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Canadian 24-hour movement guidelines for the early years (0–4 years): exploring the perceptions of stakeholders… Riazi, Negin; Ramanathan, Subha; O’Neill, Meghan; Tremblay, Mark S; Faulkner, Guy Nov 20, 2017

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RESEARCH Open AccessCanadian 24-hour movement guidelines forthe early years (0–4 years): exploring theperceptions of stakeholders and end usersregarding their acceptability, barriers touptake, and disseminationNegin Riazi1, Subha Ramanathan1, Meghan O’Neill1, Mark S. Tremblay2 and Guy Faulkner1*AbstractBackground: It is important to engage stakeholders and end users in the development of guidelines forknowledge translation purposes. The aim of this study was to examine stakeholders’ (experts in pediatric and familymedicine, physical activity knowledge translation, and research) and end users’ (parents and early childhoodeducators) perceptions of the Canadian 24-Hour Movement Guidelines for the Early Years (0–4 years).Methods: Stakeholders (n = 10) engaged in telephone interviews and end users (n = 92) participated in focus groups(n = 14) to discuss perceived clarity and need for the guidelines, potential barriers to implementation, identification ofcredible messengers, and methods for dissemination of the guidelines. A thematic analysis was conducted.Results: The proposed guidelines were very well received by both stakeholders and end users. A clear need for suchguidelines was identified, and most believed the guidelines were achievable. Stakeholders and end users identifiedseveral potential barriers to uptake, including low awareness of current guidelines; ‘daily challenges’ such as allure ofscreen time, lack of time, and competing priorities; and challenges in the context of shifting social norms. A range ofmethods and messengers of dissemination were identified. Medical and child care settings were the most frequentlycited places for dissemination, and physicians and early childhood educators were the most common suggestionsfor messengers.Conclusions: There was consistent support for the Canadian 24-Hour Movement Guidelines for the Early Years(0–4 years) from both stakeholders and end users. Moving forward, it is important to dedicate appropriatesupport and funding toward dissemination efforts in order to reach end users, particularly parents and earlychildhood educators.Keywords: Guidelines, Early years, Infants, Toddlers, Preschoolers, Physical activity, Sedentary behaviour,Screen time, Sleep, Public health* Correspondence: guy.faulkner@ubc.ca1School of Kinesiology, University of British Columbia, 2146 Health SciencesMall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.The Author(s) BMC Public Health 2017, 17(Suppl 5):841DOI 10.1186/s12889-017-4853-zBackgroundAccording to the World Health Organization, physicalinactivity in children has become a global epidemio-logical concern [1]. In Canada, data collected using ac-celerometers in the Canadian Health Measures Surveyshow that only 8% of 5- to 17-year-olds accumulate atleast 60 min of moderate to vigorous physical activity[2]. The same World Health Organization report esti-mated that in 2016, 41 million children under the age of5 years were considered overweight [1]. Physical inactiv-ity combined with tripling obesity rates over the pastthree decades (from 5% to 15%) [3] and shifting socialnorms toward more sedentary activities raise concernfor children’s health and well-being. Even society’s youn-gest generation (0–4 years) faces challenges with in-creasing rates of obesity and engagement in sedentaryactivities [4].The early years (0–4 years) are a critical period forgrowth and development for infants, toddlers, and pre-schoolers. Although the benefits of physical activity forschool-aged children have been well established [5],there has been less focus on the 0–4 age range. As de-scribed in this special issue, accumulating research dem-onstrates a positive relationship between higher levels ofphysical activity and positive health outcomes [6]. Thereis also increasing evidence to show the importance ofminimizing screen time in the early years [7], gettinggood-quality sleep in these years [8], and showing howphysical activity, sedentary behaviour, and sleep interactto produce optimal health benefits [9].As toddlers and preschoolers transition into childhoodand adolescence, physical activity tends to decrease [10]while sedentary behaviours, such as watching television,are introduced into the daily schedule [11]. It is there-fore important to help children develop healthy lifestylehabits early on, and promoting a physically active life-style at an early age may help children carry thesehealthy habits into adulthood [12]. A preliminary step tocombatting the complex issues of physical inactivity andincreasing sedentary behaviours is the development ofguidelines. These provide evidence-based recommenda-tions and standards that have the potential to contributesignificantly to overall health, and can also be used forsurveillance purposes [13]. Engaging stakeholders andend users is a crucial step, as this can help to ensure ef-fective knowledge translation [14], determine if guide-lines are relevant to the stakeholders’ and end users’needs [15], and identify strategies for effectively commu-nicating the guidelines [16].Limited research has examined perceptions of physicalactivity and sedentary behaviour guidelines for children’searly years. In the United Kingdom, in-depth interviewswere conducted with mothers of preschoolers to exam-ine their attitudes toward the UK physical activity andsedentary guidelines for the early years [17]. The resultsdemonstrated a low awareness of the guidelines amongthe majority of mothers. Although participants felt theguidelines were appropriate for the general population,some mothers felt the guidelines were unnecessary;they believed their children were already meeting thephysical activity and sedentary behaviour recommenda-tions. Additionally, some participants raised concernsthat the guidelines could place undue pressure or stresson mothers if they could not provide additional phys-ical activity opportunities for their children due to timeconstraints [16].In Canada, parents of children who were youngerthan 4 years and were enrolled in child care were in-vited to participate in semi-structured focus groups toexamine parental perceptions of the new CanadianSedentary Behaviour Guidelines for the Early Years[18]. Overall, there was support for the content of theguidelines and participants found the information clearand helpful. However, there were concerns that theguidelines ‘lumped’ together all sedentary activities (in-cluding activities like colouring and reading) as ‘bad’.Previous research also suggests that the guidelinescould be a source of guilt among parents, in light of de-manding family obligations, the omnipresence ofscreens, and cold weather conditions [17]. Overall thesestudies suggest that although parents support and valuethe development of guidelines for physical activity andsedentary behaviour for their children’s early years,meeting the recommendations in their totality may bechallenging.In June 2016, the first 24-Hour Movement Guidelinesfor Children and Youth (5–17 years) were released inCanada [19]. These novel guidelines encompassed threemovement behaviours: physical activity (light, moderate,and vigorous); sleep; and sedentary behaviours within a24-h period. In response to the development of theseguidelines, Faulkner et al. [20] conducted a study exam-ining stakeholders’ perceptions of the 24-HourMovement Guidelines for Children and Youth throughsemi-structured focus groups with 104 stakeholders in-cluding parents, teachers, exercise professionals, paedia-tricians, and youth. Overall, there was consistentsupport across stakeholder groups for the guidelines,with the exception of youth participants, who did notconsider their future health as immediately relevant.Stakeholders identified a range of barriers to the uptakeof the guidelines including concerns with accurately de-fining key terms such as ‘recreational’ screen time; every-day financial and time constraints; and the possibility ofthe guidelines becoming another source of stress andguilt for busy and overwhelmed parents. This notion ofparental ‘guilt’ is a recurring theme within studies exam-ining perceptions of national guidelines.The Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 134 of 215The current study, which was conducted concurrentlywith the development of the Canadian 24-Hour Move-ment Guidelines for the Early Years (0–4 years) [21],was designed to replicate the process described byFaulkner and colleagues [20] and had the following ob-jectives: (1) to explore stakeholder (experts in pediatricand family medicine, physical activity knowledge transla-tion, and child care) and end user (parents and childcare professionals) perceptions of the Movement Guide-lines, and (2) to identify their acceptability, perceivedbarriers to implementation, and recommended methodsand credible messengers of dissemination.MethodsData collection for this study involved two distinctphases. In phase 1, telephone interviews were conductedwith leading stakeholders from a range of relevant fields(e.g., pediatric medicine, knowledge translation, andchild care). In phase 2, focus groups were conductedwith primary end users including parents and practisingearly childhood educators (ECEs).Phase 1: Data collection interviewsKey stakeholders who worked with children 0–4 years ofage were purposefully recruited for their expertise fromthe areas of pediatric and family medicine, early child-hood education, physical activity communication, andearly childhood physical activity research to participatein telephone interviews. Four of the stakeholders weremembers of the research panel who contributed to thecreation of the Canadian 24-Hour Movement Guidelinesfor the Early Years (“Movement Guidelines”), four wererecruited through snowballing techniques, and theremaining two were identified through an online searchfor ECEs representing national and local organizations.Participants were provided with a plain-text draft ofthe Movement Guidelines [21] by email and subse-quently asked in a telephone interview about their firstimpressions of the guidelines, challenges and barriers toimplementing the guidelines, and methods and messen-gers for dissemination. Given that key stakeholders wereselected because of their likelihood to be messengers forthe Movement Guidelines, interviews concentrated ongathering specific dissemination strategies (e.g., Whatare the best ways to communicate the new guidelines toyour particular constituency? How is information sharedwithin your professional network? What resources doyou need as a [interviewee’s job title] in order to provideinformation about the guidelines to parents?). Interviewsranged between 25 and 47 min, and were conductedbetween February and March 2017.Ethics approval was obtained from the University ofBritish Columbia Research Ethics Board. All of the tele-phone interviews were held in English, and wereconducted by one researcher (Ramanathan). Informedconsent was obtained in English at the beginning of theinterview, and all interviews were audio-recorded andtranscribed verbatim.ParticipantsA total of 10 key stakeholders consisting of physicians (1family physician, 2 paediatricians), ECEs in administrativepositions with field experience (2), physical activitycommunicators (1 knowledge exchange, 1 advocacy, 1 edu-cation), and researchers (2) participated in telephone inter-views. In the end, there was representation from BritishColumbia, Alberta, Ontario and Quebec and a nationalorganization. Eight of the ten interviewees were female.Phase 2: Data collection focus groupsFocus groups were chosen for data collection in thisphase as they are useful in identifying shared experiencesand knowledge among participants, helping to stimulatefurther conversation, and identifying contrasting per-spectives on the same topic [22–24]. ECEs, ECE trainees,and parents with children 0–4 years were purposefullyrecruited through existing networks. For example, par-ents were recruited through activity programs at theUniversity of British Columbia and through localcommunity centres. ECEs were recruited throughUniversity of British Columbia Child Care Services,Simon Fraser Child Care Services, local child carecentres in Vancouver, the Early Childhood Educationprogram at the University of British Columbia, and theChildren’s Hospital of Eastern Ontario. Each focus groupwas composed of participants of similar background(e.g., a focus group of all parents or all ECEs). At thebeginning of each focus group, informed consent wasobtained (in either English or French), followed by ashort demographic survey. Ethics approval was obtainedfrom the respective institutional Research Ethics Boardsin Ontario and British Columbia, where focus groupswere held.Semi-structured focus group guides were developed forparents and ECE end users (available from the corre-sponding author on request). At the beginning of eachfocus group, participants were asked about their aware-ness of the current Canadian Physical Activity [25] andSedentary Behaviour [26] guidelines for the early years.Participants were provided with a plain-text printed draftof the Movement Guidelines [21] and the opportunity tofamiliarize themselves with the document. Participantsthen engaged in open-ended discussions about their firstimpressions of the Movement Guidelines, the clarity ofthe guidelines, and the need for an integrated guideline(e.g., Do you find these integrated guidelines helpful ornot helpful?). Participants were also asked to provide feed-back regarding the specific wording of the MovementThe Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 135 of 215Guidelines (data not reported here). They were then in-vited to discuss the compatibility of these guidelines fordaily life and the work environment (e.g., How practicaldo you think these guidelines are for your work?); thechallenges and barriers to implementing the guidelines(e.g., Are there any barriers to implementing these guide-lines?); and the best methods and messengers for dissem-inating these guidelines (e.g., What are the best ways topresent or communicate these guidelines? Who would bethe best individuals to provide information to you aboutthe guidelines?). Probes were used to encourage discussionthroughout the focus groups.Three authors (Faulkner, Riazi, O’Neill) led the focusgroups and interviews in British Columbia, and an add-itional researcher was hired to lead the francophonefocus group in Ontario. Two of these three authors werepresent at each focus group in British Columbia, withone researcher leading the focus group and the otherassisting in taking notes and follow-up questions. A sin-gle researcher led and took notes during the franco-phone focus group in Ontario. All focus groups wereaudio-recorded and transcribed verbatim.ParticipantsA total of 92 end users consisting of parents, ECEs, andECE trainees participated in focus groups. Fourteenfocus groups were conducted with parents (n = 6), ECEs(n = 7) and ECE trainees (n = 1), with the number of par-ticipants per focus group ranging from 3 to 10. Threeparticipants were interviewed due to scheduling conflictsthat prevented them from attending a focus group(representing two additional meetings with end users).Focus groups and interviews were conducted fromMarch to April 2017 in Vancouver and Burnaby (BritishColumbia) and Orléans (Ontario). Focus group meetingsranged from 40 to 95 min.End users consisted of parents (n = 40), ECEs (n = 48),and ECE trainees (n = 4), with the majority of partici-pants (83%) being female. The age of end users rangedfrom 23 to 68 years, with an average age of 39 years.Among parents, the average number of children perhousehold was 1.8. Most participants self-identified asCaucasian (38%) or Chinese (17%). The rest of the par-ticipants represented a diverse mix including Aboriginal,European, South East Indian, Hispanic, African, Portu-guese, Filipino, Brazilian, Korean, Iranian, Egyptian,Greek, and Hungarian. The majority (82%) of end usershad completed a post-secondary education. Participantsreceived a small remuneration for their participation inthe focus group.Analysis of interviews and focus groupsAudio-recordings from the interviews and focus groupswere transcribed verbatim. To maintain confidentiality,participant names were replaced using the following des-ignations: Parent, Early Childhood Educator, Physician,Physical Activity Communicator, and Researcher. Partic-ipants (male =M; female = F) partook in either a focusgroup (FG) or interview (I) conducted in either English(E) or French (F) languages. Therefore, the designationEarly Childhood Educator;M;FG;E would refer to a maleEarly Childhood Educator who participated in an Englishfocus group.We replicated the analytic process described byFaulkner et al. [20]. Analysis of the transcribed docu-ments followed an established protocol for thematicanalysis [27]. QSR International’s NVivo 11 Softwarewas used to facilitate qualitative data analysis. The tran-scripts were read line by line, and inductively coded foranalysis. Using constant comparison, each coded pieceof data was taken and compared to ones preceding it andthen categorized into themes [28]. Then relationships be-tween these higher-level concepts were determinedthrough analysis and grounded in the data [29]. Thesehigher-level themes form the basis of the results section.A number of criteria were adopted to enhance the“trustworthiness” of this study. First, the focus group andinterview transcripts were coded independently by twoauthors (Riazi and Ramanathan). This analysis independ-ently confirmed the primary outcome themes generated.Second, throughout the analysis process, interpretationswere also shared and discussed within the broaderresearch team to challenge the identified themes and theirconnections in a form of peer debriefing [30].ResultsReceptivity: ‘The whole picture’There was consistent support for the new MovementGuidelines across all stakeholder interviews and end userfocus groups. Participants demonstrated receptivity tothe guidelines regardless of their cultural, educational, orprofessional backgrounds (e.g., parent, ECE, physician,etc.). Across all interviews and focus groups, participantsapplauded the clarity and conciseness of the guidelines.As one stakeholder (Researcher;F;I;E) explained, “Ithought they were fairly clear, concise, and systematic intheir presentation”. Participants liked that the informa-tion was divided based on age (i.e., infants, toddlers, andpreschoolers), making it easier to access. One participant(Physical Activity Communicator;F;I;E) pointed out that“breaking it up into the 3 categories makes it more us-able for people working in this area”. Parents and ECEsagreed that the separation of age made it easier for themto locate the information pertinent to them.Discussion around the utility of the guidelines revealedthat well-received components of the Movement Guide-lines included the provision of specific and concretegoals, the inclusion of sleep and quality sedentaryThe Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 136 of 215activities (e.g., reading, drawing), and the recommenda-tion for replacing indoor with outdoor time. ECEs inparticular appreciated the inclusion of sleep (particularlynaps) in the guidelines because it was an importantcomponent of their child care programs. One ECE (EarlyChildhood Educator;F;FG;E) explained that having aguideline that incorporates sleep helped to support theadvice she gave to parents:I think the actual existence of it when it’s completedwould be really helpful for me because often, parentsask over the years, “How long should my child besleeping?” or “What do you think?” and we giveeducated guesses. To me, it’s helpful to have somethingto refer to or to send parents to.The recommendation for trading indoor for outdoortime was also well received by participants. Some childcare providers reported feeling resistance from parentswhen taking children outside in poor weather condi-tions (e.g., rain), and felt that the Movement Guidelineswould help support dedicated outdoor time within theirprogramming. In addition, the majority of child careproviders felt they were already meeting most of therecommendations for sleep (e.g., naps), physical activ-ity, and minimal screen time as part of their licensingregulations. For parents, the Movement Guidelinesprovided a goal to strive toward within their homes.Additionally, participants liked the integration of thethree movement behaviours (i.e., sleep, physical activity,and sedentary behaviours) in a single guideline. Partici-pants liked the holistic nature of the guidelines, whichencompassed movement behaviours during a 24-hperiod. The integration helped raise awareness that “allthe components are important” (Parent;F:FG;E). Onefather (Parent;M;FG;E) discussed the benefit of follow-ing integrated guidelines:Yeah, if [children are] really physically active, theysleep better; they’re tired at the end of the day. They’remore likely to sleep throughout the night. If they’resedentary, they’re more irritable I suppose. It all playstogether.Similar to other participants, a researcher (Research-er;M;I;E) agreed that a 24-h perspective for the Move-ment Guidelines was useful:My first impression was that it was a good idea to goto the 24-hour movement approach. It makes a lot ofsense from a public health messaging perspective todeliver the messaging in the context of what a healthyday looks like. This is an advantage of the currentguidelines.The majority of stakeholders recognized the relationshipand interplay between the movement behaviours as wellas the importance of the individual behaviours. Many alsowanted and expressed a need for such guidelines. For ex-ample, researchers felt that they could use the MovementGuidelines as measurable targets in their studies, andphysical activity communicators felt that the recommen-dations would enhance the structure and add a level of in-tegrity to their workshops. The guidelines provided anevidence-based resource for stakeholders in medicine andearly childhood education, while also providing parentswith a set of recommendations to work toward.Barriers to uptakeWhile participants showed receptivity toward the pro-posed Movement Guidelines, barriers were discussed inregard to the uptake of the guidelines. Three themes wereidentified that encompassed potential barriers to adoptionof the guidelines. These were: a lack of information aboutthe guidelines; ‘daily challenges’ such as the attraction ofscreen time, lack of time, and competing priorities; andthe challenging nature of current social norms.What guidelines? Lack of awareness among parents andeducatorsAwareness of the existing guidelines for physical activityand sedentary behaviour was low among focus groupparticipants. The majority of parents were not aware ofthe physical activity and sedentary behaviour recommen-dations, with only a small portion recalling some infor-mation about sleep recommendations. Some parentsrecalled hearing about sleep recommendations fromtheir child’s physician or hearing physical activity-relatedmessaging for children and youth through television adsand social media. However, the vast majority of focusgroup participants could not remember ever seeing theexisting physical activity and sedentary behaviour guide-lines, and often were not aware of where to access them.As one stakeholder (Researcher/Parent;F;I:E) explained:I’ve been doing work trying to increase educationaround movement in child care centres. I’ve realizedover the last 5 years or so that a lot of child care staffaren’t currently aware of our present physical activityguidelines for the early years.Although child care providers self-reported meeting themajority of recommendations from the Movement Guide-lines in their work, it was by virtue of licensing require-ments and the philosophy of the child care centre, and notbecause they were aware of them. For example, one earlychildhood educator (Early Childhood Educator;F;FG;E) ex-plained, “Everything, what is written [in the Guidelines],it’s happening right now in my daycare, so this is nothingThe Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 137 of 215new to me”. A future challenge in raising awareness of andimplementing the Movement Guidelines stems from thevariance in policies at child care centres. As one individual(Researcher/Parent;F;I;E) pointed out:Each province has a different requirement aroundoutdoor play and physical activity. If the majority ofour kids are enrolled in these centres, then that willhave a large role in whether the kids are sufficientlymeeting these guidelines.There is also variation among child care providers in re-gard to whether or not they are licensed by the province.For instance, unlicensed (licence-not-required) home childcare providers may care for only two children or a siblinggroup at any one time and do not have requirements formeeting any specific standards for health or safety (e.g., noregulations for screen time) [31]. On the other hand, li-censed child care providers provide care for three or morechildren and must meet specific requirements related tohealth, safety, space, staffing qualifications, and programstandards. Additionally, variation exists amongst types oflicensed child care providers. For instance, some occa-sional child care centres (e.g., provide only part-time oroccasional care) may not have the capacity to provide out-door space for physical activity in comparison to a full-time child care centre [31]. Consistent adoption of theMovement Guidelines will require a focus on policychanges or licensing regulations in child care centres aswell as providing support for implementation.‘Daily challenges’Although participants demonstrated receptivity towardthe new Movement Guidelines, they also identified dailychallenges such as the allure of screen time, lack of time,and competing parental responsibilities. The most com-monly mentioned challenge was screen time – referred toas a “hot button issue” by one parent (Parent;F;FG;E). Al-though most parents felt they were meeting screen timerecommendations during the week, many admitted thatscreen time over the weekend often exceeded the recom-mendation of one hour or less. There was also some con-fusion about what qualified as screen time. Parents tendedto rationalize screen time positively if it was interactive,such as completing a puzzle on a tablet. One father(Parent;M;FG;E) explained:The four-year-old has a lot of iPad time, but it’s allvery much school-based learning. Either a puzzle ormath programs or things like that. As far as time goes,it’s way exceeding it, but we’re trying to at least...it’snot watching TV all day. It’s doing something at leastinteractive to help stimulate cognitive function. That’show I rationalize it.At the same time, the majority of stakeholders and endusers understood the potential detrimental effects of ex-tended periods of screen time for children. Parents andchild care providers discussed the consequences of pro-longed screen time, including children being more leth-argic, less inclined to engage in physical activity, andmore irritable. Parents, however, also discussed the useof screens as a bargaining tool or reward if their childcompleted a certain task (e.g., finishing their dinner) oras a “babysitting device” (Parent;M;FG;E) while theparent was cooking dinner or shopping. One father(Parent;M;FG;E) explained that every day is different:Every day you’re not going to hit it [meet the guidelines].You’re choosing battles. You’re out trying to shop andyour kid is screaming and doesn’t want to stay in theshopping cart. You give them your phone to keep thementertained for 15 minutes while you do whatever.ECEs, on the other hand, stated that they were meetingthe recommendations for screen time and outdoor play.All child care providers explained that their centres hadpolicies that stipulated either minimal or zero screentime for children under their care, as well as dedicatedoutdoor play time regardless of weather. Due to the timechildren spend in child care, these centres represent anideal avenue to help children meet the recommendationsfor screen time and physical activity, at least while chil-dren are in their care.Lack of time and competing responsibilities werecommon challenges among parents who expressedconcern over their children meeting the guidelines.Consequently, a number of participants agreed that theguidelines could be a source of guilt for parents. Theconcern was that the guidelines could become “onemore thing, like one more guideline, or one more 180minutes” for parents to worry about (Early ChildhoodEducator;F;FG;E). Upon reading the proposed Move-ment Guidelines, one parent (Parent;F;FG;E) stated,I remember reading something along the lines of being– like [the guideline for a child] not being restrainedfor more than an hour at a time, and then thinkingabout how like just driving up to Whistler takes likean hour and a half or two hours with the traffic, andthen I think I read this and I think I cried againbecause I was like, “oh, no, she was restrained in thecar seat for two hours! I’m a terrible mother!”However, other parents countered that it was importantto remember that the Movement Guidelines were rec-ommendations only. “I think it’s a good reminder – it’sgoals, right? But you’re not going to reach this everyday” (Parent;F;FG;E). The majority of parents agreed thatThe Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 138 of 215the guidelines were important goals to strive toward, butthat realistically, they might not meet them every daygiven household chores. One mother (Parent;F;FG;F)expressed the need to face “reality”:Say that I have to clean the house, it’s [screen time]sometimes the only way to capture their attention. Itgives them something to watch. […] Yeah, thegovernment should send a housecleaner. Someone toprepare dinner. It’s [screen time] just a way to distractthem, because we have too much on our plate, we workfull-time, we have to clean the house and do chores, ourhouses are becoming bigger now… it’s a lot.Physical activity in the older age groups (toddlers andpreschoolers) raised some concerns among parents whofound 180 min of physical activity including energeticplay to be overwhelming. However, after clarifying thatthe 180 min could be accumulated throughout the day,parents felt that the recommendations were achievable.One stakeholder (Physical Activity Communicator;F;I;E)explained that one needs to make “connections to otherthings so that physical activity is not at the expense ofsomething else. If it is integrated into your healthy, ac-tive day, then it is easier to achieve”. Even when a parentfeels tired, said one stakeholder (Researcher/Parent;-F;I;E), it is important to incorporate physical activity indaily life without it feeling like an ‘add-on’:Recognition and education around how activities can beembedded within a day is important. It doesn’t have tobe a set 60 minutes for going outside and playing; itdoesn’t have to be that structured…Trying to thinkabout creative ways to embed it within their dailyactivities that are already happening, so it doesn’t feellike an add-on, but rather a build-in, will be helpful.In contrast, a few focus group parents felt that their chil-dren were exceeding the recommended levels of activity.One parent (Parent;F;FG;E) said, “Mine never stop mov-ing, so I’ve never considered there being any guidelines.They have so much energy”. At the same time, inter-viewees who were engaged in physical activity advocacyand research noted the issue of overestimation:“Sometimes people will just break it down into active ornot active, and we tend to overestimate how active weare in retrospect and how active kids are” (PhysicalActivity Communicator;F;I;E).Shifting social normsSeveral participants explained that as a society, we mayneed to shift our social norms in order to successfullyimplement the Movement Guidelines, particularly forscreen time and energetic play. Screens and technologywere described as ubiquitous in today’s society, and re-spondents said they were used as rewards and substitutebabysitters for even the youngest children. As one re-searcher (Researcher;M;I;E) pointed out, “It is sociallyacceptable to be using screens. Parents may feel like theyare not good parents if they are not providing the latesttechnology to their child”.With respect to recommendations for energetic play,physicians, parents, ECEs and physical activity communi-cators noted that there are competing priorities withinfamilies and child care settings, where physical activityoften gets pushed aside. A physician (Physician/Parent;-F;I;E) explained that she often sees “patients that have cul-turally placed an emphasis on reading and achievement inthe preschooling group. An increasing focus is placed onlearning instead of the importance of energetic play”.ECEs offered the perspective that as a society, we havemoved away from “a culture of the children being partici-pants in the house” (Early Childhood Educator;F;FG:E)where they can accumulate physical activity by helpingwith physically demanding chores. Children in today’s so-ciety are so busy in structured programs and activities,even as preschoolers, that parents claim there simply isnot enough time for active play. To meet recommenda-tions for energetic play, greater value will need to beplaced on free play and play-based learning once again:The focus needs to be on simple play – that’s whereyou build your pre-math, social relationships, andhealthy habits. It really just has to be a simplereminder to families and to anybody that workswith young kids that it is just about play. Let’s notover-think this! It’s not that hard to get kids activelyinvolved. (Early Childhood Educator;M;I;E)Messengers and methods of disseminationParticipants shared a number of ideas on how topresent and communicate the Movement Guidelines toCanadian families. In this section, suggestions for dis-semination have been organized into settings (location),existing communication channels (mechanisms), andmedia (format).Settings for disseminationAll parents and professionals agreed that informationabout the Movement Guidelines should be disseminatedto families in a variety of settings to increase opportun-ities for awareness and uptake. Medical settings (e.g.,doctor’s offices, hospitals), child care settings (e.g., day-cares, home care), community centres (e.g., libraries,community schools, early years centres), and schools(for four-year-olds) were cited across interviews andfocus groups. Particular emphasis was placed on phys-ician visits, partly because promotion of healthyThe Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 139 of 215behaviours (such as physical activity and adequatesleep) was viewed as the “business” of physicians, andpartly due to the frequency of visits among Canadianinfants and preschoolers to receive publicly fundedimmunizations. Physicians also felt that it was theirresponsibility to discuss the importance of energeticplay, adequate sleep, and minimizing screen time aspart of preventive health care that promotes healthygrowth and development.Child care settings were seen as another natural conduitfor sharing the Movement Guidelines as these settingsserve families with infants, toddlers, and preschoolers.ECEs and daycare staff generally said they endeavoured tobuild trusting relationships with families, often sharedinformation about activities and initiatives that could bereinforced at home (e.g., literacy techniques), and consid-ered themselves as having a “huge role in child develop-ment” (Early Childhood Educator;F;FG;E). One ECE (EarlyChildhood Educator;F;FG;E) said:I feel like our role is mostly liaising with the parents.Maybe trying to notice where there might be gaps andknowledge of what’s needed at that age andvolunteering information when it might be useful.In this way, the Movement Guidelines could easily be in-tegrated within child care programming, with noticessent home and verbal reinforcement given during meet-ings with parents. Many participants working in childcare settings felt that their centres already adhered tothe guidelines for energetic play. In these instances, theguidelines could be used to justify current practices ofencouraging energetic play outdoors in inclement wea-ther such as rain and snow: “Some parents would say,‘Oh, why are they playing outside so much?’ [And withthese guidelines, we could respond with] ‘They’re play-ing outside because you know what, you’re supposedto… this is one of the national guidelines…” (EarlyChildhood Educator;F;FG;E).With respect to community centres across Canada, itwas suggested that programming for infants, toddlers, andpreschoolers with caregiver accompaniment (e.g., StrongStart in British Columbia, Ontario Early Years programsin Ontario) and programming for preschoolers (withoutcaregiver accompaniment) could introduce and model theMovement Guidelines. Like physicians, ECEs recognizedthe important role they played in sharing health and well-ness information, and were keen to play their part:Female ECE (Early Childhood Educator;F;FG;E):Preschool teachers…have so much clout and somuch…Interviewer: They hold influence…Female ECE: …influence. I never actually realized ituntil…I’m only, I’m new as a Strong Start facilitator,so only a couple of years, and it’s just amazing howmuch parents really look to you.Repeatedly hearing about the Movement Guidelinesfrom credible sources in a variety of settings would belikely to prompt action and to foster awareness andmindfulness among families. For example, one parent(Parent;F;FG;E) explained, “…Getting those reminders allthe time I think is a good thing because it’s easy to for-get and then you get into kind of these routines, andmaybe bad habits let’s say, and so just to have that con-stant reminder I think would be a good thing”. Therewas also a sense that in order to promote uptake, therewould need to be an endorsement of the guidelines fromprofessional societies, such as the College of Family Phy-sicians of Canada, the Canadian Paediatric Society, andthe Public Health Agency of Canada. These endorse-ments, which would ultimately enhance the credibility ofthe Movement Guidelines, could take the form of logosintegrated within the Movement Guidelines, or weblinks to the guidelines posted on the websites of profes-sional societies and government organizations.Disseminating the movement guidelines within existingcommunication channelsWith many settings and programs already devoted tothe early years, there was consensus that the dissemin-ation and, to some extent, the implementation of theMovement Guidelines should be integrated withinexisting communication channels. For instance,adherence to the guidelines could become a licensingregulation for child care programs. As another example,pre- and post-natal classes at hospitals and publichealth units could introduce new parents to the Move-ment Guidelines in their sessions: “The guidelinescould be embedded within prenatal care, to motivatepeople to start thinking about how to structure the daybefore even having children” (Researcher;M;I;E). Withrespect to post-natal care, a physician explained thatnurses in Ontario already deliver a Healthy Babies,Healthy Children public health program with homevisits or telephone calls for new parents, and informa-tion about the Movement Guidelines could be includedin these visits. Non-emergency health information fromregistered nurses is also available to parents and care-givers through telephone help lines such as Telehealthin Ontario. Information about the Movement Guide-lines could be made “…available to nurses who aregoing into homes of moms with babies and helpingthem with sleep, breastfeeding, or formula feeding. Theguidelines can also be part of the information that isThe Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 140 of 215going to moms, and nurses may [even] model theappropriate behaviours” (Physician;F;I;E).A physical activity advocate (Physical ActivityCommunicator;F;I;E) also suggested that existing work-shops for parents could be updated to include therecommendations:Public health units are amazing and they generallyhave a physical activity promoter on staff, if not morethan one, and also a child and family healthmanager. They have a mandate to do workshops andto connect with parents. Those would be good avenues[for dissemination].Other mechanisms cited were educational programsfor newcomers as a part of settlement services; govern-ment mail-outs and electronic notices (e.g., notificationsabout the Children’s Fitness Tax Credit); and listservsand newsletters (e.g., from daycares, community centres,health professional organizations).Media for disseminationFocus group and interview participants cited traditionalmedia (e.g., television ads, print news, radio), socialmedia (e.g., blogs, Facebook, Twitter) and websites askey media to disseminate the Movement Guidelines tofamilies. Parents and professional participants favouredelectronic media because of the potential to view videoand other visual examples of the Movement Guidelines(e.g., infographics), interact with the information (e.g.,click on a link for further information), and easily shareinformation personally and professionally. Web and mo-bile apps were also identified as important electronicmechanisms to learn about and track the guidelines.Parents who used pregnancy apps to track fetal growth,and later used breast/bottle-feeding apps to track infantfeeding and development, saw the potential for apps totrack energetic play, sleep, and sedentary behaviour.These apps would also serve to alert parents about theMovement Guidelines and provide suggestions forachieving them as their child grew from infant topreschooler. In medical settings, most clinicians (e.g.,nurses, physicians, physiotherapists) have access to mo-bile apps and view apps as “a rapid way of knowing whatthe guidelines are and ideally implementing them in aclinical setting” (Physician;F;I;E). It was suggested thatapps could be used to prompt clinicians to screen forbehaviours, feed into electronic medical records, or evenserve as screening tools for parents to complete whilesitting in waiting rooms. One physician explained, “Ifparents don’t prioritize these behaviours on their own,they would not necessarily ask their physician about it.It is up to the physician to screen for them and beginthe discussion” (Physician/Parent;F;I;E).Participants working in physical activity promotion alsoused electronic media to promote programs and initia-tives. One participant (Physical Activity Communicator;-F;I;E) explained, “In the webinars that we do, we couldleverage the new guidelines, and definitely through ourcommunications we can start some conversations aroundthese guidelines”. One final suggestion for disseminatingthe Movement Guidelines in an electronic format was anonline training module for ECEs and primary schoolteachers. A researcher-informant (Researcher;F;I;E) noted,“The most fiscally responsible time and logical time [todisseminate information about the guidelines] is [physicalactivity] training within the ECE college curriculum beforethey enter the field” and that an “online module that ECEprograms can pick up and administer to their studentsprior to leaving the college” was an ideal way of equippingeducators with the skills to facilitate energetic play in day-care settings. Such a module could also be useful for on-going professional development of teachers as well aslicense renewal for ECEs.Non-electronic formats to disseminate the MovementGuidelines included printed pamphlets, posters, mag-nets, professional conference presentations and booths,peer-reviewed journal articles (and their electronic ver-sions), and a telephone help-line. One suggestion fromthe key stakeholder interviews was the development ofready-to-use-tools such as workshop outlines with prac-tical strategies, discussion points, and activities gearedtoward ECEs. As explained by a physical activity educa-tor (Physical Activity Communicator;F;I;E), “If therewere resources that showed what the guidelines look likein practice in homes, daycares, at a community centre,in a community in general, that would be helpful”. Whilethere was unanimous support for the spirit of the Move-ment Guidelines among ECEs, they felt a one-hour prac-tical workshop delivered to program facilitators in childcare and community settings would alleviate the burdenof determining how to incorporate the MovementGuidelines into a curriculum-packed day.DiscussionThis study examined perceptions of stakeholders(experts in medicine, physical activity knowledge transla-tion, and research) and end users (parents and ECEs) onthe new 24-Hour Movement Guidelines for the EarlyYears (0–4 Years). It is valuable to engage stakeholdersand end users in the development of guidelines in orderto assess acceptability of information, barriers to uptake,and identification of key messengers and methods fordissemination [15]. Overall, there was consistent supportfor the Movement Guidelines across all stakeholder andend user groups regardless of gender, culturalbackground, or profession. The integration of physicalactivity, sleep, and sedentary behaviour into one all-The Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 141 of 215encompassing guideline was well received. This is an en-couraging finding as the uptake of a new innovation isstrongly related to its perceived acceptability by potentialadopters [32].The majority of expert stakeholders and end users per-ceived the Movement Guidelines as providing a set ofhealthy goals that were largely achievable. In comparisonto the 24-Hour Movement Guidelines for Children andYouth [20], there appeared to be less tension among par-ticipants, particularly parents, regarding the likelihood oftheir child meeting the Movement Guidelines. Parentsdiscussed how their toddlers and preschoolers were ‘nat-urally’ active. This perception may be accurate, as 70% ofCanadian 3- to 4-year-olds meet the daily recommenda-tion of at least 180 min of physical activity at any inten-sity [33]. Parents also described having control andawareness of their child’s sleep patterns and access toscreen time. Additionally, licensing regulations at childcare centres were congruent with the Movement Guide-lines with respect to nap times, minimal screen time,and scheduled outdoor time. Meeting the Children andYouth Guidelines, on the other hand, raised more con-cerns regarding feasibility since physical activity, screentime, and sleep in this age group were affected by nu-merous factors such as school structure (e.g., more timespent sitting), ubiquity of screen time (e.g., video games,screens in school), and time spent doing homework (e.g.,may affect hours of sleep in older youths).Despite the overall acceptability of the MovementGuidelines for the early years, participants cited a num-ber of challenges to uptake. Such challenges were largelycentred on discussions about screen time – suggestingthat screen time was increasingly creeping into the livesof their children, and was inevitable. In the examinationby Carson and colleagues of parental perceptions of theCanadian Sedentary Behaviour Guidelines for the EarlyYears [18], parents also expressed the “need to balancemultiple demands of family life” (p. 3) and feelings ofguilt when not adhering to the guidelines. For example,in Carson et al. [18] and the present study, parentsstated that they used children’s screen time as a tool tofinish daily tasks (e.g., meal preparation, householdchores) or to reward children for good behaviour. Inboth studies, parents also discussed the educationalvalue of some television programs and the use of tabletsfor interactive learning activities. This perception thatscreens can be used as an educational resource in theearly years has increasingly been documented in studiesfrom around the world [17, 18, 34, 35], which demon-strates shifting social norms and value placed on screentechnologies, even for our youngest children.At the same time, parents expressed concerns aboutscreen time and acknowledged the potentially harmfuleffects based on experience monitoring their child’sbehaviour or through intuition. Speculatively, the theoryof cognitive dissonance [36] might be one relevant con-sideration in interpreting reactions to the MovementGuidelines in our study as perhaps in other studies. Thistheory argues that dissonance is a negative state that oc-curs when an individual simultaneously holds two cogni-tions (e.g., attitudes or values) that are psychologicallyincompatible. Since dissonance is likely unpleasant, oneis motivated to reduce it by adding, changing, or redu-cing the importance of cognitions to make them morecompatible. Aronson [37] argued that central to disson-ance theory is not the conflict of two opposing cogni-tions, but a conflict between the self-concept andcognitions about some behaviour. In the current context,a parent highly values the health of their child and maybe aware that too much screen time may be harmful.Yet, if the child is engaging in screen time exceedingrecommended guidelines, then other cognitions aresought to avoid dissonance – that screen time is educa-tional, chores need to be done, or bad weather is a bar-rier. This is not to discount these reasons as realchallenges for parents, but it is also important to con-sider the cumulative effects of cognitive dissonance inresponding to the Movement Guidelines in general.Following on this theoretical perspective, individuals aremotivated to avoid attitude-dissonant information inorder to stabilize an existing attitude or decision – or, inother words, turning parents off the guidelines asreported in one study [18]. In our study, the MovementGuidelines were interpreted by parents as ‘goals’ to strivetoward, but unrealistic most days. Cognitive consonanceis maintained.This is theoretical speculation, but cognitive disson-ance may provide an interesting lens for future researchexamining perceptions of Movement Guidelines acrossthe lifespan. A particular focus is on screen time, givenacknowledged parental concerns over this issue. Asothers have noted [17, 18], a good starting point is to in-clude messaging about Movement Guidelines that aregain-framed, pragmatic, and include practical strategiesfor replacing screen time. This will assist with reinfor-cing confidence that the recommendations are achiev-able. This should occur within a systematic, multi-levelapproach including efforts to change how people thinkabout the guidelines [16] and how environments andpolicies support people to meet those guidelines [38].Similar to previous research in Canada [20] and theUK [17], the present study found that participants had alow awareness of existing guidelines. Setting cognitivedissonance aside for a moment (i.e. low awareness re-flects avoidance of attitude-dissonant information), thelikely explanation may be the lack of effective (or of any)dissemination efforts. For example, a lack of a sustainedand funded approach to the knowledge translation ofThe Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 142 of 215the current Canadian physical activity guidelines foradults has been recognized as potentially explaining lowawareness of their recommendations [16]. It is importantto develop evidence-based guidelines, which act as abasis for planning, policy, and evaluation; however,equally crucial are the efforts to “promote awareness, ac-ceptance, adoption, and adherence to guidelines” (p. 1)[39]. Nevertheless, there appears to be a gap betweenthe development of guidelines and their translation intopolicy or practice [40, 41]. Future dissemination of theMovement Guidelines, with dedicated funding, will re-quire consideration of the recommendations suggestedby participants.Interactions with the medical system and/or medicalprofessionals were obvious points of contact when infor-mation about the Movement Guidelines could be con-veyed. Parents also identified child care settings asimportant for receiving information about the guidelines.In 2011, more than half (54%) of Canadian parents withchildren under 4 years of age indicated they used childcare [42]. Notably, ECEs were accepting of their role aspromoters of the Movement Guidelines, and recognizedthat they played an important part in children’s growthand development. ECEs may therefore be key messen-gers for communicating the Movement Guidelines toparents, and in helping children meet the recommenda-tions at least while under their care. Disseminating theMovement Guidelines within existing systems of know-ledge exchange for medical and child care professionalsmakes intuitive sense, and will vary by profession andjurisdiction. However, there was agreement among studyparticipants that dissemination and implementation ofthe guidelines should be a collaborative approach.The Movement Guidelines need to be disseminatedthrough a number of messengers (e.g., medical profes-sionals, ECEs, Canadian government) and methods (e.g.,traditional formats, social media, workshops). Whilesuggested methods of dissemination were wide and var-ied, there was some consensus that web-based and mo-bile applications would be useful for promptingdiscussion of the Movement Guidelines, tracking behav-iours, and providing creative, interactive solutions tohelp implement them. Repetition of the information wasconsidered vital; participants repeatedly mentioned thevalue of receiving the information from diverse sourcesat multiple times, in varying formats.Strengths, limitations, and future directionsStrengths of this study included a relatively large samplesize (n = 102) with a professionally diverse range of stake-holders and end users. However, the sample was primarilyfemale (n = 84) and from urban settings, with the majorityof participants having completed a post-secondary educa-tion. An exploration of perspectives of Indigenous parents,for example, and sampling on a broader geographic scalewould be informative. Attempts were made to includestakeholders and end users of varying professional back-grounds (e.g., experts in medicine, researchers, parents,and ECEs), but we acknowledge that some importantvoices have not been considered regarding the acceptabil-ity of the Movement Guidelines. Given participants’ rec-ommendations to incorporate the Movement Guidelinesinto licensing standards and regulations, another voicemissing in this study is that of policy-makers. Weattempted to recruit a public health policy-maker for thestakeholder interviews, but were unable to do so withinthe study timelines. Another potential limitation was thatfour of the stakeholder interviewees had contributed tothe creation of the Movement Guidelines. However, as in-terviews focused on dissemination strategies to profes-sional groups and end users, it was both appropriate andadvantageous to include individuals who were already fa-miliar with the Movement Guidelines. One final limitationof this study was that only one researcher was present inthe francophone focus groups and was therefore taskedwith both facilitating discussion and taking notes tocapture both the order of speakers and key points of con-versation requiring follow-up questions. Although themoderator was skilled and experienced, it may be ideal tohave two researchers present during a focus group todivide these tasks.ConclusionsIn summary, stakeholders and end users were very re-ceptive to the Canadian 24-Hour Movement Guidelinesfor the Early Years (0–4 years). The behavioural recom-mendations were largely considered feasible, althoughincreasing screen time was identified by participants asan emerging concern in the early years. Engaging physi-cians and ECEs in dissemination efforts may be criticalfor increasing awareness of the Movement Guidelinesamong Canadian parents. In turn, uptake by parents willlikely be dependent on the messaging and resourcescreated to facilitate implementation.AbbreviationsECE: Early childhood educator; Movement Guidelines: 24-Hour MovementGuidelines for the Early Years (0–4 years)AcknowledgmentsWe sincerely thank all the participants for their time in contributing to thestudy, all those who helped with recruitment, and Jean-Christian Gagnon forconducting the French-language focus group.FundingPublication charges for this article have been funded by the Public HealthAgency of Canada. Guy Faulkner is supported by a Canadian Institutes ofHealth Research-Public Health Agency of Canada (CIHR-PHAC) Chair inApplied Public Health.The Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 143 of 215Availability of data and materialsThe dataset used during the current study is available from thecorresponding author on reasonable request.About this supplementThis article has been published as part of BMC Public Health Volume 17Supplement 5, 2017: 24-Hour Movement Guidelines for the Early Years: AnIntegration of Physical Activity, Sedentary Behaviour, and Sleep. The fullcontents of the supplement are available online at https://bmcpublichealth.-biomedcentral.com/articles/supplements/volume-17-supplement-5.Authors’ contributionsNR, GF and MST were responsible for the initiation, conceptualization, anddesign of the study. NR, GF, SR, and MO were responsible for data collectionand analysis. All authors (NR, SR, MO, MST, GF) were responsible for revisingthe manuscript critically for important intellectual content. All authors readand approved the final manuscript.Ethics approval and consent to participateEthics approval was obtained from the relevant institutional Research EthicsBoards in Ontario and British Columbia. All participants in this study gavetheir informed consent.Consent for publicationNot applicableCompeting interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Kinesiology, University of British Columbia, 2146 Health SciencesMall, Vancouver, BC V6T 1Z3, Canada. 2Healthy Active Living and ObesityResearch Group, CHEO Research Institute, 401 Smyth Road, Ottawa, ON K1H8L1, Canada.Published: 20 November 2017References1. 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Accessed 17 Oct 2017.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:The Author(s) BMC Public Health 2017, 17(Suppl 5):841 Page 145 of 215

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