Rationale
Moderate-to vigorous-intensity physical activity (MVPA) in children is associated with many health-related benefits, including improved aerobic fitness, cognitive abilities and self-confidence, with reduced rates of cardiovascular risk factors and depression1. Evidence suggests that children who participate in regular physical activity in childhood are more likely to remain active into adulthood, thus reducing the risk of non-communicable diseases such as stroke, heart disease, diabetes, cancer and chronic lung disease2, 3. Excessive sedentary behaviour, particularly recreational screen-time, has been shown to have adverse health effects and is associated with increases in adiposity, metabolic risk and metabolic syndrome in children and adolescents4. A systematic review by de Rezende et al5 investigated associations between sedentary behaviour and health outcomes and found that for children and adolescents, there was moderate evidence of a negative association of television viewing and screen-time for blood pressure, total cholesterol, obesity, self-esteem, social behaviour, physical fitness and academic achievement5.
Clinical and public health guidelines have an important role in providing people with evidence-based information to ensure optimal health outcomes6. The current WHO guidelines for children aged 5 to 17 years recommend that children achieve at least 60 minutes of MVPA and no more than 2 hours of recreational screen-time every day7. Despite the existence of and efforts to implement these guidelines, most children do not meet them. The most recent Global Matrix 3.0 investigating the physical activity and sedentary behaviours of children, found that only 40 to 46% of children between the ages of 5 and 17 years in very high income countries (such as the United States, Australia, New Zealand, United Kingdom, Spain) were achieving the recommended levels of physical activity (PA)8. Low to middle income countries and high income countries had similar low rates of PA at 40–46% and 34–39% respectively9. Given these low rates of PA, further efforts are required to identify ways to help children achieve more daily MVPA and limit their screen-time.
Typically, PA interventions for children have been delivered in the school setting, as a way of reaching many children in an equitable way. However, another important time in children’s daily schedules is the outside school hours period, the segments of the day before and after formal school lessons during the school week (typically Monday to Friday before school hours 7.30am-9.30am and after school hours 3:00 pm to 6:00 pm). These time periods have received relatively little attention for interventions, though they are recognised as having an important contribution to children’s overall daily physical activity and screen-time levels, and whether activity guidelines are met10, 11. A study of Australian children (mean age 8.1 years) found that 54% of the after school period (3–6 pm) is spent in sedentary behaviours which accounts for 21% of their total daily sedentary levels. Boys spent more time in MVPA than girls (14.9% vs 13.6% respectively) which only contributed 27.6% (boys) and 29.8% (girls) to their daily levels12.
The number of school-aged children attending before and after school childcare is increasing globally, due to changing societal trends, including an increasing number of families with two working parents, single parent families, and reduced childcare support from extended families13. Recent estimates suggest that, in the United States, 18% of school-aged children attend after school programs14. In Australia, nearly 10% of primary school-aged children attend before and/or after school childcare services15. Given the growing numbers of children who attend these services and the lack of PA that takes place in this setting, an opportunity exists to positively influence activity behaviours.
To date, relatively little research has focused on children’s physical activity and screen-time behaviours in before and after school childcare programs. A handful of studies have attempted to describe children’s physical activity and/or screen-time in Outside School Hours Care (OSHC). These studies have typically reported children achieve between 8 to 24 minutes of MVPA in this setting11,16,17. Several studies have also attempted to intervene on children’s PA (typically in the after school setting). Mears and Jago’s17 review of 6 intervention studies found evidence for efficacy was mixed. Thus far, it appears that intervention studies have been geographically localised, and not disseminated on a large scale.
Efforts to understand, and intervene on, children’s activity patterns in OSHC, to date, have been fragmented and lacking cohesion. It is possible that having guidelines for physical activity and screen-time specific to OSHC may positively influence and guide practice18. Currently, guidelines for OSHC are not widely available or endorsed. We are aware that some jurisdictions around the world have published physical activity and/or screen-time guidelines for this setting, typically in grey literature sources. It is unclear whether the existing guidelines have followed evidence-based methodologies during their development.
Beets et al19 conducted a review of the literature to determine state-level after school provider documentation to identify standards/policies for promoting physical activity in the after school care setting. This review was conducted in the United States and identified that of the 47 out of 52 states with an after school program policy, 14 included language incorporating physical activity, and five of these specified actual times that children should be active. This review included only grey literature and identified documents from registries of state after school networks19. The authors of the review chose two organisations to review based on them being recognised as “national leaders in the advocacy of policies and standards to provide quality afterschool programs for all school-age youth”19. Whilst their review was the first of its kind, its scope was limited to the United States and to the two “recognised organisations”. In the nearly 10 years since this prior review was published, there has been increasing attention and research focussing on activity behaviours in this setting, as well as improved quality processes within programs (for example, the National After School Association of America released Healthy Eating and Physical Activity Standards in 2011 and an update in 2018).
Given the importance of children’s activity behaviours in this setting and the lack of recent evidence of guidelines and development in the field of after school care research, an updated scoping review of the literature was warranted.
This scoping review aimed to determine the published guidelines that exist for physical activity and/or sedentary behaviour for the outside school hours care setting and the methods used to create the guidelines, internationally. This scoping review was considered on the basis of a knowledge to action framework20. This provides a conceptual framework from which to consider the processes for knowledge creation and the integration into knowledge application. It is made up of two distinct components: knowledge creation and knowledge action which funnel and cycle between one another to provide a broad range of solutions for various stakeholders including health professionals, patients, policymakers, the public and government to help with the implementation of knowledge into action. Specifically, the following research questions were addressed under the framework: