{"paper_id":"11903fe5-45eb-42be-9869-9915d66e87c2","body_text":"1 \nA rapid systematic review of the effect of The Daily Mile™ on children's 1 \nphysical activity, physical health, mental health, wellbeing, academic 2 \nperformance and cognitive function 3 \n 4 \nGavin Breslin1,2, Medbh Hillyard1,2*, Noel Brick2¶, Stephen Shannon1,2,3¶, Brenda McKay-5 \nRedmond4&, Barbara McConnell4& 6 \n 7 \n 8 \n1 Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, 9 \nColeraine, Northern Ireland  10 \n2 School of Psychology, Ulster University, Coleraine, Northern Ireland  11 \n3Sport and Exercise Sciences Research Institute, Ulster University, Belfast, Northern Ireland  12 \n4 Early Childhood Studies Department, Stranmillis University College, Belfast, Northern 13 \nIreland  14 \n 15 \n*Corresponding author 16 \nEmail address: m.hillyard@ulster.ac.uk (MH) 17 \n 18 \n¶These authors contributed equally to this work  19 \n&These authors also contributed equally to this work  20 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n 2 \nAbstract  21 \nBackground 22 \nA minority of children in the United Kingdom meet the recommended physical activity 23 \nguidelines. One initiative which has been introduced to try and increase the physical activity 24 \nlevels of school children is The Daily Mile™ (TDM).  The aim of this review was to 25 \ndetermine the effect of TDM on children’s physical activity levels, physical health, mental 26 \nhealth, wellbeing, academic performance and cognitive function.  27 \n 28 \nMethods 29 \nSix databases were systematically searched from TDM’s inception (2012) to 30th June 2022.  30 \nStudies were included if they involved school-aged children (aged 4-12 years), taking part in 31 \nTDM and measured at least one pre-defined outcome.  32 \n 33 \nResults 34 \nThirteen studies were included from the 123 studies retrieved.  Longer-term participation in 35 \nTDM was found to increase moderate-to-vigorous physical activity and physical fitness. 36 \nNone of the studies reported a significant change in Body Mass Index or academic 37 \nperformance. An acute bout of TDM was not found to improve cognitive function, however 38 \none good-quality study reported that longer-term participation in TDM increased visual 39 \nspatial working memory. There was evidence from one fair-quality design study that TDM 40 \ncan improve mental health in the short term. There were no significant effects on wellbeing, 41 \nhowever scores on self-perceptions improved mainly for children with low baseline self-42 \nperceptions. 43 \n 44 \n 45 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 3 \nConclusion 46 \nThere is evidence to show that TDM can increase physical activity and physical fitness. 47 \nHowever, higher-quality research, with adequate participant randomisation and longer-term, 48 \npost-intervention follow-up is needed to ensure that any changes accurately reflect the 49 \ncomponents of TDM and are sustained beyond an intervention time frame. Policy 50 \nrecommendations of TDM increasing PA levels in the short term are supported by the 51 \nevidence in this review.  However, long-term improvement on mental health, wellbeing, 52 \nacademic performance and cognitive function requires further good-to excellent quality 53 \nresearch. Promisingly, several protocol articles that include randomised controlled trials with 54 \nlong term follow-up have been published. These higher-quality design studies may provide a 55 \nstronger evidence-base on the effects of TDM on children’s health and should underpin 56 \nfuture recommendations in public health policy.  57 \n 58 \nSystematic Review registration: PROSPERO CRD42022340303 59 \nKey Words 60 \nDaily Mile, physical activity, primary school, cognition, wellbeing, academic performance 61 \n62 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 4 \nBackground 63 \nThere is convincing scientific evidence to support the benefits of promoting regular physical 64 \nactivity (PA) to enhance children’s health. Health benefits from PA participation include 65 \nimproving children’s fitness [1], maintaining healthy weight [2], strengthening muscles and 66 \nbones, improving sleep quality, and mental health and wellbeing enhancements [3]. There is 67 \nalso some evidence that children who are active have improved cognitive outcomes, such as 68 \nacademic performance and executive function [4].  In addition, children who are substantially 69 \nactive during childhood and adolescence are more likely to maintain their physical activity 70 \nbehaviour through adulthood [5]. Therefore, evidence highlights the importance of providing 71 \nchildren and young people with suitable opportunities for PA. 72 \n 73 \nRecommendations from the United Kingdom (UK) Chief Medical Officers (CMO) is that 74 \nchildren and young people (5-18 years) should engage in at least 60-minutes per-day of PA at 75 \na moderate-to-vigorous intensity level [6].  However, despite the known benefits of PA, 76 \nbetween 20-44.6% of children aged 5-16 years are currently meeting the recommended level 77 \nof PA in the UK [7] with children from socially disadvantaged backgrounds being less likely 78 \nto meet the PA recommendations [8,9]. For example in Northern Ireland where only 20% of 79 \nchildren from a low socio-economic status meet the recommended 60 minutes of Moderate-80 \nto-Vigorous Physical Activity (MVPA) per-day [10]. The World Health Organisation’s 81 \n(WHO) Global Action Plan on Physical Activity 2018-2030 aims to reduce the global 82 \nprevalence of physical inactivity by 10% by 2025 and by a further 5% by 2030 [11]. 83 \n 84 \nPA levels are found to increase in children between the ages of three and six [12], this is due 85 \nto developmental changes leading to improvements in motor skills and co-ordination along 86 \nwith growing language skills providing greater opportunities for interactive play with 87 \ncaregivers and peers [13].   However, levels then begin to decrease from age six. A recent 88 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 5 \nstudy found that on average, levels of MVPA decreases by 2.2 minutes/day/year between the 89 \nages of six and eleven (95% CI 1.9 to 2.5) [14]. Furthermore, children aged 15 years are less 90 \nlikely to meet the PA guidelines than children aged nine [15].  As most children attend school 91 \nregularly, the school setting provides a suitable environment to intervene to try and increase 92 \nthe PA levels of children from a wide range of backgrounds [2].  93 \n 94 \nThe lack of sufficient time is reported as one of the most prevalent barriers for teachers when 95 \nattempting to implement PA interventions [16]. One initiative which has been introduced in 96 \nan attempt to overcome these challenges and increase the PA levels of school-aged children is 97 \nThe Daily Mile (TDM) [17]. TDM began in Scotland in 2012 and involves children walking, 98 \nrunning or wheeling outside for 15 minutes (approximately one mile) on a minimum of three 99 \ndays of the week [17]. TDM core principles state that it should take place in addition to 100 \nPhysical Education time and should happen during curriculum time, and therefore not during 101 \nlunch or break time [17]. The practical premise behind TDM is that it is easy to set up, 102 \nrequires no additional equipment, and can be easily integrated into the school day [17]. 103 \nDemonstrating its popularity, schools from across 87 countries have signed up to TDM, with 104 \nover 10,000 schools across the UK signed up [17]. Currently in Northern Ireland 490 schools 105 \n(over 50%) have signed up on the Daily Mile Foundation website.  106 \n 107 \nThe UK Childhood Obesity Plan encourages every school to implement an active mile 108 \ninitiative such as The Daily Mile [18]. However, despite the large number of participating 109 \nschools, and Government recommendations, the scientific evidence to support the 110 \neffectiveness of TDM is mixed and arguably limited due to the short term follow up in 111 \navailable research studies, and in some cases limited research designs [19,20]. With TDM 112 \nbeing incorporated into policy frameworks, there is the need for a strong evidence-base to 113 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 6 \nfully justify its inclusion [21], currently the evidence is not convincing. Furthermore, with 114 \nnumerous schools incorporating TDM into their COVID-19 recovery plans with the aim to 115 \nimprove children’s mental health and wellbeing, it is important to understand what effects, if 116 \nany, the TDM can have beyond increasing PA. Failing to provide such evidence exacerbates 117 \nthe potential risk of a futile policy attempt to increase children’s activity. As such, it is 118 \nsurprising that no systematic review of TDM has been conducted to date to inform policy 119 \ndecision making. 120 \n 121 \nTo respond to the lack of any review of TDM, this rapid systematic review will identify the 122 \npublished literature on TDM, evaluate their methodological quality, and summarise the 123 \nfindings of the available evidence for TDM. Specifically, the review will determine the effect 124 \nof TDM on 4-12 year old school children’s PA levels, physical health, mental health, 125 \nwellbeing, academic performance and cognitive function. The practical application of TDM 126 \nin schools, the implications for policy makers and directions for further research are 127 \ndiscussed.  128 \n 129 \nMethods 130 \nReview Question 131 \nThis review aimed to answer the following question:  132 \n1. What are the effects of participating in The Daily Mile on children's physical activity 133 \nlevels, physical health, mental health, wellbeing, academic performance and cognitive 134 \nfunction? 135 \n 136 \n 137 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 7 \nProtocol 138 \nThe review was registered on the International prospective register of systematic reviews 139 \n(PROSPERO Registration Number: CRD42022340303). The Preferred Reporting Items for 140 \nSystematic Reviews and Meta-Analyses (PRISMA) guidelines [22] were followed. A 141 \nPRISMA checklist is included as supplementary file one.  142 \n 143 \nEligibility criteria 144 \nFor inclusion in the review, studies were published in a peer-reviewed academic journal and 145 \nwritten in English language. Conference abstracts and grey literature were not eligible for 146 \ninclusion. The eligibility criteria were structured around the Population, Intervention, 147 \nControl, Outcome (PICO) framework.  148 \n 149 \nPopulation  150 \nThe population was school-aged children, between the ages of 4 and 12. If children attended 151 \na special education needs school, they were also eligible for inclusion.  152 \n 153 \nIntervention 154 \nThe intervention had to consist of TDM initiative. If a study included TDM initiative 155 \nalongside or in conjunction with another intervention, the study was excluded as it was not 156 \npossible to determine the independent effects of TDM on the specified outcomes. Studies 157 \nwith PA interventions described as similar to TDM, but not specifically TDM were not 158 \nincluded. This was to ensure included interventions were based upon the principles of TDM 159 \noutlined earlier. 160 \n 161 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 8 \nControl  162 \nStudies were included if they contained control or comparison groups, but this was not a 163 \nrequirement. 164 \n 165 \nOutcomes  166 \nFor studies to be included, they had to measure at least one outcome pertaining to the 167 \nfollowing six categories: Physical activity (PA) levels (self-report or objective measures 168 \n[accelerometers, pedometer worn devices]), physical fitness (e.g. shuttle run test, bleep test), 169 \nphysical health (e.g. weight, body mass index [BMI], body composition), mental health, 170 \npsychological wellbeing, academic performance, and cognitive function.     171 \n 172 \nInformation sources and search strategy  173 \nA systematic search of six electronic databases (MEDLINE, Embase, Web of Science, 174 \nPsycINFO, SPORTDiscus and Scopus) was conducted. The search timeframe was 2012 (the 175 \nyear of TDM ‘s inception) to the date of the search (30th June 2022). 176 \n 177 \nKeywords were used in the searches, with truncation and MeSH terms used depending on the 178 \ndatabase. The search strategy was developed by the authors, alongside the institute 179 \nlibrarian. The reference lists of eligible studies were also hand searched and Google Scholar 180 \nwas searched using key words for any available studies.  181 \n 182 \nStudy selection 183 \nAll references retrieved from the electronic databases were imported into Covidence, a web-184 \nbased systematic review software programme (Covidence systematic review software, 185 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 9 \navailable at: https://www.covidence.org). Covidence automatically removes duplicate 186 \narticles, these were then checked by a reviewer (MH) to ensure they were exact duplicates.  187 \nAfter de-duplication at least two independent reviewers screened all titles and abstracts to 188 \nassess for eligibility. Articles which met the eligibility criteria were sourced and full-text 189 \narticles were uploaded into Covidence. The full-text articles were screened independently 190 \nagainst the inclusion and exclusion criteria by all authors. The screening tool used is included 191 \nin supplementary file two. At least two independent reviewers screened each article, with any 192 \ndisagreements being resolved through consensus with a third reviewer.  193 \n 194 \nData extraction 195 \nThe review team developed a data extraction form, and a single reviewer (MH) extracted the 196 \ndata. A second reviewer (GB, NB or SS) checked the data extraction. Any disagreements 197 \nwere discussed with the other members of the research team where necessary. Only data 198 \nrelevant to the study was extracted, these included: study aim, study design, timings (how 199 \nlong TDM was implemented), participant demographics, baseline characteristics, outcomes, 200 \nresults and information for quality assessment. 201 \n 202 \nMethodological quality assessment  203 \nThe quality of the included studies was assessed using a modified version of the Downs and 204 \nBlack checklist [23]. The checklist includes 27 items which covers reporting, external 205 \nvalidity, internal validity (bias), internal validity (confounding) and power [23]. The Downs 206 \nand Black checklist can be used to assess the methodological quality of both random and 207 \nnon-randomised studies [23]. Randomised studies can score a maximum of 28 and non-208 \nrandomised studies can score a maximum of 25. Based on the overall score given to a study, 209 \nthey were classified as excellent (26-28); good (20-25); fair (15-19); and poor (≤ 14). These 210 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 10 \ncategories for classification have been previously used and reported elsewhere [24-26]. One 211 \nincluded study was a process evaluation and therefore it was not appropriate to use the 212 \nDowns and Black checklist and consequently the relevant sections of the Mixed Methods 213 \nAppraisal Tool (MMAT) were used [27]. The quality assessment was carried out by two 214 \nreviewers independently (MH, NB, BMcC or BMcKR). Scores were compared and any 215 \ndisagreements were resolved through discussions and a third reviewer was consulted if 216 \nrequired.  217 \n 218 \nResults 219 \nSearch Results 220 \nThe literature search generated 123 articles. Duplicate articles were then removed (n=85), 221 \nleaving 38 titles and abstracts for review (Fig 1). Of these, 19 articles did not meet the 222 \ninclusion criteria and were excluded. At full text screening another seven articles were 223 \nexcluded. As a result, 12 articles were deemed to meet the inclusion criteria and were 224 \nincluded in the review. Studies were excluded because they were the wrong intervention (not 225 \nTDM) or a combination of interventions, no outcomes of interest were included or were 226 \nconference abstracts.  At the initial search stage, one preprint of a study was identified as 227 \nmeeting all the inclusion criteria, with the exception that it was not peer reviewed, and as a 228 \nresult it was initially excluded. However, it was peer reviewed and published at a later stage 229 \n(August 2022), therefore was included in the review. A final total of 13 articles were included 230 \nin the systematic review.  231 \n  232 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 11 \n 233 \n 234 \n 235 \n 236 \n 237 \n 238 \n 239 \n 240 \n 241 \n 242 \n 243 \n 244 \n 245 \n 246 \n 247 \n 248 \n 249 \n 250 \n 251 \n 252 \n 253 \n 254 \n 255 \n 256 \n 257 \n 258 \n 259 \n 260 \n 261 \n 262 \n 263 \n 264 \n 265 \n 266 \n 267 \n 268 \n 269 \n 270 \n 271 \nFig 1. PRISMA 2020 flow diagram  272 \n 273 \nDescription of studies  274 \nThe study characteristics are provided in Table 1. Fields included: author’s names, year, 275 \nstudy design, duration and sample characteristics.   276 \n 277 \nRecords identified from: \nDatabases (n =123) \n \nRecords removed before \nscreening: \nDuplicate records removed  \n(n =85) \n \nRecords screened \n(n = 38) \nRecords excluded \n(n =19) \nReports sought for retrieval \n(n = 19) \nReports not retrieved \n(n =0) \nReports assessed for eligibility \n(n = 19) Reports excluded: \nWrong outcomes (n =3) \nConference abstract (n = 2) \nWrong intervention (n = 2) \n \nStudies included in the review \n(n =13) \n \nIdentification of studies via databases and registers \nIdentification \nScreening \n \nIncluded \nArticle under review during the \nsearch but subsequently \npublished \n(n=1) \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 12 \nTable 1: Author, year, study design, duration and sample characteristics of included studies 278 \nAuthor, Year Study design; duration Sample characteristics \nArkesteyn et al. 2022 [28] Single-arm pilot; 20 weeks  Schools (n=7), Children (n=550), 289 males (203 males completed \nSPPC) age=9.64 (1.87) \nBooth et al. 2022 [29] Quasi experimental between groups; Part of BBC \nTerrific Scientific project- data collected from schools \non participation in TDM and categorised them as no \nparticipation, shorter term participation (2 months or \nless) and longer-term participation (3 months or more). \nSchool classes (n=503) Children (n=6908) 50% female, Age=10.2 \n(0.7)  \nBreheny et al. 2020 [20] Cluster RCT; 12 months Schools (n=40) Children (n=2280) (baseline) (47.5% female) \nAge=8.9 (1) \nBrustio et al. 2019 [30] Quasi experimental Pre/post-test; 3months 5 schools, Children (n=795) C=49.8% female, I=45.7% female. \nAge=8(1) \nBrustio et al. 2020 [31] Quasi-experimental; 6 months N=548 (49.1% female) Age=9.14 \nChesham et al. 2018 [32] Repeated measures pilot study; Intervention group-\n8months, Control 4 months \nSchools (n=2) Children (n=379) C=50% female I=49% female \nAge=8.2 (2.0) \nDe Jonge et al. 2020 [33] Multi-arm, partly RCT with 3 groups; 12 weeks Schools (n=9), Children (n=659) C=52.1% female, Intervention \ncombined=50.2% female. Age C=10.1 (0.1) I=10.0 (0.1) \nDring et al. 2022 [34] Quasi-experimental: 5 weeks Schools (n=2) Children (n=79) Gender not reported Age=10.3 \n(0.8) \nHarris et al. 2020 [35] Two-phase multi-method; 3 months  Schools (n=1) Children (n=75) Age=7 years 8months \nHatch et al. 2021a [36] Within subject randomised crossover counterbalanced; \nsingle bout of TDM and resting separated by 7 days \nSchools (n=8) Children (n=104) (46% female) Age=10.4 (0.7) \nHatch et al. 2021b [37] Cross-sectional descriptive; Single bout of TDM Schools (n=8) Children (n=80) (50% female) Age=10.4 (0.7) \nMarchant et al.  2020 [38] Natural experiment; 3-6 months depending on school Schools (n=6), Children (n=258 imputed) (46% female) Age=10.2 \n(0.9) baseline imputed \nMorris et al. 2019 [19] RCT; one session of TDM School classes (n=14) Children (n=303) C=57% female, I=56% \nfemale. Age=8.99 (0.5) \n 279 \n 280 \nSPPC  Self-Perception Profile for Children  C-control  I-Intervention RCT- Randomised Controlled Trial 281 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 13 \nAll articles were published between 2018 and 2022. Nine studies were conducted in the UK 282 \n[19, 20, 29, 32, 34-38,], two conducted in Italy [30,31], one in Belgium [28] and one in The 283 \nNetherlands [33]. The study sample sizes ranged from 75 participants [35] to 6908 [29]. Nine 284 \nof the studies included control or comparison groups [19, 20, 29-34, 36].  Four of these nine 285 \nstudies employed some type of randomisation; two of the nine were randomised controlled 286 \ntrials [19, 20], one partial randomisation (schools which had volunteered to implement and 287 \nperform TDM were randomised into intervention and intervention-plus groups) [33] and one 288 \nadopted a within subject randomised crossover counterbalanced design [36]. 289 \n 290 \nThe children in the included studies participated in TDM for different lengths of time, 291 \nranging from one session of TDM [19, 36, 37] to 12 months participation [20]. The modal 292 \nduration of participation was three months [30, 33, 35].   293 \n 294 \nMethodological quality assessment  295 \nThe quality of the included studies varied, with scores ranging from 15 [37] to 26 [19]. One 296 \nstudy was classified as excellent [19], six as good [20, 29-31, 34, 36], five as fair [28, 32, 33, 297 \n37, 38] and none were rated poor. Due to the type of study design, one study was assessed 298 \nusing the Mixed Methods Appraisal Tool [27]. This study met 100% of the quality criteria 299 \n[35].  Modified Downs and Black quality checklist scoring for the included studies are 300 \nprovided in Table 2. 301 \n 302 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 14 \nTable 2: Modified Downs and Black quality checklist scoring for included studies 303 \n  Study \nDomain Items Arkesteyn \net al. 2022 \n[28] \nBooth \net al. \n2022 \n[29] \nBreheny \net al. 2020 \n[20] \nBrustio et \nal. 2019 \n[30] \nBrustio \net al. \n2020 \n[31] \nChesham et \nal. 2018 \n[32] \nde Jonge et \nal. 2020  \n[33] \nDring et al.  \n2022 \n[34] \nHatch \net al. \n2021a \n[36] \nHatch \net al.  \n2021b \n[37] \nMarchant \net al. 2020 \n[38] \nMorris et \nal. 2019 \n[19] \nReporting 1 1 1 1 1 1 1 1 1 1 1 1 1 \n 2 1 1 1 1 1 1 1 1 1 1 1 1 \n 3 1 1 1 1 1 1 1 0 1 1 1 1 \n 4 1 1 1 1 1 1 1 1 1 1 1 1 \n 5 0 2 2 2 2 2 1 0 2 0 2 2 \n 6 1 1 1 1 1 1 1 1 1 1 1 1 \n 7 1 1 1 1 1 1 1 1 1 1 1 1 \n 8 0 0 1 1 0 0 0 0 0 0 0 1 \n 9 1 0 1 0 1 0 0 1 0 0 0 1 \n 10 1 1 1 1 1 1 0 1 1 1 1 1 \nExternal \nvalidity \n11 1 1 1 1 1 0 1 1 1 1 1 1 \n 12 1 1 1 1 1 1 1 1 1 1 1 1 \n 13 1 1 1 1 1 1 1 1 1 1 1 1 \nInternal \nvalidity-\nbias \n14 0 0 0 0 0 0 0 0 0 0 0 0 \n 15 0 0 1 0 0 0 0 0 0 0 0 0 \n 16 1 1 1 1 1 1 1 1 1 1 0 1 \n 17 1 1 1 1 1 0 1 1 1 1 0 1 \n 18 1 1 1 1 1 1 1 1 1 1 1 1 \n 19 1 1 0 1 1 0 1 1 1 1 0 1 \n 20 1 1 1 1 1 1 1 1 1 1 1 1 \nInternal \nvalidity-\nconfoundin\ng \n21 0 1 1 1 1 1 1 1 1 0 1 1 \n 22 1 1 1 1 1 0 1 1 1 0 0 1 \n 23 0 0 1 0 0 0 0 0 1 0 0 1 \n 24 0 0 0 0 0 0 0 0 0 0 0 1 \n 25 0 1 1 0 1 1 0 1 1 0 1 1 \n 26 1 0 1 1 1 0 1 1 1 0 1 1 \nPower 27 0 0 1 0 0 0 1 1 1 0 0 1 \nTotal (28)  18 20 25 21 22 16 19 20 23 15 17 26 \nQuality  Fair Good Good Good Good Fair Fair Good Good Fair Fair Excellent \n304 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 15 \nDelivery mode 305 \nThere were variations in the implementation and execution of TDM across studies, and not 306 \nall studies followed the core principles set out by TDM Foundation (i.e., 15-minutes in 307 \nlength, performed in all weather, at least 3x/week, teacher to decide when to perform TDM, 308 \nno change in clothes, aim to jog or run for full 15 minutes).  For those studies in line with the 309 \ncore principles, eight studies reported the duration of TDM should be 15-minutes [19, 20, 28, 310 \n30-32, 34, 35] and two studies reported 20 minutes duration [36, 37]. Several studies reported 311 \nallowing teachers to choose the time of day to carry out TDM [20, 28, 30-32]. Additionally, 312 \nseveral studies reported the desired frequency of TDM, with three studies encouraging daily 313 \nparticipation [28, 20, 34]. One study suggested TDM should be performed on all days 314 \nwithout Physical Education lessons [33] and one study stated it should be performed on at 315 \nleast three days of the week [29]. There was also some variation in the specified exercise 316 \nintensity with some studies reporting children should run or walk [20, 28, 31, 32, 36, 37] and 317 \none reported that children were asked to run or jog, only stopping for occasional rests if 318 \nrequired [30].  319 \n 320 \nAn additional core principle of TDM is that it should be inclusive for every child, and 321 \nchildren with mobility difficulties should take part [17]. Two studies reported that children 322 \nwith a physical or intellectual disability were excluded from the study [20, 30], two studies 323 \nincluded children with physical or intellectual disabilities in the intervention, but they were 324 \nexcluded from the analysis [19, 31]. One study recruited two special education schools 325 \n(n=36), the children took part in the study, but did not complete the Self-Perception Profile 326 \nFor Children (SPPC) [28].  327 \n 328 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 16 \nThere was a large variation in intervention fidelity, with some studies not measuring 329 \ncompliance and implementation.  Those that did, reported compliance in the intervention and 330 \nintervention plus groups as 88% and 90% respectively [33]. One study reported school level 331 \ncompliance, with two schools performing TDM 3x/week, two schools performing TDM 332 \n4x/week and three schools performing it 5x/week [28]. One study reported that all but seven 333 \nparticipants out of 79 participated in TDM daily [34].  334 \n 335 \nOutcomes 336 \nThere was large variation in the outcome measures reported across the 13 studies. The 337 \noutcome measures and measurement tools, main findings and any comments of note 338 \nregarding any methodological issues (i.e., missing data etc) are provided in Table 3. 339 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 17 \nTable 3: Study outcome measures, measurement tools, main findings and comments 340 \nAuthors (year of study) Outcome measure (s) \nand measurement tool \nMain findings Comments \nArkesteyn et al. 2022 [28] Self-perceived \ncompetence &self-esteem- \n(SPPC self-reported).  \nMental health (SDQ \nparents complete) \nSmall but significant increase in perceived global self-worth \n(p=.041) \n \nChildren with low baseline SPPC scores showed significant \nincreases with large effect sizes for global self-worth (p=<.001), \nscholastic competence (p=.001), social competence (p=.003), \nathletic competence (p=.002), physical appearance (p=<.001) and \nbehavioural conduct (p=.003) \n \nTotal difficulties score- no interaction effect for time x gender. \n \nSignificant reductions over time reported by parents for total \ndifficulties (p<.001), hyperactivity (p=.004), peer problems \n(p=.008) and emotional symptoms (p=<.001) \nMost increases \noccurred between \nweek 10 and week \n20. Compliance was \nmonitored- 2 schools \nparticipated 3x/week \n2 schools 4x/week 3 \nschools 5x/week \nBooth et al. 2022 [29] Cognition: Inhibition- \n(stop-signal task), visual \nspatial working memory-\n(static boxes search task), \nverbal working memory \n(reading span task) (self-\ncompleted on computer).  \n \nSubjective wellbeing- \n(Adapted Children’s \nFeeling scale and Felt \nArousal Scale children \nself-report). Fitness (20m \nshuttle run test child \ncomplete) \nSignificant difference in visual spatial working memory scores in \nunadjusted models. Longer term group significantly higher scores \nin visual working memory (adjusted for age, sex, SES) p<0.001, \ncompared to those who did not participate in TDM \n \nNo statistically significant differences in wellbeing between those \nparticipating in TDM and those who did not take part \n \nLonger Term participation group greater shuttle distance than the \ngroup who did not do the TDM p<0.05. And those who had shorter \nterm participation, p<0.01. Remained statistically significant when \nadjusted for age, sex and SES \nLonger term \nparticipation (more \nthan 3 months) but \nwas not possible to \nquantify further \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 18 \nBreheny et al. 2020 [20] BMIz score at 12 months \n(British 1990 growth ref \ndata) Fitness (British \nAthletics Linear Track \nTest) \nChild reported QOL \n&Wellbeing (CHU9D & \nMDI Self-reported \nelectronically under \nteacher supervision) \nAcademic Performance \n(teacher rated)  \nNo significant impact on BMIz scores. Subgroup analysis showed \nsignificant interaction by sex- modest and statistically significant \nintervention effect on BMIz for girls at 12 months  \n \nFitness: Small difference in favour of control group at both 4 and \n12 months but not statistically significant for imputed or complete \ncase analysis \n \nQOL and Wellbeing: Small non-significant differences between \ngroups in favour of intervention \n \nAcademic performance: Small difference in academic attainment in \nfavour of intervention at 12 months (p=< 0.001). Only significant \nin complete case analysis and not after imputation \nHigh levels of \nmissing data in \nsecondary outcomes \nBrustio et al. 2019 [30] Fitness (6-minute run test) \n \nBMI \nAfter correcting for age and gender significant group x time \ninteractions were observed. TDM group showed an increased result \nbetween baseline and post-test (estimated difference=25.15m, \nSE=6.39m, p<0.001; percent change=3.1%, compared with control \ngroup (estimated difference =4.44m, SE=6.69m, p=0.911; percent \nchange =0.5%) \n \nNo significant group x time interactions were observed in BMI \nOn average, TDM \nwas implemented \n3x/week \nBrustio et al. 2020 [31] Fitness- (6-minute run test \nchild complete) \n \nWaist-to-height ratio \n \nBMI \nFitness: Significant group*time interactions reported after \ncorrecting for age and BMI. I2 different T1-T2 and T1-T3. I3 \ndifferent T2-T3 and T1-T3, but not T1-T2. Control different T2-T3 \nand T1-T3 \nEffect size greater for 3xweek (effect size 0.51) rather than 2xweek \n(effect size 0.29) \n \nWaist-to-height ratio: Significant difference in group x time \ninteraction effect, with I3 lower between pre and mid test. \nNo difference in BMI between groups \nData in results \ndiffers from abstract \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 19 \nChesham et al. 2018 [32] MVPA (Accelerometer), \nFitness (20m SRT, Body \ncomposition skin folds \n(Standard ISAK \nprocedures)  \nMVPA relative increase of 9.1 minutes per day (95% CI 5.1min-\n13.2min) p=0.027 \n \nFitness: Total shuttle distance relative increase of 39.1m (95% CI \n21.9 to 56.3m p=0.037) \n \nSkin folds- relative decrease of 1.4mm (-2.0 to -0.8) p=0.034 \nSome \nmethodological \nissues- Different \nduration and data \ncollection points of \ncontrol and \nintervention groups  \nDring et al. 2022 [34] Cognitive function \n(Stroop test, Sternberg \nparadigm, flanker task \nChildren self-complete on \nlaptop) \nBody composition (4 \nskinfold sites) Body mass \nand BMI (Age and sex-\nspecific British 1990 \ngrowth reference). \nPhysical fitness (MSFT-\n20m shuttle runs (child \ncomplete) \nStroop test- No difference in response times on the simple level. \nResponse times on complex level intervention group significantly \nfaster at follow up compared to control group  p=0.048. For \naccuracy no difference between intervention and control group at \nfollow-up for either simple (p=0.434) or complex (p=0.580) levels \n \nSternberg Paradigm and Flanker test- No difference for response \ntimes or accuracy at any level  \n \nNo difference between the intervention and control group in body \ncomposition, body mass or BMI \n \nSignificant difference between the intervention and control group at \nfollow-up for distance covered on MSFT. Intervention group 880m, \ncompared to control group 740m p=0.002 \n \nDe Jonge et al. 2020 [33] Fitness (SRT child \ncomplete) \nSignificant increase in SRT between control and intervention \ngroups. The change in SRT score in the intervention group was \nsignificantly greater than the change intervention-plus group \nTwo intervention \ngroups, Intervention \nplus group- \nadditional support \nfor teachers didn’t \nmake any difference  \nHarris et al. 2020 [35] MVPA (SOFIT \nadministered by one \nobserver)  \nKS1 students- 100% of TDM in MVPA. Max time spent \nperforming MVPA occurred when students interacted with peers & \nteachers promoted activity. KS2 students spend 13mins (88.1%) of \nTDM at MVPA \nKS1 did TDM on \n54/59 (91.5%) days. \nKS2 did TDM on \n51/59 (86.4%) days \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 20 \nHatch et al. 2021a [36] Inhibitory control (Stroop \ntest) Visual working \nmemory (Sternberg \nparadigm) cognitive \nflexibility (Flanker test) \nAll self-completed on \nlaptop \nNo difference in response times between TDM and resting \n \n \n \n \nHatch et al. 2021b [37] Fitness- (Multi-stage \nfitness test child \ncomplete) \nHighest fit children ran further than less fit children (main effect of \nfitness, p<0.001) \n \nMarchant et al. 2020 [38] Fitness (20m SRT child \ncomplete)  \nBoth groups equal increases in shuttle runs. No significant \ndifference in shuttle run increase for deprived compared to non-\ndeprived children when age and gender were adjusted for \nSeasonal differences \nin data collection \nbetween schools  \nMorris et al. 2019 [19] PA (Accelerometers) \nMaths fluency (MASSAT \nchildren complete) \nExecutive function (Trail \nMaking Task, Digit \nRecall, Flanker and \nAnimal Stroop children \nself-complete 4 paper \ntests) \nChildren in TDM engaged in statistically significantly more MVPA \np≤0.001. Achieving 10.67±2.74min of MVPA during TDM \ncompared to the control (0.44±0.95min) \n \nMaths fluency: No significant improvements \n \nExecutive function: No significant difference \n \n 341 \nI2- Intervention group 2x week Daily Mile participation. I3- Intervention group 3x week Daily Mile participation SPPC -Self-perception Profile 342 \nfor Children SDQ-The Strengths and Difficulties Questionnaire BMI- Body Mass Index SRT-Shuttle run test QOL- Quality of  Life CHU9D-343 \nChild Health Utility 9 Dimension MYDI-Middle Years Development Instrument MVPA-Moderate to vigorous physical activity  SOFIT-System 344 \nfor observing fitness instruction time ISAK- The International Society for the Advancement of Kinanthropometry. MSFT-Multistage fitness test 345 \nPA- Physical activity MASSAT-Maths Addition and Subtraction, Speed and Accuracy Test346 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 21 \nEffects on physical activity  347 \nThree studies measured and reported PA levels or PA intensity [19, 32, 35]. One session of 348 \nTDM resulted in a greater amount of MVPA (10.67±2.74 min) compared to the control 349 \ngroup, (0.44±0.95 min), the difference was statistically significant [19]. One study reported 350 \nPA levels after longer term (8 months) participation in TDM, for MVPA there was a relative 351 \nincrease of 9.1 minutes per day [32]. Harris and colleagues reported that Key Stage 1 children 352 \nspent 100% of time during TDM at MVPA and at Key Stage 2 the children spent 88.1% of 353 \nTDM at MVPA [35].  354 \n 355 \nEffects on physical fitness 356 \nNine studies [20, 29-34, 37, 38] measured and reported physical fitness. A variety of different 357 \ntests were use; 6-minute run test [30,31], 20m shuttle run test [32-34, 38], Multi-stage fitness 358 \ntest [37] and British Athletics Linear Track Test [20]. Six studies [29-34] reported a 359 \nsignificant improvement in fitness in the intervention group compared to the control group. 360 \nOne study categorised children by fitness quartile and reported ‘highest fit children ran 361 \nfurther than less fit children’ (p<0.001) [37]. One study compared the shuttle run distances 362 \ncompleted by children categorised as deprived and those who were non-deprived and found 363 \nboth groups had equal increases in shuttle run distance [38]. One study found small increases 364 \nin fitness at both four and 12 months in favour of the control group (p=0.048), however there 365 \nwere high levels of missing data, and this result was not statistically significant when only 366 \ncomplete cases were analysed or when imputed values were used [20].  367 \n 368 \nEffects on physical health 369 \nThree studies reported BMI pre and post intervention [30, 31, 34], however none of the 370 \nstudies found a significant difference in BMI between groups. In one study where BMIz 371 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 22 \nscores (Body mass index z-scores, are a measure of relative weight adjusted for child age and 372 \nsex) were reported [20] although TDM did not have a significant impact on BMIz scores at 373 \n12 months, subgroup analysis indicated significant interaction by sex, with the intervention 374 \neffect for girls being modest and statistically significant at 12 months [20].  375 \n 376 \nThree studies reported on body composition [31, 32, 34]. One study reported no difference in 377 \nwaist circumference, hip circumference, or sum of skin folds, between intervention and 378 \ncontrol groups [34]. One study reported a relative decrease of 1.4mm in skin folds [32]. In 379 \none study, lower waist-to-height ratios were found between pre and mid test in the group who 380 \ncompleted TDM more than 2.5 times a week on average [31].  381 \n 382 \nEffects on psychological wellbeing 383 \nPsychological wellbeing was reported in two studies [20, 29], one study found small 384 \ndifferences in favour of the intervention group after 12 months of TDM, but the results were 385 \nnot statistically significant [20] and the other study found no statistically significant 386 \ndifferences in wellbeing between those participating in TDM and those who did not take part 387 \n[29]. 388 \n 389 \nSmall but significant increases in perceived global self-worth were found using The Self-390 \nPerception Profile for Children (SPPC) [28]. Children with low baseline SPPC scores showed 391 \nsignificant increases with large effect sizes for global self-worth, scholastic competence, 392 \nsocial competence, athletic competence, physical appearance and behavioural conduct [28]. 393 \n 394 \n 395 \n 396 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 23 \nEffects on Mental Health 397 \nOne study [28] reported the impact of participation in TDM on mental health, as measured by 398 \nThe Strengths and Difficulties Questionnaire [39] completed by their parents. There were 399 \nsignificant reductions over time reported by parents for total difficulties, hyperactivity, peer 400 \nproblems and emotional symptoms [28].  401 \n 402 \nEffects on academic performance  403 \nTwo studies reported the effect of TDM on academic performance [19, 20]. One study found 404 \na small difference in teacher rated academic attainment in favour of the intervention group at 405 \n12 months, however there was high levels of missing data (over 50%), and this was only 406 \nsignificant when complete cases were analysed and not when imputed values were used [20]. 407 \nOne study found no significant improvements in maths fluency scores after a single bout of 408 \nTDM [19].  409 \n  410 \nEffects on cognition 411 \nTwo studies included explored the effects of an acute bout of TDM on various aspects of 412 \ncognitive function [19, 36]. No significant improvements were found in executive function 413 \n[19], inhibitory control [36], cognitive flexibility [36] or working memory [36] after a single 414 \nbout of TDM.  415 \n 416 \nHowever, one study where children had longer term participation in TDM (3 months or 417 \nmore) found that those who had participated in TDM for longer had higher scores in visual 418 \nspatial working memory than those who did not participate in TDM [29]. In addition, 419 \nalthough one study did not find five weeks participation in TDM to increase response times 420 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 24 \nin the simple level in the Stroop test, response times were significantly faster on more 421 \ncomplex versions of the Stroop test in the intervention group [34]. 422 \n 423 \nDiscussion 424 \nThis systematic review summarised the results from 13 studies, examining the impact of 425 \nTDM on children’s physical activity levels, physical fitness, physical health, psychological 426 \nwellbeing, academic performance, and cognitive function. To the best of our knowledge, this 427 \nis the first systematic review of TDM initiative for primary school-aged children.  Over the 428 \npast ten years there has been a rapid adoption of TDM and other ‘active miles’ in schools, 429 \ncommunity settings, and such approaches have been cited in, and formed the basis of 430 \nGovernment policy.  This review was conducted in response to the limited evidence base to 431 \nsupport such widescale adoption, and to guide the future integration of TDM into health 432 \ninterventions and potential policy. All studies included in this review were also assessed for 433 \nmethodological quality to examine what degree of confidence could be placed alongside 434 \nstudy outcomes.   435 \n 436 \nOverall, both acute and longer-term participation in TDM was found to increase MVPA by 437 \napproximately ten minutes per-day [19, 32]. This is a relatively greater increase in MVPA 438 \nthan found by other PA interventions in primary school children [40, 41]. Although findings 439 \nshow that children do not spend the whole 15-minutes of TDM at a moderate-to-vigorous 440 \nintensity [19, 32, 35], the reported increases are welcomed given higher levels of MVPA 441 \nhave been associated with improved cardiometabolic health in children [42]. Additionally, it 442 \ngoes some way to help children achieve the public health recommended 60 minutes of 443 \nMVPA per day.  444 \n 445 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 25 \nIn addition to an increase in MVPA, in general, the included studies reported a positive effect 446 \nof TDM on physical fitness, however, the variety different fitness tests used across studies 447 \nmakes direct comparisons difficult. One of the studies which lasted for 5 weeks, reported the 448 \nintervention group completed 140 metres more than the control group in the multi-stage 449 \nfitness test at follow-up [34]. This shows that improvements in fitness can be achieved in a 450 \nrelatively short space of time when TDM is conducted five days per-week [34]. Frequency of 451 \nparticipation is an important factor to consider, with those who participated at least twice a 452 \nweek showing an increase of 5.6% in a 6-minute run test, whereas those who performed 453 \nTDM three or more times a week had an increase of 8.8% [31]. These results suggest there 454 \nmay be a dose-response associated with TDM, requiring implementation according to the 455 \ncore principles (performed at least 3x/week) to maximise improvements in physical fitness.  456 \n 457 \nNone of the included studies reported a significant reduction in BMI. This is in contrast with 458 \na Cochrane Review which found that PA interventions can reduce BMI in children aged six 459 \nto 12 [43].  This likely suggests the effect of 15 minutes of daily (3-4 times week) exercise is 460 \nnot enough to substantially impact weight. However, as children’s body composition is 461 \nnaturally changing at this developmental stage, a reduction in BMI should not be a primary 462 \naim of TDM implementation. 463 \n 464 \nLonger-term (20 weeks) participation in TDM was reported to improve children’s mental 465 \nhealth as measured by The Strengths and Difficulties Questionnaire, along with small but 466 \nsignificant increases in perceived global self-worth [28]. The greatest increase occurred 467 \nbetween weeks 10 and 20, suggesting that the changes in self-esteem may only take place 468 \nwhen the PA in school is sustained for a longer period of time [28].  In addition, the finding 469 \nthat children with lower baseline SPPC scores had large positive increases in perceptions of 470 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 26 \ncompetence, physical appearance and behavioural conduct (see Table 2) indicates that the 471 \neffect of TDM may be greater for children with lower initial perceptions of self-worth and 472 \nself-competence. Although these results are promising, especially with schools adopting 473 \nTDM into their COVID-19 recovery plans for children’s mental health and wellbeing, the 474 \nresults were found in a single arm pilot study so there was not a control group for 475 \ncomparison.  476 \n 477 \nMore research is needed with regards to the effect of TDM on academic performance, with 478 \nonly two studies reporting outcomes of academic performance [19, 20]. In one study [20] 479 \nacademic performance was measured through teacher reported scores, which has potential for 480 \nbias.  In addition, there was a large degree of missing data (over 56%) and therefore these 481 \nresults should be interpreted with caution.  482 \n 483 \nThis review found that a single bout of TDM did not have a significant effect on cognition. 484 \nThis is in contrast with two systematic reviews which found the majority of acute PA 485 \ninterventions in children improved cognitive function [44, 45]. These results suggests that 15 486 \nminutes of exercise may not be enough to impact cognition and a longer bout of exercise may 487 \nbe required to see benefits, or there may have been methodological issues that did not capture 488 \nthe potential effects. However, longer term participation in TDM improved visual spatial 489 \nworking memory [29] and increased response times on complex levels in the Stroop test [34]. 490 \nHowever, the latter finding was based on a small study (n=79) with a quasi-experimental 491 \ndesign. Consequently, larger, randomised controlled trials are needed to strengthen the 492 \nevidence base of what, if any, effects are present for TDM on cognition.  493 \n 494 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 27 \nMany of the findings suggest that timing of data sampling and the length of intervention are 495 \nimportant factors to consider. In one study, improvements in waist-to-height ratios in the 496 \nintervention group were reported at three months but at six months they had reverted to 497 \nsimilar scores to baseline [31]. No formal process evaluation was carried out so it is not 498 \npossible to assess how often TDM was performed and how this may have changed over the 499 \nduration of the study. These results may suggest that compliance and motivation dropped off 500 \nafter the initial excitement of participation or that TDM only has benefits initially [20]. Given 501 \nthe implications for both research recommendations and TDM implementation in practice, 502 \nfuture studies should record compliance and report on intervention fidelity throughout the 503 \nintervention period.  504 \n 505 \nOne study reported that although children enjoyed participating in TDM they expressed an 506 \nappeal for more variety in activity types and described TDM as ‘a bit boring’ [36]. This was 507 \nalso reported by Marchant and colleagues [38] where pupils discussed one of the barriers to 508 \nTDM being lack of enjoyment and boredom associated with it, suggesting that after initial 509 \nexcitement wore off motivation decreased [38].  510 \n 511 \nOne of the key attractive features of TDM is the simplicity of adoption and delivery by 512 \nteachers, with no equipment or special training required. However, research into the barriers 513 \nand facilitators of TDM have found that approximately half the teachers use some form of 514 \nreward system to increase motivation [46].  Different methods include awarding tokens, 515 \ntracking distance, or teachers running with pupils [46]. According to theories of motivation 516 \n(i.e., Self-Determination Theory [47]), if this is done in an outcome-orientated, controlling 517 \nstyle, it may undermine longer term autonomous motivation for PA. Additional planning and 518 \npreparation by teachers can add to their already heavy workload and may result in waning 519 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 28 \nparticipation in TDM. Qualitative research supports this feeling, suggesting TDM may not be 520 \nas simple to implement in practice with additional costs associated with extra staff time to 521 \nprepare for an engaging and exciting Daily Mile experience [48]. Teachers reported the need 522 \nto keep TDM ‘fresh’ by adding new motivational strategies to keep pupils engaged [48].  523 \n 524 \nThe intensity TDM is performed at is another important consideration.  The majority of 525 \nlonger-term studies failed to measure or report the intensity that TDM was performed. As a 526 \nresult, it is not possible to report the effect of intensity on the outcomes in most studies.  It is 527 \nprobable that the studies in which the children performed TDM at a higher intensity saw 528 \ngreater improvements in physical fitness. One study reported a large variation in intensity 529 \nwith the most active children spending the duration of TDM in MVPA, compared to the least 530 \nactive children who only spent 33% at MVPA [19].  More attention in future research could 531 \nassess intensity, and if intensity levels are implicated in affective experiences of TDM [49].  532 \n 533 \nThere is also a concern that the long-term sustainability of TDM is limited due to the lack of 534 \nbehaviour change theory principles underpinning it in the school environment. It has been 535 \nsuggested that it may be beneficial to develop a programme theory in order to help 536 \nunderstand and explain the behaviour of staff and pupils involved in TDM [50]. Physical 537 \nactivity interventions which were theoretically underpinned have been found to have the 538 \ngreatest effect on long-term behaviour change [51]. More so, the potential theoretical 539 \nunderpinnings of TDM should consider principles from a broad range of approaches, 540 \nincluding social-cognitive, humanistic, dual-process, and socioecological frameworks [52].  541 \n 542 \nAnother factor which needs to be considered in further research is the need to include 543 \nchildren with physical or intellectual disabilities. These children were not included in many 544 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 29 \nof the studies in this review, or were excluded from analysis, despite one of TDM core 545 \nprinciples being inclusivity. Children with intellectual or physical disabilities are an 546 \nimportant group to target as are often reported as being less fit and have poorer health than 547 \ntheir non-disabled peers [53]. The ‘Walk-Buds’ trial which is currently underway, operates a 548 \npeer buddy system, where younger children are partnered with an older peer with similar 549 \ninterests to complete their physical activity [54]. A similar approach may be worth 550 \nconsidering with TDM. Furthermore, evaluation into the impact of TDM for children with 551 \nintellectual or physical disabilities is needed to provide evidence of the benefits for these 552 \ngroups.  553 \n 554 \nStrengths and limitations  555 \nThis systematic review followed the PRISMA guidelines, and all papers were screened 556 \nindependently by two authors. Data extraction was done by one author and checked by a 557 \nsecond, and quality assessment was completed independently by two reviewers. This review 558 \nimplemented a comprehensive search strategy which was developed by the team and 559 \ninstitution librarian. A further strength of the study was that it looked at both the acute and 560 \nlong-term effect of TDM.  However, there were limitations. There was a high level of 561 \nheterogeneity between the studies included in the review and therefore it was difficult to 562 \ncompare studies directly. One such difference was how TDM was implemented; for example, 563 \nthe duration of TDM, how many times a week it was performed and the intensity at which it 564 \nwas performed. Moreover, there were large variations in both the reporting of intervention 565 \nfidelity and the compliance to the intervention. Future studies need to record and report 566 \nfidelity and compliance data at an individual level as it may be a potential confounder. 567 \n 568 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 30 \nMost studies included in this review involved schools who had self-selected themselves to 569 \ntake part, it is likely that schools with staff who have an interest in PA and are aware of the 570 \nbenefits and importance of it were more likely to take part and were more motivated to 571 \nfacilitate TDM and as a result there could be some sampling bias.  572 \n 573 \nConclusion and future directions 574 \nThe Daily Mile is performed in over 15,600 schools and nurseries across the world [17], in 575 \naddition to underpinning some public health policy. However, the evidence supporting its 576 \nbenefits is limited to a relatively small number of mostly fair-to-good quality studies (n=13). 577 \nAs such, this systematic review has gone some way to clarify the quality and robustness of 578 \nthis existing evidence base.  Findings from this review suggest TDM can increase children’s 579 \nphysical fitness and MVPA levels. There is also some fair-to-good quality evidence that it 580 \nmay improve body composition, mental health, and self-perceptions. TDM did not affect 581 \nBMI or academic performance, however. An acute bout of TDM did not affect cognitive 582 \nfunction, although longer term participation was found to improve some areas of cognitive 583 \nfunction.  Whilst initial results are promising, the long-term benefits are unclear due to an 584 \ninsufficient number of studies, and a dearth of good and excellent quality study designs 585 \nacross each of the outcomes reported. As such, higher quality research is needed with longer 586 \nterm follow up to explore the sustainability of intervention effects. There is also a need for 587 \nprocess evaluations and proper reporting to ascertain implementation.   588 \n 589 \nA longitudinal quasi-experimental cohort study is currently underway, following children 590 \nfrom year 1 to year 6 [55]. It is hoped this, and future studies will provide greater evidence to 591 \nsupport the long-term benefits of TDM not only on PA, but on the other outcomes covered in 592 \nthis review.  In addition, as only four of the included studies employed any randomisation, 593 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint \n\n 31 \nfuture randomised controlled trials are required to ensure that any public policy 594 \nrecommendations for TDM on improving mental health, wellbeing, cognitive function and 595 \nacademic achievement are centred on a stronger scientific evidence base.  596 \n 597 \nAcknowledgments 598 \nWe would like to acknowledge the support of the Daily Mile Network Northern Ireland, 599 \nNicola Topping from the Education Authority Northern Ireland and Colette Brolly from the 600 \nPublic Health Agency in Northern Ireland. 601 \n 602 \nReferences  603 \n 604 \n1. Eddolls WT, McNarry MA, Stratton G, Winn CO, Mackintosh KA. 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CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 4, 2022. ; https://doi.org/10.1101/2022.11.03.22281578doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}