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Guidelines for physical activity and screen-time in the outside school hours childcare setting: a scoping review.

Globally millions of children attend outside school hours care. Children’s activity in this setting is critical to meeting daily physical activity recommendations. Guidelines are evidence-based statements intended to optimise practice. This study aimed to identify guidelines for physical activity and screen time for use in outside school hours care. Methods: Guidelines were identified by systematically searching Medline, Emcare, Embase, Scopus, ERIC, Sportsdiscus, TROVE, ProQuest, UpToDate, NICE, SIGN and Google in accordance with PRISMA-ScR guidelines. Results were screened independently by two reviewers and data synthesized narratively. Results: Nine guideline documents were identified from grey literature only (n = 8 USA, n = 1 Canada). The guidelines focused predominantly on the after school care period (n = 9 vs n = 1 for the before-school period). All had recommendations for physical activity, whilst 7 also had screen time recommendations. The guidelines varied considerably in their physical activity and screen time recommendations, though taken together, they recommended > 30–60 minutes of MVPA and < 60 minutes of recreational screen time per session. All guidelines were developed by expert/stakeholder panels, but none followed rigorous guideline development methods. Limited

has been shown to have adverse health effects and is associated with increases in adiposity, metabolic risk and metabolic syndrome in children and adolescents 4 . A systematic review by de Rezende et al 5 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 achievement 5 .
Clinical and public health guidelines have an important role in providing people with evidence-based information to ensure optimal health outcomes 6 . 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 day 7 . 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% respectively 9 . 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 met 10,11 . 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 levels 12 .
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 families 13 . Recent estimates suggest that, in the United States, 18% of school-aged children attend after school programs 14 . In Australia, nearly 10% of primary school-aged children attend before and/or after school childcare services 15 . 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 setting 11,16,17 . Several studies have also attempted to intervene on children's PA (typically in the after school setting). Mears and Jago's 17 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 screentime specific to OSHC may positively influence and guide practice 18 . 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 al 19 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 networks 19 . 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.

Objectives
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 framework 20 . 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: Knowledge creation (inquiry and synthesis)

1.
What published guidelines currently exist for physical activity and/or screen-time specifically for use in the outside school hours childcare setting (OSHC)?
a. Are they still in use? b.
Are they endorsed or implemented by Government authorities?

2.
What do these guidelines recommend?
a. How much physical activity do they encourage? b.
How much screen-time do they permit?
Knowledge Action (adapt knowledge to local frameworks)

3.
What methodological processes were followed to create these guidelines? Methods: Protocol and Registration: 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 Metaanalysis (PRISMA-ScR) guidelines for scoping reviews 21 . Ethics approval was not required for this review.

Eligibility Criteria
To be eligible, the guidelines needed to refer to physical activity and/or screen-time behaviours of primary/elementary school-aged children (i.e., aged between approximately 4 and 12 years) specifically in OSHC setting.
The guidelines had to include specific recommendations for physical activity and/or screen-time, in the OSHC setting. The guidelines must have been for use in the OSHC setting (i.e., in the hours of the day before and after formal school lessons), in a formal childcare setting (as opposed to informal childcare provided by a family member), and published by an authorative organisation (e.g., YMCA,

Government department etc.)
For the purpose of this review, to be considered a guideline, the document was required to provide specific directives for the volume of physical activity, in terms of duration, with or without intensity (e.g., that children should achieve at least 30 minutes of MVPA). Statements that are 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 provide 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 22 , 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, non-government organisation or private sector guidelines published in grey literature also.
There were no exclusion criteria or language limits. All guidelines, relevant articles or studies, even if no longer currently in use, were considered for the review.

Information Sources
An initial scoping search was undertaken 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 ( Fig. 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 (

Synthesis of results
Due to the descriptive nature of the extracted data, data were synthesised narratively by the primary reviewer (RV) and cross checked by the research team.

Results:
Selection of sources of evidence A total of 269 citations were identified from the database and grey literature searches. Of those, 26 were reviewed in full text and nine were included in the final scoping review (Fig. 3). Seventeen documents were excluded due to a lack of time-specific guidelines for use in the outside school hours care setting e.g. only providing guidelines for the whole day rather than specific for the outside school hours setting or referring to ways to improve physical activity during the school day in lesson breaks such as recess and lunch. All nine included guidelines were identified through online grey literature sources; none of the guidelines were published in scientific, peer-reviewed sources.

Characteristics of included documents
Of the nine documents included, eight originated from the United States and one from Canada. These documents all targeted the after school care period. Table 1 provides a summary of the included guideline documents and Table 2 summarises the specific physical activity and screen-time recommendations from those guideline documents.    • Ensure that digital devices are used for homework, research, or digital learning that is active rather than passive • No television or movies are allowed • Daily total screen-time is limited to: a) 1-to 2-hr. programs-40 min b) 3 hrs. or more-60 min Before-And-After School Programs (Kindergarten to Grade 6) -Policies and Guidelines for School Boards 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) Despite these differences, taken together, the guidelines were fairly consistent in their recommendations for PA between 30 to 60 minutes per session. This seems congruent with daily PA guidelines published by many jurisdictions, which commonly recommend children should accumulate at least 60 minutes of MVPA per day 7 . Given that a large portion of children's discretionary time occurs during the after school period, it seems reasonable to expect that children should achieve half or more of their daily PA whilst they are in this setting.

Synthesis Of Results
Compared with the PA guidelines, the guidelines for screen-time varied more widely in their recommendations. All guidelines allowed use of screens for homework/educational purposes.
Collectively, no more than 60 minutes of recreational screen-time per after school care session was recommended, which, like the PA guidelines, aligns well with daily screen-time recommendations (which state that recreational screen-time should be no more than 2 hours per day) 7 . Two guidelines 24, 28 did not allow any recreational screen-time, whereas the remaining five screen-time guidelines allowed recreational screen-time with restrictions, such as based on duration, content (banning "commercial" television or movies), or bout length. Like PA guidelines, most screen-time guidelines (n = 6) were based on the whole afternoon care session, but some gave varying screentime allowances depending on the session length.
All but one of the guidelines were developed in consultation with an expert panel, typically comprising of representatives from industry (e.g., care staff), government (e.g., Education Department, Health Department), non-government bodies (e.g., YMCA) and academics. Only one guideline clearly stated that parents were involved in the guideline development process 31 . The guideline developers typically reported that they consulted the scientific literature, however none of the guidelines appeared to follow "gold-standard" methodologies for guideline development, such as the Grading for  35 . In recent years, there has been an increased focus on these methodologies and tools, which are believed to improve the quality of ensuing guidelines, and to assist in their implementation 33 . Such methodologies have quickly gained traction in clinical and health services contexts; however, they are yet to be widely adopted in public health/education, which may explain why these methodologies were not applied for the development of the guidelines identified in this review.

Strengths And Limitations
This review has several methodological strengths. The protocol was prospectively registered, and an extensive search strategy was used, covering both scientific and grey literature. Our review is the first of its kind to identify and compare international guidelines for physical activity and screen-time in out of school care settings. Limitations included that our database searches were restricted to works published in English, thus there may be non-English guidelines that were not identified by our search strategy (though we are not aware of any

Ethics approval and consent to participate
Not applicable

Consent for publication
Not applicable

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
This research was not supported by any funding.   PRISMAScRFillableChecklistBMCPediatrics.docx