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Perceptions of physical activity and sedentary behaviour guidelines among end-users and stakeholders: a systematic review

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Perceptions of physical activity and sedentary behaviour guidelines among end-users and stakeholders: a systematic review

Abstract and Figures

Background Many of the world’s population, across all age groups and abilities, are not meeting or even aware of internationally recommended physical activity (PA) and sedentary behaviour (SB) guidelines. In order to enhance awareness and uptake, guidelines should be perceived positively by targeted users. The purpose of this study was to review the literature on end-user and stakeholder perceptions of PA and SB guidelines. Methods The electronic databases APA PsycInfo, CINAHL, MEDLINE, and SPORTDiscus, using EBSCOhost Research Platform, and Web of Science were searched from inception to June, 2021 with keyword synonyms for “perceptions”, “PA guidelines”, and “SB guidelines”. Studies of any design that collected stakeholder and/or end-user responses to a PA and/or SB guideline were included and assessed for risk of bias. The PA and/or SB guideline could be any type of official form (e.g., national documents, organizational guidelines, expert consensus statements, etc.) from any country, that targets individuals at the regional, provincial/statewide, national, or international level, and includes all types of guidelines (e.g., strength, aerobic, clinical, nonclinical, screen-time, sitting, etc.). Data were extracted and analyzed using thematic synthesis. Results After screening 1399 abstracts and applying citation screening, 304 full-texts were retrieved. A total of 31 articles met the inclusion criteria. End-users and stakeholders for PA guidelines across all age groups expressed the need for simplified language with more definitions, relatable examples and imagery, and quantification of PA behaviours. There was concern for the early years and child PA guidelines leading to guilt amongst parents and the SB guidelines, particularly the recommendations to limit screen-time, being unrealistic. General age group PA guidelines were not perceived as usable to populations with differing abilities, clinical conditions, and socioeconomic status. Guidelines that targeted clinical populations, such as persons with multiple sclerosis and persons with spinal cord injury, were well received. Conclusions There is a clear need to balance the evidence base with the pragmatic needs of translation and uptake so that the guidelines are not ignored or act as a barrier to actual engagement.
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Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
https://doi.org/10.1186/s12966-022-01245-9
REVIEW
Perceptions ofphysical activity
andsedentary behaviour guidelines
amongend-users andstakeholders:
asystematic review
Heather Hollman1* , John A. Updegraff2, Isaac M. Lipkus3 and Ryan E. Rhodes1
Abstract
Background: Many of the world’s population, across all age groups and abilities, are not meeting or even aware
of internationally recommended physical activity (PA) and sedentary behaviour (SB) guidelines. In order to enhance
awareness and uptake, guidelines should be perceived positively by targeted users. The purpose of this study was to
review the literature on end-user and stakeholder perceptions of PA and SB guidelines.
Methods: The electronic databases APA PsycInfo, CINAHL, MEDLINE, and SPORTDiscus, using EBSCOhost Research
Platform, and Web of Science were searched from inception to June, 2021 with keyword synonyms for perceptions”,
“PA guidelines”, and “SB guidelines”. Studies of any design that collected stakeholder and/or end-user responses to a
PA and/or SB guideline were included and assessed for risk of bias. The PA and/or SB guideline could be any type of
official form (e.g., national documents, organizational guidelines, expert consensus statements, etc.) from any country,
that targets individuals at the regional, provincial/statewide, national, or international level, and includes all types of
guidelines (e.g., strength, aerobic, clinical, nonclinical, screen-time, sitting, etc.). Data were extracted and analyzed
using thematic synthesis.
Results: After screening 1399 abstracts and applying citation screening, 304 full-texts were retrieved. A total of 31
articles met the inclusion criteria. End-users and stakeholders for PA guidelines across all age groups expressed the
need for simplified language with more definitions, relatable examples and imagery, and quantification of PA behav-
iours. There was concern for the early years and child PA guidelines leading to guilt amongst parents and the SB
guidelines, particularly the recommendations to limit screen-time, being unrealistic. General age group PA guidelines
were not perceived as usable to populations with differing abilities, clinical conditions, and socioeconomic status.
Guidelines that targeted clinical populations, such as persons with multiple sclerosis and persons with spinal cord
injury, were well received.
Conclusions: There is a clear need to balance the evidence base with the pragmatic needs of translation and uptake
so that the guidelines are not ignored or act as a barrier to actual engagement.
Keywords: Physical activity, Sedentary behavior, Review
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Background
Regular physical activity (PA) can prevent and treat
numerous noncommunicable diseases and improve men-
tal health and quality of life of people of all ages [1, 2].
Open Access
*Correspondence: heatherh@uvic.ca
1 Behavioural Medicine Laboratory, School of Exercise Science, Physical
and Health Education, University of Victoria, PO Box 1700 STN CSC,
Victoria, B.C. V8W 2Y2, Canada
Full list of author information is available at the end of the article
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Page 2 of 13
Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
As a result, several national and international PA guide-
lines have been developed and implemented with the
aim to provide stakeholders (i.e., policymakers, research-
ers, and healthcare providers) and end-users (i.e., target
population, parents, early childhood educators) guidance
in the minimal doses required for obtaining health ben-
efits. Several countries, including Canada, USA, the UK,
and Australia, released their first set of PA guidelines in
the 1990s and each have undergone several modifica-
tions since. For example, the history of the American PA
guidelines started in 1975 when the American College
of Sports Medicine (ACSM) published the first specific
exercise recommendations Guidelines for Graded Exer-
cise Testing and Exercise Prescription [3]. In tandem, the
ACSM also published exercise dose recommendations
for improving and maintaining physical fitness in 1978
and then adjusted them in 1990, and 1998 with a focus
more towards health outcomes [4].
e first internationally recommended PA guidelines
were released in 2010 from the WHO as a result of its
global mandate on promoting PA for public health and
the limited existence of national guidelines on PA for
public health in low- and middle- income countries [5].
ese guidelines were updated in 2020 to include spe-
cific recommendations on PA for pregnant and postpar-
tum women and people living with chronic conditions or
disability as well as the addition of sedentary behaviour
(SB) guidelines [6]. In response to accumulating evidence
that SB contributes to health independently from PA [7,
8], SB-related messages have also been included in sev-
eral national PA guidelines for adults and children in
the UK, Australia, New Zealand, Canada, Germany, and
Norway [9]. However, SB guidelines have been scruti-
nized for having an inconsistent evidence base [6, 9, 10].
ere is no doubt that SBs, particularly screen-time (ST),
have effects on health, but research is still preliminary to
inform SB thresholds [6].
Despite these efforts in developing PA and SB guide-
lines, uptake is still concerningly low, as 31.1% of adults
age 15years or older, worldwide, remain physically inac-
tive (i.e., not meeting one of the following: 1) 30min of
moderate-intensity PA on at least 5days every week, 2)
20min of vigorous-intensity PA on at least 3days every
week, or 3) an equivalent combination achieving 600
metabolic equivalent minutes per week) [11]. Among
adolescents worldwide, 80.3% of 13–15-year-olds were
not meeting 60 min of moderate-to-vigorous intensity
PA per day and girls were less active than boys [11]. Over
half of children in Canada, USA, and Australia are not
meeting PA or ST recommendations put forward by their
national governing bodies [1214].
is discrepancy between available guidelines and PA
participation may exist partly due to limited awareness of
PA and/or SB guidelines [1518]. However, information
about acceptance and reception of guidelines may have
even greater importance given that reception of guide-
lines has influence on attitudes, perception of capability,
and intention to enact the guidelines [19, 20]. e per-
suasion-communication model proposes that in order for
behaviour change to occur, message acceptance, recep-
tion, and retention are necessary [21]. Despite numerous
PA and SB guideline reviews and epidemiology reports,
no review has ever collected impressions of PA and/or SB
guidelines.
e purpose of this study was to review the literature of
end-user (i.e., targeted populations, parents, early child-
hood educators) and stakeholder (i.e., researchers, policy-
makers, healthcare practitioners) perceptions towards PA
and SB guidelines put forward by national and interna-
tional governing bodies. A specific aim was to separately
evaluate the perceptions of PA and SB guidelines that tar-
geted each age group (i.e., early years, children and youth,
adults, older adults) and clinical population and evaluate
the perceptions by end-user and stakeholder.
Methods
is systematic review was registered in PROSPERO
CRD42020207107 and follows the PRISMA items for
reporting systematic reviews [22].
Eligibility criteria
Inclusion criteria was any study design where perceptions
of PA and/or SB guidelines by end-users and/or stake-
holders were collected. Responses could be in the form
of perceptions, attitudes, or opinions, and be from people
of all ages and abilities. e PA and/or SB guideline could
be any type of official form (e.g., national documents,
organizational guidelines, expert consensus statements,
etc.) from any country, that targets individuals at the
regional, provincial/statewide, national, or international
level, and includes all types of guidelines (e.g., strength,
aerobic, clinical, nonclinical, ST, sitting, etc.). Studies
were excluded if they evaluated perceptions of end-users
and stakeholders to PA or SB in general instead of a spe-
cific PA or SB guideline (e.g. [6, 23, 24]), if only knowl-
edge or awareness of the guidelines was collected, if they
weren’t available in English language, and if they weren’t
published in a peer-reviewed journal.
Information sources, search strategy, andstudy selection
Two systematic searches, search #1 for PA guidelines and
search #2 for SB guidelines, were conducted across APA
PsycInfo, SPORTDiscus, MEDLINE, and CINAHL, using
EBSCOhost Research Platform, and Web of Science.
Search #1 included key word synonyms of “perception”
and “PA guidelines” and search #2 included key word
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Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
synonyms of “perception” and “SB guidelines”. See Sup-
plementary Table1 for full search strategies.
We managed study selection using Covidence software
[25], a web-based screening and data extraction tool rec-
ommended by the Cochrane Collaboration. After identi-
fying and removing duplicate records, one reviewer (HH)
screened the citation information for each record using
the set criteria. Covidence allows each reviewer to select
“Yes”, “No”, or “Maybe” to include or exclude imported
articles. If the reviewer thought “Maybe”, it was labeled
as “Yes” and moved to the full-text screen. Full-text
screening was completed by HH and RR. Disagreements
between reviewers were resolved through discussion
until consensus was reached. When consensus was not
reached, the last author (RR) provided a final decision.
Studies found to be ineligible during the full-text screen-
ing were recorded along with reasons for exclusion. Study
selection for both searches was completed at the end of
June, 2021.
Data collection process anddata items
Data extraction was completed by HH and a research
assistant (see acknowledgement section) for search
#1, HH alone for search #2, and both were reviewed by
RR. Extracted information included authors, country of
research, whether it was national or regional, the sample
size and participant characteristics, study design, the spe-
cific PA and/or SB guideline assessed, the outcome vari-
able (e.g., perception, attitude, or opinion of the PA and/
or SB guideline), and the results of each study (see Sup-
plementary Table2).
Risk ofbias assessment
A risk of bias analysis was conducted across studies,
applying the VAKS tool for studies with a qualitative
design [26], the NIH Quality Assessment Tool for Obser-
vational Cohort and Cross-Sectional Studies for the stud-
ies that employed surveys [27], and the RoB 2 tool for the
study with randomized controlled trial design [28]. e
VAKS tool is divided into five subjects: formal require-
ments, credibility, transferability, dependability, and con-
firmability with all subjects weighed equally. Subjects
have a range between five and seven criteria, of which
each is scored on a four-point scale from 1 = “totally
disagree” to 4 = “totally agree”. For each subject, the cri-
terion scores are added and divided by the number of
relevant criteria for each subject. e scores of the sub-
jects are added to create a final score and if the result is
15 or above, the article is recommended, between 10 and
14, it is recommended with reservations, and below 10,
it is not recommended [26]. e NIH Quality Assess-
ment Tool for Observational Cohort and Cross-Sectional
Studies includes 14 criteria scored “Yes”, “No”, or “Other
(cannot determine, not applicable, or not reported)” and
the overall quality rating (i.e. good, fair, or poor) is up to
the discretion of the researcher with consideration of all
the criteria and their potential for bias [27]. e RoB 2
assesses bias within domains of deviations from the ran-
domization process, intended interventions, missing
outcome data, measurement of the outcome, and selec-
tion of the reported results [28]. e methodological
quality of studies were independently scored by HH and
a research assistant for search #1 and HH for search #2.
Discrepancies of search #1 were resolved through discus-
sion and consensus between HH and the research assis-
tant and the final scores for both searches were reviewed
by RR.
Analysis
Qualitative results were synthesized using thematic syn-
thesis [29] where first the text was coded ‘line-by-line’ by
HH using QSR NVivo Software [30]. Quantitative data
were included in the synthesis to support qualitative
findings. ere was a pre-set organization of themes by
PA, SB, type of PA (i.e., aerobic, strength) or SB (i.e., ST,
sitting), age and/or clinical status that the guideline tar-
geted. e first stage of analysis involved an iterative pro-
cess of reading and re-reading studies to find codes that
informed the primary research purpose of perceptions
of end-users and stakeholders of PA and/or SB guide-
lines. Both raw data, such as participant quotes, as well
as author interpretations were coded. Abstracts, results,
and discussion sections were screened because findings
of qualitative studies may not be limited to the results
section [29]. As HH coded each study, codes were added,
and new ones were developed when necessary. All stud-
ies were eventually coded using the final coding scheme
(see Supplementary Table3). Upon completion of cod-
ing, “descriptive themes” were developed based on the
data retrieved from the primary studies, and then further
refined into “analytical themes” generated by the inter-
pretations of the authors of this study. Triangulation was
performed by RR who reviewed the codes and themes
and suggested revisions when indicated.
Results
Study selection
irty-one articles were selected for inclusion and the
PRISMA Flow Diagram for search #1 and #2 can be seen
in Figs.1 and 2 respectively. For search #1 (see Fig.1),
after the removal of 645 duplicates, 640 records were
screened by titles and abstracts, resulting in 370 records
excluded. e remaining 250 records were screened
full text and 228 studies were excluded because they a)
employed ineligible study designs (n = 204), b) measured
ineligible outcomes (n = 22), c) evaluated an irrelevant
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Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
Fig. 1 PRISMA Flow Diagram for Search #1
Fig. 2 PRISMA Flow Diagram for Search #2
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Page 5 of 13
Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
intervention (n = 2), and d) were a study erratum (n = 1).
For search #2 (see Fig.2), after removal of 396 duplicates,
759 records were screened by titles and abstracts, result-
ing in 705 records excluded. e remaining 54 records
were screened full text and 44 studies were excluded
because they a) were additional duplicates not identified
by Covidence automation tool (n = 2), b) were already
identified in search #2 (n = 9), and c) employed an ineli-
gible study design (n = 33). A total of 21 studies from
search #1 and 10 studies from search #2 with 31 inde-
pendent samples passed the inclusion criteria and were
included for analysis (Supplementary Table2; Figs.1 and
2).
Study characteristics
Full data extraction details are provided in Supplemen-
tary Table2 and study characteristics are presented in
Table1. Of the 31 selected articles, n = 15 targeted guide-
lines for early years (0–5years), n = 11 for children and
youth (6–17years), n = 6 for adults (18–64 years), n = 4
for older adults (65years and older), and n = 4 for spe-
cific clinical populations (i.e., cancer survivors, persons
with multiple sclerosis (MS), and persons with spinal
cord injury (SCI)). Six papers included perceptions of
guidelines that targeted more than one population (e.g.,
children plus adults). Perceptions were collected from PA
guidelines (n = 10), SB guidelines (n = 3), and ST guide-
lines (n = 5) alone, and PA and SB guidelines (n = 10),
and PA and ST guidelines (n = 3) combined. Over 70% of
the studies employed qualitative interviews (n = 15) and/
or focus groups (n = 11). Characteristics of the PA, SB,
and ST guidelines can be viewed in the Supplementary
Table2.
Risk of bias analyses for studies that employed qualita-
tive designs (n = 26), seen in Table2, demonstrated that
most articles (n = 23) were recommended, two studies
were recommended with reservation, and one article was
not recommended. Risk of bias analyses for the cross-
sectional survey studies (n = 9), seen in Table3, demon-
strated above 50% in five articles (56%) and below 50% in
4 articles (44%). e main limitations were lack of sample
size justification, lack of measuring exposure of interest
prior to measuring an outcome, lack of examining vary-
ing levels of exposure as related to the outcome, lack of
assessing exposure more than once, lack of blinding out-
come assessor to the exposure status of participants, and
lack of measuring and adjusting for key potential con-
founding variables and their impact on the relationship
between exposure(s) and outcome(s). e randomized
controlled trial was deemed high risk (Table4) because
24% of randomized participants dropped out and there
was no evidence that the result wasn’t biased by the
drop-outs.
Table 1 Overall Study Characteristics
Parents and early childhood educators were both classied as end-users
Characteristic Number of
Datasets Percentages
Total studies/samples (N = 31) Number of
unique data sets (N = 31)
Location
Canada 13 42%
USA 7 23%
Australia 6 19%
UK 3 10%
South Korea 1 3%
Sweden 1 3%
Study design
Interviews 15 48%
Focus groups 11 35%
Cross-sectional surveys 10 32%
Workshops 1 3%
Randomized controlled trial 1 3%
Comments from news posts 1 3%
Electronic telephone interview 1 3%
User
End-user 25 81%
Stakeholder 9 29%
Child & youth 5 16%
General adult 2 6%
Older adult 2 6%
Parent 21 68%
Researcher 3 10%
Policymaker 3 10%
Healthcare provider 8 26%
Public health practitioner 2 6%
Educator 3 10%
Recreation/sport practitioner 2 6%
Early childhood educator 2 6%
Early childhood educator trainee 1 3%
Undergraduate student 1 3%
Office worker 2 6%
Clinical population 6 19%
Type of guideline
Physical activity 23 74%
Sedentary behaviour 13 42%
Screen-time 8 26%
Guideline target
Early years (0–4) 15 48%
Child & youth (5–17) 11 35%
Adult (18–64) 6 19%
Older adult (65 +) 4 13%
Clinical population 4 13%
User characteristic
African American 1 3%
Somali 1 3%
Low socioeconomic status 2 6%
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Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
Representative quotes for the themes of perceptions
of guidelines that targeted each age group and clinical
condition can be seen in Supplementary Table4. The
results will be presented divided by age groups.
Early years (0–4years)
The PA, SB, and ST guidelines were homogenous
(Supplementary Table2) with the exception of an older
PA guideline which recommended 30–90min of PA
per day [47], the Maternal Child and Health PA rec-
ommendations of active play every day without a time
threshold [46], and the recent 24-Hour Movement
Guidelines recommending up to 1h of ST per day for
children 1–2years [52, 55]. Of the 15 articles, 13 col-
lected responses of original guideline documents, one
from a health professional communication document
[46], and one from a guidelines draft [52].
Overall positive support forPA andSB/ST guidelines
End-users (parents) and stakeholders (pediatricians)
thought the PA guidelines were achievable and realis-
tic [32, 46, 54, 57]. It was often reported that children of
this age were “naturally active” and already exceeded PA
guidelines [32, 46, 47, 52]. End-users (parents) thought
the SB guidelines were acceptable, sensible, clear, and
understandable [32, 35, 37] and stakeholders (pediatri-
cians) agreed or strongly agreed (96%) with the SB guide-
lines [57].
Meeting theSB/ST guidelines isunrealistic
e principles of the SB/ST guidelines were commended
[35, 45] however the majority of end-users reported
that meeting the SB/ST guidelines was unrealistic [31,
3537, 41, 42, 55] and only half (51%) of pediatricians
thought they were very realistic [57]. Parents often relied
on the benefits of SB/ST such as its use as a “babysitter”
Table 2 Risk of Bias Scores for the Qualitative Studies
R Recommended, RWR Recommended with Reservations NR Not Recommended
Authors Formal
Requirements Credibility Transferability Dependability Conrmability Total Recommendation
Beck et al., 2016 [31] 3.00 4.00 3.40 4.00 2.50 16.90 R
Bentley et al., 2015 [32] 3.00 3.57 4.00 4.00 2.50 17.07 R
Berry et al., 2010 [33] 3.00 3.86 4.00 4.00 2.83 17.69 R
Bevington et al., 2020 [34] 2.50 2.71 3.40 2.67 1.17 12.98 RWR
Birken et al., 2015 [35] 3.00 4.00 3.20 4.00 3.00 17.20 R
Brown & Smolenaers, 2018 [36] 2.50 4.00 3.00 4.00 2.67 16.20 R
Carson et al., 2014 [37] 3.00 4.00 3.40 3.33 3.00 17.40 R
Evans et al., 2011 [38] 2.50 3.86 3.20 4.00 3.00 16.60 R
Faulkner et al., 2016 [39] 3.00 3.86 3.40 4.00 2.83 17.09 R
Gardner et al., 2017 [40] 3.00 4.00 3.40 4.00 3.83 18.23 R
Golden et al., 2020 [41] 3.00 3.60 3.40 4.00 3.00 17.00 R
Hale et al., 2019 [42] 2.70 4.00 4.00 4.00 3.30 18.00 R
Handler et al., 2019 [43] 3.00 4.00 3.40 4.00 3.50 17.90 R
Hattersley et al., 2009 [44] 3.00 3.57 3.40 4.00 2.33 16.30 R
Hinkley & McCann, 2018 [45] 3.00 3.29 3.20 3.83 2.50 15.82 R
Huxtable et al., 2018 [46] 3.33 4.00 4.00 4.00 2.83 18.17 R
Irwin et al., 2005 [47] 2.67 4.00 3.40 4.00 2.67 16.74 R
Learmonth et al., 2019 [48] 3.00 4.00 4.00 4.00 3.50 18.50 R
Martin Ginis et al., 2018 [49] 2.50 4.00 3.60 4.00 3.20 17.30 R
Neher et al., 2020 [50] 3.00 3.86 4.00 4.00 3.67 18.53 R
Nobles et al., 2020 [51] 2.83 4.00 3.40 4.00 3.50 17.73 R
Riazi et al., 2017 [52] 3.00 4.00 3.40 4.00 3.17 17.57 R
Sebastiao et al., 2015 [53] 3.00 4.00 3.40 4.00 3.50 17.90 R
Slater et al., 2010 [54] 2.50 2.71 3.20 2.80 2.33 13.505 RWR
Stanley et al., 2020 [55] 3.00 4.00 3.40 4.00 3.00 17.40 R
The Health Perspective, 2002 [56] 1.33 1.00 1.60 1.83 1.00 6.76 NR
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Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
to occupy children while parents complete household
chores, using the stroller to transport children to where
they can be active, improving family communication,
regulating behaviour, and using it for educational pro-
gramming [32, 3537, 41, 42].
Guidelines should be tailored toindividuals andencourage
achievable goals rather thanrigid times
End-users liked the simplicity and clarity of the guide-
lines [37, 42, 52, 55] although many thought that the PA
guidelines were too general (i.e., one-size-fits-all) [32,
34, 42]. Both end-users and stakeholders reported that
the guidelines should be more tailored to developmental
stage, physical ability, [32, 36, 52, 55] and socioeconomic
status [42, 55]. End-users preferred when guidelines were
broken down into more achievable steps that could be
built upon [32, 3436, 42, 52, 55].
Guidelines should provide suggestions andvisuals
ofexamples thatstakeholders can apply
Both end-users and stakeholders reported that PA and
SB/ST guidelines could result in guilt to parents [32,
37, 42, 52, 55]. Suggestions included providing exam-
ples and more details around quantifying PA and SB/
ST behaviours [32, 34, 36, 37, 42, 46, 54, 55]. ere was
some confusion over “what counted” as ST [36] and par-
ents wanted specific strategies to help them achieve the
recommended ST and PA behaviours [37, 38, 46, 54, 55].
End-users wanted more of a focus on images rather than
text that were reflective of diverse activities and diverse
Table 3 Risk of Bias Scores for the Quantitative Surveys
+ = Yes;—= No, NA Not available, NR Not recorded
1.Was the research question or objective in this paper clearly stated?
2.Was the study population clearly specied and dened?
3.Was the participation rate of eligible persons at least 50%?
4.Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in
the study prespecied and applied uniformly to all participants?
5.Was a sample size justication, power description, or variance and eect estimates provided?
6.For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
7.Was the timeframe sucient so that one could reasonably expect to see an association between exposure and outcome if it existed?
8.For exposures that can vary in amount or level, did the study examine dierent levels of the exposure as related to the outcome (e.g., categories of exposure, or
exposure measured as continuous variable)?
9.Were the exposure measures (independent variables) clearly dened, valid, reliable, and implemented consistently across all study participants?
10.Was the exposure(s) assessed more than once over time?
11.Were the outcome measures (dependent variables) clearly dened, valid, reliable, and implemented consistently across all study participants?
12.Were the outcome assessors blinded to the exposure status of participants?
13.Was loss to follow-up after baseline 20% or less?
14.Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total Percentage
Birken et al., 2015 [35] + + NR + - + + - + - + - NA + 8/12 67%
Carson et al., 2013 [57] + + - + - + + - + - + - NA + 8/13 62%
Faught et al., 2020 [58] + + - - - - + - - - + - - - 4/14 29%
Jarvis et al., 2021 [59] + + NA + + - + - + - + - NA + 8/12 67%
Learmonth et al., 2019 [48] + + + + - - + - - - + - NA - 6/13 46%
Martin Ginis et al., 2018 [49] + + NR + - - + NA NA - + - NA - 5/10 50%
Park et al., 2015 [60] + + - + - - + NA NA - + - NA - 5/11 45%
Sebastiao et al., 2015 [53] + + NR + - + NR - + + + - NA - 7/11 64%
Slater et al., 2010 [54] + + + + - - + - + - + + NA - 8/13 62%
Table 4 Risk of Bias Score for the Randomized Controlled Trial
SC some concerns, LR low risk of bias, HR high risk of bias
Randomization
Process Intended
Interventions Adhering to
Intervention Missing
Outcome Data Measurement of
Outcome Reported Result Risk-of-Bias
Judgment
Tennant et al.,
2019 [61]SC LR LR HR LR LR HR
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Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
individuals that were colourful and inviting [34, 36, 42,
52, 55].
Children & youth (5–17years)
e PA, SB, and ST guidelines were homogenous (Sup-
plementary Table 2). Of the 11 articles, 9 collected
responses of original guideline documents, one from an
end-user guide [59], and one from a guidelines draft [39].
Conicting positive andnegative perception oftheguidelines
Stakeholders (pediatricians) and end-users (parents)
generally responded positively (i.e., agreeable, message
believability, realistic) to the concept of PA and SB/ST
guidelines [38, 54, 57, 59], however youth themselves
weren’t as agreeable [38, 39]. Youth expressed anger to
the idea of limiting television time [38] or a disengaged
attitude because their future health wasn’t an immedi-
ate concern [39]. End-users (parents and youth) often
reported that the ST guidelines were unrealistic [38, 44,
54] with 20% fewer pediatricians considering the PA and
SB guidelines very realistic compared to the early years
[57]. Users reported guidelines that integrated PA and
SB/ST behaviours provided a holistic approach and didn’t
affect message processing (i.e., degree to which guideline
information is thought about and predictive of attitudes
and behaviours) [39, 43, 61].
End‑users need more guidance onmonitoring
andintegrating PA andSB guideline recommendations
intotheir daily lives
Parents reported difficulty quantifying PA and SB behav-
iours when children and youth spent varying times in
multiple environments (home, school, day care, com-
munity centre) every day [39]. In order to be achievable,
the guidelines should include examples of what differ-
ent levels of PA intensities look like and how they can be
incorporated into daily life, taking into account the many
barriers such as time, energy, and costs [34, 38, 39, 43, 51,
54]. End-users (parents and youth) did not like the lan-
guage of the PA guidelines, describing it as academic,
clinical, and inaccessible [51], nor the one-size-fits-all
recommendations of the PA and SB guidelines [34]. ey
preferred when guideline messages broke recommenda-
tions down into more achievable goals [34, 39, 51].
Guidelines should be tailored toability anddevelopmental
stage
End-users reported that the guidelines should include
more examples and imagery of children with varying lev-
els of ability, mobility, pain, gender, and age [34, 38, 39,
43, 51, 54]. Parents of children and youth with disabilities
requested more relatable examples and language as the
24-Hour Movement Guidelines were not inclusive nor
compatible with the abilities and needs of children and
youth with disabilities [43].
Adults (18–64years)
e PA, SB, and ST guidelines were homogenous with the
exception of two older versions of PA guidelines recom-
mending 60min of PA per day [33, 56]. e SB guideline
from Gardner and colleagues [40] was unique to desk-
workers (Supplementary Table2). Of the six articles, four
collected responses from original guideline documents,
one from an end-user guide [33], and one from a guide-
lines draft [58].
The PA andSB guidelines are too simplistic
End-users and stakeholders primarily reported nega-
tive feedback regarding the PA guidelines [33, 34, 51, 56,
58] and SB guidelines [40, 58]. End-users felt that the
guidelines were too simplistic [33] and along with health
practitioners, thought they didn’t account for varying
abilities, health situations, and socioeconomic status’ of
individuals [51, 58]. e simplicity resulted in end-users
questioning the credibility of the PA and SB guidelines
[33, 40]. In order to enhance confidence in the guidelines,
end-users requested evidence of the reasoning behind
the guidelines as well as the associated health and social
benefits [34, 40, 51].
Guidelines need tobe more understandable tovarying
literacy levels withfocus onstrength‑based language
ere were common concerns of the literacy level of the
PA and SB guidelines with end-users reporting that cer-
tain terms, such as “sedentary, “vigorous”, “intensity”,
“movement”, and “muscle-strengthening” needed to be
either removed, modified, or described [51, 58]. End-
users and stakeholders preferred the message of increas-
ing PA to eventually meet PA and SB guidelines, because
evidence exists demonstrating activity levels below such
levels will still result in health benefits [34, 51, 56, 58].
End-users desired messages that motivated, encouraged,
and invited people to work towards meeting the guide-
lines [51, 58]. End-users also wanted to see more exam-
ples of activities of varying intensities that people with
varying abilities, cultural backgrounds, and ages could
easily fit into their routines [33, 34, 40, 51, 58].
Older Adults (65 + years)
e PA guidelines were homogenous with the exception
of an older PA guideline that recommended 60min of PA
per day [33] ( Supplementary Table2). Of the four arti-
cles, two collected responses of original guideline docu-
ments, two from end-user guides [33, 53], and one from a
guidelines draft [58].
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Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
PA guideline content needs toapply more understandable
andinclusive language
End-users reported overall negative perceptions of the
content and layout of the PA guidelines [33, 51, 53]. Dif-
ficult language and technical terminology, such as “aero-
bic”, “intensity”, “moderate”, and “muscle-strengthening”
resulted in confusion by many end-users [51, 53].
Guidelines should be tailored tovarying abilities andcultural
backgrounds
End-users wanted images of PA that were representative
and realistic for them (e.g. chair-based activity) [33, 51,
53]. Further, end-users wanted clear instructions on how
to achieve varying levels of activity [58] along with appli-
cable health benefits, such as changes in mobility [51]. In
contrast to the original guidelines, end-users responded
positively to public health brochures that included more
detailed instructions and visual illustrations [53].
Clinical population guidelines
Two PA guidelines targeted cancer survivors, recom-
mending either 150min of moderate- to vigorous-inten-
sity PA or 150min of moderate-intensity or 75min of
vigorous intensity PA per week [50, 60]. One PA guide-
line targeted persons with MS, recommending 30 min
of aerobic exercise 2 × per week and resistance exercise
training 2 × per week [48]. One PA guideline targeted
persons with SCI which included two specific guidelines,
one for cardiorespiratory fitness the second for cardio-
metabolic health benefits [49] (Supplementary Table2).
Of the four articles, three collected responses of original
guideline documents and one from a clinical implemen-
tation document [50].
Guidelines are unclear forcancer survivors
Two articles collected perceptions of cancer health pro-
fessionals to PA guidelines [50, 60]. Health practitioners
thought PA guidelines were important but also unclear
and were surprised that they were not unique to cancer
patients [50, 60].
Overall positive support forPA guidelines thattarget persons
withMS andpersons withSCI
Perceptions of end-users and stakeholders to PA guide-
lines specific for persons with SCI [49] and persons with
MS [48] were overall positive. Persons with MS reported
that the PA guidelines were acceptable and appropriate
[48] while health practitioners and end-users reported
overall confidence in the PA guidelines for persons with
SCI, except for the cardiometabolic health guideline for
people with tetraplegia [49]. ere were a few concerns
including confusion that could result from not know-
ing which of the two guidelines for persons with SCI to
implement (fitness or health), that the term “physical
activity” may be more appropriate than “exercise”, and
that the importance of improving fitness may be over-
shadowed by the cardiometabolic health guideline [49].
Discussion
e purpose of this review was to evaluate end-user and
stakeholder perceptions of PA and SB guidelines, sub-
divided by age group and clinical population. is is the
first review of its kind, providing valuable information to
researchers and policymakers about the overall reception
of each guideline by end-users and stakeholders. e sys-
tematic search retrieved 31 articles, of which the majority
employed qualitative designs. Several negative responses
were identified that, if addressed, may inform implemen-
tation strategies needed to ultimately improve uptake of
guidelines [62].
ere were many positive responses from both end-
users and stakeholders to PA guidelines, particularly
those that targeted early years and specific clinical pop-
ulations (i.e., persons with MS and persons with SCI).
Most users felt that toddlers and preschoolers were natu-
rally active and could easily achieve the PA recommen-
dations. Although there was overall consensus for the
importance of PA and SB guidelines across age groups,
there were several difficulties in understanding and
applying them. e SB and ST guidelines for the early
years were often perceived as unrealistic with parents
relying on occupying their children with ST to accom-
plish housework and SB like strollers to transport chil-
dren to places that they can be active. Parents of older
children did not rely on ST as much; however, children
and youth reported anger and frustration towards ST
guidelines and did not see immediate value in following
PA guidelines. Adults and older adults reported that the
PA and SB guidelines were too simplistic and requested
evidence in support of the guidelines.
PA and SB guidelines are typically written with the
evidence-base in mind over the usefulness to end-users,
however, it is important that when guidelines are com-
municated to end-users, that the information is compre-
hendible and obtainable [63]. e following are several
recommendations that researchers and policymakers
could consider to improve perception and ultimately
uptake of PA and SB guidelines. Across the age-group
guidelines, users requested more lay language, definitions
of terms, and descriptions of behaviour quantification.
For example, terms such as “moderate- and vigorous-
intensity” may be described with reference to the Talk
Test that states individuals should be able to speak short
sentences during moderate-intensity PA but only a few
words at a time during vigorous-intensity PA [64]. Users
requested examples that people of varying ages, abilities,
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Page 10 of 13
Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
and socioeconomic and cultural backgrounds could
employ to achieve guideline recommendations. ese
examples should be demonstrated in visually appealing
ways with clear instructions when guidelines are being
communicated to end-users.
Users, particularly parents, need strategies for imple-
menting ST rules, for example through increased self-
efficacy of minimizing ST [65]. Parents also need to be
informed that school-based PA is inadequate for result-
ing in ongoing PA behaviours into adulthood [66, 67].
Parents requested strategies for promoting child PA dur-
ing evenings and weekends, while faced with the barriers
of limited time and busy family schedules. Family-based
PA interventions have shown promise for PA levels of
both children and parents and should be tailored to the
psychosocial environment of the family [68, 69]. Youths
requested more information of reachable health-benefits
and consequences of movement behaviours, for example,
improved cognitive outcomes including math, science,
and reading achievements or ST resulting in increased
obesity, sleep problems, depression, and anxiety [70,
71]. Further, youth may choose reasons other than those
resulting in health or cognitive benefits for being active.
For example, research has shown autonomous motiva-
tion (e.g., intrinsic motivation, integrated motivation,
and identified regulation) as an important predictor for
leisure-time PA in children and adolescents [72, 73].
erefore, guideline communication efforts targeting
youth could highlight the importance of choosing PA that
is interesting, enjoyable, and important to the individual
[73]. Adults and older adults requested more information
about evidence behind the guidelines which could be eas-
ily translated from the numerous systematic reviews that
have been conducted and published by global experts in
PA guideline development.
Health practitioners and clinical populations prefer PA
guidelines that target clinical populations. In response to
feedback from mothers of children and youth with dis-
abilities, authors from Handler and colleagues (2019)
developed an Ability Toolkit to supplement the children
& youth PA guidelines [74]. is toolkit provides exam-
ples of movement behaviours that are more applicable
to children and youth with disabilities. End-user per-
ceptions of this toolkit have not yet been collected but
responses could help inform additional tailored toolkits
for other target populations.
PA and SB/ST guidelines are put forward to achieve
maximal health benefits. at said, our findings revealed
that stakeholders and end-users were not always recep-
tive to one-size-fits-all threshold messages and that either
adding to or replacing these messages with phrases that
encourage overall more movement or less SB/ST may be
better received. More research is needed to determine
whether PA interventions that recommend changes in
movement behaviours phrased in more general terms is
still effective for resulting in health benefits.
Limitations
Despite strengths of this review, there are limitations
worth mentioning. e review was limited by the search
terms, search engines employed, and peer-reviewed arti-
cles in English. e literature was limited by insufficient
consistency of outcome measures across the quantita-
tive data that prevented any form of quantitative analysis
and an inadequate amount of articles to break down per-
ceptions of each guideline by specific end-user or stake-
holder. Articles that collected perceptions of recently
developed PA guidelines for target or clinical popula-
tions, such as pregnant and postpartum women [75,
76] or the 2018 American College of Sports Medicine
Roundtable Exercise Guidelines for Cancer Survivors
[77], were not available.
Conclusions
Guidelines have been evolving for several decades now
with minimal awareness and levels of enactment across
the globe. Available end-user and stakeholder percep-
tions indicate modifications, such as more lay language,
definitions, and implementation strategies, are needed
when guidelines are being communicated to end-users.
Perhaps a set of behavioural guidelines that target specific
end-users and stakeholders for each guideline may be the
most appropriate step forward in actualizingbehaviours
and habits.
Abbreviations
PA: Physical activity; SB: Sedentary behaviour; ST: Screen-time; PRISMA:
Preferred Reporting Items for Systematic Reviews and Meta-Analyses; MS:
Multiple sclerosis; SCI: Spinal cord injury.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12966- 022- 01245-9.
Additional le1: Supplementary Table1. Full Search Strategies for Each
Database.
Additional le2: Supplementary Table2. Extraction Data of End-user
and Stakeholder Perceptions of Physical Activity (PA) or Sedentar y Behav-
iour (SB) Guidelines.
Additional le3: Supplementary Table3. Codes for the Final Coding
Scheme.
Additional le4: Supplementary Table4. Selected Quotes for Each
Theme.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 13
Hollmanetal. Int J Behav Nutr Phys Act (2022) 19:21
Acknowledgements
The authors would like to thank Sarah Paradiso, the research assistant who
helped in extracting data and risk of bias analysis for search #1.
Authors’ contributions
HH, JU, IL, and RR were all involved in the study conceptualization and design
of the systematic review. HH and RR were responsible for generating the
systematic review terms, performing the systematic searches, extracting the
data, performing the risk of bias analyses, performing the thematic synthesis,
and for creating and revising the manuscript, tables, figures, and supplemen-
tary tables. JU and IL contributed to revisions of the manuscript, tables, figures,
and supplementary tables. All authors have read and approved the final
manuscript.
Funding
The authors did not receive any funding related to this study.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Not applicable
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Author details
1 Behavioural Medicine Laboratory, School of Exercise Science, Physical
and Health Education, University of Victoria, PO Box 1700 STN CSC, Victoria,
B.C. V8W 2Y2, Canada. 2 Kent State University, Kent, USA. 3 Duke University,
Durham, USA.
Received: 15 November 2021 Accepted: 10 January 2022
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