A scoping review of physical activity and screen time guidelines for use in Outside School Hours Care

Physical activity (PA) is associated with an array of health benefits across the lifespan, such as improved cardiovascular health, reduced rates of obesity, cancer and other non-communicable diseases [1]. In children aged 5–17 years, specifically, it has been linked with improved body composition, cardiovascular and metabolic health, cardiorespiratory and musculoskeletal fitness, academic achievement and cognition, improved mental health and quality of life, emotional regulation and social behaviour [2]. In addition, excessive recreational screen time has been associated with a wide range of physical and mental health deficits [3, 4]. Since around the 2000s, PA and sedentary behaviour (including recreational screen time) have been viewed as being “independent” health behaviours, with independent health impacts. However, more recently, the field has recognised that daily activities are constrained within the 24-h day, and that more time on one activity must necessarily mean less time for something else, leading to a “whole-of-day” or integrated approach [5]. In keeping with this paradigm shift, the latest iterations of children’s PA guidelines published by the World Health Organization, and various countries including Canada [6], Australia [7], New Zealand [8], South Africa [9], Finland [10] and Croatia [11] recommend that each day children aged 5–17 years should get at least 60 min of moderate- to- vigorous physical activity (MVPA), no more than 2 h of recreational screen time and between 9 and 11 h of sleep for children aged 5–13 years, or 8–10 h of sleep for those aged 14–17 years [12].

Despite these clear and achievable guidelines, the most recent PA global matrix conducted in 2018 identified that that only 40 to 46% of children between the ages of 5 and 17 years in high income countries (such as the United States, Australia, New Zealand, United Kingdom and Spain) were achieving the recommended levels of PA [13]. Low- to middle- income countries and high income countries had similar low PA prevalence of 40–46% and 34–39% respectively [14]. Results are similar for screen time use. The same global matrix identified that in children from high and very high income countries only 27–39% were adhering to the guideline of no more than 2 h recreational screen time use [14]. This was consistent with earlier findings from Atkin in 2014 [15] which found approximately two thirds of children exceeded the screen time guidelines. Given this low prevalence of sufficient PA, and high prevalence of excessive recreational screen time, further efforts are required to identify ways to help children achieve healthy daily MVPA and screen time.

Many of these efforts have been during the school period as way of reaching children in an equitable way [16]. However the school day only contributes less than half the total daily target for children aged 5–17 years; and with increasing academic pressures there is less time available for school based PA interventions [17‐19]. Another period of the day which has the ability to make a substantial contribution to children’s activity patterns is the outside school hours period [18, 20]. This refers to the time before and after school hours, on weekends and school holidays. It has been identified as a potential period to improve PA and combat childhood obesity [19]. A study of Australian children (mean age 8.1 years) found that the after school period (between the hours of 3 – 6 pm) accounted for 30% of children’s total daily MVPA, 25% of their daily light PA and 80% of their total daily recreational screen time [21].

Many primary or elementary school aged children (5–12 years of age) attend formal childcare before and after school, and during school holidays in services referred to as Outside School Hours Care (OSHC) [22]. This is partly due to changing societal trends, including an increasing number of families with two working parents, single parent families, and reduced childcare support from extended families [23]. Recent estimates suggest that, in the United States, 18% of school aged children attend after school programs [24]. In Australia, nearly 10% of primary school aged children (5–12 years) attend before and/or after school childcare services [25]. Given the growing numbers of children who attend these services, providing specific MVPA and screen time recommendations for use in OSHC, may improve practice and positively influence activity behaviours to help children achieve the 24-h guideline recommendations [26].

To our knowledge, no previous studies have attempted to identify guidelines addressing PA and/or screen time in the OSHC setting. Beets et al. [19] conducted a related review which attempted to identify documentation relating to PA promotion for US-based after school program providers. By identifying current standards and policy, Beets and colleagues hoped the review would allow “the compilation of baseline standards and policies that could be tested empirically, with the results of such investigations used to develop national guidelines” p.412 [19]. Their review found 47 states had an after school program policy of which 14 US states had after school program documentation incorporating language about promoting PA. Five of those 14 states specified actual durations of time that children should be active. Beets reported that these were only published in grey literature sources [19].

Given the importance of children’s PA and screen time behaviours in the before and after school periods can have on achieving the 24-h movement guidelines; coupled with the role that guideline documents can play in promoting healthy practice, we set out to review the current state of the international literature regarding guidelines for PA and screen time in the OSHC setting.

This scoping review aimed to determine the published guidelines that exist for PA and/or screen time for OSHC and the methods used to create the guidelines. Specifically, we aimed to answer the following research questions:

The aim of this scoping review was not to assess these guidelines for methodological rigour, but rather understand the content and processes used to create such guidelines.

The protocol for this review was prospectively registered (JBI database, registered 26.3.19 at https://​joannabriggs.​org/​research/​registered_​titles.​aspx). The scoping review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA-ScR) guidelines for scoping reviews [27]. Ethics approval was not required for this review.

To be eligible, the guidelines needed to refer to PA and/or screen time behaviours of primary/elementary school aged children (aged between approximately 5 and 12 years) specifically in OSHC setting. This age range was selected as children aged 13 and over are commonly in high school and do not access OSHC.

The guidelines had to include specific recommendations for PA and/or screen time, in the OSHC setting. The guidelines must have been for use in the OSHC setting (in the hours of the day before and after formal school lessons or school holidays), in a formal childcare setting (as opposed to informal childcare provided by a family member), and published by an authoritative organisation (e.g., Young Men’s Christian Association (YMCA), Government department etc.)

For the purpose of this review, to be considered a guideline, the document was required to have provided specific directives for the volume of PA, in terms of duration, with or without intensity (e.g., that children should achieve at least 30 min of MVPA) during OSHC. Statements that were worded generally (e.g., that children should be given opportunity for active play) were not considered guidelines and therefore not included. It was not required that the guideline provided specific details of the methods used for creation, however this information was also collected where available (e.g., if processes such as GRADE were followed or other guideline development tools).

In accordance with scoping review recommendations [28], any existing literature was considered for inclusion. This included, but was not limited to, quantitative journal articles/pieces of original research, theses, government (either state or national) reports/guidelines and non-government organisation or private sector guidelines published in grey literature also.

There were no exclusion criteria however database searches were only in English. All guidelines, relevant articles or studies, even if no longer currently in use, were considered for the review.

An initial scoping search was undertaken in March 2019 of six databases (MEDLINE, Emcare, Embase, Scopus, ERIC and Sportsdiscus). After this initial search, the key words and subject heading words from the sources identified as appropriate were added to the search strategy and searched across databases (Table 1). This search strategy was created in collaboration with an academic librarian. Reference lists of all included sources were screened for further potentially eligible guidelines.

The search strategy was adapted for use in grey literature (Table 2). The following sources were searched: Google, TROVE, ProQuest Dissertations and Theses, UpToDate, National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN). Grey literature was searched for the first 500 articles. Searches were stopped after 10 irrelevant articles were sequentially identified through the screening process. No geographical limits were placed on Google searches to identify as many international guidelines as possible.

Results from the database and grey literature searches were collated and exported into Covidence software [29] to allow for removal of duplicates and screening.

Two authors (RV and LL) independently screened all results based on title and abstract in Covidence. Disagreements were discussed and resolved without requiring a third author. A flowchart in accordance with PRISMA-ScR [27] was created with reasons for exclusion recorded.

An Excel spreadsheet, as recommended by the Joanna Briggs Institute (JBI) [28], was used to table the data extraction from the included documents, including bibliographic details, document type, source, country of origin, sponsors, aims of guidelines, methods of development and guideline recommendations (Supplementary File 1). Data extraction was completed by the primary author (RV), with any discrepancies/uncertainties referred to a secondary author (LL). Information regarding who created the guidelines (e.g. government agencies, academics, researchers), how much PA and/or screen time is being advocated, what methods were followed to develop the guidelines, and whether/how the guidelines have been disseminated/implemented was also collected.

Due to the descriptive nature of the extracted data, data were synthesised narratively by the primary author (RV) and cross checked by the authorship team.

A total of 274 citations were identified from the database and grey literature searches. 18 duplicates were removed, and 256 title and abstract screening. Of those, 26 were reviewed in full text and nine were included in the final scoping review (Fig. 1). All nine included guidelines were identified through online grey literature sources; none of the guidelines were published in scientific, peer-reviewed sources. Seventeen documents were excluded due to a lack of time-specific guidelines for use in the OSHC setting e.g. only providing guidelines for the whole day rather than specific for OSHC setting or referring to ways to improve PA during the school day in lesson breaks such as recess and lunch.

Of the nine documents included [30‐38], eight originated from the United States and one from Canada. These documents all targeted the after school care period, with only 2 documents also targeting the before school period [30, 31]. Table 3 provides a detailed summary of the included guideline documents and Table 4 the specific PA and/or screen time recommendations from those guideline documents.

The included guideline documents were developed by either a department of education (n = 2), a collaboration between a department of health and private sector/after school network (n = 2), a collaboration between a University centre with government funding; private sector and/or after school sector and/or non for profit e.g. YMCA (n = 4); or a collaboration between a department of health, a university, private sector, afterschool network and families (n = 1).

Eight of the nine included guideline documents used a similar method to create their guidelines. This consisted of a panel of experts including research personnel, industry personnel (e.g. OSHC directors, facilitators) and government authorities. It is clear from five of the guidelines that key stakeholders were also included in the development process in (e.g. The Move More North Carolina [37] guidelines additionally collaborated with parents, administrators, funders and community partners). Funding came from a variety of sources, with three of the guideline documents funded by government departments and five funded through a combination of industry and universities. The Minnesota guidelines [32] did not “create” their own guidelines as such, so did not require funding. Rather, they summarised and collated the current guidelines from the Out of School Nutrition and Physical Activity (OSNAP) [35], Healthy Eating and Physical Activity (HEPA) [34], New York State Healthy Eating and Physical Activity Alliance (NY) [38] and Move More North Carolina guidelines (MMNC) [37]. The methods used to create the Ontario Ministry of Education guidelines [31] are unclear as no details of methods or contact details / corresponding author were provided.

Strengths of this review include that it was prospectively registered, and a search strategy that covered both scientific and grey literature was implemented. In addition, it is a novel scoping review, with the only other review of OSHC guidelines having come from Beets et al. [19]. By contrast that earlier review only assessed local policies and guidelines and did not attempt to gauge an international perspective. There are some limits to the results of this review too. The search strategy used English terminology, and so there may be non-English guidelines that were not identified by our search strategy (though we are not aware of any). Likewise, all guidelines originated from North American jurisdictions, thus their generalizability to other world regions and cultures is unclear.