Neck pain is a major contributor to disability worldwide and commonly emerges in early adulthood. College populations report high neck pain prevalence, and rising reliance on digital devices—particularly tablets—has focused attention on device-related ergonomic risk factors. This study examined the association between tablet tilt angle and clinically significant neck pain among undergraduate students in real-world educational settings and sought demographic and behavioral correlates that could inform prevention.
This was a cross-sectional, national self-reported survey conducted across 17 universities in Thailand between August 2024 and February 2025. The final target sample size of 328 was calculated using prior prevalence estimates, a 95% confidence level, 5% margin of error, and 10% non-response allowance. Participants were recruited by convenience sampling from allied health science programs.
Eligibility criteria included age 18–25 years, at least one year of tablet use for educational purposes, normal or corrected vision, and regular tablet use (≥2 hours/day on ≥5 days/week). Exclusion criteria removed respondents with spinal trauma, prior spinal surgery, specified spinal or systemic diagnoses, neurological deficits, pregnancy, regular analgesic or muscle relaxant use, and those performing structured exercise ≥3 sessions/week to reduce confounding.
A 22-item questionnaire in the native language collected demographics, tablet use patterns (brand/model, duration, purpose, sitting posture, and tablet tilt angle), and neck symptoms. The screening item used the Nordic Musculoskeletal Questionnaire phrasing for neck discomfort lasting >24 hours in the past month. Those answering yes rated pain intensity with an 11-point Numeric Rating Scale (NRS). The instrument underwent content review by five specialists with an Index of Item-Objective Congruence of 0.88 and internal reliability measured by Cronbach’s alpha (value reported in source). The online survey (Google Forms) ensured anonymity; incomplete responses were excluded.
Neck pain was defined as reported neck discomfort in the past month plus an NRS score ≥ 4, producing a binary outcome (cases vs reference). Descriptive statistics summarized sample characteristics. Associations were screened with Pearson’s chi-square and Mann–Whitney U tests (p < 0.20 threshold for inclusion). A stepwise multiple logistic regression with variable selection by Akaike information criterion (AIC) assessed independent associations; results are presented as adjusted odds ratios (aOR) with 95% confidence intervals. Model discrimination was assessed using area under the curve (AUC). Analyses were performed in R (version 4.3.2), and statistical significance was set at p < 0.05.
A total of 328 responses were obtained from 17 institutions across four regions (central 41.9%, north 20.8%, northeast 12.1%, south 25.2%); 15 respondents were excluded per criteria. Participants were predominantly female, with a median age of 21 years (IQR 20–22) and median BMI 21.3 kg/m2. The observed prevalence of tablet-related clinically significant neck pain (NRS ≥ 4) was 42.17%.
Univariable analyses identified age, sex, academic year, tablet tilt angle, and sitting posture during tablet use as associated with neck pain at the p < 0.20 screening level. Height, BMI, and daily device time were not significantly associated.
In the stepwise multiple logistic regression, academic year and tablet tilt angles remained independently associated with clinically significant neck pain. Fourth-year students had lower odds of neck pain compared with first-year students (aOR = 0.30, 95% CI 0.14–0.66; P = 0.003). Relative to a 0° tilt, tilt angles of 10° (aOR = 3.93, 95% CI 1.83–8.46; P < 0.001) and 60° (aOR = 2.94, 95% CI 1.15–7.51; P = 0.024) were significantly associated with increased odds of neck pain. These estimates were adjusted within the multivariable model described above.
The combined model incorporating the identified factors produced an area under the curve of 0.69 (95% CI 0.63–0.75), indicating moderate discriminatory ability to predict clinically significant neck pain in this sample.
The study reports a 42% prevalence of clinically meaningful tablet-related neck pain (NRS ≥ 4) among undergraduate respondents, a figure slightly lower than some prior student studies that used broader case definitions. The stricter NRS ≥ 4 threshold emphasizes moderate pain likely to impact function.
Two tablet tilt angles—10° and 60°—were independently associated with higher odds of neck pain, suggesting a non-linear or U-shaped relationship between tablet tilt angle and cervical symptoms. Lower tilt angles likely increase cervical flexion to maintain viewing, increasing gravitational loading on cervical extensors; higher tilt angles may alter posture or visual demands in other ways that also increase strain. Fourth-year students exhibited lower risk, which the authors attribute to differences in typical activity and reduced continuous tablet use during clinical or practical training, leading to greater postural variation and less sustained cervical loading.
Findings support the importance of device positioning as a modifiable ergonomic factor. Proper tablet positioning and posture may reduce musculoskeletal strain associated with educational tablet use. The observed associations suggest that avoiding very low tilt positions (near flat) and extreme high tilt configurations could mitigate risk, though exact optimal angles were not prescribed beyond the observed associations.
Strengths include a national sample across multiple institutions, a validated questionnaire with expert review, clear exclusion criteria to limit confounding, and use of an established pain threshold (NRS ≥ 4) to identify clinically relevant symptoms. Limitations include the cross-sectional design, which precludes causal inference; convenience sampling and potential selection bias; reliance on self-reported tilt angle and posture rather than objective measurement; and residual confounding from unmeasured factors. Specific numerical values for some reliability statistics and full item-level data are reported in the source but are not repeated here beyond the reported IOC value.
In this nationwide cross-sectional sample of undergraduate students, clinically significant neck pain (NRS ≥ 4) was common. Tablet tilt angles of 10° and 60° were independently associated with increased odds of neck pain, and fourth-year students had lower odds compared with first-year students. These results highlight device positioning and posture as modifiable targets for ergonomic interventions in educational settings. Further longitudinal and interventional research with objective postural measures is needed to establish causality and optimal device configurations.