Introduction

Physical activity in childhood

Health benefits of physical activity can be found in all age groups.1,2 In children, physical activity promotes overall health, fitness and wellbeing.3 It enhances their body composition and skeletal health, and contributes to the prevention and delay of chronic diseases (e.g. obesity, type 2 diabetes, hypertension and cardiovascular diseases).4-6 It improves their psychological health, including self-esteem, and promotes social contacts and friendships.3 In terms of learning, it improves their concentration power, and ability to set priorities and goals.7 It can improve their intellectual development and academic and physical performance.8-10 In terms of economic benefits, it contributes to lower healthcare utilization and costs associated with physical inactivity-related diseases.5,10,11 In children with disabilities, it contributes to their overall development, quality of life, sense of self, social wellbeing and future health.7,8

Overall, physical inactivity increases the risk of many adverse health conditions, especially chronic diseases. For example, it contributes approximately 6% to the burden of coronary heart disease, 7% to type 2 diabetes, and 10% to breast cancer and colon cancer.5 Physical activity can add around one year of life expectancy.5 According to the World Health Organization (WHO), physical inactivity is the fourth leading risk factor of global mortality and is responsible for approximately 6% of all deaths worldwide. Annually, it causes approximately 0.6, 1.6 and 1.0 million deaths in high-, middle- and low-income countries, respectively.12

Childhood has been recognized as the most crucial period to promote the uptake and adherence to physical activity.13-15 This period is recognized as the most physically active period in a person's life.15 It is also an important transition point where the physical activity level starts to decline.16 The 2013/2014 Health Behavior in School-Aged Children survey, conducted in 33 countries, reported a 9% and 10% decrease in moderate-to-vigorous physical activity among boys and girls from 11 to 15 years of age, respectively.17 According to the WHO's physical activity guideline, children should engage in at least 60 minutes of moderate-to-vigorous physical activity per day and reduce their sedentary time.18 However, globally, the physical activity level remains low among children. The data from 34 countries show that only 24% and 15% of school-aged boys and girls, respectively, are physically active.19

Physical activity among ethnic Chinese children

In China, the situation is even worse. Evidence suggests that the physical activity level among children has not improved over the past two decades.20,21 In 2014, only 9% of children were physically active, much less than in many high-income countries. Approximately 25% of physically active children did not achieve the required amount of moderate-to-vigorous physical activity.22 Because Chinese schools are typically evaluated in terms of their academic performances, schools prefer to allocate more resources (including time) on academic curriculums compared to physical activity.23 In schools, health (physical) education and structured exercise programs do exist. Health education sessions are delivered orally and/or in written format. Structured exercise sessions are held to achieve the recommended intensity and duration of physical activity. However, the development process of these programs remains questionable, and most of these programs are not based on behavior change theories.24-26

Similarly, in many high-income countries, ethnic Chinese children are less physically active compared to children of other ethnic origins.4,27,28 For example, a study reported that approximately 45% of Chinese-American children were not actively playing outdoor games and sports.28 In high-income countries, ethnic Asian sub-groups are often aggregated as a homogenous group, and the same generic physical activity promotion intervention is provided to all.4,27 The intervention that works in children of other ethnicities may not have the same positive impact on ethnic Chinese children.

There are socio-cultural issues that hinder physical activity among ethnic Chinese children. Generally, parents of ethnic Chinese children are more concerned about their child's safety and academic achievements, which in turn promotes sedentary behavior and impedes physical activity.29 After school hours and on weekends, these children spend more time on academic studies than on physical activity.23 In addition, ethnic Chinese girls are less likely to engage in physical activity. In many conservative Chinese societies, there is significant socio-cultural pressure on girls to avoid physical activity. The image of Chinese women does not fit well with being physically active.4 Thus, there is a need for a socio-culturally appropriate intervention for ethnic Chinese children, addressing their specific barriers to physical activity.

Rationale for this systematic review

Several qualitative studies and cross-sectional surveys have been conducted to determine the barriers and facilitators to physical activity among ethnic Chinese children.4,28-36 Until now, no systematic review on this topic has been published in English. A few systematic reviews on the same topic are available in Chinese, but they are extremely brief and limited in scope, and their quality remains questionable. These reviews searched only a few Chinese databases with a limited search strategy and included only cross-sectional surveys.37-40 Overall, the findings from these studies can be grouped into four broad themes: i) personal (e.g. unhealthy physical activity-related behavior of children), ii) socio-cultural (e.g. parental pressure to perform well in academics and less on doing physical activity), iii) environmental (e.g. poor availability of and access to physical activity facilities, unsafe neighborhood for doing physical activity) and iv) policy- and program-related (e.g. inappropriate content and structure of physical activity programs, and those delivering these programs).

A child's residence can have an impact on his or her views, experiences, attitudes, understandings, perceptions and perspectives regarding barriers and facilitators to physical activity.41 Thus, to uncover any associated differences or similarities in their views, experiences, attitudes, understandings, perceptions and perspectives, our systematic review will separately analyze data from studies conducted in Chinese and non-Chinese territories. The aim of our systematic review is to summarize the personal, social, environmental and policy- and program-related barriers and facilitators to physical activity among ethnic Chinese children. In other words, the findings will be grouped into four broad themes, namely, i) personal (relating to physical or psychological factors of children), ii) socio-cultural (relating to people the child would come in contact with), iii) environmental (structural elements such as facilities and transport) and iv) policy- and program-related (relating to programs, organizations and staff).3 We will follow the Joanna Briggs Institute (JBI) systematic review process to ensure its quality.42 English and Chinese databases will be searched with a comprehensive search strategy. The review will include qualitative studies and cross-sectional surveys, and will be written in English for a wider dissemination among international readers. The systematic review process will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and JBI systematic reviews guidelines.42,43

Review objective

The purpose of this systematic review is to summarize the barriers and facilitators to physical activity among ethnic Chinese children.

Inclusion criteria

Participants

This review will include studies conducted among ethnic Chinese children (between 6 and 17 years of age) residing in either Chinese or non-Chinese territories or among people who have responsibility for the children (such as their ethnic Chinese/non-Chinese parents, guardians or teachers). The study will be excluded if the group mean age of ethnic Chinese children is < 6 years or >= 18 years, or if it includes children of other ethnicities and not ethnic Chinese children. If it includes ethnic Chinese children and children of other ethnicities, only the barriers and facilitators to physical activity among ethnic Chinese children will be extracted. The study will be excluded if it is not possible to extract these findings (i.e. not possible to distinguish between ethnic Chinese children and children of other ethnicities).

Phenomena of interest

This review will include studies that focus on the views, experiences, attitudes, understandings, perceptions and perspectives regarding the barriers and facilitators to physical activity.

Context

Any study setting will be included, such as home, community and school, either in Chinese or non-Chinese territories.

Types of studies

The review will include studies that focus on qualitative data including, but not limited to, designs such as phenomenology, ethnography, grounded theory and action research. Qualitative studies provide an in-depth understanding of the barriers and facilitators to physical activity among children, including identification and exploration of areas unknown to researchers.44 We will also include cross-sectional surveys where free-text relating to the review question is reported within the paper.

Methods

Search strategy

An initial limited search was carried out in MEDLINE and China National Knowledge Infrastructure (CNKI) databases using the initial keywords physical activity, barriers, facilitators, Chinese and children. The titles and abstracts of the studies were screened for keywords, and the index terms used to describe the article were also identified. The search results were inspected to ensure that the relevant articles were identified.

We aim to search a wide range of sources to find published and unpublished studies. The following databases will be searched for published studies: MEDLINE (1946-present), Embase (1947-present), CINAHL (1937-present), PsycINFO (1806-present), British Nursing Index (1993-present), Allied and Complementary Medicine Database (1985-present), Web of Science (1900-present), Scopus (1788-present), CNKI (1979-present), Wanfang (1995-present) and VIP (1989-present). The search strategy to be used in MEDLINE is detailed in Appendix I. This search strategy will be adopted for other databases (including Chinese databases) in consultation with an information specialist/librarian. The search for unpublished studies will include EThOS, OpenGrey, ProQuest Dissertations and Theses, CNKI and Wanfang. The reference list of all the identified reviews and studies selected for inclusion will be screened for additional studies. No language restrictions will be applied, and translations will be sought where necessary.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X8.2 (Clarivate Analytics, PA, USA) a reference management software. Subsequently, all the duplicate citations will be removed.

Titles and abstracts will be screened for eligibility using the inclusion criteria by two reviewers independently (HW and KC/HB). Studies identified as potentially eligible or those without an abstract will have their full text retrieved, and their details will be imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). Full text of the studies will be assessed against the inclusion criteria by two reviewers independently (HW and KC/HB). Full-text studies that do not meet the inclusion criteria will be excluded, and the reasons for exclusion will be reported. Any disagreements that arise between the two reviewers will be resolved through discussion. If consensus is not reached, then a third reviewer (KC/HB) will be involved.

Assessment of methodological quality

All studies selected for inclusion will be critically assessed by two reviewers (HW and KC/HB) using the standardized critical appraisal tools incorporated within JBI SUMARI (one for qualitative studies and one for cross-sectional studies).42,45 These tools use a series of criteria that can be scored as being met (yes), not met (no) or unclear, or where appropriate, not applicable (n/a) to that particular study. The two reviewers will independently assess each criterion and comment on it. Any disagreements that arise between the reviewers will be resolved through discussion. If consensus is not reached, then a third reviewer (KC/HB) will be involved. The results of critical appraisal for all questions will be presented in a table and narrated.

All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis, where possible. A cutoff score will not be used to include or exclude studies, as many studies are likely to be of poor quality.42 Apart from high-quality studies, poor-quality studies can also generate potentially valuable insights. Together, they can lead to a richer understanding of the research phenomenon.46

Data extraction

Data will be extracted independently by two reviewers from studies included in the review using the standardized data extraction tool incorporated within JBI SUMARI42 (HW and KC/HB). Any disagreements that arise between the two reviewers will be resolved through discussion. If consensus is not reached, then a third reviewer (KC/HB) will be involved. For clarification or additional data, where necessary, the corresponding author of the included paper will be contacted by email (two times per author). In the first phase of data extraction, study characteristics will be extracted: study period, design, location (territory [Chinese/non-Chinese] and country), phenomena of interest, context (such as home, community and school), participant characteristics (such as age and sex), inclusion and exclusion criteria, sample size, recruitment method, data collection procedure and tool, data analysis technique and authors' conclusion. In the second phase of data extraction, specific study findings will be extracted: barriers and facilitators to physical activity among ethnic Chinese children. In addition, where possible, illustrations from the text that support these findings will be extracted (one illustration per finding). The findings and illustrations will be the actual verbatim words of the authors. The credibility of each finding will be assessed using the following criteria42:

* Unequivocal: the finding is accompanied by an illustration that is beyond a reasonable doubt and is not open to challenge.

* Credible: the finding is accompanied by an illustration that is lacking a clear association with it and is open to challenge.

* Not supported: when neither unequivocal nor credible can be applied and when the most notable findings are not supported by the data.

Data synthesis

To uncover any associated differences or similarities in the views, experiences, attitudes, understandings, perceptions and perspectives regarding barriers and facilitators to physical activity, the data from Chinese and non-Chinese territories will be analyzed separately.

Study findings from all study designs will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.47 This will involve the aggregation or synthesis of findings to generate a set of statements that represent the aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis to produce a single comprehensive set of synthesized findings. Where textual pooling is not possible, the findings will be presented in narrative form.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of research synthesis and presented in a Summary of Findings.48 The Summary of Findings will include the major elements of the review and details of how the ConQual score is developed. The table will include the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review will then be presented with the type of research informing it, a score for dependability, credibility and the overall ConQual score.

Acknowledgments

The authors thank Jane Grogan, a senior research librarian at The University of Nottingham (UK), for her contribution to the search strategy.

Appendix I: Search strategy for MEDLINE

1. exp physical fitness/

2. exp physical education and training/

3. exp exercise/

4. exp sports/

5. exp sedentary lifestyle/

6. (physical adj (fitness OR education OR training OR activit^* OR inactivit^*)).mp.

7. (exercise^* OR sport^* OR sedentariness).mp.

8. (sedentary adj (lifestyle OR behavio$r)).mp.

9. 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8

10. (barrier^* OR imped^* OR challenge^* OR hinder^* OR hindrance^* OR obstacle^* OR obstruct^* OR deter^* OR facilitat^*).mp.

11. exp qualitative research/

12. exp interview/

13. exp focus groups/

14. exp cross-sectional studies/

15. exp surveys and questionnaires/

16. (qualitative OR interview^* OR focus group^* OR cross-sectional OR cross sectional OR survey^*).mp.

17. 11 OR 12 OR 13 OR 14 OR 15 OR 16

18. 10 OR 17

19. exp child/

20. exp adolescent/

21. exp students/

22. exp minors/

23. (child^* OR adolescen^* OR student^* OR minor^* OR kid^* OR teen^* OR youth^* OR young OR juvenile^*).mp.

24. 19 OR 20 OR 21 OR 22 OR 23

25. exp Asian Continental Ancestry Group/

26. exp China/

27. (Chinese OR China).mp

28. 25 OR 26 OR 27

29. 9 AND 18 AND 24 AND 28

References