A systematic evaluation of physical activity and diet policies in Scotland: results from the 2021 Active Healthy Kids Report Card.

BACKGROUND: Policymaking regarding physical activity (PA) and diet plays an important role in childhood health promotion. This study provides a detailed examination of Scottish government and policy for child and adolescent PA and diet and discusses strengths and areas for improvement. METHODS: Scottish policy documents (n = 18 [PA]; n = 10 [diet])-published in 2011-20-were reviewed for grading using an adapted version of the Health-Enhancing Physical Activity Policy Audit Tool Version 2. RESULTS: There is clear evidence of leadership and commitment to improving PA and diet and tackling obesity in children and adolescents. The allocation of funds and resources for policy implementation has increased substantially over the past decade. Progress through early key stages of public policymaking-policy agenda and formation-has improved. However, there is limited information on later key stages, including policy monitoring and evaluation. CONCLUSIONS: Childhood PA and diet are a clear priority in Scotland, and PA and diet policies clearly support the desire to achieve other goals, including reducing inequalities and increasing active travel in Scotland. Nonetheless, future policies should be further strengthened through clear(er) plans of implementation, and monitoring and evaluation to support their societal impact.

Adolescents' interactive electronic device use, sleep and mental health: a systematic review of prospective studies.

Optimal sleep, both in terms of duration and quality, is important for adolescent health. However, young people's sleeping habits have worsened over recent years. Access to and use of interactive electronic devices (e.g., smartphones, tablets, portable gaming devices) and social media have become deep-rooted elements of adolescents' lives and are associated with poor sleep. Additionally, there is evidence of increases in poor mental health and well-being disorders in adolescents; further linked to poor sleep. This review aimed to summarise the longitudinal and experimental evidence of the impact of device use on adolescents' sleep and subsequent mental health. Nine electronic bibliographical databases were searched for this narrative systematic review in October 2022. Of 5779 identified unique records, 28 studies were selected for inclusion. A total of 26 studies examined the direct link between device use and sleep outcomes, and four reported the indirect link between device use and mental health, with sleep as a mediator. The methodological quality of the studies was generally poor. Results demonstrated that adverse implications of device use (i.e., overuse, problematic use, telepressure, and cyber-victimisation) impacted sleep quality and duration; however, relationships with other types of device use were unclear. A small but consistent body of evidence showed sleep mediates the relationship between device use and mental health and well-being in adolescents. Increasing our understanding of the complexities of device use, sleep, and mental health in adolescents are important contributions to the development of future interventions and guidelines to prevent or increase resilience to cyber-bullying and ensure adequate sleep.

Results from Scotland's 2021 report card on physical activity and health for children and youth: Grades, secular trends, and socio-economic inequalities.

Background: The 2021 Active Healthy Kids Scotland Report Card aimed to identify secular trends and socio-economic inequalities, and to assess the physical activity and health of children and youth prior to COVID-19. Methods: An expert panel searched for data published in 2018-2020. Grades were assigned to nationally representative data using the Active Healthy Kids Global Alliance methodology. Results: The expert panel, following national consultation, awarded the following grades: Community/Environment B-, Organized Sport and Physical Activity B-, Government/Policy C-/C+, Active Transportation C-, Family/Peers D-, Recreational Screen Time F. Five indicators were graded inconclusive (INC): Overall Physical Activity; Active Play; Physical Fitness; Diet; Obesity. Grades have remained stable or declined, and surveillance has reduced, increasing the number of INC grades. There were marked socio-economic inequalities for eight indicators (Recreational Screen Time; Overall Physical Activity; Organized Sport & Physical Activity; Active Transportation; Diet; Obesity; Family/Peers; Community/Environment). Conclusions: Despite a decade of favorable policy, physical activity and health of children and youth has not improved, and marked socio-economic inequalities continue to persist in Scotland. There is a clear need for greater monitoring of physical activity and health, and improved policy implementation and evaluation, particularly as many indicators and related inequalities may have worsened following the COVID-19 pandemic.

Utilising active play interventions to promote physical activity and improve fundamental movement skills in children: a systematic review and meta-analysis.

BACKGROUND: Children's physical activity levels are low and efforts to improve their physical activity levels have proven difficult. Freely chosen and unstructured physical activity (active play) has the potential to be promoted in a variety of settings and potentially every day of the year in contrast to other physical activity domains, but active play interventions are an under-researched area. Therefore, the primary aim of this systematic review was to determine the effect of active play interventions on children's physical activity levels, particularly moderate-to-vigorous intensity physical activity (MVPA), and fundamental movement skills (FMS). METHODS: Studies were included if they were solely or  predominantly active play randomised, or cluster randomised controlled trials that targeted children aged 3-12 years. They had to report on at least one of the following outcomes: objectively measured physical activity, FMS, cognition and weight status. During December 2016, four databases (PE Index, SPORTDiscus, Medline and ERIC) were searched for relevant titles. Duplicates and irrelevant titles and abstracts were removed. The included studies had their quality assessed using the Effective Public Health Practice Project (EPHPP) tool. Suitable studies were combined in a meta-analysis using a random-effect model. A narrative synthesis was conducted for all outcomes. RESULTS: Of the 4033 records, 91 studies were eligible for full text screening, of which 87 were removed, leaving four studies (representing five papers). The meta-analysis of two studies highlighted there was no significant effect of active play interventions on MVPA. However, the narrative synthesis suggested that active play interventions may increase total volume of physical activity. Only two studies examined the effect of active play interventions on children's FMS, one study examined effects on weight status and none examined effects on cognition. CONCLUSIONS: Due to the small number of eligible studies and their heterogeneity, the review could not draw firm conclusions on the effect of active play interventions on children's physical activity levels. High-quality active play interventions, targeting different times of the day (school and after school) in different populations and settings, and with a wider range of outcomes, are required to determine the potential of active play.

A qualitative study of parental strategies to enable pre-school children's outdoor and nature experiences during COVID-19 restrictions.

Outdoor and nature experiences including play have been shown to be beneficial for children's physical, cognitive, social and emotional development. Parents/carers play an important role in encouraging or impeding their child's access to the outdoor environment and participation in outdoor play. The COVID-19 pandemic and associated restrictions on free movement and social interactions placed an unprecedented pressure on families to manage the drastic change in their daily routines. This paper reports findings from two combined data sets generated in 2020 during the COVID-19 pandemic and provides a deeper understanding of the interconnected nature of how contextual factors influence parenting processes and outcomes relating to young children's outdoor and nature experiences and subsequent child health. Findings have the potential to inform the messaging of existing outdoor play policies and the content of new interventions aiming to promote the exposure of children to the natural outdoor environment.

Outdoor nature-based play in early learning and childcare centres: Identifying the determinants of implementation using causal loop diagrams and social network analysis.

Nature-based play benefits children's health and development. However, the delivery of this in early learning and childcare centres (ELC) is extremely diverse, and implementation is not well understood. We applied a systems science perspective to understand the factors crucial to implementing nature-based outdoor play in ELC settings. Through Group Model Building workshops with 20 participants in managerial and practitioner roles, crucial factors were appraised using Causal Loops Diagrams. Twelve thematic causal loops emerged. Network analysis was employed to analyse the diagram. Exponential Random graph models explained the diagram construction process. Centrality measures alongside conditional uniform tests identified six leverage factors: use of outdoor space, culture of being outdoors, ELC culture of outdoor play, perceived child safety and enjoyment, educator confidence and educator agency. This research brings novel and practically relevant evidence about the important factors, and interdependencies, involved in the implementation of outdoor play practice within ELC settings.

A Low-Cost Method for Understanding How Nature-Based Early Learning and Childcare Impacts Children's Health and Wellbeing.

Nature-based play and learning provision is becoming increasingly popular across the early learning and childcare (ELC) sector in Scotland. However, there remains a lack of understanding of how the program is expected to function. This has implications for program learning and may affect wider rollout of the program. Secondary data analysis of parent interviews (n = 22) and observations (n = 7) in Scottish ELC settings, and review of internationally published studies (n = 33) were triangulated to develop a program theory using the Theory of Change approach. This approach makes a program's underlying assumptions explicit by systematically demonstrating the relationship between each component: inputs, activities, outcomes, impact, and the contexts of the program. Findings suggested that location of outdoor nature space, affordances, availability of trained practitioners, and transport to location lead to activities such as free play, educator-led activities, and interactions with nature, resulting in longer durations of physical activity, interactions with peers and educators, and increased engagement with the natural environment. These activities are vital for supporting children's physical, cognitive, social, and emotional development. Our results demonstrate the value of using secondary data analysis to improve our understanding of the underlying theory of nature-based ELC which can support future evaluation designs. These findings will be of interest to program evaluators, researchers, practitioners, and funders, who find themselves with limited resources and want to better understand their program before investing in an evaluation. We encourage researchers and evaluators in the field of early years and outdoor play in other countries to refine this logic model in their own context-specific setting.

Nature-Based Early Childhood Education and Children's Social, Emotional and Cognitive Development: A Mixed-Methods Systematic Review.

This systematic review synthesised evidence on associations between nature-based early childhood education (ECE) and children's social, emotional, and cognitive development. A search of nine databases was concluded in August 2020. Studies were eligible if: (a) children (2-7 years) attended ECE, (b) ECE integrated nature, and (c) assessed child-level outcomes. Two reviewers independently screened full-text articles and assessed study quality. Synthesis included effect direction, thematic analysis, and results-based convergent synthesis. One thousand three hundred and seventy full-text articles were screened, and 36 (26 quantitative; 9 qualitative; 1 mixed-methods) studies were eligible. Quantitative outcomes were cognitive (n = 11), social and emotional (n = 13), nature connectedness (n = 9), and play (n = 10). Studies included controlled (n = 6)/uncontrolled (n = 6) before-after, and cross-sectional (n = 15) designs. Based on very low certainty of the evidence, there were positive associations between nature-based ECE and self-regulation, social skills, social and emotional development, nature relatedness, awareness of nature, and play interaction. Inconsistent associations were found for attention, attachment, initiative, environmentally responsible behaviour, and play disruption/disconnection. Qualitative studies (n = 10) noted that nature-based ECE afforded opportunities for play, socialising, and creativity. Nature-based ECE may improve some childhood development outcomes, however, high-quality experimental designs describing the dose and quality of nature are needed to explore the hypothesised pathways connecting nature-based ECE to childhood development (Systematic Review Registration: CRD42019152582).

Nature-Based Early Childhood Education and Children's Physical Activity, Sedentary Behavior, Motor Competence, and Other Physical Health Outcomes: A Mixed-Methods Systematic Review.

BACKGROUND: The purpose was to synthesize evidence on the association between nature-based Early Childhood Education (ECE) and children's physical activity (PA) and motor competence (MC). METHODS: A literature search of 9 databases was concluded in August 2020. Studies were eligible if (1) children were aged 2-7 years old and attending ECE, (2) ECE settings integrated nature, and (3) assessed physical outcomes. Two reviewers independently screened full-text articles and assessed study quality. Synthesis was conducted using effect direction (quantitative), thematic analysis (qualitative), and combined using a results-based convergent synthesis. RESULTS: 1370 full-text articles were screened and 39 (31 quantitative and 8 qualitative) studies were eligible; 20 quantitative studies assessed PA and 6 assessed MC. Findings indicated inconsistent associations between nature-based ECE and increased moderate to vigorous PA, and improved speed/agility and object control skills. There were positive associations between nature-based ECE and reduced sedentary time and improved balance. From the qualitative analysis, nature-based ECE affords higher intensity PA and risky play, which could improve some MC domains. The quality of 28/31 studies was weak. CONCLUSIONS: More controlled experimental designs that describe the dose and quality of nature are needed to better inform the effectiveness of nature-based ECE on PA and MC.

Nature-based early childhood education for child health, wellbeing and development: a mixed-methods systematic review protocol.

BACKGROUND: Several systematic reviews have reviewed the evidence relating to nature on aspects of children and adolescent's health and wellbeing; however, none have looked at the associations or effectiveness of attending nature-based early childhood education (ECE). The main objective is to systematically review and synthesise the evidence to determine if nature-based ECE enhances children's health, wellbeing and development. METHODS: We will search the following electronic databases (from inception onwards): MEDLINE, Scopus, PsycINFO, ERIC, SportDiscus, Australian Education Index, British Education Index, Child Development and Adolescent studies, and Applied Social Sciences Index and Abstracts. Grey literature will be identified searching dissertations and reports (e.g. Open Grey, Dissertations Theses Database [ProQuest], and Google Scholar). All types of studies (quantitative and qualitative) conducted in children (aged 2-7 years old) attending ECE who had not started education at primary or elementary school will be included. The exposure of interest will be nature-based ECE settings that integrate nature into their philosophy and/or curriculum and environment. The outcomes of interest will be all aspects of the child's physical, cognitive, social and emotional health wellbeing and development. Two reviewers will independently screen full-text articles. The study methodological quality (or bias) will be appraised using appropriate tools. If feasible, a meta-analysis will be conducted using a random-effect model for studies similar in exposure and outcome. Where studies cannot be included in a meta-analysis, findings will be summarised based on the effect directions and a thematic analysis will be conducted for qualitative studies. DISCUSSION: This systematic review will capture the state of the current literature on nature-based ECE for child health, wellbeing and development. The results of this study will be of interest to multiple audiences (including researchers and policy makers). Results will be published in a peer-reviewed journal. Gaps for future research will be identified and discussed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019152582.

An active play intervention to improve physical activity and fundamental movement skills in children of low socio-economic status: feasibility cluster randomised controlled trial.

INTRODUCTION: Active play is a novel approach to addressing low physical activity levels and fundamental movement skills (FMS) in childhood and new interventions must be developed and evaluated. AIM: This study aimed to determine the feasibility of a 10-week school-based 'active play' intervention, and present preliminary findings on four outcomes: physical activity levels, FMS, inhibition, and maths fluency. METHODS: This was a feasibility cluster RCT in which eight schools (one primary three class per school) were paired and randomly allocated to either the 10-week intervention (n = 4) or waiting-list control (n = 4). The active play intervention consisted of a 1-h outdoor physical activity session per week, incorporating 30 min of facilitated games and 30 min of free play. Feasibility measures were gathered using appropriate methods and physical activity was measured using an ActiGraph GT3X accelerometer, FMS were assessed using the Test of Gross Motor Development-2 (TGMD-2), inhibition was measured using a Flanker Test and maths fluency was assessed using the One Minute Basic Number Facts Test. RESULTS: Sixty-six percent of eligible children (n = 137) agreed to participate in the research. No schools withdrew from the study and three participants were lost to follow-up. Compliance to the intervention was high-none of the participants missed more than two of the ten scheduled active play sessions. Data lost to follow-up were minimal; most were lost (14%) for school day physical activity. Active play sessions were shorter than planned on average by 10 min, and participants spent a mean of 39.4% (14.2) of the session time in moderate-to-vigorous intensity physical activity (MVPA). There was preliminary evidence of a small intervention effect on MVPA (d = 0.3), FMS score (d = 0.4), inhibition (fish trial: d = 0.1, arrow trial d = 0.1) and maths fluency (addition: d = 0.3, subtraction: d = 0.1). CONCLUSION: The active play intervention was feasible and benefitted from a relatively high MVPA content; however, preliminary findings suggest the intervention had a small effect on the outcomes. Having more active play sessions per week and/or extending the duration of the intervention may increase the effects and these should be tested before a future definitive cluster RCT is undertaken. TRIAL REGISTRATION: This trial was registered on the International Standardised Randomised Controlled Trials Number register (ISRCTN) in August 2017 (ISRCTN11607781).

Pragmatic evaluation of the Go2Play Active Play intervention on physical activity and fundamental movement skills in children.

Active play is a novel approach to addressing low physical activity levels and fundamental movement skills (FMS) in children. This study aimed to determine if a new school-based, 'Go2Play Active Play' intervention improved school day physical activity and FMS. This was a pragmatic evaluation conducted in Scotland during 2015-16. Participants (n = 172; mean age = 7 years) were recruited from seven primary schools taking part in the 5-month intervention, plus 24 participants not receiving the intervention were recruited to act as a comparison group.189 participants had physical activity measured using an Actigraph GT3X accelerometer at baseline and again at follow-up 5 months later. A sub-sample of participants from the intervention (n = 102) and comparison (n = 21) groups had their FMS assessed using the Test of Gross Motor Development (TGMD-2) at baseline and follow-up. Changes in school day physical activity and FMS variables were examined using repeated measures ANOVA. The main effect was 'group' on 'time' from baseline to follow-up. Results indicated there was a significant interaction for mean counts per minute and percent time in sedentary behavior, light intensity physical activity and moderate to vigorous physical activity (MVPA) (all p < 0.01) for school day physical activity. There was a significant interaction for gross motor quotient (GMQ) score (p = 0.02) and percentile (p = 0.04), locomotor skills score and percentile (both p = 0.02), but no significant interaction for object control skills score (p = 0.1) and percentile (p = 0.3). The Go2Play Active Play intervention may be a promising way of improving physical activity and FMS but this needs to be confirmed in an RCT.

Results From Scotland's 2016 Report Card on Physical Activity for Children and Youth.

BACKGROUND: The 2016 Active Healthy Kids Scotland Report Card aims to improve surveillance of physical activity (PA), facilitate international comparisons, and encourage evidence-informed PA and health policy. METHODS: Active Healthy Kids Canada Report Card methodology was used: a search for data on child and adolescent PA and health published after the 2013 Scottish Report Card was carried out. Data sources were considered for grading if based on representative samples with prevalence estimates made using methods with low bias. Ten health behaviors/outcomes were graded on an A to F scale based on quintiles (prevalence meeting recommendations ≥80% graded A down to <20% graded F). RESULTS: Three of the seven Health Behaviors and Outcomes received F or F- grades: Overall PA, Sedentary Behavior, and Obesity. Active and Outdoor Play and Organized Sport Participation could not be graded. Active Commuting to School was graded C, and Diet was graded D-. Family and Peer Influence was graded D-; Perceived Safety and Availability of Space for PA as well as the National Policy Environment were more favorable (both B). CONCLUSIONS: Grades were identical to those in 2013. Scotland has a generally favorable environment for PA, but children and adolescents have low PA and high sedentary behavior. Gaps in surveillance included lack of objectively measured PA, no surveillance of moderate-to-vigorous PA in children, summary surveillance data not expressed in ways which match recommendations (eg, for PA in young children; for screen-time), and no surveillance of Sport Participation, Active and Outdoor Play, or Sitting. Scottish policy does not include sedentary behavior at present.

Objectively Measured Sedentary Time in Children and Their Parents.

BACKGROUND: No studies have examined associations in objectively measured sedentary time between parents and young people using activPAL posture sensors, which provide a more accurate estimate of sedentary time compared to accelerometer-based devices. This study examines patterns and associations of activPAL measured sedentary time and number of sedentary breaks on weekdays and weekend days in preschool (2-4 yrs), primary (5-11 yrs) and secondary school aged children (12-17 yrs) and their parents. METHODS: 51 parents (16 M, 35 F; mean age 39 (+/-8) yrs) and 51 children (28 M, 23 F; mean age 9 (+/-5) yrs) wore an activPAL monitor for 7 days to measure time spent sedentary and number of breaks in sedentary time. Data was assessed by Pearson's correlations and t-tests. RESULTS: Secondary school children spent a greater percentage of their day sedentary (64.5 (+/-8.5) %) than preschool (57.4 (+/-7.3) %) and primary school children (57.2 (+/-5) %). For the secondary school parent dyad, there were no significant positive associations for time sedentary (r = -0.167, p = 0.494) and percentage of day sedentary (r = -0.247, p = 0.308). For the primary school parent dyad, there were medium, but non-significant positive correlations for time sedentary (r = 0.38, p = 0.146) and percentage of day sedentary (r = 0.363, p = 0.167). For the preschool parent dyad, there were medium-large positive correlations for percentage of waking day sedentary at weekends (r = 0.479, p = 0.083) and number of sedentary breaks (r = 0.648, p = 0.012) at weekends. CONCLUSIONS: There were positive associations in sedentary time between primary school children and their parents, and between preschool children and their parents at the weekend. Thus, interventions aimed at reducing sedentary time of parents and children together, particularly at the weekend for young children, may be effective in these age groups. Secondary school children were more sedentary and had fewer sedentary breaks than younger children, thus interventions should promote breaks in sedentary time as well as reducing total sedentary time in this age group.