Developing information on physical activity for under-fives is one of the 22 initiatives in the Childhood Obesity Plan, and an important part of the broad population health approach for keeping New Zealand children healthy.
Zero to five is a highly influential age and stage for children. It is when they learn basic fine and gross motor skills through movement, play and other every day experiences. Physical skills such as balance, coordination, eye movement, running, catching, throwing will be developed, enabling children to be physically active throughout their lives.
Active Movement resources contain advice on fundamental movement skills for children under five, but are now over a decade old.
Allen + Clarke completed a scoping project on physical activity for children under five years. The purpose of the project was to:
- review literature on fundamental movement skills/physical activity, sedentary behaviour, screen time and sleep for children under five years from 2003 to 2015
- complete a survey of stakeholders including lead maternity carers, Well Child Tamariki Ora and Early Childhood Education providers, public health units and regional sports trusts to find out what resources they would use, and in what format they would use them (ie, printed or online)
- produce a report to the Ministry with options for updating the current advice, based on the literature review and stakeholder survey. The Ministry asked Allen + Clarke to include information on which option provides the best value for money, affordability, and relevance to key stakeholders and consumers.
The Ministry’s preference in the Report is option three – to develop population health guidelines on physical activity, sedentary behaviour, screen time and sleep, and accompanying resources for parents and people who work with children under five years.
In light of the recent findings in the draft Ending Childhood Obesity Report (ECHO Report) (WHO 2015), it is timely to review the existing Active Movement resources (which are now ten years old) alongside the evidence base. This will help to determine if an update of the existing Active Movement resources is needed and, if so, what the most appropriate way to update the information is.
The Ministry of Health contracted Allen + Clarke to complete a literature review examining the effect of physical activity (PA) and fundamental movement skills (FMS), time spent being sedentary and sleep on a range of health outcomes for children aged under five years (i.e., from birth to four years inclusive). As part of this work, Allen + Clarke also reviewed population health advice on PA, sedentary behaviour and sleep from countries similar to New Zealand, and undertook a survey of New Zealand stakeholders’ views to determine which FMS resources they use (including the Active Movement resources), how they use them, how the Active Movement resources could be improved and what else they need.
This report is informed by three evidence collection approaches: a narrative review of academic research published since 2011, a review of population health advice provided in five comparison countries (Australia, Canada, Ireland, the United Kingdom and the United States of America), and a survey of New Zealand users’ views of the Active Movement resources.
The narrative review of academic research built on evidence presented in earlier systematic reviews undertaken by Timmons et al (2012) and Le Blanc et al (2012). Allen + Clarke reviewed a total of 28 articles exploring 21 unique studies. The findings presented are generally consistent with those found by Timmons et al and Le Blanc et al’s earlier reviews.
A survey of New Zealand-based users’ satisfaction with the Active Movement resources was conducted. The survey explored views on the existing Active Movement resources and preferences for new resources (i.e., type, content/required information, access and format). A total of 225 completed survey responses from a wide range of stakeholders (including early childhood educators, regional sports trusts, health practitioners, parents, and others working with children aged under five years) were received.
Key findings from the academic literature review
Findings are based on the best available evidence. The evidence reviewed was not always from large samples or high quality studies. A total of 28 articles covering 21 unique studies were identified. There is considerable consistency between the evidence base explored by Allen + Clarke and the evidence base covered by previous systematic reviews undertaken by Timmons et al (2012) and Le Blanc et al (2012).
All three health behaviours - physical activity, sedentary behaviour, and sleep habits - appear to be associated with health outcomes although to varying degrees. Taking a holistic approach by developing national recommendations around all three behaviours could be warranted.
Dose-response relationships for all three health behaviours exist, but evidence on the exact nature of this is limited. Such evidence is crucial in determining how much PA, time spent being sedentary and sleep is necessary to promote healthy growth and development in very young children. While evidence is emerging, it is not sufficiently large enough or varied enough to provide definitive recommendations on the frequency, intensity, duration, type and context of PA, sedentary behaviour and sleep, required to achieve optimal health outcomes - at this time.
Adiposity/obesity was the most frequently examined health outcome. Confidence in the conclusions drawn for adiposity is higher compared with conclusions made for other health outcomes because of the depth of evidence available. In addition to adiposity, all three health behaviours appear to be linked with other health outcomes also but the available research is very limited and varies in quality.
Where associations do exist, the strength of associations or changes seen are typically small. A potential reflection of the many factors that can exert an effect on health outcomes (other than PA, sedentary behaviour and sleep). The strength of the relationships/impacts reported may have been underestimated because of study design limitations; however, small changes at an individual level, if applied population wide, could have large public health benefits.
Interventions targeting increased PA or reduced screen time had low success in changing health outcomes. This lack of impact may be reflective of the studies not being sufficiently powered to detect associations or the intervention not intensive or different enough to exert an effect above usual practice control.
Key findings from the review of population health advice from other countries
Australia, Canada, Ireland, the United Kingdom and the USA provide population health advice on PA for children aged under five years. This advice includes information about the amount and type of activity young children should be doing, where and how often (i.e., information about the type, frequency, duration, intensity and context). Most of the studied countries present advice by age (i.e., advice for infants, toddlers and pre-schoolers). One presents advice by developmental stage (i.e., walking or not walking). Regardless, the advice provided is highly consistent across all countries: all children should participate in unstructured play throughout the day. Toddlers and pre-schoolers are encouraged to use movements that involve all of the main muscle groups and to be physically active for at least three hours per day.
Other countries also generally provide advice on time spent being sedentary for children aged under five years. This advice is usually nested within PA guidelines for very young children or presented as a complementary guideline. As with PA, there is a very high degree of consistency (i.e., children aged under two years should have no screen-time, older children should have very restricted screen time). Ireland was the only study country that did not provide advice on time spent being sedentary.
Allen + Clarke’s review did not find national population advice on sleep for very young children although some evidence describing the importance of sleep for development and health outcomes was identified.
Key findings from the survey of Active Movement resource users
The survey results indicate that the Active Movement resources are currently used at least occasionally by 80 percent of survey respondents. They are used to promote fundamental movement skills for children aged under five years, to share ideas and to encourage children to be active. Stakeholders are aware of all of the resources but the brochures have the highest profile of the Active Movement resources. Users find that the individual resources meet their needs and are suitable, easy to use and understand, and that they are easy to access. Respondents identified positive outcomes when using the Active Movement resources including providing ideas about PA and encouraging young children to be active, understanding the importance of PA for young children and improving confidence. The main reason for not using the Active Movement resources is the availability of other similar resources used by respondents. It is not clear from survey responses as to why they prefer to use other PA/FMS resources.