized in Table 2, ordered by the total number of exposures and with examples of the observed risk activities. Activities that carried a risk of impact injury to the eye accounted for 77 exposure-scenes (32% of total exposure-scenes) and were not associated with any protective eyewear depiction. There were 76 open vehicle exposures (31% of total exposure-scenes) with no depictions of protective eyewear. Fifteen depictions of protective eyewear occurred in the 42 moderate-high risk sports exposure-scenes (17% of total exposure-scenes). There were 27 low risk sports exposures (11%) with no protective eye-wear use depicted. There were 9 exposures to dust with two depictions of protective eyewear use. There were 6 biologic exposure-scenes and 3 chemical exposure-scenes, and both categories had no protective eyewear use depicted. Four exposures to heat were observed with two depictions of protective eyewear use. There were no exposure-scenes with optical radiation. Human and non-human characters demonstrated similar proportions; human characters were shown using eye protection in 9 scenes of 134 exposures (7%) compared to non-human characters in 10 scenes of 110 exposures (9%). The depiction of eyewear protection was also examined comparing live-action and animated characters; animated characters had 16 depictions of protective eyewear in 170 exposure-scenes (11%) compared to live-action characters in 3 scenes of 74 exposures (4%).
Table 2: No. of Risk Exposures With Depiction of Protective Eyewear by Exposure Type
Additional analysis was performed to create a high-risk subcategory by removing three risk activities: low-risk sports, open vehicles, and optical radiation. These categories accounted for 103 exposure-scenes and had no depictions of protective eyewear. The remaining categories (impact, moderate-high risk sports, dust, biologic, chemical, and heat-related activities) represented 141 exposure-scenes. Impact exposures comprised the use of hand tools, power tools, heavy equipment, and explosives. Hand tool use was depicted in 65 of 77 impact exposure-scenes. Moderate-high risk sports included archery, miscellaneous ball sports, baseball, basketball, karate, fishing, and scuba diving; miscellaneous ball sports and scuba diving accounted for 24 of 42 sports exposure-scenes. The remaining categories (dust, biologic, chemical, and heat-related activities) had 22 exposure-scenes of the following activities: fossil excavation, chiseling, body fluids, food, industrial solvents, frying, and welding. Protective eyewear use in this high-risk subcategory occurred in 19 of 141 instances (13%).
This study demonstrated that there were few depictions of eye protection during hazardous activities in popular children’s television programs. Both human and non-human characters were infrequently depicted using protective eyewear. Although risk exposure events were commonly depicted, few characters suffered injury as a result of risky behavior. Six eye injuries were depicted, although physical consequences were minimal and treated indifferently by the participating characters and bystanders.
Sub-analysis of the study data was performed without three risk-exposure types—low-risk sports, open vehicles, and optical radiation—to create a high-risk subcategory of activities that are more likely to occur in the pediatric population. Low-risk sports, such as swimming and soccer, have formal recommendations for protective eyewear use that are less stringent, which may account for the lack of eye protection depicted. Open vehicle exposures (eg, riding a motorcycle or open cockpit plane) and optical radiation exposures are high-risk activities but not likely to occur in a pediatric population. The remaining groups (impact, moderate-high risk sports, dust, biologic, chemical, and heat-related activities) represented activities that children are more likely to engage in and demonstrated minimal use of protective eyewear.
A significant proportion of the exposure-scenes were impact and sports exposures, which have been significantly associated with ocular injury. The 2010 AAO survey data showed that more than half of reported eye injuries occurred in the home, with one in four injuries due to home repair or power tools and more than one in four occurring during sports-related activities (AAO, unpublished data, 2010). In 2000, more than 42,000 sports- and recreation-related eye injuries were reported, with 43% occurring in individuals younger than 15 years.21 From 2001 to 2009, an estimated 208,517 cases of sports-related eye injuries from selected sports were treated in U.S. emergency departments, with the majority of injuries occurring in the 7- to 14-year-old age group.22 In this study, the evaluated television content depicted no use of protective eyewear in any impact exposure-scene, whereas most of the protective eyewear depictions occurred in scenes containing moderate-high risk sports.
There are three main limitations to this study. First, the sample size of 30 episodes from a single broadcast year was relatively small and may be insufficient to draw broad conclusions. The six program series represented only one cable station and one broadcast station, whereas numerous stations offer children’s programming. The selection of programs for evaluation may unfairly generalize the portrayal of eye protection. A larger sample size inclusive of other program types (eg, reality television and game shows) and less popular programs may reveal different rates of protective eyewear depiction. There is an inherent subjective nature to data coding of injury exposure events. This subjectivity is complicated because of the diverse actions that could lead to eye risk. Eye protection guidelines are often broad or ambiguous, and generally describe potential mechanisms of injury instead of outlining specific tasks requiring protective eyewear.19 Additionally, this study only examined participants who were actively engaged in an eye risk activity, whereas in reality bystanders may be at ocular risk during certain activities. This subjectivity and ambiguity enhances the potential for variability in the observations of reviewers and differences between recorded risks and actual risks.
Despite a difficult-to-quantify cause-and-effect relationship, media content has been shown to affect children’s behavior. Studies have documented the positive effects of television-modeling behavior on activities relevant to safety and injury in children.6,10 Similarly, literature concerning violence prevention, nutrition, sexuality, and tobacco use show there are both positive and negative correlations between media content and children’s behavior.7–12,23
This study identified low rates of depiction of protective eyewear in children’s television programs. There were few actual ocular injuries in the sampled programming, and when injuries occurred they were mild and resulted in little to no morbidity. Exposure to inadequate depictions of protective eyewear and unrealistic depictions of traumatic ocular sequelae may cause children to develop distorted perceptions of eye injury risk. This could lead to unhealthy attitudes and behaviors, similar to what has been suggested for other types of injury.24,25 Media content with more depictions of protective eyewear use might help modify childhood behavior and allow for the recognition of activities that are associated with ocular risk.
Future studies could more extensively assess the portrayal of eye protection in children’s programming by sampling a longer broadcast time frame and more program types, and focusing on programs likely to be viewed by children on various television stations. Investigations could also be attempted to determine whether the depiction of protective eye-wear use and eye injuries in media programming influence the attitudes and behaviors of children. Decreasing the frequency and severity of ocular injuries will continue to require a broad approach by health professionals, advocacy groups, and public health organizations.
- Feist RM, Farber MD. Ocular trauma epidemiology. Arch Ophthalmol. 1989;107:503–504 doi:10.1001/archopht.1989.01070010517021 [CrossRef] .
- Brophy M, Sinclair SA, Hostetler SG, Xiang H. Pediatric eye injury-related hospitalizations in the United States. Pediatrics. 2006;117:e1263–e1271 doi:10.1542/peds.2005-1950 [CrossRef] .
- May DR, Kuhn FP, Morris RE, et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol. 2000;238:153–157 doi:10.1007/PL00007884 [CrossRef] .
- Ervin-Mulvey LD, Nelson LB, Freeley DA. Pediatric eye trauma. Pediatr Clin North Am. 1983;30:1167–1183.
- Liebert RM. Effects of television on children and adolescents. J Dev Behav Pediatr. 1986;7:43–48 doi:10.1097/00004703-198602000-00008 [CrossRef] .
- Potts R, Runyan D, Zerger A, Marchetti K. A content analysis of safety behaviors of television characters: implications for children’s safety and injury. J Pediatr Psychol. 1996;21:517–528 doi:10.1093/jpepsy/21.4.517 [CrossRef] .
- Huesmann LR, Moise-Titus J, Podolski CL, Eron LD. Longitudinal relations between children’s exposure to TV violence and their aggressive and violent behavior in young adulthood: 1977–1992. Dev Psychol. 2003;39:201–221 doi:10.1037/0012-1622.214.171.124 [CrossRef] .
- Browne KD, Hamilton-Giachritsis C. The influence of violent media on children and adolescents: a public-health approach. Lancet. 2005;365:702–710.
- Collins RL, Elliott MN, Berry SH, Kanouse DE, Hunter SB. Entertainment television as a healthy sex educator: the impact of condom-efficacy information in an episode of friends. Pediatrics. 2003;112:1115–1121 doi:10.1542/peds.112.5.1115 [CrossRef] .
- Potts R, Doppler M, Hernandez M. Effects of television content on physical risk-taking in children. J Exp Child Psychol. 1994;58:321–331 doi:10.1006/jecp.1994.1037 [CrossRef] .
- Dorey E, McCool J. The role of the media in influencing children’s nutritional perceptions. Qual Health Res. 2009;19:645–654 doi:10.1177/1049732309334104 [CrossRef] .
- Wakefield M, Flay B, Nichter M, Giovino G. Role of the media in influencing trajectories of youth smoking. Addiction. 2003;98(suppl 1):79–103 doi:10.1046/j.1360-0443.98.s1.6.x [CrossRef] .
- Potts R, Swisher L. Effects of televised safety models on children’s risk taking and hazard identification. J Pediatr Psychol. 1998;23:157–163 doi:10.1093/jpepsy/23.3.157 [CrossRef] .
- Pelletier AR, Quinlan KP, Sacks JJ, Van Gilder TJ, Gilchrist J, Ahluwalia HK. Injury prevention practices as depicted in G-rated and PG-rated movies. Arch Pediatr Adolesc Med. 2000;154:283–286.
- Glik D, Kinsler J, Todd WA, et al. Unintentional injury depictions in popular children’s television programs. Inj Prev. 2005;11:237–241 doi:10.1136/ip.2003.004184 [CrossRef] .
- Ramsey LT, Ballesteros MF, Pelletier AR, Wolf J. Injury prevention practices as depicted in G and PG rated movies: the sequel. Inj Prev. 2005;11:353–356 doi:10.1136/ip.2005.009035 [CrossRef] .
- Winston FK, Duyck Woolf K, Jordan A, Bhatia E. Actions without consequences: injury-related messages in children’s programs. Arch Pediatr Adolesc Med. 2000;154:366–369 doi:10.1001/archpedi.154.4.366 [CrossRef] .
- Potts R, Henderson J. The dangerous world of television: a content analysis of physical injuries in children’s television programming. Children’s Environments. 1991;8:7–14.
- Glazier R, Slade M, Mayer H. The depiction of protective eye-wear use in popular television programs. J Trauma. 2011;70:965–969 doi:10.1097/TA.0b013e3181e7c710 [CrossRef] .
- Czarnecki F, Janowitz I. Ergonomics and safety in law enforcement. Clin Occup Environ Med. 2003;3:399–417 doi:10.1016/S1526-0046(03)00100-6 [CrossRef] .
- American Academy of Pediatrics Committee on Sports Medicine and Fitness. Protective eyewear for young athletes. Pediatrics. 2004;113:619–622.
- Kim T, Nunes AP, Mello MJ, Greenberg PB. Incidence of sports-related eye injuries in the United States: 2001–2009. Graefes Arch Clin Exp Ophthalmol. 2011;249:1743–1744 doi:10.1007/s00417-010-1556-x [CrossRef] .
- Waylen AE, Leary SD, Ness AR, Tanski SE, Sargent JD. Cross-sectional association between smoking depictions in films and adolescent tobacco use nested in a British cohort study. Thorax. 2011;66:856–861 doi:10.1136/thoraxjnl-2011-200053 [CrossRef] .
- Uberos DJ, Gomez A, Munoz A, Molina A, Galdo G, Perez FJ. Television and childhood injuries: is there a connection?Arch Pediatr Adolesc Med. 1998;152:712–714.
- Villani S. Impact of media on children and adolescents: a 10-year review of the research. J Am Acad Child Adolesc Psychiatry. 2001;40:392–401 doi:10.1097/00004583-200104000-00007 [CrossRef] .
No. of Risk Exposures With Depiction of Protective Eyewear by Program
|Programa||Risk Exposures||Adequate Protective Eyewear|
| iCarly||53||1 (2%)|
| SpongeBob SquarePants||37||3 (8%)|
| Victorious||18||0 (0%)|
| The Cat in the Hat Knows a Lot About That||87||13 (15%)|
| Curious George||23||0 (0%)|
| Dinosaur Train||26||2 (8%)|
No. of Risk Exposures With Depiction of Protective Eyewear by Exposure Type
|Risk Exposureb||NA/NR (%)a|
|Total||19/244 (8)||9/134 (7)||10/110 (9)|
|Impact||0/77 (0)||0/54 (0)||0/23 (0)|
|Open vehicle||0/76 (0)||0/40 (0)||0/36 (0)|
|Sports (moderate-high)||15/42 (36)||6/14 (43)||9/28 (32)|
|Sports (low)||0/27 (0)||0/17 (0)||0/10 (0)|
|Dust||2/9 (22)||2/3 (67)||0/6 (0)|
|Biologic||0/6 (0)||0/2 (0)||0/4 (0)|
|Chemical||0/3 (0)||0/3 (0)||0/0 (0)|
|Heat||2/4 (50)||1/1 (100)||1/3 (33)|