Summary of the Main Findings
Our study found that a high proportion of Ethiopian children met the WHO guidelines, adding a new insight from a low-income country’s context. Remarkably, over 90% of children met the physical activity and sleep guidelines, while more than half met the sedentary behaviour and combined guidelines. Children who lived in rural areas were more likely to meet the sedentary behaviour, sleep and combined guidelines than those who lived in urban areas. However, the differences between boys and girls in meeting the guidelines were small and not statistically significant.
Adherence to the WHO 24-hour movement behaviours guidelines
A recent review highlighted the evidence gap in 24-hour movement behaviours among preschool children in Sub-Saharan Africa [23]. To the author’s knowledge, no studies were found from Ethiopia to compare with our results. Our results were higher than other studies reported for meeting physical activity [3, 5–10, 13, 14, 16], sleep [3, 7–11, 13, 14, 16] and sedentary behaviour guidelines [3, 4, 6–9, 11, 14, 16, 19]. A possible reason for this might be lifestyle and environmental factors in Ethiopia [36]. Most children usually spent more time outdoors and engaged in unstructured play, which contributes to accumulating more physical activity [37] that may help them to sleep well because they are more physically tired [38–39]. Almost half of Ethiopian children had limited access to screen devices due to lack of electricity in the rural areas, which helped them to meet the sedentary behaviour guidelines. This may prevent or limit screen time before bed which would also support better sleep [40–42]. In contrast, the adherence to the sedentary behaviour guidelines was lower in our study than in the study reported from China (88.2%) [10]. As suggested by Guan et al., (2020), the high levels of adherence to the sedentary behaviour guidelines among Chinese children may have been related to cultural differences. In addition, most Ethiopian parents traditionally count time by observing the position of their shadows based on the Sun’s movement, rather than relying on clocks or watches, which might affect the accuracy of estimates of children's screen duration. This should be considered when interpreting our findings. Our combined adherence to WHO guidelines was higher than other published studies [3–16, 18, 19]. A possible reason is that a higher proportion of Ethiopian children met the physical activity and sleep guidelines. These findings are consistent with earlier studies regarding compliance with physical activity [4, 11, 15, 18, 19], sleep [4–6, 15, 18] and sedentary behaviour guidelines [5, 13, 15].
Our study found that there was no significant difference between boys and girls in meeting the individual and combined WHO guidelines. These findings were consistent with several previous studies [9, 14, 15, 19]. Conversely, our results were in contrast with some evidence reported for combined [21, 43], physical activity [22, 43] and sleep [43]. A possible explanation for the lack of difference between boys and girls in our study relates to the parenting rules [44] and cultural context in Ethiopia where boys and girls are free to play outside equally at preschool age unlike later age.
Associations between meeting the WHO guidelines and socio-demographic factors
We found that children who lived in rural areas were over seven times more likely to meet the sedentary behaviour, sleep and subsequently the combined guidelines than those who lived in urban areas. Our findings related to rural/urban differences in adherence to sedentary behaviour guidelines was consistent with previous studies [9, 14, 15, 20, 22]. However, our finding was different from a study conducted in South Africa, which reported that urban children were more likely to meet the sedentary behaviour guidelines than rural children [9]. Possible reasons could include limited access to screen devices in rural Ethiopia, which could be linked to the lack of availability of electric power in the setting. Our sleep adherence was inconsistent with the two studies conducted in South Africa, which reported no urban-rural difference in meeting the sleep guidelines [9], and higher sleep adherence among urban children than their rural peers [20]. Possible reasons for this contrasting finding might be due to country contexts. Most rural children in Ethiopia have less screen time before bed and spend considerable time active outdoors. These factors may contribute to better sleep quality and duration than in urban children [38, 39]. Our study found that rural children were more likely to meet the combined guidelines than urban children. A possible explanation of this finding is that most rural children complied with the sedentary behaviour and sleep guidelines than urban children with further research needed to confirm differences between rural and urban children in meeting the combined guidelines.
However, our study did not show significant associations between meeting the physical activity guidelines and any socio-demographic factor. This finding differs from studies from Croatia, South Africa and Zimbabwe [9, 15, 22], which showed that rural children were more likely to meet physical activity guidelines than their urban peers. Most Ethiopian children from urban and rural areas met the physical activity guidelines. This may be due to children’s participation in unstructured physical activities both in urban and rural areas. Also, Ethiopia has a low rate of private car ownership, which may encourage children to walk more to catch public transport, such as minibuses or small taxis to reach their destinations. This could help them to accumulate the required physical activity recommendations in both settings.
Recommendations
Our findings contribute to bridging the evidence gap and laying the foundation for future advocacy, research, and surveillance on 24-hour movement behaviours in this age group to ensure healthy childhood development in Ethiopia. Our study suggests that interventions focused on reducing screen time and promoting healthy movement behaviours in urban areas are needed. This study provides the first evidence from a low-income country’s context, conducting the SUNRISE main study [24], which includes a nationally representative sample of 1,000 children, would provide a greater opportunity to determine the population prevalence of guidelines adherence across the regions of Ethiopia.
Strengths and Limitations
The strengths of this study include the use of device-measured physical activity and sleep data, providing quality evidence regarding adherence to the WHO guidelines and how this differed among boys and girls as well as urban and rural settings from a low-income country context. However, this study has some limitations. A convenience sampling was used to select kindergarten or rural kebele, which might limit the generalisability of the findings even if this approach is practical. Accurately estimating children’s screen time proved challenging for most parents, as they do not rely on watches, even if we followed the SUNRISE standardised protocol [24]. Our sedentary screen time finding needs to be interpreted with caution.