A systematic review of determinants of sedentary behaviour in youth: a DEDIPAC-study

The cross-sectional and prospective associations of parental practices and environmental factors with 24-hour movement behaviours among school-aged Asian children

BACKGROUND

Parental practices and neighbourhood environmental factors may influence children's movement behaviours. We aimed to investigate the cross-sectional and prospective associations of parental practices and neighbourhood environmental factors with accelerometer-measured 24-hour movement behaviours (24 h-MBs) among school-aged children in Singapore.

METHODS

The Growing Up in Singapore Towards healthy Outcomes (GUSTO) study collected information on dimensions of parental practices and neighbourhood environment at age 5.5 years. Confirmatory factor analyses were performed to generate latent variables and used to compute overall parental practices [involvement in PA + support for PA + control of screen viewing context] and environmental scores [facilities for active play + active mobility facilitators + barriers*-1]. Children wore an accelerometer on their non-dominant wrist for seven consecutive days at ages 5.5 and 8 years. The R-package GGIR 2.6 was used to derive moderate-to-vigorous-intensity physical activity (MVPA), light-intensity physical activity (LPA), inactivity, and total-sleep (napping+night sleep) minutes per day. Associations were determined using compositional data analysis with multivariate linear regression models, taking into account potential confounders.

RESULTS

Among 425 children (48% girls, 59% Chinese), higher parental involvement in PA, parental support for PA and overall parental practices were associated with 24 h-MBs at ages 5.5 and 8 years, specifically with greater time spent in MVPA and less time being inactive relative to the remaining movement behaviours. The corresponding mean changes in the overall 24 h-MB for increasing parental practices from lowest to highest scores (- 2 to + 2 z-scores) indicated potential increases of up to 15-minutes in MVPA, 20-minutes in LPA, 5-minutes in sleep duration, and a reduction of 40-minutes in inactivity at age 5.5 years. At age 8 years, this could translate to approximately 15-minutes more of MVPA, 20-minutes more of LPA, a 20-minute reduction in sleep duration, and a 20-minute reduction in inactivity. Parental control of screen viewing contexts and neighbourhood environmental factors were not associated with 24 h-MBs.

CONCLUSIONS

Parental practices but not environmental factors were associated with higher MVPA and lower inactivity among Singaporean children, even at a later age. Further research may provide insights that support development of targeted public health strategies to promote healthier movement behaviours among children.

STUDY REGISTRATION

This study was registered on 4th August 2010 and is available online at ClinicalTrials.gov: NCT01174875.

Differences in Physical Activity, Sedentary Behavior, Health-Related Physical Performance Indices and Academic Achievement: A Comparative Study of Normal-Weight and Obese Children in Qatar

Background: The relationship between physical activity (PA), health-related physical performance (PP), and academic achievement (AA) plays an important role in childhood. This study examined the differences in PA, sedentary behavior, health-related PP, maturity status, and AA between normal-weight and obese school children in Qatar. Methods: Eighty schoolchildren were recruited (age: 12.1 ± 0.6 years). Based on age-specific BMI percentiles, the children were classified as normal weight (n = 40) or obese (n = 40). Moore's equations were used to estimate their maturity status (PHV). The measurements encompassed anthropometric data as well as PP tests (medicine ball throw, postural stability, handgrip strength). AA was assessed by reviewing school records for grade point average in Mathematics, Science, and Arabic courses. The total amount of time spent participating in PA each week was calculated using the International Physical Activity Questionnaire Short Form. Results: Handgrip strength was the only parameter that showed a relevant group difference (p < 0.001, ηp2 = 0.15; normal weight: 19.7 ± 3.46 N; obese: 21.7 ± 2.80 N). We found only one moderate correlation between PHV and handgrip strength (r = 0.59). Conclusions: The findings suggest that obesity status alone might not serve as a sufficient predictor of AA in school or PA levels.

Why do people sit? A framework for targeted behavior change

To improve health and wellbeing, it is crucial that people regularly interrupt their sitting. In this paper, we propose a framework for examining and changing sitting behavior that addresses two key steps in the process towards developing effective interventions. First, we suggest that research should move away from its current focus on sitting time, which is an outcome of behavior. Rather, researchers should focus on stand-to-sit and sit-to-stand transitions, which are discrete units of behavior. Second, drawing on goal hierarchy models, we suggest that people rarely engage in stand-to-sit and sit-to-stand transitions for the purpose of being in a sitting or standing position; rather, we suggest that these transitions are means to higher-order goals (e.g., to complete work tasks, to watch television, to eat dinner). To improve adherence to and effectiveness of sitting behavior interventions, intervention designers should aim to increase the frequency of sit-to-stand (and stand-to-sit) transitions. To achieve this aim, intervention designers should capitalize on the higher-order goals that are typically served by these transitions. We suggest four concrete intervention strategies to increase sit-to-stand transitions in congruence with people's everyday goals. We also describe the implications of our framework for theory and methods in sitting behavior research.

Use of screens and intake of unhealthy food among children and adolescents: association with physical activity in a cross-sectional study

BACKGROUND

The intake of unhealthy food taken on very regular basis may bring even further negative impact on health if associated with excessive time using of screen-based electronic devices.

OBJECTIVE

To estimate the association between the use of different types of screen-based devices and the intake of unhealthy foods amongst children and adolescents and to determine whether daily physical activity (DPA) has a moderating effect on the association.

METHODS

Cross-sectional study carried out with a probabilistic sample of students from second to fifth grade of public elementary schools in Feira de Santana, Bahia (n = 2,477; girls: 53.2%; age: 9.1 ± 1.38 years; BMI z-score 0.37 ± 4.19 Kg/m²). Food intake, screen use, and physical activity were assessed using an online questionnaire based on previous day recall (Web-CAAFE). Prevalence Ratios (PR) and 95% Confidence Intervals (95%CI) were estimated via multiple zero-inflated negative binomial regression, with adjustments for sex, age, and weekly frequency of school meal intake. The moderating effect of DPA was verified by inserting interaction terms with each screen-based device individually and with the daily sum of screen-based device exposure (∑ Screens).

RESULTS

The majority of students (72.2%) reported using screens. The intake of unhealthy foods was positively associated with the use of cell phones (PR = 1.21; 95%CI = 1.13-1.30), computers (PR = 1.33; 95%CI = 1.22-1.46), and video games (PR = 1.36; 95%CI = 1.22-1.52). TV use was inversely associated with intake of unhealthy foods (PR = 0.92; 95%CI = 0.87-0.99). DPA moderated the effect of video game use on intake of unhealthy foods, that is, among students with DPA ≥ 4 who used video games, the intake of unhealthy foods was 21% lower (PR = 0.79; 95%CI = 0. 65-0.97). Overall, ∑ Screen-based devices were associated with a 20% increase in intake of unhealthy foods.

CONCLUSION

The intake of unhealthy foods was positively associated with the use of cell phones, computers, and video games. In addition, a frequency of four or more DPA attenuated the effect of video game exposure on intake of unhealthy foods. Upcoming investigations on the use of screen-based devices and the intake of unhealthy foods among schoolchildren should consider the exposure to different types of screen-based devices, as well as the influence of DPA.

Child psychological well-being and adult health behavior and body mass index

OBJECTIVE

Psychological well-being (PWB) is linked with health behaviors among adults, but it is unclear if childhood PWB prospectively predicts healthy adulthood biobehavioral profiles. Such evidence may identify developmental windows for establishing positive health trajectories across the lifespan. Using data spanning 30 years, we investigated whether PWB at age 11 was associated with health behaviors and body mass index (BMI) at ages 33 and 42. We hypothesized children with higher versus lower PWB would engage in healthier behaviors, have lower BMI in adulthood, and be more likely to maintain optimal levels over time.

METHOD

Data were from 4,728 participants of the 1958 National Child Development Study. At age 11, participants wrote an essay about how they imagined their lives at age 25. Two judges rated each essay for multiple facets of PWB, which were combined into a summary score (Cronbach's α = .91). At ages 33 and 42, participants reported on cigarette smoking, physical activity, and diet; BMI was also assessed. Regression models evaluated PWB's association with adult outcomes at each follow-up, and with patterns over time.

RESULTS

Child PWB was unassociated with smoking in adulthood. However, greater child PWB was associated with healthier adult physical activity, diet, and BMI when adjusting for sex. Child PWB was associated with the likelihood of maintaining optimal BMI in adulthood, but not with maintaining healthy behaviors. Some associations were not independent of other childhood covariates.

CONCLUSIONS

Early life lays the foundation for lifelong health. Childhood PWB may contribute to healthier behaviors and BMI in adulthood. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Correlates of Sedentary Time Among Children and Adolescents in Ethiopia: A Cross-Sectional Study

PURPOSE

To assess the correlates of sedentary time among children and adolescents in Ethiopia.

METHODS

The study was conducted in representative samples of children and adolescents in the capital city of Ethiopia, Addis Ababa. Multivariable logistic regression models were used to determine associations of sedentary time and predictor variables.

RESULTS

The mean sedentary time was 4.61 (95% confidence interval [CI], 4.35-4.86) hours per day. Overall, the prevalence of high sedentary time (>3 h/d) was 68.2% (95% CI, 64.2-72.2). Results of multivariable logistic regression analyses showed a statistically significant association between high sedentary time and female household head (adjusted odds ratio [AOR] = 0.50; 95% CI, 0.32-0.80), literate mothers (AOR = 1.98; 95% CI, 1.26-3.11), child attending public school (AOR = 1.79; 95% CI, 1.12-2.85), children who belonged to the poor and rich household wealth tertiles compared with medium wealth tertile (AOR = 2.30; 95% CI, 1.42-3.72 and AOR = 2.04; 95% CI, 1.14-3.65, respectively), and those families that did not have adequate indoor play space for children (AOR = 0.45; 95% CI, 0.29-0.72).

CONCLUSION

The study found that time spent sedentary was high in the study area as compared with other studies of similar settings. Several modifiable factors were identified that can be targeted in interventions to reduce sedentary time in the study setting.

An analytical model for spatial developing of sports places and spaces

Purpose

In terms of the use of sports places and spaces, per capita is a determining parameter for the status and perspective of the future. Although there are many uses for the per capita indicator in sports places, there are no consistent scientific and methodological methods for calculating it. Therefore, this study aims to provide an analytical model to determine the per capita index of sports places and spaces.

Design/methodology/approach

One of the matters that can be considered as the basic information required to develop and construct sports facilities is determination of per capita, which can be used as the most vital information to plan and develop this type of urban utilities. In the history of contemporary urbanization, the use of the per capita concept is one of Reinhard Laumeister’s innovations, a founder of modern urban engineering in Germany, hence, the use of per capita was triggered in 1876, almost 133 years ago.

Findings

The underlying information of the research in two spatial and descriptive sections was analyzed in the geographic information systems (GIS) software. After the division and network distribution of the boundary by the Thiessen Networks analytic function in the Arc GIS, per capita of each polygon was separately calculated using the presented formula and the population of the related blocks

Originality/value

Finally, with the qualitative per capita achieved in the previous stage, the study area was classified based on the need for the development of indoor pools to three, privileged, semi-privileged and deprived spectrums.

The impact of height-adjustable desks and classroom prompts on classroom sitting time, social, and motivational factors among adolescents

PURPOSE

This quasi-experimental study examined the impact of height-adjustable desks in combination with prompts to break up prolonged sitting time during class time and identified social and motivational factors associated with breaking up sitting time among adolescents. Teachers' perceptions of strategies were also examined.

METHODS

Over 17 weeks, 1 classroom in a government secondary school in Melbourne, Australia, was equipped with 27 height-adjustable desks and prompts (posters and desk stickers) to break up classroom sitting time. Teachers received professional development in the use of the desks and prompts. One group of adolescents (n = 55) had 2-5 lessons/week using the height-adjustable desks in an intervention classroom, and a comparison group matched by year level and subject (n = 50) was taught in traditional "seated" classrooms. Adolescents wore an activPAL monitor at baseline (T0), 4 weeks (T1), and 17 weeks (T2) and completed a survey at T0 and T2. Six teachers participated in interviews at T2. Effect sizes were calculated (d).

RESULTS

Linear mixed models found that, compared to the traditional "seated" classrooms, the adolescents in the intervention classroom had significantly lower sitting time (T1: -9.7 min/lesson, d = -0.96; T2: -6.7 min/lesson, d = -0.70) and time spent in sitting bouts >15 min (T2: -11.2 min/lesson, d = -0.62), and had significantly higher standing time (T1: 7.3 min/lesson, d = 0.84; T2: 5.8 min/lesson, d = 0.91), number of breaks from sitting (T1: 1.3 breaks/lesson, d = 0.49; T2: 1.8 breaks/lesson, d = 0.67), and stepping time (T1: 2.5 min/lesson, d = 0.66). Intervention classroom adolescents reported greater habit strength (d = 0.58), self-efficacy for breaking up sitting time (d = 0.75), and indicated that having a teacher/classmate remind them to stand as helpful (d = 0.50).

CONCLUSION

This intervention shows promise for targeting sitting behaviors in the classroom and indicates that incorporating social and motivational strategies may further enhance outcomes.

Within-Person Associations Between Physical and Social Contexts With Movement Behavior Compositions in Adolescents: An Ecological Momentary Assessment Study Using a Compositional Data Analysis Approach

BACKGROUND

External contexts, including the social and physical contexts, are independent predictors of momentary physical activity and sedentary behaviors. However, no studies to date have examined how external contexts are related to overall momentary movement behavior compositions using compositional data analysis. Therefore, this study aimed to determine differences in momentary movement behavior compositions between different social and physical contexts in adolescents.

METHODS

Overall, 119 adolescents (mean age 14.7 y, SD = 1.44) provided details about their momentary physical and social contexts over 4 days using ecological momentary assessment. Sedentary behaviors, light-intensity physical activity, and moderate to vigorous physical activity were assessed using ActiGraph GT3X+ accelerometers. Compositional multivariate multilevel models were estimated to determine if movement behavior compositions differed between contexts.

RESULTS

Participants engaged in significantly less sedentary behaviors when outdoors compared with indoors and replaced it with moderate to vigorous physical activity. Participants also engaged in significantly less sedentary behaviors when with friends or friends and family and replaced it with light-intensity physical activity.

CONCLUSION

These results highlight the potential of targeting external contexts to increase physical activity and to reduce sedentary behavior in adolescents' daily lives. These factors could be targeted in mobile health and just-in-time adaptive interventions to improve young people's movement behavior compositions.

Mediators of Effects on Physical Activity and Sedentary Time in an Activity Tracker and Behavior Change Intervention for Adolescents: Secondary Analysis of a Cluster Randomized Controlled Trial

Background

Adolescence is a critical age where steep declines in physical activity and increases in sedentary time occur. Promoting physical activity should therefore be a priority for short- and long-term health benefits. Wearable activity trackers in combination with supportive resources have the potential to influence adolescents’ physical activity levels and sedentary behavior. Examining the pathways through which such interventions work can inform which mediators to target in future studies.

Objective

The aim of this paper is to examine the impact of the Raising Awareness of Physical Activity (RAW-PA) intervention on potential mediators of behavior change after intervention, and whether these mediated the intervention effects on physical activity and sedentary time at 6-month follow-up.

Methods

RAW-PA was a 12-week intervention, grounded in social cognitive theory and behavioral choice theory, aimed at increasing physical activity among inactive adolescents through combining a wearable activity tracker with digital resources delivered via a private Facebook group (n=159 complete cases). The targeted potential mediators were identified from previous studies conducted in adolescents and included self-efficacy, peer support, family support, teacher support, self-regulation strategies, barriers, and enjoyment. Outcomes included sedentary time as well as light- and moderate-to-vigorous–intensity physical activity. A series of mixed linear models were used to estimate intervention effects on physical activity and sedentary behavior at follow-up and on potential mediators after intervention and to test whether there were indirect effects of the intervention on physical activity and sedentary behavior via mediators.

Results

Adolescents in the intervention group (n=75) engaged in higher sedentary time and lower light intensity at 6-month follow-up compared to the wait-list controls (n=84). There were no intervention effects for moderate-to-vigorous–intensity physical activity. The intervention group perceived more barriers to physical activity than the wait-list control group at 6-month follow-up (mean adjusted difference=1.77; 95% CI 0.19-3.34; P=.03). However, indirect effects for each outcome were not statistically significant, indicating that perceived barriers to physical activity did not mediate intervention effects for physical activity or sedentary time.

Conclusions

RAW-PA did not beneficially impact hypothesized mediators in these inactive adolescents, despite strategies being designed to target them. This suggests that the lack of overall intervention effects on physical activity and sedentary time observed in the RAW-PA study could be due to the limited impact of the intervention on the targeted mediators. Future studies should consider different strategies to target theoretically informed potential mediators and identify intervention strategies that effectively target key mediators to improve physical activity among inactive adolescents. Finally, intervention effects according to level of wearable tracker use or level of engagement with the intervention should be explored. This may provide important insights for designing successful wearable activity tracker interventions.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12616000899448; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370716&isReview=true

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-016-3945-5

The diurnal pattern and social context of screen behaviours in adolescents: a cross-sectional analysis of the Millennium Cohort Study

Background

Screen behaviours are highly prevalent in young people and excessive screen use may pose a risk to physical and mental health. Understanding the timing and social settings in which young people accumulate screen time may help to inform the design of interventions to limit screen use. This study aimed to describe diurnal patterns in adolescents’ screen-based behaviours and examine the association of social context with these behaviours on weekdays and weekend days.

Methods

Time use diary data are from the sixth wave (2015/2016) of the Millennium Cohort Study, conducted when participants were aged 14 years. Outcome variables were electronic games/Apps, TV-viewing, phone calls and emails/texts, visiting social networking sites and internet browsing. Social context was categorised as alone only, parents only, friends only, siblings only, parents and siblings only. Multilevel multivariable logistic regression was used to examine the association between social contexts and screen activities.

Results

Time spent in TV-viewing was greatest in the evening with a peak of 20 min in every hour between 20:00 and 22:00 in both sexes on weekdays/weekend days. Time spent using electronic games/Apps for boys and social network sites for girls was greatest in the afternoon/evening on weekdays and early afternoon/late evening on weekend days. Screen activities were mainly undertaken alone, except for TV-viewing. Compared to being alone, being with family members was associated with (Odds Ratio (95% Confidence Interval)) more time in TV-viewing in both boys and girls throughout the week (Weekdays: Boys, 2.84 (2.59, 3.11); Girls, 2.25 (2.09, 2.43); Weekend days: Boys, 4.40 (4.16, 4.67); Girls, 5.02 (4.77, 5.27)). Being with friends was associated with more time using electronic games on weekend days in both sexes (Boys, 3.31 (3.12, 3.51); Girls, 3.13 (2.67, 3.67)).

Conclusions

Reductions in screen behaviours may be targeted throughout the day but should be sensitive to differing context. Family members, friends, and adolescent themselves may be important target groups in behaviour change interventions. Future research to address the complex interplay between social context, content and quality of screen behaviours will aid the design of behaviour change interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13552-8.

Trends in sedentary behaviour and associated factors among adults in Mongolia: results from national cross-sectional surveys in 2009, 2013 and 2019

OBJECTIVE

The study aimed to evaluate trends in the prevalence and correlates of sedentary behaviour (SB) in people aged 15-64 years from 2009 to 2019 in Mongolia.

DESIGN

Repeat population-based cross-sectional study.

SETTING

Nationally representative sample of persons living in the general community aged 15-64 years in Mongolia.

PARTICIPANTS

The sample included 17 780 people (15-64 years) who participated in Mongolia STEPS surveys 2009, 2013 or 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES SELF-REPORTED

SB, along with physical measurements, health status and health behaviour, and sociodemographic covariates. Multinomial logistic regression calculated OR with 95% CI for moderate and high SB, with low SB as reference category.

RESULTS

Across study years, the proportion of low (<4 hours) SB was 62.3%, moderate (4-<8 hours) SB was 26.4% and high (≥8 hours) SB was 11.3%. Compared to the survey year 2009, in the survey years 2013 and 2019, high SB increased significantly, while moderate SB increased in the survey year 2013 but not in 2019. Urban residence was positively associated with moderate and high SB. Male sex and higher education were positively associated with moderate SB. Current tobacco use, current heavy alcohol use, and obesity class II were positively and high physical activity was negatively associated with moderate and/or high SB. Belonging to the Khalkha ethnic group and hypertension increased the odds of moderate or high SB in 2019 and 2013, respectively. Age, higher number of adults household members and inadequate fruit and vegetable intake were not associated with moderate or high SB.

CONCLUSION

More than 1 in 10 people aged 15 years and older engaged in high SB. Several sociodemographic and health variables associated with moderate and/or high SB were identified that can help guide public interventions.

Health and Academic Performance With Happy Children: A Controlled Longitudinal Study Based on the HOPP Project

Background

Overweight/obesity in children and adolescents, largely arising due to increased food intake and reduced physical activity, is a major health concern. Physical activity (PA) integrated into learning has been shown to not only lead to improved health outcomes and wellbeing but also positively affect academic performance. The Health and Academic Performance with Happy Children (HAPHC) project aims at enhancing health and academic performance in elementary school children via implementation of a daily unit of Physical Activity Across the Curriculum (PAAC), which is carried out within the school setting. In this project, PA as an integrated part of learning will be evaluated and the learning material adapted for a large scale implementation across several European countries.

Methods

In three European countries (Austria, Slovenia, and Belgium), 12 primary schools in total will be recruited to act as either intervention or control school in a large intervention study, which applies the PAAC pedagogy during lectures. It is estimated that, at least 3,000+ children across the three countries will be recruited in this study. All teachers of intervention schools will receive training and materials/teaching equipment that will allow them to integrate a daily PA unit of 45 min over 3 years across the curriculum. In response to the daily PA intervention, the following primary outcomes will be assessed: changes in health related physiological factors, academic achievement, psycho-social aspects and wellbeing.

Impact of Project

The HAPHC project aims at promoting public health by increasing PA at an early age within the school setting and therewith preventing the increasing risk of non-communicable diseases across Europe. HAPHC project aims to develop knowledge and materials, which will ensure that the PAAC can be scalable to other European countries.

Trial Registration Number

ClinicalTrials.gov, identifier: NCT04956003.

Physical Inactivity and Sedentariness: Languorous Behavior Among Adolescents in 80 Countries

PURPOSE

High rates of adolescent physical inactivity and sedentary behavior have been reported worldwide, but the combined prevalence of languorous behavior (physical inactivity and/or sedentary behavior) may more accurately reflect just how few adolescents meet World Health Organization recommendations.

METHODS

We analyzed nationally representative data from 325,219 students in 80 countries that participated in the Global School-based Student Health Survey between 2009 and 2018. Students were classified as physically inactive if they reported engaging in moderate or vigorous physical activity less than 60 minutes daily. Students were classified as being sedentary if they sat for three or more hours per day outside of school, such as when having screen time not related to studying. Statistics for each country were generated using complex samples analysis, then the results from all countries were synthesized.

RESULTS

In total, 84% of students were physically inactive, 37% were sedentary, and 91% met the definition for the concept we are calling languorous behavior.

DISCUSSION

Establishing specific evidence-based guidelines for increasing physical activity and decreasing sitting time will enable progress toward reducing languorous behavior among adolescents.

Prevalence and Associated Factors of Excessive Recreational Screen Time Among Colombian Children and Adolescents

Objectives: Excessive recreational screen time (RST) is associated with detrimental effects for physical, psychological and cognitive development. This article aims to describe the prevalence of excessive RST among Colombian preschoolers, children and adolescents and explore its factors associated.

Methods: We analyzed data from the National Survey of Nutrition 2015. The sample included 4,503 preschoolers, 5,333 school-aged children and 6,623 adolescents. Poisson regression models with robust variance were conducted to estimate prevalence ratios and determine associated factors of excessive RST.

Results: Fifty percent of preschoolers, 61% of school-aged children and 73% of adolescents in Colombia had excessive RST. Positive associations were observed with the availability of TV in the child’s bedroom, the availability of video games at home, and eating while using screens. A negative association with rural area was observed for all age groups.

Conclusion: The majority of Colombian children and adolescents have excessive RST. Younger preschoolers, older school-aged children, wealthiest children and those from urban areas should be targeted by interventions to decrease RST. These interventions should promote limiting the availability of electronic devices in children’s bedrooms and not eating in front of screens.

Time spent in different sedentary activity domains across adolescence: a follow-up study

OBJECTIVE

This longitudinal study aimed to verify possible changes in the time spent in sedentary activities occurring as screen-time, educational, cultural, social, and transportation domains in a sample of Brazilian adolescents between 2015 and 2017.

METHODS

It is a longitudinal prospective study with 586 adolescents from 12 to 15 years old at the Baseline (2015) enrolled in 14 public schools from Curitiba, Brazil. The Adolescent Sedentary Activity Questionnaire assessed the time spent in sedentary activities in five domains (recreational screen-time, educational, cultural, social, and transportation). A series of linear random effects regressions analyzed changes in the sedentary time between 2015 and 2017, with p < .05.

RESULTS

Overall, 323 adolescents dropped out of the study resulting in a retention rate of 44.9%. The overall sedentary time remained stable from 2015 to 2017 (-3.98 min/day, 95%CI: -15.39; 7.42). The screen-time decreased (-22.22 min/day, 95%CI: -30.30; -14.15), and educational (8.29 min/day, 95% CI: 3.52; 13.06), cultural (3.41 min/day, 95% CI: 0.66; 6.15) and social sedentary activities (8.20 min/day, 95% CI: 2.06; 14.34) increased from 2015 to 2017.

CONCLUSION

Significant reductions in screen-time were evidenced along with increases in time spent on other sedentary activities of educational, cultural, and social nature. KeywordsSedentary behavior, Adolescent health, Longitudinal studies.

Associations of the perceived neighborhood environment and screen time in adolescents living in a medium-sized city in Brazil: a cross-sectional study

Individual attributes have been investigated to explain sedentary behavior. However, few studies have evaluated this association at the neighborhood level. This study aimed to determine the association between screen time (ST) among adolescents and perceived neighborhood characteristics. This cross-sectional study was conducted using a multistage household survey in Vespasiano, Brazil, in 2015-2016. Logistic regression analyses were performed to assess the associations between the adolescent self-reported ST (television, computer, and video game > 2 h/day) and neighborhood characteristics (green space, sidewalk maintenance, street lighting, social disorder, safety during the day, and risk of violence) reported by an adult. Four hundred and twenty-three adolescents aged 11-17 participated in the study. ST was reported by 74.0% of the adolescents. After adjustment for confounder variables, neighborhood characteristics did not remain associated with ST. The results evidence no associations between ST among adolescents and perceived neighborhood environment and indicate the need for future studies of this relation.

Identifying risk profiles for excess sedentary behaviour in youth using individual, family and neighbourhood characteristics

There are few known determinants of sedentary behaviour (SB) in children. We generated and compared profiles associated with risk of excess SB among children (n = 294) both at 8-10 and 10-12 years of age (Visits 1 and 2, respectively), using data from the QUebec Adipose and Lifestyle InvesTigation in Youth. Excess SB was measured by accelerometry and defined as >50% of total wear time at <100 counts/minutes. Recursive partitioning analyses were performed with candidate individual-, family-, and neighbourhood-level factors assessed at Visit 1, and distinct groups at varying risk of excess SB were identified for both timepoints. From the ages of 8-10 to 10-12 years, the prevalence of excess SB more than doubled (24.5% to 57.1%). At Visit 1, excess SB was greatest (73%) among children simultaneously not meeting physical activity guidelines, reporting >2 h/day of weekday non-academic screen time, living in low-dwelling density neighbourhoods, having poor park access, and living in neighbourhoods with greater disadvantage. At Visit 2, the high-risk group (70%) was described by children simultaneously not meeting physical activity guidelines, reporting >2 h/day of non-academic screen time on weekends, and living in neighbourhoods with low disadvantage. Risk factors related to individual lifestyle behaviours are generally consistent, and neighbourhood factors generally inconsistent, as children age from late childhood to pre-adolescence. Multiple factors from developmental, behavioural and contextual domains increase risk for excess sedentary behaviour; these warrant consideration to devise effective prevention or management strategies.

Self-reported physical activity and sedentary behaviour amongst adolescents in Sweden vary depending on sex, age and parental education

AIM

The aim of this study was to investigate self-reported physical activity and sedentary behaviour by sex, age and parental education in a large representative sample of Swedish adolescents.

METHODS

This study is based on data from the national dietary survey Riksmaten Adolescents, which was conducted by the Swedish Food Agency in 2016-2017. In total, 3477 students from grade five (11-12 years), eight (14-15 years) and eleven (17-18 years) were included. A web questionnaire was used to collect information about physical activity and sedentary behaviour.

RESULTS

In total, 53% reported active transport to and from school, 93% that they usually participate in the physical education, 76% reported a physically active leisure time, and 66% reported that they participated in organised physical activities. In addition, 12% and 6% reported two hours or less of screen time on weekdays and weekends, respectively. Participation in physical activity was generally lower amongst girls, older adolescents and for those from families with low-parental education.

CONCLUSION

This study provide reference values for self-reported physical activities and sedentary behaviours amongst adolescents in Sweden. Strategies to increase physical activity and reduce screen time are needed, particularly amongst girls, older adolescents and amongst those with low-parental education.

Adolescents' physical activity and sedentary behaviour in Indonesia during the COVID-19 pandemic: a qualitative study of mothers' perspectives

BACKGROUND

Socio-behavioural adaptations during the COVID-19 pandemic may have significantly affected adolescents' lifestyle. This study aimed to explore possible reasons affecting changes in physical activity and sedentary behaviour in Indonesian adolescents during the pandemic based on mothers' perspectives.

METHODS

We recruited parents (n = 20) from the Yogyakarta region of Indonesia (July-August 2020) using purposive and snowball sampling. Individual interviews were audio-recorded, transcribed verbatim and anonymised. Data were imported into NVivo software for a reflexive thematic analysis.

RESULTS

The interviews lasted between 38 and 113 min (M = 65 min). Participants' age ranged between 36 and 54 years (M = 42.6 years). Participants' children ranged in age from 12 to 15 years (M = 13.7 years, female: 9, male: 11). Themes related to changes in physical activity during the pandemic were 1) self-determination and enjoyment, 2) supports from others, and 3) physical activity facilities and equipment. Themes related to changes in sedentary behaviour during the pandemic included 1) educational demands, 2) psychological effects due to the pandemic, 3) devices and internet availability, 4) parental control, and 5) social facilitators.

CONCLUSIONS

During the pandemic, mothers perceived their children to be less active and using more screen-based devices, either for educational or recreational purposes, compared to before. The present themes might be useful when developing interventions and policies promoting physical activity and reducing sedentary behaviour in adolescents. Interventions could, for example, consider increasing parents' and adolescents' awareness on current activity guidelines, providing education on healthier recreational screen time, and involving parents, peers, and teachers. Increasing the accessibility of physical activity facilities and equipment, making use of adolescents' favourite program and social media for interventions, and providing activities that are fun and enjoyable may also important.

Does Kinship vs. Foster Care Better Promote Connectedness? A Systematic Review and Meta-Analysis

Internationally, there is an increasing trend toward placing children in kinship vs. foster care. Prior research suggests that children in kinship care fare better compared to children in foster care; however, the reasons for this remain unclear. We conducted a systematic review and meta-analysis to examine the hypothesis that kinship care better preserves children's connectedness to caregiver, birth family, culture, and community; which, in turn, is associated with more optimal child outcomes. Thirty-one studies were reviewed that compared children aged 0-18 years in kinship care vs. foster care on levels of connectedness, three of which had outcomes that permitted meta-analysis. Findings indicated that children in kinship vs. foster care were more likely to feel connected to family in general; however, there was not a clear advantage for kinship vs. foster care for caregiver, birth parent, cultural, and community connectedness. While levels of connectedness were generally associated with more adaptive child outcomes for children in both kinship and foster care, no reviewed studies examined the hypothesis that children's connectedness may mediate the relationship between placement type and child well-being and placement outcomes. Results are discussed with respect to limitations and policy implications of the current evidence-base and the need for more rigorous research to help identify how to improve child well-being in home-based care.

Meeting 24-h movement guidelines: Prevalence, correlates, and the relationships with overweight and obesity among Chinese children and adolescents

BACKGROUND

Meeting 24-h movement guidelines by children and adolescents has been associated with improved indicators of health, although it has been under-studied in China. Hence, this study aimed to investigate the prevalence of meeting the 24-h movement guidelines, its correlates, and its relationships with body mass index in children and adolescents in China.

METHODS

Cross-sectional data from the 2017 Youth Study in China of 114,072 children and adolescents (mean age = 13.75 years, 49.18% boys) were used. Meeting 24-h movement guidelines (≥60 min of daily moderate-to-vigorous physical activity, ≤2 h of daily leisure screen time, 9-11 h and 8-10 h nightly sleep duration for 6-13-year-olds and 14-17-year-olds, respectively) and height and weight of all participants were assessed. The prevalence of meeting the 24-h movement guidelines and World Health Organization weight status categories were determined. Generalized linear models were used to determine the correlates of meeting the 24-h movement guidelines and the relationships of meeting the 24-h movement guidelines with overweight (OW) and obesity (OB).

RESULTS

Only 5.12% of Chinese children and adolescents met the 24-h movement guidelines, and 22.44% were classified as OW/OB. Older children and adolescents were less likely to meet the 24-h movement guidelines. Parental education level and family income were positively related to meeting the 24-h movement guidelines. Children and adolescents meeting the 24-h movement guidelines showed lower odds ratios for OW/OB. Compared with participants meeting the 24-h movement guidelines, boys in 4th-6th grades met none of the recommendations (OR = 1.22, 95%CI: 1.06-1.40), met the screen time recommendation only (OR = 1.13, 95%CI: 1.01-1.28), met the nightly sleep duration recommendation only (OR = 1.14, 95%CI: 1.03-1.28), and had significantly higher odds ratios for OW/OB. Similar trends were observed for girls in 4th-6th grades: meeting none of the guidelines (OR = 1.35, 95%CI: 1.14-1.59), meeting sleep duration guidelines only (OR = 1.23, 95%CI: 1.08-1.39), and meeting moderate-to-vigorous physical activity + nightly sleep duration guidelines (OR = 1.24, 95%CI: 1.01-1.54). For girls in 7th-9th grades, the following trend was observed: meeting none of the guidelines (OR = 1.30, 95%CI: 1.01-1.67).

CONCLUSION

Very few Chinese children and adolescents met the 24-h movement guidelines. Age (negatively correlated), parental education level, and family income (both positively correlated) were correlates of meeting the 24-h movement guidelines. Children and adolescents meeting the 24-h movement guidelines were more likely to have lower risks for OW/OB, especially in the youngest age group (Grades 4-6); and girls in the middle age group (Grades 7-9) were also more likely to have lower risks for OW/OB. Further research studies should explore additional correlates and determinants for meeting the 24-h movement guidelines. Also, future studies should use longitudinal or interventional designs to determine the relationships between meeting the 24-h movement guidelines and OW/OB and other health indicators, while taking sex and age differences into account.

Adolescents' sedentary time, affect, and contextual factors: An ecological momentary assessment study

BACKGROUND

Few adolescents achieve sufficient levels of physical activity, and many are spending most of their time in sedentary behavior. Affective response following sedentary time may influence motivation to remain sedentary. Ecological Momentary Assessment (EMA) is a real-time data capture methodology that can be used to identify factors influencing sedentary time, such as the context of the home setting, and resulting affective state within a free-living setting. The purpose of this study was to evaluate the relationship between context at home and adolescent sedentary time, and the relationship of sedentary time and subsequent affect.

METHODS

Adolescents (n = 284; 10-16 y) participated in an EMA study that used random, interval-based sampling methods. Adolescents each received 22 unannounced surveys over 7-days through a smartphone application. One survey was randomly sent within each 2-h time-period. These time-periods occurred between 4:00 pm-8:00 pm on weekdays and 8:00 am-8:00 pm on the weekend. This 15-question survey included a series of questions on context (indoors/outdoors, alone/not alone) and positive affect. Adolescents concurrently wore an accelerometer at the hip, and the 30-min bout of accelerometry data prior to each survey was used in analyses. Mixed-effect location scale models were used to examine the association between context at home and sedentary time (stage 1) and the adjusted sedentary time and positive affect (stage 2), with each model adjusted for covariates.

RESULTS

Adolescents were 12.6 ± 1.9 y of age on average, about half were White (58%), and engaged in high levels of sedentary behavior during the 30 min prior to the survey (21.4 ± 6.8 min). Most surveys occurred when adolescents were with others (59%) and indoors (88%). In Stage 1, both being alone and being indoors at home were positively associated with sedentary time (p <  0.001 for both). In Stage 2, adjusted sedentary time was not related to positive affect. Age was negatively related to positive affect (p <  0.001).

CONCLUSIONS

Both contextual factors, being alone and indoors at home, were related to additional time spent sedentary compared to being with someone or outdoors. After adjustment, sedentary time was not related to subsequent positive affect, indicating other factors may be related to adolescent's positive affect in home settings.

Barriers and facilitators to meeting recommended physical activity levels among new immigrant and refugee children in Saskatchewan, Canada

Newcomers are often healthy when they arrive in Canada, yet experience health declines shortly thereafter, possibly due to lifestyle changes. As part of the Healthy Immigrant Children study, this mixed-methods study aims to analyze possible predictors of physical activity among 300 newcomer children, and explore their lived experiences using a sub-sample of 19 parents and 24 service providers. Data collection involved questionnaires concerning socioeconomic status and physical activity, anthropometric measurements, and in-depth interviews. Participants aged 5 years and older largely met physical activity recommendations (82.9%), while none of the 3-4-year-olds did. Males were more active than females, especially among older ages. Many participants engaged in too much screen time (53.4-90.0%). Age and income predicted physical activity among males, while parents' education level was the only significant predictor among females. Barriers to physical activity included: recreational physical activity being an unfamiliar concept, gender limitations, financial resources, safety concerns, and children's preference for screen time. Schools played a central role in newcomer children's health by providing accessible opportunities for physical activity. Newcomer families preferred to have their children involved in culturally relevant physical activities. Given the growing newcomer population, it is important to support active lifestyle practices among them. Novelty: About 83% of newcomer children aged 5 years and older met physical activity recommendations, while none of the 3-4-year-olds did. Age and income predicted males' physical activity, while parents' education level predicted females' physical activity. Schools provide accessible opportunities for newcomer children to engage in physical activity.

Sensor-based physical activity, sedentary time, and reported cell phone screen time: A hierarchy of correlates in youth

BACKGROUND

Evidence on correlates relies on subjective metrics and fails to include correlates across all levels of the ecologic model. We determined which correlates best predict sensor-based physical activity (PA), sedentary time (ST), and self-reported cell phone screen time (CST) in a large sample of youth, while considering a multiplicity of correlates.

METHODS

Using sensor-based accelerometry, we assessed the PA and ST of 2179 youths. A χ² automatic interaction detection algorithm was used to hierarchize the correlates associated with too much ST (> 50th percentile), insufficient moderate-to-vigorous PA (MVPA) (<60 min/day), and prolonged CST (≥2 h/day).

RESULTS

Among youth 10-14 years old, the correlates for being inactive consisted of being a girl, not having sport facilities in the neighborhood, and not perceiving the neighborhood as a safe place, whereas in the youth 15-18 years old, the correlate for being inactive was not performing sports (9.7% chance of being active). The correlates for predicting high ST in the younger group was not performing sports (55.8% chance for high ST), and in the older group, the correlates were not owning a pet, perceiving the neighborhood as safe, and having inactive parents (63.7% chance for high ST). In the younger group, the greatest chances of having high CST were among those who were in the last elementary school years, who were girls, and who did not have friends in the neighborhood (73.1% chance for high CST), whereas in the older group, the greatest chance for having high CST was among those who were girls and had a TV in the bedroom (74.3% chance for high CST).

CONCLUSION

To counteract ST and boost MVPA among youths, a specific focus on girls, the promotion of sport participation and facilities, neighborhood safety, and involvement of family must be prioritized.

Evaluation of the Skeleton Avatar Technique for Assessment of Mobility and Balance Among Older Adults

Background: Mobility and balance is essential for older adults' well-being and independence and the ability to maintain physically active. Early identification of functional impairment may enable early risk-of-fall assessments and preventive measures. There is a need to find new solutions to assess functional ability in easy, efficient, and accurate ways, which can be clinically used frequently and repetitively. Therefore, we need to understand how functional tests and expert assessments (EAs) correlate with new techniques.

Objective: To explore whether the skeleton avatar technique (SAT) can predict the results of functional tests (FTs) of mobility and balance: Timed Up and Go (TUG), the 30-s chair stand test (30sCST), the 4-stage balance test (4SBT), and EA scoring of movement quality.

Methods: Fifty-four older adults (+65 years) were recruited through pensioners' associations. The test procedure contained three standardized FTs: TUG, 30sCST, and 4SBT. The test performances were recorded using a three-dimensional SAT camera. EA scoring was performed based on the video recordings of the 30sCST. Functional ability scores were aggregated from balance and mobility scores. Probability theory-based statistical analyses were used on the data to aggregate sets of individual variables into scores, with correlation analysis used to assess the dependency between variables and between scores. Machine learning techniques were used to assess the appropriateness of easily observable variables/scores as predictors of the other variables included.

Results: The results indicate that SAT data of the fourth 4SBT stage could be used to predict the aggregated results of all stages of 4SBT (with 7.82% mean absolute error), the results of the 30sCST (11.0%), the TUG test (8.03%), and the EA of the sit-to-stand movement (8.79%). There is a moderate (significant) correlation between the 30sCST and the 4SBT (0.31, p = 0.03), but not between the EA and the 30sCST.

Conclusion: SAT can predict the results of the 4SBT, the 30sCST (moderate accuracy), and the TUG test and might add important qualitative information to the assessment of movement performance in active older adults. SAT might in the future provide the means for a simple, easy, and accessible assessment of functional ability among older adults.

Screen-based behaviors in Australian adolescents: Longitudinal trends from a 4-year follow-up study

The longitudinal trends of screen time, a highly prevalent behavior in adolescents, are relatively unknown. This study examined longitudinal trends in screen time among a large sample of Australian primary school-aged children transitioning into secondary school-aged adolescence. Data were derived from the Longitudinal Study of Australian Children (LSAC). In 2010, 2179 children (49.7% boys; 10.3 ± 1.1 years) completed a time-use diary, recording their main activities during waking hours. This was repeated with the same sample in 2012 (12.4 ± 0.5 years) and 2014 (14.4 ± 0.5 years). Data were analyzed for time spent in TV viewing, computer use, electronic gaming, and social networking and online communication. Repeated-measures MANCOVA tests were performed to analyze trends in screen time. Trends were also analyzed by sex. Total screen time significantly increased (+85.9 min/day) over four years (η_p² = 0.010, P < .001), but differed by sex, with a larger increase in boys (boys: +41.6, girls: +22.7 min/day). Electronic gaming increased in boys (+43.2 min/day) and decreased in girls (-16.8 min/day). In contrast, girls reported larger increases in TV viewing (boys: +0.4, girls: +29.1 min/day), computer use (boys: +24.8, girls: +34.3 min/day) and time communicating online and social networking (boys: +4.3, girls: +15.2 min/day). To conclude, screen time among adolescents increases between the ages of 10 and 14 years, but differs by sex and screen time domain. Future screen time reduction interventions may choose to focus on recreational computer use and electronic gaming in boys and TV viewing and time spent communicating online and social networking for girls.

Electronic Devices as Correlates of Sedentary Behavior and Screen Time Among Diverse Low-Income Adolescents During the School Year and Summer Time

Excessive screen time among adolescents increases risk for overweight and obesity. Having electronic devices in the adolescent's bedroom is associated with more screen time. The present study expanded on previous studies by also examining portable personal electronic devices and social media membership as correlates of screen time use and total sedentary time in the school year and summer among diverse low-income adolescents. Adolescents aged 10-17 years were recruited from lower-income areas; n=150 (34 African Americans, 23 American Indians, 16 Asian/Pacific Islanders, 39 Latinos, and 38 White/non-Hispanics) completed surveys and wore accelerometers in both the school year and summer. Total sedentary time was computed from accelerometers. Recreational screen time was assessed with a 3-item validated scale. Adolescents reported the presence of 6 electronic devices in their bedrooms, ownership of 4 portable devices, and social media membership. General linear modeling was conducted for both time periods, with demographic covariates and interactions with sex and race/ethnicity. More electronic devices in bedrooms were related to more screen time during the school year and summer, and to more total sedentary time in summer. Personal electronics were related only to more screen time in the school year. Social media membership was related to more total sedentary time in summer, but only among African Americans, American Indians, and non-Hispanic Whites. Electronic devices in bedrooms was confirmed as a risk factor for sedentary behavior among low-income adolescents of color. Social media membership and use should be further studied with diverse adolescents.

Prevalence and correlates of adherence to the combined movement guidelines among Czech children and adolescents

Background

There are limited studies on the prevalence of adherence to the combined guidelines for physical activity (PA), sedentary behavior, and sleep in children and adolescents. Moreover, little is known about correlates of adherence to the guidelines. Therefore, the main aim of this study is to examine the prevalence and identify the correlates of adherence to the combined movement guidelines among children and adolescents.

Methods

A total of 355 children aged 8–13 years (44% boys) and 324 adolescents aged 14–18 years (43% boys) from the Czech Republic participated in this study. PA and sleep duration were estimated using multi-day 24-h raw data from wrist-worn accelerometers. Recreational screen time was parent proxy-reported in children and self-reported in adolescents. Seventeen potential correlates were grouped into three homogenous categories for biological and cognitive, behavioral, and family correlates. The multi-level multivariable logistic regression was applied to identify correlates of adherence to combined movement guidelines and to specific combinations of any of two recommendations.

Results

Approximately 6.5% of children and 2.2% of adolescents met all recommendations of the combined movement guidelines. In children, girls (OR = 0.4; 95% CI = 0.1–0.9) and participants with overweight or obese fathers (OR = 0.3; 95% CI = 0.1–0.7) had significantly lower odds of adherence to the combined movement guidelines. Additionally, children had higher odds of meeting specific combinations of two recommendations if they reported regular fruit and vegetable intake, participated in organized PA, or if their fathers had a university degree. Meanwhile, paternal overweight and obesity, and high sleep efficiency were associated with lower odds of meeting specific combinations of recommendations. In adolescents, sex, fruit and vegetable intake, organized PA, and active play were correlates of meeting specific combinations of any two recommendations.

Conclusions

A low proportion of children and adolescents met the combined movement guidelines and several correlates related to family were identified. Family is a key source of influence for healthy movement behaviors during childhood and adolescence.

Effectiveness and promising behavior change techniques of interventions targeting energy balance related behaviors in children from lower socioeconomic environments: A systematic review

This systematic review aims to summarize the evidence regarding the effectiveness of interventions targeting energy balance-related behaviors in children from lower socioeconomic environments and the applied behavior change techniques. The literature search was conducted in Cochrane, Embase, Psycinfo and Pubmed. Articles had to be published between January 2000 and September 2019. Studies were included that i) targeted dietary behavior, physical activity and/or sedentary behavior; ii) had a controlled trial design; iii) included children aged 9–12 years old; iv) focused on lower socioeconomic environments; and v) took place in upper-middle or high income countries. Two independent researchers extracted data, identified behavior change techniques using the Behavior Change Technique Taxonomy v1, and performed a methodological quality assessment using the quality assessment tool of the Effective Public Health Practice Project. We included 24 studies, of which one received a high and three a moderate quality rating. Demonstration, practice and providing instructions on how to perform a behavior were the most commonly applied behavior change techniques. Seven studies reported significant beneficial intervention effects: five on physical activity, one on physical activity and sedentary behavior and one on dietary behavior. When comparing effective versus non-effective interventions, and comparing our review to previous reviews focusing on children from the general population, similar behavior change techniques were applied. More high quality research is needed to evaluate the effectiveness of interventions and their behavior change techniques targeting children of low socioeconomic environments.

PROSPERO registration number: CRD42016052599

Gender and education differences in sedentary behaviour in Canada: an analysis of national cross-sectional surveys

Background

Canadians spend the majority of their days sedentary. Gender and education are important social determinants of health that impact health behaviours. There is evidence that gender and educational differences in sedentary behaviour exist. In Canada, while general trends suggest that leisure sedentary activities have changed; there has been no comprehensive assessment examining whether historical changes in sedentary behaviour differ by gender and education level. Our objective was to examine whether gender and educational differences in accelerometer-measured sedentary time and self-reported sedentary behaviours exist among Canadians and if differences are consistent across age groups, over time and across multiple survey sources.

Methods

We summarize amounts of total accelerometer-measured sedentary time and self-reported sedentary activities (e.g., passive travel, television, computer, video games, screen, reading) by age (i.e. children: 6–11 years, youth: 12–17 years, adults: 18–34 years, 45–49 years, 50–64 years, and older adults: ≥ 65 years), gender (girls/women, boys/men) and household education level (< post-secondary vs. ≥ post-secondary) over time in the Canadian Community Health Survey, Canadian Health Measures Survey, General Social Survey, and the Health Behaviour in School-Aged Children study. Gender and education level differences are examined using independent sample t-tests or chi-square analyses.

Results

While few differences were found for total accelerometer-measured sedentary time, gender and education differences in self-reported, type-specific sedentary behaviour were identified. Among youth, data from all surveys consistently identified that boys engaged in more video/computer game play (e.g., boys: 0.35–2.68 vs. girls: 0.09–2.15 h/day), while girls engaged in more leisure reading (e.g., boys: 0.45–0.65 vs. girls: 0.71–0.99 h/day). Those with a higher education or household education often reported more leisure reading and passive travel. Education level differences in screen time were often age dependent, with leisure computer use greater in higher education groups in adults only and leisure television watching generally higher in lower education groups in children and adults, but not youth.

Conclusions

This information is valuable as it helps to identify segments of the population which may be at greater risk for engaging in higher volumes of sedentary behaviour. In turn, this information can identify target audiences and behaviours for policies and interventions. Future work is needed to further understand factors contributing to these differences (e.g., preferences, occupation, family structure).

School- and Leisure Time Factors Are Associated With Sitting Time of German and Irish Children and Adolescents During School: Results of a DEDIPAC Feasibility Study

Objective: The study aims to investigate to what extent school- and leisure time-related factors are associated with sedentary behavior during school in German and Irish children and adolescents. Methods: The study based on a sample of 198 children and adolescents surveyed in 2015. Sedentary and activity behavior were measured using the activPAL physical activity monitor. Information on socio-economic status, school- and leisure-time related factors were provided by questionnaires. Associations between school- and leisure time-related factors and sedentary time during school were estimated using linear multi-level models. Results: Access to play equipment in school was associated with reduced sitting time (hours/day) of children (ß = 0.78; 95%CI = 0.06-1.48). Media devices in bedroom and assessing the neighborhood as activity friendly was associated with increased sitting time of children (ß = 0.92; 95%CI = 0.12-1.72 and ß = 0.30; 95%CI = 0.01-0.60, respectively). The permission to use media devices during breaks was associated with increased sitting time (hours/day) of adolescents (ß = 0.37; 95% CI = 0.06-0.69). A less safe traffic surrounding at school was associated with reduced sitting time of adolescents (ß = -0.42; 95% CI = -0.80 to -0.03). Conclusion: Results suggest that school- and leisure time-related factors are associated to the sedentary behavior during school. We suggest that future strategies to reduce sedentary time should consider both contexts.

Associations between self-efficacy and sedentary behaviour: a meta-analysis

Objective: The study sought to synthesize research on the relationship between time spent engaged in sedentary behaviours (SB) and self-efficacy. Analyses investigated whether such associations are moderated by age, conceptualization of self-efficacy, conceptualization of SB, and/or SB measurement.Design and Main Outcome Measures: The review was registered with PROSPERO (no. CRD42018086899). Studies including associations between self-efficacy and SB were identified through a systematic search of six databases. Inclusion criteria were met by k = 26 original studies.Results: A random effect meta-analysis showed that higher levels of self-efficacy were associated with lower levels of SB (r = -.158, 95% CI [-.220, -.094]). Moderator analyses indicated that associations between self-efficacy and SB may be similar in strength across age groups, the conceptualizations of self-efficacy or SB and SB measurements.Conclusion: The findings provide preliminary guidance for future interventions targeting reduction of SB, although more longitudinal research is needed to draw causal inferences.

Latin American interventions in children and adolescents' sedentary behavior: a systematic review

OBJECTIVE To identify and evaluate the effects of community-based interventions on the sedentary behavior (SB) of Latin American children and adolescents. METHODS A systematic review on community-based trials to reduce and/or control SB in Latin American countries (Prospero: CRD42017072157). Five databases (PubMed, Web of Science, Scopus, SciELO and Lilacs) and a reference lists were searched. RESULTS Ten intervention studies met the eligibility criteria and composed the descriptive synthesis. These studies were conducted in Brazil (n=5), Mexico (n=3), Ecuador (n=1) and Colombia (n=1). Most interventions were implemented in schools (n=8) by educational components, such as meetings, lessons, and seminars, on health-related subjects (n=6). Only two studies adopted specific strategies to reduce/control SB; others focused on increasing physical activity and/or improving diet. Only one study used an accelerometer to measure SB. Seven studies investigated recreational screen time. Eight studies showed statistically significant effects on SB reduction (80%). CONCLUSIONS Latin America community-based interventions reduced children and adolescents' SB. Further studies should: define SB as a primary outcome and implement strategies to reduce such behaviour; focus in different SBs and settings, other than recreational screen time or at-home sitting time; and use objective tools together with questionnaires to measure sedentary behaviour in.

Cross-sectional and longitudinal associations between physical activity, sedentary behaviour and bone stiffness index across weight status in European children and adolescents

Background

The associations between physical activity (PA), sedentary behaviour (SB) and bone health may be differentially affected by weight status during growth. This study aims to assess the cross-sectional and longitudinal associations between PA, SB and bone stiffness index (SI) in European children and adolescents, taking the weight status into consideration.

Methods

Calcaneus SI was first measured by quantitative ultrasound among children aged 2–9 years old in 2007/08. It was measured again after 2 years in the IDEFICS study and after 6 years in the I. Family study. A sample of 2008 participants with time spent at sports clubs, watching TV and playing computer/games self-reported by questionnaire, and a subsample of 1037 participants with SB, light PA (LPA) and moderate-to-vigorous PA (MVPA) objectively measured using Actigraph accelerometers were included in the analyses. Weight status was defined as thin/normal and overweight/obese according to the extended International Obesity Task Force criteria. Linear mixed-effects models were used to estimate the cross-sectional and longitudinal associations between PA, SB and SI percentiles, stratified by weight status.

Results

The cross-sectional association between weekly duration of watching TV and SI percentiles was negative in thin/normal weight group (β = − 0.35, p = 0.008). However, baseline weekly duration of watching TV (β = − 0.63, p = 0.021) and change after 2 years (β = − 0.63, p = 0.022) as well as the change in weekly duration of playing computer/games after 6 years (β = − 0.75, p = 0.019) were inversely associated with corresponding changes in SI percentiles in overweight/obese group. Change in time spent at sports clubs was positively associated with change in SI percentiles after 2 years (β = 1.28, p = 0.001), with comparable effect sizes across weight status. In the subsample with accelerometer data, we found a positive cross-sectional association between MVPA and SI percentiles in thin/normal weight group. Baseline MVPA predicted changes in SI percentiles after 2 and 6 years in all groups.

Conclusions

Our results suggested the beneficial effect of PA on SI. However, the increasing durations of screen-based SB might be risk factors for SI development, especially in overweight/obese children and adolescents.

Determinants of Ageism against Older Adults: A Systematic Review

Ageism is a widespread phenomenon and constitutes a significant threat to older people's well-being. Identifying the factors contributing to ageism is critical to inform policies that minimise its societal impact. In this systematic review, we gathered and summarised empirical studies exploring the key determinants of ageism against older people for a period of over forty years (1970-2017). A comprehensive search using fourteen databases identified all published records related to the umbrella concept of "ageism". Reviewers independently screened the final pool to identify all papers focusing on determinants, according to a predefined list of inclusion and exclusion criteria. All relevant information was extracted and summarised following a narrative synthesis approach. A total of 199 papers were included in this review. We identified a total of 14 determinants as robustly associated with ageism. Of these, 13 have an effect on other-directed ageism, and one on self-directed ageism. The quality of contact with older people and the positive or negative presentation of older people to others emerged as the most robust determinants of other-directed ageism; self-directed ageism is mostly determined by older adults' health status. Given the correlational nature of most studies included in this review, inferences on causality should be made cautiously.

Correlates of sedentary behaviour in Asian adults: A systematic review

The objective of this study is to systematically review the evidence on correlates of sedentary behaviour (SB) among Asian adults. We searched for studies that examined individual, environmental, and political/cultural correlates of total and domain-specific SB (transport, occupation, leisure, and screen time) in Asian adults published from 2000 onwards in nine scientific databases. Two reviewers independently screened identified references. Following quality assessment of included studies, we performed narrative synthesis that considered differences based on SB measurements, regions, and population characteristics (PROSPERO: CRD42018095268). We identified 13 249 papers of which we included 49, from four regions and 12 countries. Researchers conducted cross-sectional analyses and most relied on SB self-report for SB measurement. Of the 118 correlates studied, the following associations were consistent: higher age, living in an urban area (East Asia), and lower mental health with higher total SB; higher education with higher total and occupational SB; higher income with higher leisure-time SB; higher transit density with higher total SB in older East Asians; and being an unmarried women with higher SB in the Middle East. We encourage more research in non-high-income countries across regions, further exploration of important but neglected correlates using longitudinal designs and qualitative research, and the use of objective instruments to collect SB data.

Informing Behaviour Change: What Sedentary Behaviours Do Families Perform at Home and How Can They Be Targeted?

Home-based interventions targeting children's sedentary behaviours have had limited and inconsistent effectiveness, possibly due to a mismatch between the behaviours targeted, the behaviours actually performed, and health-risk messages parents need to initiate change. Between October 2017-February 2018, 540 parents completed an online survey indicating their own and their child's participation in 15 home-based sedentary behaviours (child mean age 11.1 ± 2.61 years, 52% male; parent mean age 40.7 ± 6.14, 93% female). Parents also indicated which home-based sedentary behaviours they and their child could reduce, and what health-risk messages would make them change their child's behaviours. The most prevalent sedentary behaviours among children (particularly older children) and parents were screen-based leisure-time activities, specifically TV/video/DVD use (67.5 and 62.5 min/day, respectively) and using a tablet/smart phone for leisure (53.6 and 80.8 min/day, respectively). Importantly, these were also perceived as the most feasible behaviours parents and children could reduce. Parents reported that the following messages would help them reduce their child's sedentary behaviour: sitting may increase the risk of poor mental health (85.2% of parents) and adversely impact future health as an adult (85.1%). These findings highlight feasible behavioural targets and intervention content for programs aiming to reduce sedentary behaviours in the home environment. Further research is needed to test these strategies.

Correlates of leisure-time sedentary behavior among 181,793 adolescents aged 12-15 years from 66 low- and middle-income countries

BACKGROUND

Sedentary behavior is a growing public health concern in young adolescents from low- and middle-income countries (LMICs). However, a paucity of multinational studies, particularly in LMICs, have investigated correlates of leisure-time sedentary behavior (LTSB) in young adolescents. In the current study, we assessed socio-demographic, socio-economic, socio-cultural and health behavior related correlates of LTSB among adolescents aged 12-15 years who participated in the Global school-based Student Health Survey (GSHS).

METHODS

Self-reported LTSB, which was a composite variable assessing time spent sitting and watching television, playing computer games, talking with friends during a typical day excluding the hours spent sitting at school and doing homework, was analyzed in 181,793 adolescents from 66 LMICs [mean (SD) age 13.8 (1.0) years; 49% girls). Multivariable logistic regression was used to assess the potential LTSB correlates.

RESULTS

The overall prevalence of ≥3 hours/day of LTSB was 26.4% (95%CI = 25.6%-27.2%). Increasing age (OR = 1.14; 95%CI = 1.11-1.17), past 30-day smoking (OR = 1.85; 95%CI = 1.69-2.03), alcohol consumption (OR = 2.01; 95%CI = 1.85-2.18), and bullying victimization (OR = 1.39; 95%CI = 1.31-1.48) were positively associated with increased LTSB across the entire sample of 181,793 adolescents. Food insecurity (OR = 0.93; 95%CI = 0.89-0.97) and low parental support/monitoring (OR = 0.91; 95%CI = 0.85-0.98) were negatively associated with LTSB. There were some variations in the correlates between countries.

CONCLUSIONS

Our data indicate that in adolescents aged 12 to 15 years living in LMICs, LTSB is a complex and multi-dimensional behavior determined by socio-demograhic, sociocultural, socio-economic, and health behavior related factors. Future longitudinal data are required to confirm/refute these findings, and to inform interventions which aim to reduce sedentary levels in adolescents living in LMICs.

Sociodemographic Differences in Young Children Meeting 24-Hour Movement Guidelines

BACKGROUND

Little is known about variation in meeting the 24-Hour Movement Guidelines (including physical activity [PA], sleep, and screen time [ST]) in early childhood. The aim was to evaluate sociodemographic differences in meeting the 24-Hour Movement Guidelines.

METHODS

Parents of 3-4 year old children reported sociodemographic information and ST. Sleep and PA were measured using accelerometry, and height and weight were objectively measured. The 24-Hour Movement Guidelines include daily PA (total PA: ≥3 h; including ≥1 h of moderate to vigorous), sleep (10-13 h), and ST (≤1 h). Meeting guidelines by age, sex, race, poverty level, and weight status were assessed using chi-square and linear regression models.

RESULTS

Of 107 children, 57% were white and 26% lived in households at or below the poverty level. Most children met the PA (91.5%) and sleep (86.9%) guidelines, but few met ST (14.0%) or all 3 (11.3%) guidelines. African American children and children who lived at or below the poverty level were less likely to meet the sleep, ST, and all 3 guidelines compared with others (P < .01 for all). There were no other differences.

CONCLUSION

These results suggest future interventions should focus on reducing differences in movement, namely in sleep and ST.

Determinants of change in accelerometer-assessed sedentary behaviour in children 0 to 6 years of age: A systematic review

Sedentary behaviour tracks from early to middle childhood, suggesting the need to intervene early. The aim of this systematic review was to identify determinants of change in accelerometer-assessed sedentary behaviour in young children, with a view to informing interventions. Ten electronic databases were searched. Longitudinal and intervention studies were included if they (a) targeted sedentary behaviour in young children (less than of equal to 6 years), (b) assessed change in accelerometer-assessed sedentary behaviour, and (c) reported on at least one determinant of change in sedentary behaviour. Intervention components were coded according to clusters of behaviour change technique (BCT) (ie, grouping similar BCTs components). Data synthesis was guided by the socioecological model. Sixteen studies (four longitudinal; 12 intervention) met the inclusion criteria. Two (out of five identified determinants) were associated with an increase in sedentary behaviour in longitudinal studies: the after childcare/school period and transition from childcare to school. Three (out of 21 identified determinants) were associated with a decrease in sedentary behaviour in intervention studies: "goals and planning" (ie, "behavioural contract"), "repetition and substitution" (ie, "graded tasks"), and "reward and treat" (ie, "incentives"). The environmental and interpersonal determinants identified in this review may help to inform behavioural strategies, timing, and settings for future interventions.

Sedentary Behaviors in Today's Youth: Approaches to the Prevention and Management of Childhood Obesity: A Scientific Statement From the American Heart Association

This scientific statement is about sedentary behavior and its relationship to obesity and other cardiometabolic outcomes in youth. A deleterious effect of sedentary behavior on cardiometabolic health is most notable for screen-based behaviors and adiposity; however, this relation is less apparent for other cardiometabolic outcomes or when sedentary time is measured with objective movement counters or position monitors. Increasing trends of screen time are concerning; the portability of screen-based devices and abundant access to unlimited programming and online content may be leading to new patterns of consumption that are exposing youth to multiple pathways harmful to cardiometabolic health. This American Heart Association scientific statement provides an updated perspective on sedentary behaviors specific to modern youth and their impact on cardiometabolic health and obesity. As we reflect on implications for practice, research, and policy, what emerges is the importance of understanding the context in which sedentary behaviors occur. There is also a need to capture the nature of sedentary behavior more accurately, both quantitatively and qualitatively, especially with respect to recreational screen-based devices. Further evidence is required to better inform public health interventions and to establish detailed quantitative guidelines on specific sedentary behaviors in youth. In the meantime, we suggest that televisions and other recreational screen-based devices be removed from bedrooms and absent during meal times. Daily device-free social interactions and outdoor play should be encouraged. In addition, parents/guardians should be supported to devise and enforce appropriate screen time regulations and to model healthy screen-based behaviors.

Examining total and domain-specific sedentary behaviour using the socio-ecological model - a cross-sectional study of Irish adults

BACKGROUND

Sedentary behaviour (SB) has been linked with detrimental effects on morbidity and mortality. This study aims to identify the individual, social and environmental correlates of total sedentary behaviour and the contexts in which sitting time accumulates in an Irish adult cohort.

METHODS

Cross-sectional analysis of data from 7328 adults of the nationally representative Healthy Ireland Survey. Ordinal regression analyses were used to examine participants' socio-demographic characteristics, lifestyle factors, physical and mental health status, perceived neighbourhood environmental factors, and their association with total daily sitting times and sitting times across the domains of occupation, leisure screen-time and transportation/leisure.

RESULTS

Overall median of sitting time per day was 450 min (7.5 h). Male gender, and living in an urban location were associated with increased total-, occupational, and screen-time sitting (p < 0.001). Younger age was associated with increased total and occupational sitting times (p < 0.001), while being older was associated with increased screen-time and transportation/leisure sitting (p < 0.001). Insufficient physical activity levels were associated with increased sitting across all domains (p < 0.001). Higher socio-economic classification and education levels were associated with increased total, occupational, and transportation/leisure SB (p < 0.001), while lower socio-economic classification and education levels were associated with increased screen-time sitting (p < 0.001). Alcohol consumption was associated with screen-time and transportation/leisure sitting (p < 0.01), while smoking was associated with increased screen-time sitting (p < 0.001). Being married was associated with less screen-time (p < 0.001) and transportation/leisure sitting (p = 0.02), while those with a caring role had less total (p = 0.04) and screen-time sitting (p = 0.01). A significant negative association between neighbourhood attributes and total (p = 0.04), and transportation/leisure sitting times (p < 0.001) was found.

CONCLUSION

The results of this study provide a starting position for development of targeted interventions aimed at the most sedentary, such as males with sedentary occupations in higher socio-economic groups and education levels, those with insufficient levels of physical activity and who live in an urban location.

Correlates of sedentary behaviour among adolescents and adults with hazardous, harmful or dependent drinking in South Africa

Background

There is lack of information on the correlates of sedentary behaviour among persons with alcohol use disorders. The study aimed to examine socio-demographic and health correlates among adolescents and adults with hazardous, harmful or probable dependent alcohol use (= problem drinking).

Method

Data from the cross-sectional South African National Health and Nutrition Examination Survey (SANHANES-1) 2011-12 were analysed. From a total sample of 15 085 persons aged 15 years and older, 2849 adolescents and adults (mean age = 37.1 years, standard deviation [s.d.] = 15.1) were identified as problem drinkers, based on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Multivariable logistic and linear regression were used to determine the associations between socio-demographic characteristics, health variables and high sedentary behaviour (≥8 h/day) and total minutes of sedentary behaviour a day.

Results

The prevalence of high sedentary behaviour (≥ 8 h/day) was 11.9% overall (11.9% among men and 12.1% among women), and the mean (s.d.) duration of sedentary behaviour was 263 (169) min/day. In bivariate analysis, older age, population group, functional disability, cognitive impairment, having hypertension, having had a stroke and posttraumatic symptoms were correlated with high sedentary behaviour. In adjusted logistic regression analysis, older age and being Indian or Asian were positively, and having been diagnosed with angina was negatively, associated with high sedentary behaviour. In linear regression analysis, older age, not employed and having had a stroke were positively, and being of mixed race and having angina were negatively, associated with total minutes (up to 960 min/day) of sedentary behaviour in a day.

Conclusion

The study provides socio-demographic and health correlates of sedentary behaviour among problem drinkers. This information can guide possible future interventions in reducing sedentary behaviour among problem drinkers.

Evidence synthesis - Where are children and adults physically active and sedentary? - a rapid review of location-based studies

INTRODUCTION

Geographical positioning systems (GPS) have the capacity to provide further context around where physical activity (PA) and sedentary time (ST) are accrued especially when overlaid onto objectively measured movement. The objective of this rapid review was to summarize evidence from location-based studies which employed the simultaneous use of GPS and objective measures of PA and/or ST.

METHODS

Six databases were searched to identify studies that employed the simultaneous use of GPS and objective measures of PA or ST to quantify location of movement. Risk of bias was assessed, and a qualitative synthesis completed.

RESULTS

Searching identified 3446 articles; 59 were included in the review. A total of 22 studies in children, 17 in youth and 20 in adults were captured. The active transportation environment emerged as an important location for moderate-to-vigorous intensity physical activity (MVPA) in children, youth and adults. In children and youth, the school is an important location for MVPA, especially the schoolyard for children. Indoor locations (e.g., schools, homes) appear to be greater sources of lighter intensities of PA and ST. The review was limited by a lack of standardization in the nomenclature used to describe the locations and methods, as well as measures of variance.

CONCLUSION

Evidence suggests that the active transportation environment is a potentially important contributor of MVPA across an individual's lifespan. There is a need for future location-based studies to report on locations of all intensity of movement (including minutes and proportion) using a whole-day approach in larger representative samples.

High sedentary time in children is not only due to screen media use: a cross-sectional study

Background

Sedentary behaviour has become a growing public health concern. Currently, it is a common belief that screen time (SCT) is a key factor in high overall sedentary time (ST) and is often used as a primary outcome. However, the evidence is lacking. Therefore, this study investigated the association of objectively assessed total ST with SCT among children. Further, SCT was investigated separately for sedentary level, weight status, gender, and migration background.

Methods

For 198 primary school children (7.1 ± 0.7 years, boys: 43.9%) ST was assessed objectively using a multi-sensor device (Actiheart®; CamNtech, Cambridge, UK). The sample was split into three groups (tertiles) to investigate SCT of children with low, medium and high ST. SCT and socio-demographic parameters, such as migration background, were assessed using a parental questionnaire; anthropometric data was collected at schools.

Results

Absolut SCT did not differ significantly among the three sedentary groups: Daily average of SCT was 83.8 ± 55.0 min (27.4% of ST) for children with high ST, 82.8 ± 50.5 min (39.8% of ST) for children with medium ST, and 77.2 ± 59.4 min (71.3% of ST) for those with low ST. However, relatively the SCT percentage of total ST was significantly higher among children with low ST (p < 0.01). Significantly higher SCT was found in children with migration background (p < 0.01), while underweight children had significantly less SCT (p < 0.05). An association of total SCT and overall ST was found for the whole sample (B = 17.11, [2.75; 31.48], p = 0.02), but did not remain when analysis were separated for the groups, except for normal weight children (B = 15.97, [0.13; 31.81], p = 0.05).

Conclusions

The amount of SCT is the same among high, low and medium sedentary children, and high ST is largely independent of SCT. Therefore, SCT cannot be the key contributor to high ST and should not solely be used for predicting or changing children’s sedentary behaviour. Moreover, children’s weight status to classify activity levels and the role of possible compensation mechanisms should be considered in future research and when trying to intervene on ST.

Trial registration

German Clinical Trials Register (DRKS), DRKS-ID: DRKS00000494 DATE: 25/08/2010.

Validity and reliability of an instrument to measure factors associated with screen time in Brazilian students

This study analyzed the validity and reliability of an instrument with scales measuring factors associated with screen time in adolescents. Two cross-sectional studies included students for analyses of validity and internal consistency (n=1138, 51.5% boys) and test-retest reproducibility (n=194, 56.2% boys). Individual (attitude, self-efficacy and expectations), social (behaviors, rules, beliefs and family support and support of school members) and physical environmental (home and bedroom equipment) factors of screen time were evaluated. All the scales of the instrument met the statistical criteria of the validity of the exploratory factorial analysis (p<0.001). The exploratory factorial analysis indicated five one-dimensional and three two-factor scales (self-efficacy, expectations and familiar behavior), with factorial loads of 0.56 to 0.88. There were significant correlations between the scores of almost all the scales and the reported screen time (p<0.05). Eight of nine scales/subscales showed Cronbach's α value being higher than 0.70, and ICC ranged from 0.63 to 0.83. In conclusion, the instrument presented scales with acceptable validity and reliability and can be used to measure factors associated with screen time in Brazilian students.

Road map towards a harmonized pan-European surveillance of obesity-related lifestyle behaviours and their determinants in children and adolescents

OBJECTIVES

To develop a road map towards a harmonized pan-European surveillance system for children and adolescents.

METHODS

Representatives of five European surveillance systems and the German Health Interview and Examination Survey for Children and Adolescents contributed to the road map through a structured workshop in 2016.

RESULTS

A conceptual framework for this road map was developed with seven action points (APs) guiding the successive cross-country harmonization. First, key indicators of health behaviour and their determinants in children and adolescents will be identified (AP1, 2); short screening instruments will be developed and implemented to assess and monitor key indicators (AP3, 4). In parallel, optional supplementary modules could be implemented to provide objective data (AP5). This would allow mutual calibration and improvement of existing instruments before their progressive replacement by more comparable measurement tools (AP6). The establishment of a competence platform is envisaged for guiding the harmonization process (AP7).

CONCLUSIONS

This approach builds on existing systems, provides comparable key health indicators across European regions, helps to assess temporal trends and-once in place-will facilitate health reporting and monitoring of national and international health targets.