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Disseminating the Movement Behaviour Guidelines for Young Children in Hong Kong: Process and Outcome Evaluations

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Title: Disseminating the Movement Behaviour Guidelines for Young Children in Hong Kong: Process and Outcome Evaluations
Language: English
Authors: Catherine M. Capio (ORCID 0000-0003-1698-5740), Rachel A. Jones, Catalina S. M. Ng, Cindy H. P. Sit, Kevin K. H. Chung
Source: International Journal of Child Care and Education Policy. 2025 19.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 21
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Education Level: Early Childhood Education
Elementary Education
Kindergarten
Primary Education
Descriptors: Foreign Countries, Young Children, Physical Activities, Physical Activity Level, Health Promotion, Guidelines, Evidence Based Practice, Kindergarten, Health Behavior, Sleep, Motor Development
Geographic Terms: Hong Kong
DOI: 10.1186/s40723-025-00149-y
ISSN: 1976-5681
2288-6729
Abstract: Health promotion strategies in early childhood are needed to address the global problem of physical inactivity. In Hong Kong, where the movement guidelines recommended by the World Health Organization for young children have been adopted by the health authorities, we implemented evidence-informed dissemination strategies targeting teachers and parents in kindergarten settings. Workshops, resource materials, and social media content delivered information about the (1) specifications and rationale behind the movement guidelines; (2) benefits associated with meeting each of the guidelines; and (3) practical strategies for teachers and parents to promote the adoption and implementation of the guidelines. Using the Reach, Evaluation, Adoption, Implementation and Maintenance (RE-AIM) framework, we conducted process and outcome evaluations to assess the processes and outcomes related to the dissemination. We used a mixed-methods triangulation design-convergence model, where data were gathered through workshop audits, online surveys, focus groups, and device-based physical activity monitoring. The process evaluation suggested that enablers and barriers to implementing the movement guidelines may be rooted in policies and social expectations, but knowledge translation may be supported by tailoring the information to the Hong Kong context. The outcome evaluation revealed that the dissemination effectively increased and maintained teachers' and parents' knowledge of the guidelines for physical activity, sedentary behaviours and sleep. The physical activity of children was also enhanced, suggesting that kindergarten-based health promotion can improve children's outcomes by capitalising on the roles of teachers and parents.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1476111
Database: ERIC
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  Value: <anid>AN0186340853;[ds0u]01jul.25;2025Jul04.05:49;v2.2.500</anid> <title id="AN0186340853-1">Disseminating the movement behaviour guidelines for young children in Hong Kong: process and outcome evaluations </title> <p>Health promotion strategies in early childhood are needed to address the global problem of physical inactivity. In Hong Kong, where the movement guidelines recommended by the World Health Organization for young children have been adopted by the health authorities, we implemented evidence-informed dissemination strategies targeting teachers and parents in kindergarten settings. Workshops, resource materials, and social media content delivered information about the (<reflink idref="bib1" id="ref1">1</reflink>) specifications and rationale behind the movement guidelines; (<reflink idref="bib2" id="ref2">2</reflink>) benefits associated with meeting each of the guidelines; and (<reflink idref="bib3" id="ref3">3</reflink>) practical strategies for teachers and parents to promote the adoption and implementation of the guidelines. Using the Reach, Evaluation, Adoption, Implementation and Maintenance (RE-AIM) framework, we conducted process and outcome evaluations to assess the processes and outcomes related to the dissemination. We used a mixed-methods triangulation design-convergence model, where data were gathered through workshop audits, online surveys, focus groups, and device-based physical activity monitoring. The process evaluation suggested that enablers and barriers to implementing the movement guidelines may be rooted in policies and social expectations, but knowledge translation may be supported by tailoring the information to the Hong Kong context. The outcome evaluation revealed that the dissemination effectively increased and maintained teachers' and parents' knowledge of the guidelines for physical activity, sedentary behaviours and sleep. The physical activity of children was also enhanced, suggesting that kindergarten-based health promotion can improve children's outcomes by capitalising on the roles of teachers and parents.</p> <p>Keywords: Physical activity; Sedentary behaviour; Sleep; Implementation; Dissemination; Medical and Health Sciences Public Health and Health Services</p> <p>Supplementary Information The online version contains supplementary material available at https://doi.org/10.1186/s40723-025-00149-y.</p> <hd id="AN0186340853-2">Introduction</hd> <p>Globally, only 27% to 33% of children and adolescents meet the current recommendation of an average of one hour of moderate to vigorous physical activity (PA) daily (Aubert et al., [<reflink idref="bib1" id="ref4">1</reflink>]). However, in Hong Kong the percentage is lower, with only 20% to 26% of children aged 5–17 years meeting such PA recommendation (Huang et al., [<reflink idref="bib27" id="ref5">27</reflink>]). Similar trends are seen in younger children (i.e. aged 5 years and below), with less than 30% of young children meeting the recommended three hours of PA with at least one hour being of moderate to vigorous intensity level (Government of Hong Kong SAR, [<reflink idref="bib25" id="ref6">25</reflink>]). PA promotion within Hong Kong needs to be strengthened across all ages but specifically within the early years to prevent the decline in PA participation throughout primary school (Wong et al., [<reflink idref="bib59" id="ref7">59</reflink>]). Parents and teachers are key agents in the promotion of PA and movement behaviours for children (Klohe-Lehman et al., [<reflink idref="bib29" id="ref8">29</reflink>]; Wolbring et al., [<reflink idref="bib58" id="ref9">58</reflink>]), thus dissemination of relevant knowledge and strategies to promote children's PA among parents and teachers is urgently needed. This paper reports on the processes and outcomes of disseminating movement guidelines for young children among parents and teachers.</p> <hd id="AN0186340853-3">Movement guidelines for young children and dissemination</hd> <p>Health behaviours that track through adolescence and adulthood are formed during early childhood, making this a crucial period for health promotion (Kwon et al., [<reflink idref="bib30" id="ref10">30</reflink>]). In young children, movement behaviours consisting of PA, sedentary behaviours (SB) and sleep contribute to the health and well-being of children (WHO, [<reflink idref="bib53" id="ref11">53</reflink>]). By building upon high-quality systematic reviews and using a rigorous, systematic, and transparent method that considered the strength of current evidence, associated benefits and harms, equity, and human rights, the World Health Organization (WHO) determined that optimal combinations of movement behaviours reduce risks for adiposity and injuries, support motor and cognitive development, and enhance cardiometabolic, skeletal, and psychosocial health (Willumsen & Bull, [<reflink idref="bib57" id="ref12">57</reflink>]), and launched guidelines for movement behaviours of children under five years of age (WHO, [<reflink idref="bib54" id="ref13">54</reflink>]). These guidelines were adopted by the health authorities in Hong Kong but modified to suit the local context (i.e. the guidelines are applied for children 2–6 years; see supplementary file for details).</p> <p>Movement guidelines for young children need to be disseminated deliberately and strategically (Draper et al., [<reflink idref="bib17" id="ref14">17</reflink>]) to ensure that parents and teachers understand them and are equipped with strategies to promote behaviour change. Such dissemination is particularly important for parents and teachers of young children (i.e. those under six years). Studies have previously shown that the movement guidelines for young children were acceptable to parents and teachers in different regions, including those in Hong Kong (Capio et al., [<reflink idref="bib7" id="ref15">7</reflink>]; Draper et al., [<reflink idref="bib18" id="ref16">18</reflink>]; Riazi et al., [<reflink idref="bib43" id="ref17">43</reflink>]; Stanley et al., [<reflink idref="bib48" id="ref18">48</reflink>]). Baumann and colleagues ([<reflink idref="bib3" id="ref19">3</reflink>]) described dissemination as an active and planned process through which information (i.e. movement guidelines) is distributed to a target audience (i.e. parents and teachers), and dissemination strategies describe the approaches or actions of such process. In South Africa, 2-h workshops and distribution of printed materials were found to be feasible, acceptable, and effective strategies for disseminating the movement guidelines to community-based organisation representatives that included teachers (Draper et al., [<reflink idref="bib18" id="ref20">18</reflink>]). From an implementation perspective, the Expert Recommendations for Implementing Change (ERIC) framework (Waltz et al., [<reflink idref="bib52" id="ref21">52</reflink>]) also include conducting training, developing and distributing educational materials, and promoting adaptability as implementation strategies (Powell et al., [<reflink idref="bib42" id="ref22">42</reflink>]) that we considered relevant for dissemination in the Hong Kong context.</p> <hd id="AN0186340853-4">Environment for dissemination</hd> <p>Early childhood education settings such as kindergartens have been identified as a natural avenue for information dissemination, with multiple communication channels for parents and teachers (Stanley et al., [<reflink idref="bib48" id="ref23">48</reflink>]). Kindergartens are suitable places for the dissemination of movement guidelines in Hong Kong, as practically all children attend kindergarten classes, which consist of nursery, junior kindergarten, and senior kindergarten levels (Census & Statistics Department, [<reflink idref="bib10" id="ref24">10</reflink>]). Formative research in Hong Kong kindergartens has shown that deliberate dissemination strategies are urgently needed for parents and teachers of young children (Capio et al., [<reflink idref="bib8" id="ref25">8</reflink>], [<reflink idref="bib7" id="ref26">7</reflink>]). Parents have limited awareness and knowledge of the movement guidelines, while teachers report adequate awareness but have inaccurate knowledge of the specific guidelines. Key stakeholders from the education and health sectors suggested that the uptake of the movement guidelines would be potentially impacted by space limitations, time constraints, and high social priority for academic achievement. Dissemination, therefore, needs to consider resources that are appropriate for small homes and classrooms and would facilitate short bouts of PA.</p> <hd id="AN0186340853-5">Current study</hd> <p>In this evaluation study, we aimed to assess the processes and outcomes of disseminating the movement guidelines for young children in Hong Kong to teachers and parents in kindergartens. The key functions of a process evaluation include examining the implementation mechanisms (i.e. what, how) through which the intervention brought about change and the contexts that act as enablers or barriers to the outcomes (Moore et al., [<reflink idref="bib36" id="ref27">36</reflink>]). On the other hand, the purpose of an outcome evaluation is to assess whether the intended effects (i.e. changes in knowledge, attitudes, skills, or behaviours) occurred following programme implementation (Feldman et al., [<reflink idref="bib20" id="ref28">20</reflink>]). While verifying the intended outcomes generates evidence of effectiveness, understanding operational implementation is equally important. We therefore expect that the synthesised findings from the process and outcome evaluations can facilitate further strategy development and inform decision-making in similar health promotion work (Skivington et al., [<reflink idref="bib46" id="ref29">46</reflink>]), not only in Hong Kong but also in places where similar contexts might be present (e.g., Singapore, Macau, China).</p> <p>The process and outcome evaluations were guided by the RE-AIM framework (Glasgow et al., [<reflink idref="bib24" id="ref30">24</reflink>]), which has been used as a framework for both dissemination and implementation (Baumann et al., [<reflink idref="bib3" id="ref31">3</reflink>]). This framework consists of five dimensions: reach (R), effectiveness (E), adoption (A), implementation (I), and maintenance (M). Reach refers to the extent of participation by the target audience, effectiveness is the impact of the intervention on the target outcomes, adoption is the extent to which the target audience accepts the program, implementation is the consistency of program delivery, and maintenance is the extent to which behaviour change is maintained over time (Glasgow et al., [<reflink idref="bib23" id="ref32">23</reflink>]). Evaluations based on the RE-AIM framework adopt a broad focus on multiple contextual factors that impact the uptake of evidence-based health interventions (Glasgow et al., [<reflink idref="bib22" id="ref33">22</reflink>]). Our process evaluation specifically focused on (<reflink idref="bib1" id="ref34">1</reflink>) assessing the extent of participation in the dissemination activities and adoption of the movement guidelines among parents and teachers of children in kindergartens and (<reflink idref="bib2" id="ref35">2</reflink>) identifying the enablers and barriers to the delivery and use of the movement guidelines from the parents' and teachers' perspectives. Our outcome evaluation assessed the impact of the dissemination activities on (<reflink idref="bib1" id="ref36">1</reflink>) parents' and teachers' awareness and knowledge of the movement guidelines, and (<reflink idref="bib2" id="ref37">2</reflink>) children's likelihood of meeting the movement guidelines.</p> <hd id="AN0186340853-6">Methods</hd> <p>All procedures were reviewed and approved by the research ethics committee of the last author's affiliated university (Ref. 2019–2020-0145).</p> <hd id="AN0186340853-7">Dissemination strategies</hd> <p>Drawing from the findings of Draper and colleagues ([<reflink idref="bib18" id="ref38">18</reflink>]) and the recommendations of implementation experts in the ERIC project (Powell et al., [<reflink idref="bib42" id="ref39">42</reflink>]), the dissemination strategies consisted of workshops, distribution of resource materials, and sharing of social media content (Table 1). Two-hour workshops were held separately for parents and teachers in each participating kindergarten. Printed resource materials (i.e. booklets) that summarised the movement guidelines for young children were also distributed to the workshop participants; additional copies of these booklets were given to the kindergartens for further distribution to parents and teachers who missed attending the workshop. Posters and flyers were also distributed to the kindergartens, which they displayed on the premises of the kindergarten over the course of the school year (i.e. 2021–2022). Practical ideas on how to promote PA, SB, and sleep guidelines were shared via social media (i.e. WhatsApp group) to parents and teachers on a weekly basis during the period of implementation. The content of the dissemination strategies was informed by formative work with local stakeholders (Capio et al., [<reflink idref="bib8" id="ref40">8</reflink>], [<reflink idref="bib7" id="ref41">7</reflink>]) and included: (<reflink idref="bib1" id="ref42">1</reflink>) specifications and rationale behind the movement guidelines; (<reflink idref="bib2" id="ref43">2</reflink>) benefits associated with meeting each of the guidelines; and (<reflink idref="bib3" id="ref44">3</reflink>) practical strategies for teachers (i.e. in class) and parents (i.e. daily activities) to promote young children's uptake of the movement guidelines.</p> <p>Table 1 Dissemination strategies were implemented by the participating kindergartens</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Participant groups</p></th><th align="left"><p>Activity</p></th><th align="left"><p>Description</p></th></tr></thead><tbody><tr><td align="left"><p>(1) Teachers</p><p>(2) Parents and primary caregivers</p></td><td align="left"><p>Workshop</p></td><td align="left"><p>• Conducted on-site at the kindergarten and delivered separately for the participant groups</p><p>• The content included an introduction to the movement guidelines, the rationale and evidence behind the guidelines, and practical strategies that can enable children to meet the guidelines</p><p>• The delivery and content were tailored according to the needs of the participant groups (e.g., lesson context for teachers, and home context for parents)</p><p>• Duration: 2 h per workshop</p></td></tr><tr><td align="left" /><td align="left"><p>Social media</p></td><td align="left"><p>• Reminders through online messaging chat groups (i.e. WhatsApp) reinforced the concepts that were introduced in the educational meetings</p><p>• Participants could ask questions/clarifications, which the project team responded to</p><p>• Practical strategies for daily activities were shared through WhatsApp and Facebook</p></td></tr><tr><td align="left" /><td align="left"><p>Resource materials</p></td><td align="left"><p>• Printed materials (i.e. posters, brochures, activity sheets) were delivered to the kindergartens, which they either posted on the kindergarten premises or distributed to teachers and parents (including to those who did not attend the workshop)</p><p>• Videos and picture cards were shared through WhatsApp and Facebook</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0186340853-8">Evaluation framework and design</hd> <p>Table 2 outlines the alignment of the RE-AIM framework with the process and outcome evaluations, alongside the objectives, methods, and specific evaluation questions. The dimensions of Reach, Adoption and Implementation were examined in the process evaluation using a mixed-methods triangulation design-convergence model, with equal weight drawn from the quantitative and qualitative components (Creswell & Plano Clark, [<reflink idref="bib15" id="ref45">15</reflink>]). Quantitative data were gathered through workshop audits and online surveys; qualitative data were gathered through focus groups. The dimensions of Effectiveness and Maintenance were examined in the outcome evaluation using a non-randomised observational design. The following outcomes were assessed: (<reflink idref="bib1" id="ref46">1</reflink>) awareness and knowledge of the movement behaviour guidelines among parents and teachers; (<reflink idref="bib2" id="ref47">2</reflink>) extent to which children met the guidelines for PA, SB, and sleep; and (<reflink idref="bib3" id="ref48">3</reflink>) objectively measured PA of children. Quantitative data were gathered through online surveys and device-based PA monitoring; qualitative data were gathered through online surveys. All data gathering instruments were administered in Chinese. English-language validated questionnaires were translated and back-translated following standard procedures (Brislin, 1970). Figure 1 illustrates the flow of data gathering procedures for the process and outcome evaluations, including the relevant RE-AIM dimensions.</p> <p>Table 2 Methods and questions for the elements of the RE-AIM framework (Glasgow et al., [<reflink idref="bib24" id="ref49">24</reflink>])</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Evaluation</p></th><th align="left"><p>Objectives</p></th><th align="left"><p>RE-AIM dimension</p></th><th align="left"><p>Operational definition</p></th><th align="left"><p>Methods</p></th><th align="left"><p>Evaluation questions</p></th></tr></thead><tbody><tr><td align="left" rowspan="6"><p>Process</p></td><td align="left" rowspan="4"><p>To assess the extent of participation in the dissemination activities and adoption of the movement guidelines among parents and teachers of children in kindergartens</p></td><td align="left"><p>Reach</p></td><td align="left" rowspan="2"><p>Extent of participation in dissemination activities</p></td><td align="left" rowspan="2"><p>Workshop audit <sup>a</sup></p></td><td align="left"><p>How many workshops were conducted in the participating kindergarten?</p></td></tr><tr><td align="left" /><td align="left"><p>How many teachers and parents joined the WhatsApp groups following the workshops?</p></td></tr><tr><td align="left" rowspan="2"><p>Adoption</p></td><td align="left" rowspan="2"><p>Acceptance of the guidelines</p></td><td align="left"><p>Workshop audit <sup>a</sup></p><p>Online survey <sup>a</sup></p></td><td align="left"><p>How did the teachers and parents rate the value of the workshops?</p><p>How did the teachers and parents rate the utility of dissemination activities?</p></td></tr><tr><td align="left"><p>Focus group <sup>b</sup></p></td><td align="left"><p>What are the strategies that kindergartens implement to support the parents and teachers in applying their knowledge to promote healthy movement behaviours?</p></td></tr><tr><td align="left" rowspan="2"><p>To identify the enablers and barriers to the delivery and use of the movement guidelines from the parents' and teachers' perspectives</p></td><td align="left"><p>Implementation</p></td><td align="left"><p>Delivery and use of the guidelines</p></td><td align="left"><p>Online survey <sup>c</sup></p></td><td align="left"><p>Did the dissemination activities promote awareness and knowledge of the movement guidelines?</p><p>To what extent did the teachers and parents find the movement guidelines easy/difficult to implement?</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Online survey <sup>c</sup> Focus group <sup>b</sup></p></td><td align="left"><p>What were the factors in the school, home, community, or social contexts that influenced the uptake of the movement guidelines (enablers, barriers)?</p></td></tr><tr><td align="left" rowspan="3"><p>Outcome</p></td><td align="left" rowspan="3"><p>To assess the impact of the dissemination activities on (1) parents' and teachers' awareness and knowledge of the movement guidelines and (2) children's likelihood of meeting the movement guidelines</p></td><td align="left" rowspan="2"><p>Effectiveness</p></td><td align="left" rowspan="2"><p>Impact of the dissemination activities on the teachers, parents, and children</p></td><td align="left" rowspan="2"><p>Online survey <sup>d</sup></p><p>PA monitoring <sup>e</sup></p></td><td align="left"><p>To what extent were teachers and parents of the implementation group aware and knowledgeable of the movement guidelines following implementation?</p><p>To what extent did children from the implementation group meet the guidelines for (1) physical activity, (2) sedentary behaviour, and (3) sleep?</p></td></tr><tr><td align="left"><p>Did children from the implementation group accrue greater physical activity compared to those from the comparison group?</p></td></tr><tr><td align="left"><p>Maintenance</p></td><td align="left"><p>Sustained awareness and knowledge of the guidelines</p></td><td align="left"><p>Online survey <sup>f</sup></p></td><td align="left"><p>To what extent were teachers and parents of the implementation aware and knowledgeable of the movement guidelines at 6 months post-implementation?</p></td></tr></tbody></table> </ephtml> </p> <p> <sups>a</sups> <emph>n</emph> = 158 parents, <emph>n</emph> = 91 teachers; <sups>b</sups><emph>n</emph> = 10 parents, <emph>n</emph> = 20 teachers; <sups>c</sups><emph>n</emph> = 102 parents, <emph>n</emph> = 28 teachers (first term); <emph>n</emph> = 336 parents, <emph>n</emph> = 48 teachers (second term); <sups>d</sups><emph>n</emph> = 293 parents, <emph>n</emph> = 44 teachers; <sups>e</sups><emph>n</emph> = 41 children; <sups>f</sups><emph>n</emph> = 143 parents, <emph>n</emph> = 28 teachers</p> <p>Graph: Fig. 1 Data gathering procedures for the process and outcome evaluation components</p> <hd id="AN0186340853-9">Participants</hd> <p>Eight kindergartens from across representative districts with middle socioeconomic backgrounds in Hong Kong participated in the dissemination activities and evaluation (i.e. implementation group). A second group of six kindergartens with comparable socioeconomic backgrounds and from the same representative districts participated only in the outcome evaluation for comparison (i.e. comparison group). Children enrolled in Hong Kong kindergartens are aged 3 to 6 years old. The dissemination strategies were facilitated over one school year during the period of the COVID-19 pandemic. Each kindergarten in the implementation group was informed that they could have up to six workshops delivered in-person (i.e. three each for teachers and parents). However, due to the pandemic-related school suspensions in Hong Kong, only two workshops (i.e. one each for teachers and parents) were eventually delivered in-person for most kindergartens. For one kindergarten, two workshops were held for teachers and one for parents. Kindergartens in the comparison group first participated in the outcome evaluation through online surveys for parents and teachers, and PA monitoring of children. Workshops were subsequently held for parents and teachers in the comparison kindergartens post-evaluation. Because the participants were recruited via the kindergartens, the actual number of participating individuals varied across the evaluation processes (see Table 2).</p> <hd id="AN0186340853-10">Process evaluation procedures</hd> <p></p> <hd id="AN0186340853-11">Workshop audits</hd> <p>Reach and Adoption were assessed using the workshop audit data. The participating kindergarten invited teachers and parents to attend the workshops, which were delivered in-person and on-site. The number of workshops held in each kindergarten and the number of participants (parents and teachers) attending each workshop was recorded. After each workshop, participants completed a short questionnaire (7-point Likert-type scale) which asked questions about the value of the workshop (higher scores represented greater perceived value). As shown in Table 2, responses were recorded from 126 parents and 73 teachers from eight kindergartens in the implementation group.</p> <hd id="AN0186340853-12">Online surveys</hd> <p>Online surveys were administered twice (i.e. one survey per school term) to assess Adoption and Implementation. The survey comprised seven-point Likert-type scales, close-ended dichotomous questions (i.e. Yes or No, adapted from Kay et al. ([<reflink idref="bib28" id="ref50">28</reflink>]) and LeBlanc et al. ([<reflink idref="bib32" id="ref51">32</reflink>])) and open-ended questions. The Likert-type scales were used to assess adoption and included questions about the helpfulness and usefulness (higher scores represented greater perceived utility) of the social media information and participants' perceived difficulty (higher scores represented greater difficulty) in promoting the movement guidelines in school or home settings. The dichotomous and open-ended questions were used to evaluate implementation, based on whether the dissemination activities promoted participants' awareness of PA, SB, and sleep guidelines, and knowledge of the recommended time for each movement behaviour. Open-ended questions also queried about the perceived barriers and enablers of promoting the movement guidelines. The participating kindergartens forwarded the invitations to the teachers and parents of children in their respective kindergartens, regardless of whether they joined the workshop or not. Valid responses were gathered from 102 parents and 28 teachers in the first term and 336 parents and 48 teachers in the second term (see Table 2).</p> <hd id="AN0186340853-13">Focus groups</hd> <p>Focus groups were conducted to gather insights about Adoption and Implementation. Two researchers moderated the discussions, which explored participants' (a) access to information related to the guidelines; (b) strategies and efforts to promote the movement guidelines among their pupils or children; and (c) perceived enablers and barriers to implementing the movement guidelines. Focus groups were organised during the period when there was increasing concern among kindergartens in relation to the pandemic. Consequently, only six kindergartens agreed to participate, and focus groups were organised online (i.e. via Zoom) to avoid in-person contact. Six focus groups involving 20 teachers and three focus groups involving 10 parents were conducted. The teachers were all females, and they had been in their current roles for two to eight years of teaching. The parents were mostly mothers (80%). Three scheduled focus groups with parents were cancelled due to the heightened severity of the pandemic situation in Hong Kong at that time.</p> <hd id="AN0186340853-14">Outcome evaluation procedures</hd> <p></p> <hd id="AN0186340853-15">Online surveys</hd> <p>Two further online surveys were administered to inform Effectiveness (i.e. at the end of the school year) and Maintenance (i.e. at 6 months later). The surveys consisted of similar questions to assess the teachers'awareness and knowledge of PA, SB, and sleep guidelines that were used in the process evaluation. Additionally, the parents responded to items from validated English-language questionnaires (Corder et al., [<reflink idref="bib14" id="ref52">14</reflink>]; Wijndaele et al., [<reflink idref="bib56" id="ref53">56</reflink>]) that measured the extent to which children met the movement guidelines. The questionnaire has good internal consistency (Cronbach's alpha = 0.762) and has also been used in a longitudinal study of child development in Hong Kong (Capio et al., [<reflink idref="bib5" id="ref54">5</reflink>]). To assess the effectiveness, the survey was administered to teachers and parents from implementation and comparison kindergartens. Valid responses were collected from 44 teachers (<emph>n</emph> = 23 implementation; <emph>n</emph> = 21 comparison) and 293 parents (<emph>n</emph> = 146 implementation; <emph>n</emph> = 143 comparison). To assess maintenance, the survey was again administered to teachers and parents of implementation kindergartens (<emph>n</emph> = 28 teachers; <emph>n</emph> = 143 parents) 6 months later.</p> <hd id="AN0186340853-16">PA monitoring</hd> <p>To further assess Effectiveness, we conducted device-based PA monitoring. We used the Digi-Walker CW700 (Yamax Co.), which has been validated for measuring PA among preschool children (McKee et al., [<reflink idref="bib34" id="ref55">34</reflink>]). Pedometers count steps and are widely considered a suitable tool for objective measurement of ambulatory PA in children (Clemes & Biddle, [<reflink idref="bib12" id="ref56">12</reflink>]). More recently, pedometers have been recommended as a suitable tool for PA surveillance in early childhood (Mwase-Vuma et al., [<reflink idref="bib39" id="ref57">39</reflink>]). Out of the participants who responded to the online survey at the end of the school year, 76 parents indicated willingness for their children to participate in PA monitoring, but only 48 parents eventually consented. Pedometers were sent to the participants' homes by post, along with the instructions for wearing, removal, and recording (i.e. time on and off). A 7-day monitoring period was prescribed, after which the parents returned pedometers to the kindergartens. A minimum of 4 days of recorded data was required for analysis, and 41 participants (<emph>n</emph> = 21 implementation group, <emph>n</emph> = 20 comparison group) returned sufficient data.</p> <hd id="AN0186340853-17">Data processing and analysis</hd> <p></p> <hd id="AN0186340853-18">Quantitative data analysis</hd> <p>The data from close-ended questions in the surveys were analysed using descriptive statistics to determine the percentages of parents and teachers who were aware and knowledgeable of the movement guidelines. Similarly, descriptive statistics were used to analyse the data from the parent-proxy questionnaire to determine the percentages of children who met the guidelines for PA, SB, and sleep. The outcomes of the implementation and comparison of kindergartens were compared using Chi-square tests. The data from device-based PA monitoring were compared between the implementation and comparison groups using analysis of covariance, accounting for participants' characteristics. Finally, given the binary outcomes, logistic regression was conducted (Harris, [<reflink idref="bib26" id="ref58">26</reflink>]) to determine the contribution of the intervention (i.e. implementation or control group) to the likelihood of (a) parents and teachers having knowledge of the guidelines and (b) children meeting each guideline component. All statistical analysis procedures were performed using SPSS 27.0 with statistical significance set at p < 0.05.</p> <hd id="AN0186340853-19">Qualitative data analysis</hd> <p>A realist framework was adopted where language is assumed to capture participants' experiences of reality (Terry et al., [<reflink idref="bib50" id="ref59">50</reflink>]). Thematic analysis was conducted following a six-phase analytic approach (Clarke & Braun, [<reflink idref="bib11" id="ref60">11</reflink>]). The analysis was guided by the evaluation questions related to the participants' participation in the dissemination activities and adoption of the movement guidelines, as well as the enablers and barriers to their implementation. To ensure the trustworthiness of the analysis, a team of three members read the transcripts and performed coding independently (bilingual members read the original and translated transcripts). Coding and theme generation were inductive (i.e. bottom up) and semantic (i.e. the explicit meaning of gathered data) to align with the realist framework. The researchers engaged in three rounds of iterative discussions to discuss the codes that were independently generated and develop themes that deliberately explored multiple interpretations and reflexivity (Smith & McGannon, [<reflink idref="bib47" id="ref61">47</reflink>]). Thematic analysis was supported by NVivo 12.0.</p> <hd id="AN0186340853-20">Results</hd> <p></p> <hd id="AN0186340853-21">Process evaluation</hd> <p></p> <hd id="AN0186340853-22">Reach</hd> <p>Seventeen workshops were conducted, of which eight sessions were for parents and nine sessions were for teachers. A total of 158 parents and 91 teachers attended one workshop each and received printed resource materials on the rationale and specifications of the movement guidelines. Among those who responded to the workshop audit questionnaire (<emph>n</emph> = 199; 126 parents, 73 teachers), 92% (<emph>n</emph> = 183) provided their contact details to join the designated social media messaging group on WhatsApp (i.e. separate groups for parents and teachers). The parents and teachers in the messaging groups received practical suggestions related to implementing the movement guidelines in the context of school activities (for teachers) and home routines (for parents).</p> <hd id="AN0186340853-23">Adoption</hd> <p>On the seven-point Likert scale, the parents rated the workshops' informative value as 6.25 (SD = 0.98), while the teachers rated it as 5.92 (SD = 0.81). The parents' rating of the information disseminated on social media on helpfulness was 5.73 (SD = 1.16) and on usefulness was 5.80 (<emph>SD</emph> = 1.32). The teachers' rating on the helpfulness of the disseminated information was 5.38 (<emph>SD</emph> = 0.51) and on usefulness was 5.54 (<emph>SD</emph> = 0.78).</p> <p>From the focus groups, the teachers reported that adopting the movement guidelines was made possible by the <emph>availability of equipment and materials</emph> that support physical play in the kindergartens. For instance, the teachers noted that following the workshops, play areas (e.g., climbing wall) improved and the availability of equipment (e.g., bicycles, balls) increased. The teachers further reported that adopting the movement guidelines meant their <emph>teaching approaches changed</emph>, with some teachers integrating movement into other learning areas. They described strategies that included warm-up physical activities at the start of each class, integrating movements into the learning themes and with music and rhythm, and adding movement to story-telling.</p> <hd id="AN0186340853-24">Implementation</hd> <p>The percentage of parents and teachers who were aware of the movement guidelines and had knowledge of the movement guidelines increased during the implementation period; higher levels of awareness than knowledge was reported (Table 3).</p> <p>Table 3 Percentage of teachers and parents who were aware and had knowledge of the movement guidelines during the process evaluation</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" colspan="6"><p>Movement guidelines</p></th></tr><tr><th align="left" /><th align="left" colspan="2"><p>Physical activity</p></th><th align="left" colspan="2"><p>Sedentary behaviour</p></th><th align="left" colspan="2"><p>Sleep</p></th></tr><tr><th align="left" /><th align="left"><p>Term 1</p></th><th align="left"><p>Term 2</p></th><th align="left"><p>Term 1</p></th><th align="left"><p>Term 2</p></th><th align="left"><p>Term 1</p></th><th align="left"><p>Term 2</p></th></tr></thead><tbody><tr><td align="left" colspan="7"><p>Awareness of the guidelines (teachers)</p></td></tr><tr><td align="left"><p> Aware</p></td><td align="left"><p>46.4</p></td><td char="." align="char"><p>85.2</p></td><td char="." align="char"><p>39.3</p></td><td char="." align="char"><p>75.9</p></td><td char="." align="char"><p>39.3</p></td><td char="." align="char"><p>70.4</p></td></tr><tr><td align="left"><p> Not sure</p></td><td align="left"><p>0</p></td><td char="." align="char"><p>9.3</p></td><td char="." align="char"><p>7.2</p></td><td char="." align="char"><p>14.8</p></td><td char="." align="char"><p>7.1</p></td><td char="." align="char"><p>16.7</p></td></tr><tr><td align="left"><p> Not aware</p></td><td align="left"><p>53.6</p></td><td char="." align="char"><p>5.6</p></td><td char="." align="char"><p>53.6</p></td><td char="." align="char"><p>9.3</p></td><td char="." align="char"><p>53.6</p></td><td char="." align="char"><p>13.0</p></td></tr><tr><td align="left" colspan="7"><p>Awareness of the guidelines (parents)</p></td></tr><tr><td align="left"><p> Aware</p></td><td align="left"><p>64.7</p></td><td char="." align="char"><p>80.0</p></td><td char="." align="char"><p>55.9</p></td><td char="." align="char"><p>71.1</p></td><td char="." align="char"><p>64.7</p></td><td char="." align="char"><p>75.6</p></td></tr><tr><td align="left"><p> Not sure</p></td><td align="left"><p>15.7</p></td><td char="." align="char"><p>13.3</p></td><td char="." align="char"><p>20.6</p></td><td char="." align="char"><p>22.2</p></td><td char="." align="char"><p>17.6</p></td><td char="." align="char"><p>15.6</p></td></tr><tr><td align="left"><p> Not aware</p></td><td align="left"><p>19.6</p></td><td char="." align="char"><p>6.7</p></td><td char="." align="char"><p>23.5</p></td><td char="." align="char"><p>6.7</p></td><td char="." align="char"><p>17.6</p></td><td char="." align="char"><p>8.9</p></td></tr><tr><td align="left" colspan="7"><p>Knowledge of the guidelines (teachers)</p></td></tr><tr><td align="left"><p> Correct knowledge</p></td><td align="left"><p>42.9</p></td><td char="." align="char"><p>57.4</p></td><td char="." align="char"><p>32.1</p></td><td char="." align="char"><p>38.9</p></td><td char="." align="char"><p>35.7</p></td><td char="." align="char"><p>70.4</p></td></tr><tr><td align="left"><p> Incorrect knowledge</p></td><td align="left"><p>57.2</p></td><td char="." align="char"><p>42.6</p></td><td char="." align="char"><p>67.8</p></td><td char="." align="char"><p>61.1</p></td><td char="." align="char"><p>64.3</p></td><td char="." align="char"><p>29.6</p></td></tr><tr><td align="left" colspan="7"><p>Knowledge of the guidelines (parents)</p></td></tr><tr><td align="left"><p> Correct knowledge</p></td><td align="left"><p>59.5</p></td><td char="." align="char"><p>55.6</p></td><td char="." align="char"><p>55.0</p></td><td char="." align="char"><p>62.2</p></td><td char="." align="char"><p>76.1</p></td><td char="." align="char"><p>84.4</p></td></tr><tr><td align="left"><p> Incorrect knowledge</p></td><td align="left"><p>40.5</p></td><td char="." align="char"><p>44.4</p></td><td char="." align="char"><p>45.0</p></td><td char="." align="char"><p>37.8</p></td><td char="." align="char"><p>23.9</p></td><td char="." align="char"><p>15.6</p></td></tr></tbody></table> </ephtml> </p> <p>Data are presented as percentages</p> <p>Participants (parents and teachers) perceived that the difficulty of integrating the movement guidelines increased in the second term of the school year (see Table 4), which was impacted by a period of pandemic-related school suspension. As such, the teachers were limited to providing learning activities that the parents implemented at home.</p> <p>Table 4 Teachers' and parents' ratings of the difficulties with integrating the movement behaviour guidelines at school and home settings, respectively</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" colspan="6"><p>Perceived difficulty<sup>a</sup></p><p>Mean (SD)</p></th></tr><tr><th align="left" /><th align="left" colspan="2"><p>Physical activity</p></th><th align="left" colspan="2"><p>Sedentary behaviour</p></th><th align="left" colspan="2"><p>Sleep</p></th></tr><tr><th align="left" /><th align="left"><p>Term 1</p></th><th align="left"><p>Term 2<sup>b</sup></p></th><th align="left"><p>Term 1</p></th><th align="left"><p>Term 2<sup>b</sup></p></th><th align="left"><p>Term 1</p></th><th align="left"><p>Term 2<sup>b</sup></p></th></tr></thead><tbody><tr><td align="left"><p>Teachers</p></td><td char="(" align="char"><p>4.46 (1.66)</p></td><td char="(" align="char"><p>5.04 (1.67)</p></td><td char="(" align="char"><p>3.77(1.74)</p></td><td char="(" align="char"><p>4.15 (1.59)</p></td><td char="(" align="char"><p>4.69 (1.49)</p></td><td char="(" align="char"><p>3.62 (1.92)</p></td></tr><tr><td align="left"><p>Parents</p></td><td char="(" align="char"><p>3.28 (1.58)</p></td><td char="(" align="char"><p>5.35 (1.58)</p></td><td char="(" align="char"><p>3.55 (1.53)</p></td><td char="(" align="char"><p>3.64 (1.55)</p></td><td char="(" align="char"><p>3.31 (1.65)</p></td><td char="(" align="char"><p>3.67 (1.62)</p></td></tr></tbody></table> </ephtml> </p> <p> <sups>a</sups> Rated using a 7-point Likert-type scale with higher scores reflecting greater difficulty; <sups>b</sups> Term 2 was during a period of pandemic-related school suspension</p> <p>Four enablers of implementing the movement guidelines were identified from the focus groups and the open-ended questions: <emph>(a) stakeholders' understanding of the rationale behind the guidelines; (b) availability and accessibility of physical space in the kindergartens; (c) access to resources for practical activities; and (d) presence of social motivators for children</emph>.</p> <p>The teachers suggested that understanding the rationale of the guidelines resulted in prioritisation and integration of the guidelines into their teaching. The teachers further noted that physical spaces such as playgrounds and grass fields within the vicinity of kindergartens make physical activities possible. However, such spaces were not available most of the time during the pandemic period which affected the teachers' ability to integrate the guidelines in the learning activities. The parents, on the other hand, thought that their children were more active when they attended kindergartens, simply due to the larger physical space compared to their home environment. While the teachers suggested that examples of practical activities for kindergarten settings helped them integrate the movement guidelines into their curricula, the parents suggested that these examples were also helpful in adjusting family routines at home. Finally, siblings and friends were described as important enablers for parents to promote the guidelines to children. For instance, siblings tend to support reducing gadget-related SB, and friends motivate children to engage in outdoor play.</p> <p>The following barriers were described to affect the implementation of movement guidelines: <emph>(a) kindergarten curriculum requirements and education policies; (b) time constraints; (c) limited access to information; and (d) limited options in the community physical environment</emph>.</p> <p>The teachers noted that teaching the mandated academic learning areas in the kindergarten curriculum filled the schedule, making it challenging to integrate promotion of the movement guidelines. The teachers felt the pressure to focus on academic learning areas as the broader education policies (i.e. primary and secondary education) also heavily focused on academics. For example, local education authorities have clear guidelines for numeracy and language (i.e. Chinese and English) but not for physical fitness and health. The second barrier appears to be related to the first, as teachers perceived limited time for promoting the recommended movement behaviours while balancing academic expectations. The relative lack of focus on physical health in kindergarten is also believed to prevent teachers from acquiring specialised knowledge and skills in relation to movement behaviours.</p> <p>The parents suggested that the absence of available reliable information about ongoing community activities (e.g., sports classes, and activity clubs) made it difficult to promote movement activities outside of the kindergartens. Many parents perceived that such activities were few, while others thought that classes/clubs were available but there were no reliable information channels. Finally, the parents described the physical environment in their communities as insufficient and inconsistent because the availability of open spaces varied greatly even within the same districts.</p> <hd id="AN0186340853-25">Outcome evaluation</hd> <p></p> <hd id="AN0186340853-26">Effectiveness</hd> <p>At the end of the school year, greater percentages of teachers in the implementation group compared to the comparison group were aware of the movement guidelines (Table 5). However, the difference was significant only for SB (<emph>χ</emph><sups><emph>2</emph></sups> = 7.96, <emph>p</emph> = 0.019). There were significantly greater percentages of teachers in the implementation than the comparison group who had the correct knowledge of the guidelines for PA (<emph>χ</emph><sups><emph>2</emph></sups> = 19.57, <emph>p</emph> < 0.001), SB (<emph>χ</emph><sups><emph>2</emph></sups> = 5.60, <emph>p</emph> = 0.018), and sleep (<emph>χ</emph><sups><emph>2</emph></sups> = 26.14, <emph>p</emph> < 0.001). Logistic regression revealed that after controlling for teachers' educational attainment and years of experience, teachers from the implementation group were more likely to have correct knowledge of the guidelines for PA (<emph>B</emph> = 7.26, <emph>p</emph> = 0.011) and sleep (<emph>B</emph> = 6.92, <emph>p</emph> = 0.019), but not for SB (<emph>B</emph> = 1.79, <emph>p</emph> = 0.112). Logistic regression results are in the supplementary files.</p> <p>Table 5 Percentage of teachers and parents in the implementation and comparison kindergartens who were aware and knowledgeable of the movement guidelines as an immediate outcome</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" colspan="6"><p>Movement guidelines</p></th></tr><tr><th align="left" /><th align="left" colspan="2"><p>Physical activity</p></th><th align="left" colspan="2"><p>Sedentary behaviour</p></th><th align="left" colspan="2"><p>Sleep</p></th></tr><tr><th align="left" /><th align="left"><p>Implementation</p></th><th align="left"><p>Comparison</p></th><th align="left"><p>Implementation</p></th><th align="left"><p>Comparison</p></th><th align="left"><p>Implementation</p></th><th align="left"><p>Comparison</p></th></tr></thead><tbody><tr><td align="left" colspan="7"><p>Awareness of the guidelines (teachers)</p></td></tr><tr><td align="left"><p> Aware</p></td><td char="." align="char"><p>90.7</p></td><td char="." align="char"><p>75.0</p></td><td char="." align="char"><p>81.3</p></td><td char="." align="char"><p>58.3</p></td><td char="." align="char"><p>84.4</p></td><td char="." align="char"><p>66.6</p></td></tr><tr><td align="left"><p> Not sure</p></td><td char="." align="char"><p>6.3</p></td><td char="." align="char"><p>16.7</p></td><td char="." align="char"><p>3.1</p></td><td char="." align="char"><p>33.3</p></td><td char="." align="char"><p>6.3</p></td><td char="." align="char"><p>16.7</p></td></tr><tr><td align="left"><p> Not aware</p></td><td char="." align="char"><p>4.0</p></td><td char="." align="char"><p>8.3</p></td><td char="." align="char"><p>15.6</p></td><td char="." align="char"><p>8.3</p></td><td char="." align="char"><p>9.3</p></td><td char="." align="char"><p>16.7</p></td></tr><tr><td align="left" colspan="7"><p>Awareness of the guidelines (parents)</p></td></tr><tr><td align="left"><p> Aware</p></td><td char="." align="char"><p>77.4</p></td><td char="." align="char"><p>46.3</p></td><td char="." align="char"><p>71.9</p></td><td char="." align="char"><p>41.8</p></td><td char="." align="char"><p>71.9</p></td><td char="." align="char"><p>44.2</p></td></tr><tr><td align="left"><p> Not sure</p></td><td char="." align="char"><p>17.1</p></td><td char="." align="char"><p>34.0</p></td><td char="." align="char"><p>19.9</p></td><td char="." align="char"><p>36.3</p></td><td char="." align="char"><p>21.2</p></td><td char="." align="char"><p>31.3</p></td></tr><tr><td align="left"><p> Not aware</p></td><td char="." align="char"><p>5.5</p></td><td char="." align="char"><p>19.7</p></td><td char="." align="char"><p>8.2</p></td><td char="." align="char"><p>21.9</p></td><td char="." align="char"><p>6.8</p></td><td char="." align="char"><p>24.5</p></td></tr><tr><td align="left" colspan="7"><p>Knowledge of the guidelines (teachers)</p></td></tr><tr><td align="left"><p> Correct</p></td><td char="." align="char"><p>81.3</p></td><td char="." align="char"><p>8.3</p></td><td char="." align="char"><p>46.9</p></td><td char="." align="char"><p>8.3</p></td><td char="." align="char"><p>93.8</p></td><td char="." align="char"><p>16.7</p></td></tr><tr><td align="left"><p> Incorrect</p></td><td char="." align="char"><p>18.7</p></td><td char="." align="char"><p>91.7</p></td><td char="." align="char"><p>53.1</p></td><td char="." align="char"><p>91.7</p></td><td char="." align="char"><p>6.2</p></td><td char="." align="char"><p>83.3</p></td></tr><tr><td align="left" colspan="7"><p>Knowledge of the guidelines (parents)</p></td></tr><tr><td align="left"><p> Correct</p></td><td char="." align="char"><p>31.5</p></td><td char="." align="char"><p>14.9</p></td><td char="." align="char"><p>39.7</p></td><td char="." align="char"><p>23.6</p></td><td char="." align="char"><p>76.0</p></td><td char="." align="char"><p>54.1</p></td></tr><tr><td align="left"><p> Incorrect</p></td><td char="." align="char"><p>68.5</p></td><td char="." align="char"><p>85.1</p></td><td char="." align="char"><p>60.3</p></td><td char="." align="char"><p>76.4</p></td><td char="." align="char"><p>24.0</p></td><td char="." align="char"><p>45.9</p></td></tr></tbody></table> </ephtml> </p> <p>Data are presented as percentages</p> <p>Significantly greater percentages of parents from the implementation than the comparison group were aware of the guidelines for PA (<emph>χ</emph><sups><emph>2</emph></sups> = 31.44, <emph>p</emph> < 0.001), SB (<emph>χ</emph><sups><emph>2</emph></sups> = 27.78, <emph>p</emph> < 0.001), and sleep (<emph>χ</emph><sups><emph>2</emph></sups> = 27.03, <emph>p</emph> < 0.001). There were also significantly greater percentages of parents who had correct knowledge of the guidelines for PA (<emph>χ</emph><sups><emph>2</emph></sups> = 11.45, <emph>p</emph> = 0.001), SB (<emph>χ</emph><sups><emph>2</emph></sups> = 8.78, <emph>p</emph> = 0.003), and sleep (<emph>χ</emph><sups><emph>2</emph></sups> = 15.59, <emph>p</emph> < 0.001). Logistic regression revealed that after controlling for the available living space and educational attainment of parents, parents from the implementation group were more likely to have the correct knowledge of the guidelines for PA (B = 2.98, <emph>p</emph> < 0.001), SB (<emph>B</emph> = 2.62, <emph>p</emph> < 0.001), and sleep (<emph>B</emph> = 2.35, <emph>p</emph> < 0.001).</p> <p>High compliance with sleep guidelines was observed, with 100% of children from the implementation group and 94% of those from the comparison group meeting the recommended amount of daily sleep and the difference between groups was not significant (<emph>χ</emph><sups><emph>2</emph></sups> = 3.52, <emph>p</emph> = 0.06). A significantly greater percentage of children from the implementation group (81%) met the SB guidelines (<emph>χ</emph><sups><emph>2</emph></sups> = 4.24, <emph>p</emph> = 0.04) than those from the comparison group (67%). Similarly, a significantly greater proportion of children from the implementation group (35%) met the PA guidelines (<emph>χ</emph><sups><emph>2</emph></sups> = 44.01, <emph>p</emph> < 0.001) than those from the comparison group (4%). Logistic regression revealed that after controlling for the living space and educational attainment of parents, children from the implementation group were more likely to meet the PA guidelines (B = 2.01, <emph>p</emph> < 0.001) but not the SB guidelines (<emph>B</emph> = 0.46, <emph>p</emph> = 0.217).</p> <p>Pedometer data showed that mean daily step counts (F = 5.15, <emph>p</emph> = 0.029) were significantly higher in the implementation group (<reflink idref="bib10" id="ref62">10</reflink>,<reflink idref="bib204" id="ref63">204</reflink>, SD = 4633) than in the comparison group (<reflink idref="bib7" id="ref64">7</reflink>,<reflink idref="bib960" id="ref65">960</reflink>, SD = 2947). When the weekday and weekend data were separated, the difference was only significant for the weekday average (F = 5.44, <emph>p</emph> = 0.025) but not for the weekend average (F = 0.05, <emph>p</emph> = 0.832).</p> <hd id="AN0186340853-27">Maintenance</hd> <p>As shown in Table 6, the majority of teachers and parents from the implementation group were aware and knowledgeable of the movement guidelines at 6 months post-implementation.</p> <p>Table 6 Percentage of teachers and parents who were aware and knowledgeable of the movement guidelines at 6 months post-implementation</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" colspan="6"><p>Movement guidelines</p></th></tr><tr><th align="left" /><th align="left" colspan="2"><p>Physical activity</p></th><th align="left" colspan="2"><p>Sedentary behaviour</p></th><th align="left" colspan="2"><p>Sleep</p></th></tr><tr><th align="left" /><th align="left"><p>Teachers</p></th><th align="left"><p>Parents</p></th><th align="left"><p>Teachers</p></th><th align="left"><p>Parents</p></th><th align="left"><p>Teachers</p></th><th align="left"><p>Parents</p></th></tr></thead><tbody><tr><td align="left" colspan="7"><p>Awareness of the guidelines</p></td></tr><tr><td align="left"><p> Aware</p></td><td char="." align="char"><p>100.0</p></td><td char="." align="char"><p>72.0</p></td><td char="." align="char"><p>85.7</p></td><td char="." align="char"><p>68.5</p></td><td char="." align="char"><p>85.7</p></td><td char="." align="char"><p>71.3</p></td></tr><tr><td align="left"><p> Not sure</p></td><td char="." align="char"><p>0.0</p></td><td char="." align="char"><p>15.4</p></td><td char="." align="char"><p>7.1</p></td><td char="." align="char"><p>18.2</p></td><td char="." align="char"><p>14.3</p></td><td char="." align="char"><p>16.8</p></td></tr><tr><td align="left"><p> Not aware</p></td><td char="." align="char"><p>0.0</p></td><td char="." align="char"><p>12.6</p></td><td char="." align="char"><p>7.1</p></td><td char="." align="char"><p>13.3</p></td><td char="." align="char"><p>0.0</p></td><td char="." align="char"><p>11.9</p></td></tr><tr><td align="left" colspan="7"><p>Knowledge of the guidelines</p></td></tr><tr><td align="left"><p> Correct knowledge</p></td><td char="." align="char"><p>92.9</p></td><td char="." align="char"><p>72.7</p></td><td char="." align="char"><p>78.6</p></td><td char="." align="char"><p>70.6</p></td><td char="." align="char"><p>100.0</p></td><td char="." align="char"><p>79.0</p></td></tr><tr><td align="left"><p> Incorrect knowledge</p></td><td char="." align="char"><p>7.1</p></td><td char="." align="char"><p>27.3</p></td><td char="." align="char"><p>21.4</p></td><td char="." align="char"><p>29.4</p></td><td char="." align="char"><p>0.0</p></td><td char="." align="char"><p>21.0</p></td></tr></tbody></table> </ephtml> </p> <p>Data are presented as percentages</p> <hd id="AN0186340853-28">Discussion</hd> <p>This study aimed to evaluate the process and outcomes of disseminating knowledge related to the movement guidelines for young children to teachers and parents, who are key agents in the promotion of healthy movement behaviours in children (Klohe-Lehman et al., [<reflink idref="bib29" id="ref66">29</reflink>]; Wolbring et al., [<reflink idref="bib58" id="ref67">58</reflink>]). The disseminated content was tailored to the Hong Kong context, accounting for time issues, space limitations, and high social priority for academic achievements (Capio et al., [<reflink idref="bib8" id="ref68">8</reflink>], [<reflink idref="bib7" id="ref69">7</reflink>]). Guided by the RE-AIM framework (Glasgow et al., [<reflink idref="bib24" id="ref70">24</reflink>]), the process evaluation generated insights in relation to the reach, adoption and implementation domains, while our outcome evaluation revealed results concerning the effectiveness and maintenance.</p> <p>The process evaluation suggested that the dissemination activities were well received by parents and teachers, with the majority engaging with the workshop materials, printed resources, and social media content. Moreover, the awareness and knowledge of teachers and parents increased over the school year despite pandemic-related school restrictions. Our findings are aligned with the dissemination of movement guidelines for young children in South Africa, which reported feasible, acceptable, and effective dissemination strategies (Draper et al., [<reflink idref="bib18" id="ref71">18</reflink>]) despite the sociocultural and geopolitical differences. We suggest that in the Hong Kong context, the process was enabled by adopting a translational approach that allowed interventions to meet the requirements of dynamic and complex contexts such as those of the local kindergarten settings (Moore et al., [<reflink idref="bib37" id="ref72">37</reflink>]), particularly during the pandemic period.</p> <p>The disseminated knowledge supported teachers in adopting the movement guidelines to their practice, but current education policies appeared to pose a systemic barrier that led to time issues. In the earlier formative work in Hong Kong, teachers and parents perceived that they simply did not have enough time to integrate movement guidelines into the daily lives of young children (Capio et al., [<reflink idref="bib8" id="ref73">8</reflink>], [<reflink idref="bib7" id="ref74">7</reflink>]). Our process evaluation revealed that after having received practical information about implementing the movement guidelines, time constraints were better understood as linked to the expectations and requirements of the prevailing education policies. This process highlights the role that policies in different places play in influencing perceptions and health behaviours. The education system in most Asian societies, including Hong Kong, tends to be examination-oriented (Sum et al., [<reflink idref="bib49" id="ref75">49</reflink>]), ostensibly leading to academic-oriented activities being prioritised by both teachers and parents (Capio et al., [<reflink idref="bib8" id="ref76">8</reflink>], [<reflink idref="bib7" id="ref77">7</reflink>]). Indeed, a recent analysis of quality assessments of kindergartens by the Hong Kong Education Bureau showed the minimal presence of physical activities in the reports (Fan et al., [<reflink idref="bib19" id="ref78">19</reflink>]), suggesting limited attention to movement behaviours in pre-primary education policy.</p> <p>While future work is needed to facilitate better policies in the long term, other efforts could focus on strategies that can generate a more immediate impact. For instance, the teachers from implementation kindergartens integrated movement with academic subjects which allowed them to meet education requirements while concurrently promoting healthier behaviours. The knowledge and practical ideas that the teachers gained allowed them to incorporate movement into their curricula without having to deviate from current policy-related expectations. Future work could amplify this strategy, as researchers have also shown that integrating movement into academic learning (e.g., mathematics, language) could help children meet PA guidelines (Capio et al., [<reflink idref="bib6" id="ref79">6</reflink>]; Norris et al., [<reflink idref="bib40" id="ref80">40</reflink>]). Additionally, strategies could be extended to help parents access practical ideas for incorporating short bouts of PA at home. Online resources for PA, which grew exponentially during the pandemic (Vancini et al., [<reflink idref="bib51" id="ref81">51</reflink>]), can be curated and shared with parents (e.g., dancing or yoga can be done by children with little supervision). The use of such online resources also shifts the nature of screen time from being sedentary to active time.</p> <p>Our evaluation also shows some evidence of the impact of the COVID-19 pandemic on the implementation of movement guidelines. Other studies have shown decreased PA, increased SB, and disrupted sleep among children during the pandemic (Bates et al., [<reflink idref="bib2" id="ref82">2</reflink>]; Rossi et al., [<reflink idref="bib44" id="ref83">44</reflink>]). Our findings related to the pandemic were specifically linked to school suspensions. More teachers and parents became aware and knowledgeable of the movement guidelines despite the school suspensions, likely because we also delivered information via social media. However, teachers and parents reported greater difficulties with integrating the movement guidelines in learning and home activities during the periods of school suspension. Despite the continued access to support on social media, the restrictions related to physical spaces and socialisation made it more difficult to limit SB and promote PA. Post-pandemic, young children are again able to access community spaces and socialise with other children, which constitutes the removal of some barriers to implementing the movement guidelines.</p> <p>The important outcomes of this dissemination project include teachers and parents having the correct knowledge to implement movement guidelines. Our evaluation shows increased parents'knowledge of PA, SB and sleep guidelines and teachers'knowledge of PA and sleep guidelines, which may be associated with having been exposed to the knowledge disseminated among the implementation kindergartens. With regard to the teachers, our findings contribute to our understanding of professional development initiatives in early childhood education, leading to enhanced knowledge, skills, and practices among teachers. The dissemination process has shown that the effectiveness of professional development initiatives tends to be influenced by contextual factors such as work setting, cultural environment, and individual needs (Sheridan et al., [<reflink idref="bib45" id="ref84">45</reflink>]). The information we disseminated was tailored to the local context, hence the relative effectiveness in improving teachers' knowledge of the movement guidelines. However, more work is needed to facilitate teachers' knowledge of SB guidelines. Primary school teachers may tend to consider that SB constituted only screen time and excluded seated desk activities (De Decker et al., [<reflink idref="bib16" id="ref85">16</reflink>]). While we did not explore this conceptualisation in our focus groups, it is possible that kindergarten teachers might think of SB similarly. As such, further dissemination of SB guidelines should also consider conceptualisations of the forms of SB in school settings.</p> <p>Ultimately, the desirable outcome of our dissemination strategies is that children would meet the movement guidelines. Our evaluation indicates mixed outcomes, where the implementation had a positive impact on children meeting the PA guidelines but the impact for SB and sleep were less clear. While it appeared that the children in implementation kindergartens were more likely to meet SB guidelines, the effect of the implementation was not significant when parent and home environment factors were accounted for. Parents with higher educational attainment and larger living spaces contributed to children meeting the SB guidelines. This finding is consistent with previous research that has shown that children who are socioeconomically disadvantaged are at greater risk of excessive SB time (Musić Milanović et al., [<reflink idref="bib38" id="ref86">38</reflink>]). Nevertheless, the majority of children across the implementation and comparison groups met the SB and sleep guidelines. Research among young children in other high-income places (e.g., Canada) has shown similarly high compliance with sleep guidelines, and the majority of children comply with SB guidelines (Carson et al., [<reflink idref="bib9" id="ref87">9</reflink>]). Similar trends have also been reported among young children in greater China (Li et al., [<reflink idref="bib33" id="ref88">33</reflink>]).</p> <p>Of the three movement behaviours, the lowest compliance among young children has been consistently observed in PA guidelines (Carson et al., [<reflink idref="bib9" id="ref89">9</reflink>]; Feng et al., [<reflink idref="bib21" id="ref90">21</reflink>]; Li et al., [<reflink idref="bib33" id="ref91">33</reflink>]). By disseminating the guidelines to parents and teachers, we generated significant gains in children's PA even after controlling for socioeconomic factors. A synthesis of evidence has suggested that interventions in childcare facilities and schools are particularly important in promoting PA in children (Messing et al., [<reflink idref="bib35" id="ref92">35</reflink>]), which is supported by our findings. We further suggest that parent education, which plays a crucial role in promoting PA among young children (O'Connor, Jago, & Baranowski, [<reflink idref="bib41" id="ref93">41</reflink>]), should be delivered in kindergarten settings. Nevertheless, there remains generally low compliance with PA guidelines, which suggests that further efforts are needed to help more young children engage in more? sufficient PA. We found better PA compliance by children in the implementation kindergartens than those in the comparison kindergartens, particularly on school days. This highlights the importance of health promotion strategies that recognise kindergartens as key contributors to children's health (Brown et al., [<reflink idref="bib4" id="ref94">4</reflink>]). The World Health Organization developed an evidence-based toolkit for early childhood education administrators, teachers, and carers to establish policies and strategies that can promote PA in young children (WHO, [<reflink idref="bib55" id="ref95">55</reflink>]), which could be considered in future dissemination work. Finally, our evaluation showed that the teachers and parents who implemented kindergartens continued to be aware and knowledgeable of guidelines at the maintenance stage, suggesting that kindergarten-based health promotion may generate sustained desirable outcomes.</p> <hd id="AN0186340853-29">Strengths and limitations</hd> <p>Evaluating the study using the RE-AIM framework facilitated insights for translational impact, and the mixed-methods research design allowed us to gather a variety of data at multiple time points. We also have a baseline picture of teachers' and parents' awareness and knowledge of the movement guidelines as the Hong Kong health authorities ramp up their strategies for PA promotion. However, we do not have intact samples that responded repeatedly to the multiple surveys, hence limiting our ability to apply more robust statistical analyses. We also recognise that we have relatively small sample sizes for the teachers' surveys and children's objective PA monitoring, which may be prone to false negative results (i.e. type II errors) (Columb & Atkinson, [<reflink idref="bib13" id="ref96">13</reflink>]). Longitudinal study designs with sufficiently powered intact samples are recommended for future work in this area. As with all research conducted during the pandemic period, we also encountered difficulties due to social restrictions. We leveraged the use of social media during school suspensions, but we acknowledge that the implementation might have led to different outcomes in different circumstances. We also recognise that the teachers' and parents' experiences as expressed in the process evaluation were likely affected by pandemic-related concerns and anxieties at that time. For instance, parents of young children in Hong Kong reported difficulties during periods of school suspension during the pandemic (Lau & Lee, [<reflink idref="bib31" id="ref97">31</reflink>]). A follow-up project could evaluate further dissemination of movement guidelines as the post-pandemic situation becomes more stable.</p> <hd id="AN0186340853-30">Implications</hd> <p>Our findings are drawn from the sociocultural context of Hong Kong and the prevailing education system. We suggest a need for sustained dissemination of knowledge about movement behaviours of children, and the re-evaluation of education policies related to the health of young children that are specific to Hong Kong. The insights from our implementation process may be applicable in places where comparable circumstances exist. In societies where education policies lead to perceived time constraints or the sociocultural environment leads parents to prioritise academics over movement behaviours, dissemination of movement guidelines may consider the approach that we took in this project. Kindergartens represent an important community setting where evidence-informed guidelines may be effectively disseminated to stakeholders who would enable children to adopt healthy movement behaviours. In such setting, social media provides a useful platform when in-person interactions are restricted and consistent engagement during implementation promotes an increased and maintained uptake of health-related knowledge.</p> <p>To conclude, we found that (<reflink idref="bib1" id="ref98">1</reflink>) formative work is important to inform health promotion strategies; (<reflink idref="bib2" id="ref99">2</reflink>) enablers and barriers may be rooted in policies and social expectations; and (<reflink idref="bib3" id="ref100">3</reflink>) kindergarten-based health promotion can improve children's outcomes by capitalising on the roles of teachers and parents. We highlight the co-occurring processes of dissemination that intentionally spreads information about the movement guidelines, and the actual implementation of adopting and maintaining those guidelines (Baumann et al., [<reflink idref="bib3" id="ref101">3</reflink>]). Finally, we acknowledge that true dissemination is a dynamic process and future work should involve policy-makers in the health and education sectors.</p> <hd id="AN0186340853-31">Acknowledgements</hd> <p>The authors acknowledge the Centre for Health Protection of Hong Kong for sharing relevant information on the movement guidelines for kindergarten children.</p> <hd id="AN0186340853-32">Author contributions</hd> <p>All authors contributed to the grant proposal and study design. CMC led and managed all aspects of the project. KKHC and CSMN facilitated participant recruitment and data gathering. RAJ collaborated on the quantitative and qualitative data analysis. CMC drafted the manuscript. All authors contributed to revisions and approved the final manuscript for submission.</p> <hd id="AN0186340853-33">Funding</hd> <p>This project was funded by the Health Medical Research Fund, Food and Health Bureau, Government of Hong Kong (Reference no. 17180131).</p> <hd id="AN0186340853-34">Data availability</hd> <p>The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.</p> <hd id="AN0186340853-35">Declarations</hd> <p></p> <hd id="AN0186340853-36">Competing interests</hd> <p>The authors declare that they have no competing interests.</p> <hd id="AN0186340853-37">Supplementary Information</hd> <p>Graph: Additional file 1.</p> <hd id="AN0186340853-38">Abbreviations</hd> <p></p> <p>• PA</p> <p></p> <ulist> <item> Physical activity</item> <p></p> </ulist> <p>• SB</p> <p></p> <ulist> <item> Sedentary behaviour</item> <p></p> </ulist> <p>• ECE</p> <p></p> <ulist> <item> Early childhood education</item> <p></p> </ulist> <p>• RE-AIM</p> <p></p> <ulist> <item> Reach, Effectiveness, Adoption, Implementation, Maintenance</item> </ulist> <hd id="AN0186340853-39">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0186340853-40"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Aubert S, Barnes JD, Demchenko I, Hawthorne M, Abdeta C, Nader PA, Sala JCA, Aguilar-Farias N, Aznar S, Bakalár P, Bhawra J, Brazo-Sayavera J, Bringas M, Cagas JY, Carlin A, Chang C-K, Chen B, Christiansen LB, Christie CJ-A, Tremblay MS. 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  Data: Disseminating the Movement Behaviour Guidelines for Young Children in Hong Kong: Process and Outcome Evaluations
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  Data: English
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  Data: <searchLink fieldCode="AR" term="%22Catherine+M%2E+Capio%22">Catherine M. Capio</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-1698-5740">0000-0003-1698-5740</externalLink>)<br /><searchLink fieldCode="AR" term="%22Rachel+A%2E+Jones%22">Rachel A. Jones</searchLink><br /><searchLink fieldCode="AR" term="%22Catalina+S%2E+M%2E+Ng%22">Catalina S. M. Ng</searchLink><br /><searchLink fieldCode="AR" term="%22Cindy+H%2E+P%2E+Sit%22">Cindy H. P. Sit</searchLink><br /><searchLink fieldCode="AR" term="%22Kevin+K%2E+H%2E+Chung%22">Kevin K. H. Chung</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22International+Journal+of+Child+Care+and+Education+Policy%22"><i>International Journal of Child Care and Education Policy</i></searchLink>. 2025 19.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Label: Page Count
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  Data: 21
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  Label: Publication Date
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  Data: 2025
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  Data: Journal Articles<br />Reports - Research
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  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink><br /><searchLink fieldCode="EL" term="%22Elementary+Education%22">Elementary Education</searchLink><br /><searchLink fieldCode="EL" term="%22Kindergarten%22">Kindergarten</searchLink><br /><searchLink fieldCode="EL" term="%22Primary+Education%22">Primary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Young+Children%22">Young Children</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Activities%22">Physical Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Activity+Level%22">Physical Activity Level</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Promotion%22">Health Promotion</searchLink><br /><searchLink fieldCode="DE" term="%22Guidelines%22">Guidelines</searchLink><br /><searchLink fieldCode="DE" term="%22Evidence+Based+Practice%22">Evidence Based Practice</searchLink><br /><searchLink fieldCode="DE" term="%22Kindergarten%22">Kindergarten</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Sleep%22">Sleep</searchLink><br /><searchLink fieldCode="DE" term="%22Motor+Development%22">Motor Development</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Hong+Kong%22">Hong Kong</searchLink>
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  Label: DOI
  Group: ID
  Data: 10.1186/s40723-025-00149-y
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  Data: 1976-5681<br />2288-6729
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  Label: Abstract
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  Data: Health promotion strategies in early childhood are needed to address the global problem of physical inactivity. In Hong Kong, where the movement guidelines recommended by the World Health Organization for young children have been adopted by the health authorities, we implemented evidence-informed dissemination strategies targeting teachers and parents in kindergarten settings. Workshops, resource materials, and social media content delivered information about the (1) specifications and rationale behind the movement guidelines; (2) benefits associated with meeting each of the guidelines; and (3) practical strategies for teachers and parents to promote the adoption and implementation of the guidelines. Using the Reach, Evaluation, Adoption, Implementation and Maintenance (RE-AIM) framework, we conducted process and outcome evaluations to assess the processes and outcomes related to the dissemination. We used a mixed-methods triangulation design-convergence model, where data were gathered through workshop audits, online surveys, focus groups, and device-based physical activity monitoring. The process evaluation suggested that enablers and barriers to implementing the movement guidelines may be rooted in policies and social expectations, but knowledge translation may be supported by tailoring the information to the Hong Kong context. The outcome evaluation revealed that the dissemination effectively increased and maintained teachers' and parents' knowledge of the guidelines for physical activity, sedentary behaviours and sleep. The physical activity of children was also enhanced, suggesting that kindergarten-based health promotion can improve children's outcomes by capitalising on the roles of teachers and parents.
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  Data: 2025
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  Data: EJ1476111
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      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Young Children
        Type: general
      – SubjectFull: Physical Activities
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      – SubjectFull: Physical Activity Level
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      – SubjectFull: Hong Kong
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      – TitleFull: Disseminating the Movement Behaviour Guidelines for Young Children in Hong Kong: Process and Outcome Evaluations
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