Adherence to the WHO guidelines and associations with socio- demographic factors among Ethiopian preschool children: The SUNRISE study

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We examined the proportion of Ethiopian children aged 3.0-4.9 years who met the WHO guidelines on physical activity, sedentary behaviour and sleep for children under the age of five, and the associations between meeting the guidelines and socio-demographic factors. Methods A cross-sectional study was conducted in Adama and Lume Woreda, Ethiopia. Children were recruited through kindergartens in Adama and rural villages in Lume Woreda, Ethiopia. Physical activity and sleep were measured using ActiGraph accelerometer. Sedentary screen time and restrained sitting were parent-reported. Multivariable logistic regression models tested associations between meeting the individual and combined WHO guidelines and socio-demographic factors. Results A total of 430 children participated in the study (mean age 4.2 ± 0.6 years). More than half the children (58.0%) met all the WHO guidelines. A higher proportion met the physical activity (96.1%) and sleep guidelines (91.9%) compared to the sedentary screen time guideline (63.5%). Children who lived in rural areas were more likely to meet the sedentary behaviour (84.6% vs 38.2%, AOR = 7.31; 95%CI: 3.93, 14.02), sleep (98.6% vs 83.8%, AOR = 8.60; 95%CI: 3.55, 23.73) and combined (81.3% vs 30.1%, AOR = 7.41; 95%CI: 4.04, 13.97) guidelines than those who lived in urban areas. Conclusions Children from rural Ethiopia were more compliant with the WHO guidelines than their urban counterparts. Strategies to reduce screen time and promote healthy movement behaviours in urban areas are needed. Further studies with a larger representative sample might provide better insight across the regions of the country. Physical activity Sedentary behaviour Screen time Sleep Early childhood Background The World Health Organization (WHO) released the first global guidelines on physical activity, sedentary behaviour, and sleep for children under 5 years of age (hereafter referred to as “the guidelines”) in 2019 [ 1 ]. The guidelines focused on a 24-hour approach because, from a movement perspective, each moment in a child’s day can be categorised as physical activity, sedentary behaviour, or sleep. These guidelines recommend that, over 24-hour period, children aged 3.0-4.9 years need a minimum of 180 minutes of physical activity. Of this, at least 60 minutes should be moderate- to vigorous-intensity. Children should limit sedentary screen time to less than one hour. Parents should support children not to be restrained for more than an hour at a time. Children should obtain 10–13 hours of good quality sleep, including naps, with regular sleep and wake up times [ 1 ]. These guidelines were developed based almost exclusively on studies from high-income countries (HICs). Children from HICs represent only 10% of children in this age group globally [ 2 ]. As a result, the WHO has called for more evidence on 24-hour movement behaviours from low- and middle-income countries (LMICs) [ 1 ]. So far, studies have reported adherence to the guidelines and socio-demographic differences [ 3 – 22 ]. However, little data exist on 24-hour movement behaviours in Sub-Saharan African countries and none from Ethiopia [ 23 ]. This research examined the proportion of Ethiopian children aged 3.0-4.9 years who met the WHO guidelines on physical activity, sedentary behaviour and sleep for children under the age of five, and the associations between meeting the guidelines and socio-demographic factors, as a part of the SUNRISE international study adapted for the local context [ 24 ]. Methods Study design and setting This cross-sectional study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [ 25 ]. The study was conducted in kindergartens in Adama town and a rural village in Lume Woreda, East Shewa Zone, Oromia regional state, Ethiopia. Adama town is in the South-East, about 100 kilometres (km) from the capital, Addis Ababa. Currently, 120 kindergartens exist in the town, all of which are privately owned. Lume woreda has rural 35 kebeles, the lowest administration structure in the country, which is located about 30 km from Adama. Unlike urban areas, there are no kindergartens in rural areas. Data were collected from 1st of April 2022 to 30th of September 2022. Ethiopia remained unaffected by the COVID-19 pandemic during this period and all research-type activities continued as usual. Participants Eligible preschool children aged 3.0-4.9 years and apparently healthy at the time of measurement that would impair their physical activity or sleep were invited to participate. A combination of random and convenience sampling was used to recruit eligible children due to the nature of the study, which was new to the Ethiopian context. We used convenience sampling to recruit 18 kindergartens in Adama city and 11 rural kebeles in Lume Woreda. In the urban setting, eligible children were identified through the directors, and data collectors ensured that an equal number of boys and girls were selected from a range of economic backgrounds based on parent profiles from the school registry. Information about the selection process was provided to the directors. Parents of eligible children approached and invited to participate by the data collectors. A lottery method was applied to recruit a maximum of 20 children (10 boys/10 girls) from each kindergarten as proposed in the SUNRISE protocol [ 24 ]. In cases where more than 20 parents of eligible children agreed to participate, the maximum required number of children was randomly selected by lottery methods. Like urban areas, a similar recruitment approach was used in the rural setting, except that community health extension workers were provided list of eligible children from their health registry in each selected kebele. Measurements Physical activity, Sedentary and Sleep time Physical activity, sedentary and sleep time were measured using triaxial ActiGraph wGT3X-BT accelerometers [ 26 ], which has been validated for this age group [ 24 , 27 ]. Monitors were fully charged and initialised using ActiLife (version 6.12.1) software before being attached to an elastic belt and placed on children [ 26 ]. Eligible children were asked to continuously wear the monitor under their clothes on the right hip for five consecutive days and nights. Children and their families were instructed to remove the monitors only during water-based activities and were encouraged to refit the monitors immediately afterwards [ 24 ]. In the urban area, data collectors made daily follow-ups to check activity monitoring and compliance, while community health workers did the same in the rural setting. The monitors recorded data at a 30 Hz sampling rate. Monitor data were downloaded using ActiLife software. Data reduction and processing ActiGraph data were processed using the “PhysicalActivity” package (version 0.2-4) [ 28 ] in R software (version 4.2.2) [ 29 ]. ActiGraph ‘gt3x’ files were imported into R and collapsed to 15-second epochs for physical activity and 60-second epochs for sleep and converted to counts and saved in readable ‘csv’ format. Initially, the package used the “wearingMarking” function to differentiate wear and non-wear time. Additionally, the package uses the “markPAI” function to classify time spent in light-, moderate- and vigorous-intensity physical activity using cut-points developed specifically for preschool children [ 28 ]. A cut point of ≤ 25 counts/15 seconds was used for sedentary time [ 27 , 30 ]. The “PhysActBedRest” package (version 1.1) [ 31 ] was used to identify sleep periods using a decision tree algorithm. Data on non-wear, physical activity, sedentary time, sleep, naps and sleep efficiency were exported as ‘csv’ files [ 32 ]. Data were cleaned for plausible values and the acceleration time was visually checked against the original accelerometer counts from the ‘Y-axis’ to determine whether the child was in movement or sleep during the specified period. Data were then checked for minimum daily wear time and the number of days based on the study protocol [ 24 ]. Children who wore the monitor for a minimum of 10 hours per day during waking periods and had at least 8 hours of sleep over a 24-hour period for at least two days were included in the analyses to maintain the accuracy and reliability of the data [ 33 ]. Parent Questionnaire The SUNRISE parent questionnaire [ 24 ] was administered through face-to-face interviews to gather data about parents/caregivers’ socio-demographics and children’s screen duration, sleep quality and consistency bedtime/wake-up times. The questionnaire was translated into two local languages (Afan Oromo and Amharic language) by professional translators to suit local conditions and back translated to English. Data were collected and managed using the Research Electronic Data Capture (REDCap) mobile app hosted at the University of Wollongong, Australia [ 34 , 35 ]. Sedentary screen and restrained sitting time Parents reported the time their child spent using screen devices (smartphone, tablet, computer, television, or video game) in a typical 24-hour day while sitting or lying down. Parents also provided information about the amount of time their child spent as a passenger in a motor vehicle as a proxy estimate of restrained sitting during the weekdays. In this study, sedentary behaviour guideline was operationalised as the time children spent on screen devices as per the WHO guidelines [ 1 , 2 ]. Sleep quality Parents were asked to rate the quality of sleep for their child using a seven-point scale ranging from 1 (very low) to 7 (very high) [ 24 ]. A brief description of the scale was given to parents. Low-quality sleep was characterised as being very difficult to settle, waking multiple times during the night for prolonged periods and very restless (tosses and turns, throws off bedclothes). High-quality sleep was characterised as settles quickly and falls asleep within a few minutes, sleeps through the night and has a very sound and deep sleep. Children who obtaining less than average score (1–3) or more than average score (4–7) were categorised as having poor or good sleep quality, respectively. Parents were also asked to indicate if their child has a consistent bedtime and wake-up time. Bias Steps were taken to minimise the risk of bias and confounding effects. Data consistencies were maintained by adhering to the SUNRISE study protocol [ 24 ]. Data collectors underwent two days of training. The questionnaire was translated into local languages for consistency. The SUNRISE coordinating centre checked the data collected for implausible values and missingness. In cases where this occurred, these values were re-checked, or data were re-collected. Parent questionnaires were read out to participants directly without interpretation to avoid interviewer bias. The multivariable regression model was adjusted for the child’s sex and age to control for confounding factors. Study size The sample size was calculated using a single-proportion formula, n = z 2 p (1-p) ----------------- d 2 where ‘n’ is the required sample size, ‘z’ is the statistic corresponding to the level of confidence, set at 95% (1.96), ‘p’ is the expected proportion of children meeting all three movement behaviour guidelines taken from a similar study conducted in Zimbabwe (24%) [ 15 ] and ‘d’ is the margin of sampling error tolerated (0.05). Therefore, n = (1.96) 2 0.24 (1-0.24) = 280. ------------------------------------------------------ (0.05) 2 Allowing for 30% missing data/non-compliance with an accelerometer, the required sample size was 364. Statistical analysis Data were cleaned, imported and analysed in the R software (version 4.2.2) for Windows [ 29 ]. Normality was checked for continuous variables using histograms. Independent samples t-tests were used to determine the mean difference between boys and girls and children from urban and rural settings for continuous variables. Children who accumulated ≥ 180 minutes of total physical activity (TPA) and ≥ 60 minutes of moderate to vigorous-intensity physical activity (MVPA), ≤ 1 hour of screen time and 10–13 hours’ sleep per day were categorised as meeting the WHO physical activity, sedentary behaviour, and sleep guidelines, respectively. Additionally, children who met all three guidelines were classified as meeting the combined WHO 24-hour movement guidelines [ 1 ]. Pearson’s Chi-square tests were used to test if the proportion varied by sex and urban/rural setting. Additional analyses were performed to determine the proportion of children with consistent bedtimes and wake-up times. Binary logistic regression models were used to examine the associations between meeting the individual and combined WHO guidelines and socio-demographic factors (child sex, urban/rural residence and parent educational status). The multivariable regression model tested the associations between meeting physical activity, sedentary behaviour, sleep, and combined guidelines (dependent variables) and child sex, place of residence and parent educational level (independent variables). All models adjusted for accelerometer wear time. Statistical significance was set at P < 0.05. Results Characteristics of the Study Participants Four hundred and thirty children were recruited for this study. Out of this, 19 participants withdrew due to parents’ misconceptions about the accelerometer linked the device to radioactive materials. Thirty children did not meet the minimum daily wear time criteria for physical activity and sleep and were excluded from the analyses. A total of 381 participants (88.6% response rate) were included in the final analyses. Table 1 shows the characteristics of the study participants. The mean and standard deviation of children’s age were 4.2 (± 0.6) years. Just over half (51%) were boys and 55% were from urban areas. Nearly all children (92%) wore the accelerometer for a minimum of 10 waking hours each day. Parents reported that almost 90% of children had good sleep quality. However, only 25% of children had consistent bed and wake-up times. Table 1 Characteristics of the study participants in Ethiopia (n = 381). Variables Frequency (n) Percentage (%) Child sex Boys Girls 196 185 51.4% 48.6% Child age (years) 3.0-3.99 4.0-4.99 142 239 37.3% 62.7% Child’s place of residence Urban Rural 173 208 45.4% 54.6% Parent sex a Male Female 75 306 19.9% 80.1% Parent age (years) a ≤ 30 31–50 > 50 195 149 37 51.2% 39.1% 9.7% Parent education level a No formal school Primary school Secondary school and above 91 188 102 23.9% 49.3% 26.8% Daily accelerometer wear time < 10 hours ≥ 10 hours 29 352 7.6% 92.4% Child sleep quality Good Poor 339 42 89.0% 11.0% Child sleep efficiency Good (≥ 85%) Poor (< 85%) 264 117 69.3% 30.7% Child consistency of bedtime and wake up Consistent Inconsistent 96 285 25.2% 74.8% a Of the parent who completed the questionnaire. Table 2 describes participants’ time spent in each 24-hour movement behaviour with differences by sex and urban and rural settings. On average, children wore the accelerometer for 11.6 hours per day during waking hours, with no difference between boys and girls and children from urban and rural settings. Children averaged 24 minutes of non-wear time (i.e., removal for bathing, swimming, etc) per day, which was shorter for children in rural compared to urban areas, but there was no difference between boys and girls. Our findings showed that children had both high MVPA and TPA per day, and that this was higher in boys and in rural children. Children had 1.3 hours and 10.9 hours of the sedentary screen and sleep time per day, respectively. Urban children accumulated significantly more sedentary screen time and less sleep time than their rural peers. Table 2 Average time spent in 24-hour movement behaviours among children in Ethiopia (n = 381), stratified by sex and settings. Variables Mean (SD) P-value Mean (SD) P-value Total Boys Girls Urban Rural Waking wear time (min/day) 695.2 (60.3) 698.1 (58.4) 692.1 (62.3) 0.335 697.8 (68.4) 693.0 (52.7) 0.450 Waking non-wear time (min/day) 24.1 (61.1) 24.9 (65.3) 23.3 (56.4) 0.796 38.4 (74.0) 12.3 (44.7) < 0.001* MVPA (min/day) 114.4 (35.8) 122.2 (35.7) 106.1 (34.2) < 0.001* 98.3 (27.3) 127.7 (36.6) < 0.001* TPA (min/day) 417.3 (72.0) 429.4 (72.8) 404.5 (69.2) 0.001* 380.5 (65.0) 447.9 (62.8) < 0.001* Sedentary time (min/day) 359.1(91.6) 346.6 (98.4) 372.3 (81.9) 0.006* 406.8 (80.0) 319.4 (81.2) < 0.001* Restrained sitting (min/day) 12.4 (29.4) 13.7 (35.2) 11.1 (21.7) 0.377 24.8 (39.6) 2.1 (7.1) < 0.001* Sedentary screen time (min/day) 80.9 (89.2) 75.5 (85.6) 86.7 (92.7) 0.221 133.2 (90.5) 37.5 (60.2) < 0.001* Sleep time (min/day) 657.5 (40.6) 660.2 (38.4) 654.7 (42.7) 0.191 641.5 (44.0) 670.9 (31.9) < 0.001* Proportion of children meeting the WHO 24-hour movement guidelines Table 3 indicates that 58% of children met the combined WHO 24-hour movement guidelines. A higher proportion of children met the physical activity (96%) and sleep guidelines (92%) compared to the sedentary behaviour guideline (64%). No differences were observed between boys and girls for the proportion meeting the individual or combined guidelines. There was no difference between boys and girls as well as urban and rural children in meeting the physical activity guidelines. However, lower proportions of urban children met the sedentary behaviour, sleep and combined guidelines compared to rural children. Table 3 Proportion of Ethiopian children met the WHO 24-hour movement guidelines (n = 381), stratified by sex and setting. Variable Total n (%) Boys n (%) Girls n (%) P-value Urban n (%) Rural n (%) P-value PA guidelines Meet Not meet 366 (96.1%) 15 (3.9%) 192 (98.0%) 4 (2.0%) 174 (94.1%) 11 (5.9%) 0.090 163 (94.2%) 10 (5.8%) 203 (97.6%) 5 (2.4%) 0.155 Sedentary behaviour guidelines Meet Not meet 242 (63.5%) 139 (36.5%) 125 (63.8%) 71 (36.2%) 117 (63.2%) 68 (36.8%) 0.999 66 (38.2%) 107 (61.8%) 176 (84.6%) 32 (15.4%) < 0.001* Sleep guidelines Meet Not meet 350 (91.9%) 31 (8.1%) 183 (93.4%) 13 (6.6%) 167 (90.3%) 18 (9.7%) 0.359 145 (83.8%) 28 (16.2%) 205 (98.6%) 3 (1.4%) < 0.001* Combined guidelines Meet Not meet 221 (58.0%) 160 (42.0%) 118 (60.2%) 78 (39.8%) 103 (55.7%) 82 (44.3%) 0.429 52 (30.1%) 121 (69.9%) 169 (81.3%) 39 (18.7%) < 0.001* Physical activity guidelines: ≥60 minutes MVPA and ≥ 180 minutes TPA per day, Sedentary behaviour: ≤60 minutes of Screen time per day; Sleep guidelines: 10–13 hours of sleep per day. * Indicates statistical significance at p < 0.05. Factors associated with meeting the WHO 24-hour movement guidelines Table 4 shows that there was little association between meeting the individual and combined WHO 24-hour movement behaviour guidelines and child sex or parent educational level. In multivariate analyses, only place of residence was associated with meeting the sedentary behaviour, sleep and combined guidelines. Children who lived in rural areas were more likely to meet the sedentary behaviour (AOR = 7.31; 95%CI: 3.93, 14.02), sleep (AOR = 8.60; 95%CI: 3.55, 23.73) and combined (AOR = 7.41; 95%CI: 4.04, 13.97) guidelines than those who lived in urban areas. Table 4 Associations between meeting the WHO guidelines and socio-demographic factors among Ethiopian preschool children (n = 381). Socio-demographic factors Meeting Physical activity guidelines Meeting Sedentary behaviour guidelines Meeting Sleep guidelines Meeting Combined guidelines Adjusted OR (95%CI) P-values Adjusted OR (95%CI) P-values Adjusted OR (95%CI) P-values Adjusted OR (95%CI) P-values Child sex Boys Girls 1 0.37 (0.11, 1.10) 0.086 1 1.02 (0.63, 1.66) 0.920 1 0.79 (0.43, 1.42) 0.430 1 0.85 (0.52, 1.38) 0.506 Child place of residence Urban Rural 1 0.95 (0.23, 3.82) 0.944 1 7.31 (3.93, 14.02) < 0.001* 1 8.60 (3.55, 23.73) < 0.001* 1 7.41 (4.04, 13.97) < 0.001* Parent educational level No formal schooling Primary school Secondary school and above 1 0.20 (0.01, 1.41) 0.12 (0.00, 1.19) 0.166 0.102 1 0.77 (0.36, 1.63) 0.65 (0.25, 1.64) 0.507 0.363 1 1.12 (0.32, 3.68) 1.19 (0.30, 4.44) 0.850 0.801 1 0.73 (0.37, 1.42) 0.44 (0.18, 1.10) 0.353 0.080 Abbreviation: OR: Odds Ratio, CI = Confidence Interval, * Indicates statistical significance at p < 0.05. Discussion Summary of the Main Findings Our study found that a high proportion of Ethiopian children met the WHO guidelines, adding a new insight from a low-income country’s context. Remarkably, over 90% of children met the physical activity and sleep guidelines, while more than half met the sedentary behaviour and combined guidelines. Children who lived in rural areas were more likely to meet the sedentary behaviour, sleep and combined guidelines than those who lived in urban areas. However, the differences between boys and girls in meeting the guidelines were small and not statistically significant. Adherence to the WHO 24-hour movement behaviours guidelines A recent review highlighted the evidence gap in 24-hour movement behaviours among preschool children in Sub-Saharan Africa [ 23 ]. To the author’s knowledge, no studies were found from Ethiopia to compare with our results. Our results were higher than other studies reported for meeting physical activity [ 3 , 5 – 10 , 13 , 14 , 16 ], sleep [ 3 , 7 – 11 , 13 , 14 , 16 ] and sedentary behaviour guidelines [ 3 , 4 , 6 – 9 , 11 , 14 , 16 , 19 ]. A possible reason for this might be lifestyle and environmental factors in Ethiopia [ 36 ]. Most children usually spent more time outdoors and engaged in unstructured play, which contributes to accumulating more physical activity [ 37 ] that may help them to sleep well because they are more physically tired [ 38 – 39 ]. Almost half of Ethiopian children had limited access to screen devices due to lack of electricity in the rural areas, which helped them to meet the sedentary behaviour guidelines. This may prevent or limit screen time before bed which would also support better sleep [ 40 – 42 ]. In contrast, the adherence to the sedentary behaviour guidelines was lower in our study than in the study reported from China (88.2%) [ 10 ]. As suggested by Guan et al., (2020), the high levels of adherence to the sedentary behaviour guidelines among Chinese children may have been related to cultural differences. In addition, most Ethiopian parents traditionally count time by observing the position of their shadows based on the Sun’s movement, rather than relying on clocks or watches, which might affect the accuracy of estimates of children's screen duration. This should be considered when interpreting our findings. Our combined adherence to WHO guidelines was higher than other published studies [ 3 – 16 , 18 , 19 ]. A possible reason is that a higher proportion of Ethiopian children met the physical activity and sleep guidelines. These findings are consistent with earlier studies regarding compliance with physical activity [ 4 , 11 , 15 , 18 , 19 ], sleep [ 4 – 6 , 15 , 18 ] and sedentary behaviour guidelines [ 5 , 13 , 15 ]. Our study found that there was no significant difference between boys and girls in meeting the individual and combined WHO guidelines. These findings were consistent with several previous studies [ 9 , 14 , 15 , 19 ]. Conversely, our results were in contrast with some evidence reported for combined [ 21 , 43 ], physical activity [ 22 , 43 ] and sleep [ 43 ]. A possible explanation for the lack of difference between boys and girls in our study relates to the parenting rules [ 44 ] and cultural context in Ethiopia where boys and girls are free to play outside equally at preschool age unlike later age. Associations between meeting the WHO guidelines and socio-demographic factors We found that children who lived in rural areas were over seven times more likely to meet the sedentary behaviour, sleep and subsequently the combined guidelines than those who lived in urban areas. Our findings related to rural/urban differences in adherence to sedentary behaviour guidelines was consistent with previous studies [ 9 , 14 , 15 , 20 , 22 ]. However, our finding was different from a study conducted in South Africa, which reported that urban children were more likely to meet the sedentary behaviour guidelines than rural children [ 9 ]. Possible reasons could include limited access to screen devices in rural Ethiopia, which could be linked to the lack of availability of electric power in the setting. Our sleep adherence was inconsistent with the two studies conducted in South Africa, which reported no urban-rural difference in meeting the sleep guidelines [ 9 ], and higher sleep adherence among urban children than their rural peers [ 20 ]. Possible reasons for this contrasting finding might be due to country contexts. Most rural children in Ethiopia have less screen time before bed and spend considerable time active outdoors. These factors may contribute to better sleep quality and duration than in urban children [ 38 , 39 ]. Our study found that rural children were more likely to meet the combined guidelines than urban children. A possible explanation of this finding is that most rural children complied with the sedentary behaviour and sleep guidelines than urban children with further research needed to confirm differences between rural and urban children in meeting the combined guidelines. However, our study did not show significant associations between meeting the physical activity guidelines and any socio-demographic factor. This finding differs from studies from Croatia, South Africa and Zimbabwe [ 9 , 15 , 22 ], which showed that rural children were more likely to meet physical activity guidelines than their urban peers. Most Ethiopian children from urban and rural areas met the physical activity guidelines. This may be due to children’s participation in unstructured physical activities both in urban and rural areas. Also, Ethiopia has a low rate of private car ownership, which may encourage children to walk more to catch public transport, such as minibuses or small taxis to reach their destinations. This could help them to accumulate the required physical activity recommendations in both settings. Recommendations Our findings contribute to bridging the evidence gap and laying the foundation for future advocacy, research, and surveillance on 24-hour movement behaviours in this age group to ensure healthy childhood development in Ethiopia. Our study suggests that interventions focused on reducing screen time and promoting healthy movement behaviours in urban areas are needed. This study provides the first evidence from a low-income country’s context, conducting the SUNRISE main study [ 24 ], which includes a nationally representative sample of 1,000 children, would provide a greater opportunity to determine the population prevalence of guidelines adherence across the regions of Ethiopia. Strengths and Limitations The strengths of this study include the use of device-measured physical activity and sleep data, providing quality evidence regarding adherence to the WHO guidelines and how this differed among boys and girls as well as urban and rural settings from a low-income country context. However, this study has some limitations. A convenience sampling was used to select kindergarten or rural kebele, which might limit the generalisability of the findings even if this approach is practical. Accurately estimating children’s screen time proved challenging for most parents, as they do not rely on watches, even if we followed the SUNRISE standardised protocol [ 24 ]. Our sedentary screen time finding needs to be interpreted with caution. Conclusions Our study showed that a high proportion of Ethiopian children exhibit healthy levels of 24-hour movement behaviours. However, urban children showed a lower adherence in screen time, sleep and combined guidelines, suggesting a need for targeted support in these areas. Abbreviations HICs High-income countries LMICs low- and middle-income countries MVPA Moderate to Vigorous-intensity Physical Activity REDCap Research Electronic Data Capture STROBE Strengthening the Reporting of Observational Studies in Epidemiology TPA Total Physical Activity WHO World Health Organisation Declarations Ethics approval and consent to participate Ethics approval was obtained from the University of Wollongong Human Research Ethics Committee, Australia (IHRERC/2018/044) and the Institutional Health Research Ethics Review Committee at Adama Hospital Medical College, Ethiopia (AHMC/SR/31/01/2022). Informed written consent was provided by parents/caregivers for their children and themselves before participating in the study. Consent for publication Not applicable. Availability of data and materials Data that support the findings of this study are available upon a reasonable request. Competing interests The authors declare that they have no competing interests. Funding CA is supported by a Higher Degree Research Scholarship funded by the University of Wollongong, Australia. The funder had no role in the conceptualisation, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors' contributions CA conceptualised the study, processed and analysed data, interpreted results and was a major contributor in writing the manuscript. DC, KK and ADO conceptualised the study. KHC and DA were involved in data processing and interpreting the results. AD, SG and DT interpreted the results and edited the manuscript. All authors reviewed and approved to the final manuscript. Acknowledgements The authors expressed their gratitude to the University of Wollongong for granting a scholarship to Chalchisa Abdeta to conduct this study. We acknowledged the SUNRISE Study Coordinating Centre team (Penny Cross, Rebecca Calleia, Ajinkya Buva and Claudia Maddren) for their invaluable logistic and data management support provided during the data collection. The authors also grateful to Mr. Tadesse Tolera for his assistance in facilitating data collection in the rural area. We expressed our gratitude to our data collectors, Dr. Tsedey Shume and S/r Hermela Girma, for their hard work in collecting quality of data. We thank the parents/caregivers, educators and community health workers for their contribution to the success of data collection. Finally, we would like to extend our heartfelt thanks to the children who participated in this study. References World Health Organisation. Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age. Geneva: World Health Organisation. Licence: CC BY-NC-SA 3.0 IGO; 2019. World Health Organisation. 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Understanding the influence of 24-hour movement behaviours on the health and development of preschool children from low-income South African settings: the SUNRISE pilot study. S Afr J Sports Med. 2020;32(1):v32i1a8415. Guan H, Zhang Z, Wang B, Okely AD, Tong M, Wu J, et al. Proportion of kindergarten children meeting the WHO guidelines on physical activity, sedentary behaviour and sleep and associations with adiposity in urban Beijing. BMC Pediatr. 2020;20(1):70. Kim H, Ma J, Harada K, Lee S, Gu Y. Associations between Adherence to Combinations of 24-h Movement Guidelines and Overweight and Obesity in Japanese Preschool Children. Int J Environ Res Public Health. 2020;17(24):9320. Tanaka C, Okada S, Takakura M, Hasimoto K, Mezawa H, Ando D, et al. Relationship between adherence to WHO 24-Hour Movement Guidelines for the Early Years and motor skills or cognitive function in preschool children: SUNRISE pilot study. Japanese J Phys Fit Sports Med. 2020;69(4):327–33. Feng J, Huang WY, Reilly JJ, Wong SH. Compliance with the WHO 24-h movement guidelines and associations with body weight status among preschool children in Hong Kong. Appl Physiol Nutr Metab. 2021;46(10):1273–8. Hossain MS, Deeba IM, Hasan M, Kariippanon KE, Chong KH, Cross PL, et al. International study of 24-h movement behaviors of early years (SUNRISE): a pilot study from Bangladesh. Pilot Feasibility Stud. 2021;7(1):176. Munambah N, Gretschel P, Muchirahondo F, Chiwaridzo M, Chikwanha T, Kariippanon KE et al. 24 hour movement behaviours and the health and development of pre-school children from Zimbabwean settings: the SUNRISE pilot study. S Afr J Sports Med. 2021;33(1):v33i1a10864. Taylor RW, Haszard JJ, Healey D, Meredith-Jones KA, Taylor BJ, Galland BC. Adherence to 24-h movement behavior guidelines and psychosocial functioning in young children: a longitudinal analysis. Int J Behav Nutr Phys Act. 2021;18(1):110. Rollo S, Antsygina O, Tremblay MS. The whole day matters: Understanding 24-hour movement guideline adherence and relationships with health indicators across the lifespan. J sport health Sci. 2020;9(6):493–510. Kracht CL, Webster EK, Staiano AE. Sociodemographic Differences in Young Children Meeting 24-Hour Movement Guidelines. J Phys Act Health. 2019;16(10):908–15. Delisle Nystrom C, Alexandrou C, Henstrom M, Nilsson E, Okely AD, Masri WE. International Study of Movement Behaviors in the Early Years (SUNRISE): Results from SUNRISE Sweden's Pilot and COVID-19 Study. Int J Environ Res Public Health. 2020;17(22):8491. Tomaz SA, Hinkley T, Jones RA, Watson ED, Twine R, Kahn K, et al. Screen Time and Sleep of Rural and Urban South African Preschool Children. Int J Environ Res Public Health. 2020;17(15):5449. Martins C, Ribeiro Bandeira PF, Filho AS, Bezerra T, Clark C, Webster EK, et al. The combination of three movement behaviours is associated with object control skills, but not locomotor skills, in preschoolers. Eur J Pediatr. 2021;180(5):1505–12. Vukelja M, Milanovic D, Salaj S. Physical Activity and Sedentary Behaviour in Croatian Preschool Children: A Population-Based Study. Montenegrin J Sports Sci Med. 2022;11(1):37–42. Nusurupia J, Reilly JJ, Janssen X. Pre-school children's compliance with the WHO 24-hour movement behaviour guidelines: a systematic review of Sub-Saharan African studies. Afr J Phys Activity Health Sci (AJPHES). 2020;26(4):345–59. https://doi.org/10.37597/ajphes.2020.26.4.1 . Okely T, Reilly JJ, Tremblay MS, Kariippanon KE, Draper CE, El Hamdouchi A, et al. Cross-sectional examination of 24-hour movement behaviours among 3- and 4-year-old children in urban and rural settings in low-income, middle-income and high-income countries: the SUNRISE study protocol. BMJ Open. 2021;11(10):e049267. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. ActiGraph. ActiLife software for Windows. Pensacola, FL, USA: ActiGraph; 2019. Janssen X, Cliff DP, Reilly JJ, Hinkley T, Jones RA, Batterham M, et al. Predictive validity and classification accuracy of ActiGraph energy expenditure equations and cut-points in young children. PLoS ONE. 2013;8(11):e79124. Choi L, Liu Z, Matthews CE, Buchowski MS. Validation of accelerometer wear and nonwear time classification algorithm. Med Sci Sports Exerc. 2011;43(2):357–64. Team RC. R: A Language and Environment for Statistical Computing. 4.2.2 ed. Vienna. Austria: R Foundation for Statistical Computing; 2022. Evenson KR, Catellier DJ, Gill K, Ondrak KS, McMurray RG. Calibration of two objective measures of physical activity for children. J Sports Sci. 2008;26(14):1557–65. Tracy JD, Xu Z, Choi L, Acra S, Chen KY, Buchowski MS. Separating bedtime rest from activity using waist or wrist-worn accelerometers in youth. PLoS ONE. 2014;9(4):e92512. Tracy JD, Donnelly T, Sommer EC, Heerman WJ, Barkin SL, Buchowski MS. Identifying bedrest using waist-worn triaxial accelerometers in preschool children. PLoS ONE. 2021;16(1):e0246055. Rich C, Geraci M, Griffiths L, Sera F, Dezateux C, Cortina-Borja M. Quality control methods in accelerometer data processing: identifying extreme counts. PLoS ONE. 2014;9(1):e85134. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42(2):377–81. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O'Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inf. 2019;95:103208. World Health Organisation. WHO study finds country differences in physical activity, screen time and sleep habits of children. Geneva: World Health Organisation; Available here https://www.who.int/europe/news/item/16-12-2020-who-study-finds-country-differences-in-physical-activity-screen-time-and-sleep-habits-of-children . Published on 16 December 2020. Accessed on July 10, 2023. Williams SM, Farmer VL, Taylor BJ, Taylor RW. Do more active children sleep more? A repeated cross-sectional analysis using accelerometry. PLoS ONE. 2014;9(4):e93117. Janssen X, Martin A, Hughes AR, Hill CM, Kotronoulas G, Hesketh KR. Associations of screen time, sedentary time and physical activity with sleep in under 5s: A systematic review and meta-analysis. Sleep Med Rev. 2020;49:101226. Kahn M, Schnabel O, Gradisar M, Rozen GS, Slone M, Atzaba-Poria N, Tikotzky L, Sadeh A. Sleep, screen time and behaviour problems in preschool children: an actigraphy study. Eur Child Adolesc Psychiatry. 2021;30(11):1793–802. Lan QY, Chan KC, Yu KN, Chan NY, Wing YK, Li AM, Au CT. Sleep duration in preschool children and impact of screen time. Sleep Med. 2020;76:48–54. Staples AD, Hoyniak C, McQuillan ME, Molfese V, Bates JE. Screen use before bedtime: Consequences for nighttime sleep in young children. Infant Behav Dev. 2021;62:101522. Guerrero MD, Barnes JD, Chaput JP, Tremblay MS. Screen time and problem behaviors in children: exploring the mediating role of sleep duration. Int J Behav Nutr Phys Act. 2019;16(105). Christian H, Murray K, Trost SG, Schipperijn J, Trapp G, Maitland C, Divitini M. Meeting the Australian 24-Hour Movement Guidelines for the Early Years is associated with better social-emotional development in preschool boys. Prev Med Rep. 2022;27:101770. Goncalves WSF, Byrne R, de Lira PIC, Viana MT, Trost SG. Adherence to 24-hour movement guidelines among rural Brazalian preschool children: associations with parenting practices. Int J Behav Nutr Phys Act. 2022;19(1):133. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4598823","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":323712918,"identity":"d1c623ed-78b4-4ceb-818b-384f5394d060","order_by":0,"name":"Chalchisa Abdeta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYJCCw38qbCCshAIgcYCgBmbGAzxn0qBaDIjTwnyAt+0wlEOMFv728wcOSLadT+yXyE788MCAQY7vRgLjZx48WiTOJDMcMDh3O3HmjNzNEkCHGUveSGCWxqfFgAGoJaHsduKG27kbQFoSN9xIYMCvhf8xw4EDbOdAWjb/AGqpB2ph/o1Xi0Qyw8GGtgMgLdtAtiQY3Ehgw2uLxI3HBocZziQbz5z/dptFgoGE4cwzD9ss5+DRwt+f+PgzQ4WdbD/P2c03f1TYyPMdTz584w0eLRi2AjFjAwkaRsEoGAWjYBRgAwBOSlPHJJwm7wAAAABJRU5ErkJggg==","orcid":"","institution":"University of Wollongong","correspondingAuthor":true,"prefix":"","firstName":"Chalchisa","middleName":"","lastName":"Abdeta","suffix":""},{"id":323712919,"identity":"c2e93250-cf24-4ae5-9c1d-12e17d83ad0d","order_by":1,"name":"Dylan Cliff","email":"","orcid":"","institution":"University of Wollongong","correspondingAuthor":false,"prefix":"","firstName":"Dylan","middleName":"","lastName":"Cliff","suffix":""},{"id":323712920,"identity":"422935f5-3e2b-4a7d-9362-974746c479aa","order_by":2,"name":"Katharina Kariippanon","email":"","orcid":"","institution":"University of Wollongong","correspondingAuthor":false,"prefix":"","firstName":"Katharina","middleName":"","lastName":"Kariippanon","suffix":""},{"id":323712921,"identity":"3fe08f1a-6387-424a-a72f-23ace720d76d","order_by":3,"name":"Alem Deksisa","email":"","orcid":"","institution":"Adama Hospital Medical College","correspondingAuthor":false,"prefix":"","firstName":"Alem","middleName":"","lastName":"Deksisa","suffix":""},{"id":323712922,"identity":"d5fff635-4490-4e30-90c9-a7199b515e23","order_by":4,"name":"Sileshi Garoma","email":"","orcid":"","institution":"Adama Hospital Medical College","correspondingAuthor":false,"prefix":"","firstName":"Sileshi","middleName":"","lastName":"Garoma","suffix":""},{"id":323712923,"identity":"5f75722a-c4fa-4729-a066-a9761615a907","order_by":5,"name":"Debrework Tesfaye","email":"","orcid":"","institution":"Wolaita Sodo University","correspondingAuthor":false,"prefix":"","firstName":"Debrework","middleName":"","lastName":"Tesfaye","suffix":""},{"id":323712924,"identity":"cbef90a3-373b-43ed-8737-e6684042abb9","order_by":6,"name":"Kar Hau Chong","email":"","orcid":"","institution":"University of Wollongong","correspondingAuthor":false,"prefix":"","firstName":"Kar","middleName":"Hau","lastName":"Chong","suffix":""},{"id":323712925,"identity":"b813c720-e027-4818-a7df-45ef5561ce3f","order_by":7,"name":"Devan Antczak","email":"","orcid":"","institution":"University of Wollongong","correspondingAuthor":false,"prefix":"","firstName":"Devan","middleName":"","lastName":"Antczak","suffix":""},{"id":323712926,"identity":"e50a06ef-daad-4850-92d2-165c1b7d1a17","order_by":8,"name":"Anthony D. Okely","email":"","orcid":"","institution":"University of Wollongong","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"D.","lastName":"Okely","suffix":""}],"badges":[],"createdAt":"2024-06-18 09:15:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4598823/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4598823/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59829679,"identity":"a3516367-4bae-4b1c-9e32-15c81f2be8f8","added_by":"auto","created_at":"2024-07-08 07:10:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1137134,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4598823/v1/ea896941-1da2-4fa3-9aa2-5ffa73722971.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adherence to the WHO guidelines and associations with socio- demographic factors among Ethiopian preschool children: The SUNRISE study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization (WHO) released the first global guidelines on physical activity, sedentary behaviour, and sleep for children under 5 years of age (hereafter referred to as \u0026ldquo;the guidelines\u0026rdquo;) in 2019 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The guidelines focused on a 24-hour approach because, from a movement perspective, each moment in a child\u0026rsquo;s day can be categorised as physical activity, sedentary behaviour, or sleep. These guidelines recommend that, over 24-hour period, children aged 3.0-4.9 years need a minimum of 180 minutes of physical activity. Of this, at least 60 minutes should be moderate- to vigorous-intensity. Children should limit sedentary screen time to less than one hour. Parents should support children not to be restrained for more than an hour at a time. Children should obtain 10\u0026ndash;13 hours of good quality sleep, including naps, with regular sleep and wake up times [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These guidelines were developed based almost exclusively on studies from high-income countries (HICs). Children from HICs represent only 10% of children in this age group globally [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. As a result, the WHO has called for more evidence on 24-hour movement behaviours from low- and middle-income countries (LMICs) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. So far, studies have reported adherence to the guidelines and socio-demographic differences [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, little data exist on 24-hour movement behaviours in Sub-Saharan African countries and none from Ethiopia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This research examined the proportion of Ethiopian children aged 3.0-4.9 years who met the WHO guidelines on physical activity, sedentary behaviour and sleep for children under the age of five, and the associations between meeting the guidelines and socio-demographic factors, as a part of the SUNRISE international study adapted for the local context [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The study was conducted in kindergartens in Adama town and a rural village in Lume Woreda, East Shewa Zone, Oromia regional state, Ethiopia. Adama town is in the South-East, about 100 kilometres (km) from the capital, Addis Ababa. Currently, 120 kindergartens exist in the town, all of which are privately owned. Lume woreda has rural 35 kebeles, the lowest administration structure in the country, which is located about 30 km from Adama. Unlike urban areas, there are no kindergartens in rural areas. Data were collected from 1st of April 2022 to 30th of September 2022. Ethiopia remained unaffected by the COVID-19 pandemic during this period and all research-type activities continued as usual.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eEligible preschool children aged 3.0-4.9 years and apparently healthy at the time of measurement that would impair their physical activity or sleep were invited to participate. A combination of random and convenience sampling was used to recruit eligible children due to the nature of the study, which was new to the Ethiopian context. We used convenience sampling to recruit 18 kindergartens in Adama city and 11 rural kebeles in Lume Woreda. In the urban setting, eligible children were identified through the directors, and data collectors ensured that an equal number of boys and girls were selected from a range of economic backgrounds based on parent profiles from the school registry. Information about the selection process was provided to the directors. Parents of eligible children approached and invited to participate by the data collectors. A lottery method was applied to recruit a maximum of 20 children (10 boys/10 girls) from each kindergarten as proposed in the SUNRISE protocol [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In cases where more than 20 parents of eligible children agreed to participate, the maximum required number of children was randomly selected by lottery methods. Like urban areas, a similar recruitment approach was used in the rural setting, except that community health extension workers were provided list of eligible children from their health registry in each selected kebele.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003ePhysical activity, Sedentary and Sleep time\u003c/h2\u003e \u003cp\u003ePhysical activity, sedentary and sleep time were measured using triaxial ActiGraph wGT3X-BT accelerometers [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which has been validated for this age group [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Monitors were fully charged and initialised using ActiLife (version 6.12.1) software before being attached to an elastic belt and placed on children [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Eligible children were asked to continuously wear the monitor under their clothes on the right hip for five consecutive days and nights. Children and their families were instructed to remove the monitors only during water-based activities and were encouraged to refit the monitors immediately afterwards [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the urban area, data collectors made daily follow-ups to check activity monitoring and compliance, while community health workers did the same in the rural setting. The monitors recorded data at a 30 Hz sampling rate. Monitor data were downloaded using ActiLife software.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eData reduction and processing\u003c/h2\u003e \u003cp\u003eActiGraph data were processed using the \u0026ldquo;PhysicalActivity\u0026rdquo; package (version 0.2-4) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] in R software (version 4.2.2) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. ActiGraph \u0026lsquo;gt3x\u0026rsquo; files were imported into R and collapsed to 15-second epochs for physical activity and 60-second epochs for sleep and converted to counts and saved in readable \u0026lsquo;csv\u0026rsquo; format. Initially, the package used the \u0026ldquo;wearingMarking\u0026rdquo; function to differentiate wear and non-wear time. Additionally, the package uses the \u0026ldquo;markPAI\u0026rdquo; function to classify time spent in light-, moderate- and vigorous-intensity physical activity using cut-points developed specifically for preschool children [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A cut point of \u0026le;\u0026thinsp;25 counts/15 seconds was used for sedentary time [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The \u0026ldquo;PhysActBedRest\u0026rdquo; package (version 1.1) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] was used to identify sleep periods using a decision tree algorithm. Data on non-wear, physical activity, sedentary time, sleep, naps and sleep efficiency were exported as \u0026lsquo;csv\u0026rsquo; files [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Data were cleaned for plausible values and the acceleration time was visually checked against the original accelerometer counts from the \u0026lsquo;Y-axis\u0026rsquo; to determine whether the child was in movement or sleep during the specified period. Data were then checked for minimum daily wear time and the number of days based on the study protocol [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Children who wore the monitor for a minimum of 10 hours per day during waking periods and had at least 8 hours of sleep over a 24-hour period for at least two days were included in the analyses to maintain the accuracy and reliability of the data [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eParent Questionnaire\u003c/h2\u003e \u003cp\u003eThe SUNRISE parent questionnaire [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] was administered through face-to-face interviews to gather data about parents/caregivers\u0026rsquo; socio-demographics and children\u0026rsquo;s screen duration, sleep quality and consistency bedtime/wake-up times. The questionnaire was translated into two local languages (Afan Oromo and Amharic language) by professional translators to suit local conditions and back translated to English. Data were collected and managed using the Research Electronic Data Capture (REDCap) mobile app hosted at the University of Wollongong, Australia [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eSedentary screen and restrained sitting time\u003c/h2\u003e \u003cp\u003eParents reported the time their child spent using screen devices (smartphone, tablet, computer, television, or video game) in a typical 24-hour day while sitting or lying down. Parents also provided information about the amount of time their child spent as a passenger in a motor vehicle as a proxy estimate of restrained sitting during the weekdays. In this study, sedentary behaviour guideline was operationalised as the time children spent on screen devices as per the WHO guidelines [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSleep quality\u003c/h2\u003e \u003cp\u003eParents were asked to rate the quality of sleep for their child using a seven-point scale ranging from 1 (very low) to 7 (very high) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A brief description of the scale was given to parents. Low-quality sleep was characterised as being very difficult to settle, waking multiple times during the night for prolonged periods and very restless (tosses and turns, throws off bedclothes). High-quality sleep was characterised as settles quickly and falls asleep within a few minutes, sleeps through the night and has a very sound and deep sleep. Children who obtaining less than average score (1\u0026ndash;3) or more than average score (4\u0026ndash;7) were categorised as having poor or good sleep quality, respectively. Parents were also asked to indicate if their child has a consistent bedtime and wake-up time.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBias\u003c/h2\u003e \u003cp\u003eSteps were taken to minimise the risk of bias and confounding effects. Data consistencies were maintained by adhering to the SUNRISE study protocol [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Data collectors underwent two days of training. The questionnaire was translated into local languages for consistency. The SUNRISE coordinating centre checked the data collected for implausible values and missingness. In cases where this occurred, these values were re-checked, or data were re-collected. Parent questionnaires were read out to participants directly without interpretation to avoid interviewer bias. The multivariable regression model was adjusted for the child\u0026rsquo;s sex and age to control for confounding factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudy size\u003c/h2\u003e \u003cp\u003eThe sample size was calculated using a single-proportion formula,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ez\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ep (1-p)\u003c/span\u003e\u003c/p\u003e \u003cp\u003e-----------------\u003c/p\u003e\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;d\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ewhere \u0026lsquo;n\u0026rsquo; is the required sample size, \u0026lsquo;z\u0026rsquo; is the statistic corresponding to the level of confidence, set at 95% (1.96), \u0026lsquo;p\u0026rsquo; is the expected proportion of children meeting all three movement behaviour guidelines taken from a similar study conducted in Zimbabwe (24%) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and \u0026lsquo;d\u0026rsquo; is the margin of sampling error tolerated (0.05).\u003c/p\u003e \u003cp\u003eTherefore, n = \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(1.96)\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e0.24 (1-0.24)\u003c/span\u003e\u0026thinsp;=\u0026thinsp;280.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003cp\u003e------------------------------------------------------\u003c/p\u003e \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;(0.05)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAllowing for 30% missing data/non-compliance with an accelerometer, the required sample size was 364.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were cleaned, imported and analysed in the R software (version 4.2.2) for Windows [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Normality was checked for continuous variables using histograms. Independent samples t-tests were used to determine the mean difference between boys and girls and children from urban and rural settings for continuous variables. Children who accumulated\u0026thinsp;\u0026ge;\u0026thinsp;180 minutes of total physical activity (TPA) and \u0026ge;\u0026thinsp;60 minutes of moderate to vigorous-intensity physical activity (MVPA), \u0026le; 1 hour of screen time and 10\u0026ndash;13 hours\u0026rsquo; sleep per day were categorised as meeting the WHO physical activity, sedentary behaviour, and sleep guidelines, respectively. Additionally, children who met all three guidelines were classified as meeting the combined WHO 24-hour movement guidelines [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pearson\u0026rsquo;s Chi-square tests were used to test if the proportion varied by sex and urban/rural setting. Additional analyses were performed to determine the proportion of children with consistent bedtimes and wake-up times. Binary logistic regression models were used to examine the associations between meeting the individual and combined WHO guidelines and socio-demographic factors (child sex, urban/rural residence and parent educational status). The multivariable regression model tested the associations between meeting physical activity, sedentary behaviour, sleep, and combined guidelines (dependent variables) and child sex, place of residence and parent educational level (independent variables). All models adjusted for accelerometer wear time. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the Study Participants\u003c/h2\u003e \u003cp\u003eFour hundred and thirty children were recruited for this study. Out of this, 19 participants withdrew due to parents\u0026rsquo; misconceptions about the accelerometer linked the device to radioactive materials. Thirty children did not meet the minimum daily wear time criteria for physical activity and sleep and were excluded from the analyses. A total of 381 participants (88.6% response rate) were included in the final analyses.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the characteristics of the study participants. The mean and standard deviation of children\u0026rsquo;s age were 4.2 (\u0026plusmn;\u0026thinsp;0.6) years. Just over half (51%) were boys and 55% were from urban areas. Nearly all children (92%) wore the accelerometer for a minimum of 10 waking hours each day. Parents reported that almost 90% of children had good sleep quality. However, only 25% of children had consistent bed and wake-up times.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the study participants in Ethiopia (n\u0026thinsp;=\u0026thinsp;381).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild sex\u003c/p\u003e \u003cp\u003eBoys\u003c/p\u003e \u003cp\u003eGirls\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196\u003c/p\u003e \u003cp\u003e185\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.4%\u003c/p\u003e \u003cp\u003e48.6%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild age (years)\u003c/p\u003e \u003cp\u003e3.0-3.99\u003c/p\u003e \u003cp\u003e4.0-4.99\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003cp\u003e239\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.3%\u003c/p\u003e \u003cp\u003e62.7%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild\u0026rsquo;s place of residence\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUrban\u003c/p\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173\u003c/p\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.4%\u003c/p\u003e \u003cp\u003e54.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParent sex\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003cp\u003e306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.9%\u003c/p\u003e \u003cp\u003e80.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParent age (years)\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003cp\u003e31\u0026ndash;50\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e195\u003c/p\u003e \u003cp\u003e149\u003c/p\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.2%\u003c/p\u003e \u003cp\u003e39.1%\u003c/p\u003e \u003cp\u003e9.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParent education level\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNo formal school\u003c/p\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003cp\u003eSecondary school and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003cp\u003e188\u003c/p\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.9%\u003c/p\u003e \u003cp\u003e49.3%\u003c/p\u003e \u003cp\u003e26.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDaily accelerometer wear time\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10 hours\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6%\u003c/p\u003e \u003cp\u003e92.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild sleep quality\u003c/b\u003e\u003c/p\u003e \u003cp\u003eGood\u003c/p\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e339\u003c/p\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.0%\u003c/p\u003e \u003cp\u003e11.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild sleep efficiency\u003c/b\u003e\u003c/p\u003e \u003cp\u003eGood (\u0026ge;\u0026thinsp;85%)\u003c/p\u003e \u003cp\u003ePoor (\u0026lt;\u0026thinsp;85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e264\u003c/p\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.3%\u003c/p\u003e \u003cp\u003e30.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild consistency of bedtime and wake up\u003c/b\u003e\u003c/p\u003e \u003cp\u003eConsistent\u003c/p\u003e \u003cp\u003eInconsistent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003cp\u003e285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.2%\u003c/p\u003e \u003cp\u003e74.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e \u003cem\u003eOf the parent who completed the questionnaire.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e describes participants\u0026rsquo; time spent in each 24-hour movement behaviour with differences by sex and urban and rural settings. On average, children wore the accelerometer for 11.6 hours per day during waking hours, with no difference between boys and girls and children from urban and rural settings. Children averaged 24 minutes of non-wear time (i.e., removal for bathing, swimming, etc) per day, which was shorter for children in rural compared to urban areas, but there was no difference between boys and girls. Our findings showed that children had both high MVPA and TPA per day, and that this was higher in boys and in rural children. Children had 1.3 hours and 10.9 hours of the sedentary screen and sleep time per day, respectively. Urban children accumulated significantly more sedentary screen time and less sleep time than their rural peers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAverage time spent in 24-hour movement behaviours among children in Ethiopia (n\u0026thinsp;=\u0026thinsp;381), stratified by sex and settings.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBoys\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGirls\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWaking wear time (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e695.2 (60.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e698.1 (58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e692.1 (62.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e697.8 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e693.0 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWaking non-wear time (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.1 (61.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.9 (65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.3 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e38.4 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.3 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMVPA (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114.4 (35.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122.2 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106.1 (34.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e98.3 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e127.7 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTPA (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e417.3 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e429.4 (72.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e404.5 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e380.5 (65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e447.9 (62.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSedentary time (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e359.1(91.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e346.6 (98.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e372.3 (81.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.006*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e406.8 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e319.4 (81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRestrained sitting (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.4 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.7 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.1 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.377\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24.8 (39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSedentary screen time (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80.9 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.5 (85.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86.7 (92.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e133.2 (90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e37.5 (60.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep time (min/day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e657.5 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e660.2 (38.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e654.7 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e641.5 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e670.9 (31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eProportion of children meeting the WHO 24-hour movement guidelines\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e indicates that 58% of children met the combined WHO 24-hour movement guidelines. A higher proportion of children met the physical activity (96%) and sleep guidelines (92%) compared to the sedentary behaviour guideline (64%). No differences were observed between boys and girls for the proportion meeting the individual or combined guidelines. There was no difference between boys and girls as well as urban and rural children in meeting the physical activity guidelines. However, lower proportions of urban children met the sedentary behaviour, sleep and combined guidelines compared to rural children.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProportion of Ethiopian children met the WHO 24-hour movement guidelines (n\u0026thinsp;=\u0026thinsp;381), stratified by sex and setting.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBoys n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGirls n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePA guidelines\u003c/p\u003e \u003cp\u003eMeet\u003c/p\u003e \u003cp\u003eNot meet\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e366 (96.1%)\u003c/p\u003e \u003cp\u003e15 (3.9%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e192 (98.0%)\u003c/p\u003e \u003cp\u003e4 (2.0%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e174 (94.1%)\u003c/p\u003e \u003cp\u003e11 (5.9%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e163 (94.2%)\u003c/p\u003e \u003cp\u003e10 (5.8%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e203 (97.6%)\u003c/p\u003e \u003cp\u003e5 (2.4%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSedentary behaviour guidelines\u003c/p\u003e \u003cp\u003eMeet\u003c/p\u003e \u003cp\u003eNot meet\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e242 (63.5%)\u003c/p\u003e \u003cp\u003e139 (36.5%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125 (63.8%)\u003c/p\u003e \u003cp\u003e71 (36.2%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117 (63.2%)\u003c/p\u003e \u003cp\u003e68 (36.8%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66 (38.2%)\u003c/p\u003e \u003cp\u003e107 (61.8%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e176 (84.6%)\u003c/p\u003e \u003cp\u003e32 (15.4%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep guidelines\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMeet\u003c/p\u003e \u003cp\u003eNot meet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e350 (91.9%)\u003c/p\u003e \u003cp\u003e31 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e183 (93.4%)\u003c/p\u003e \u003cp\u003e13 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e167 (90.3%)\u003c/p\u003e \u003cp\u003e18 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e145 (83.8%)\u003c/p\u003e \u003cp\u003e28 (16.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e205 (98.6%)\u003c/p\u003e \u003cp\u003e3 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCombined guidelines\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMeet\u003c/p\u003e \u003cp\u003eNot meet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e221 (58.0%)\u003c/p\u003e \u003cp\u003e160 (42.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118 (60.2%)\u003c/p\u003e \u003cp\u003e78 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103 (55.7%)\u003c/p\u003e \u003cp\u003e82 (44.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52 (30.1%)\u003c/p\u003e \u003cp\u003e121 (69.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e169 (81.3%)\u003c/p\u003e \u003cp\u003e39 (18.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003ePhysical activity guidelines: \u0026ge;60 minutes MVPA and \u0026ge;\u0026thinsp;180 minutes TPA per day, Sedentary behaviour: \u0026le;60 minutes of Screen time per day; Sleep guidelines: 10\u0026ndash;13 hours of sleep per day. * Indicates statistical significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with meeting the WHO 24-hour movement guidelines\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows that there was little association between meeting the individual and combined WHO 24-hour movement behaviour guidelines and child sex or parent educational level. In multivariate analyses, only place of residence was associated with meeting the sedentary behaviour, sleep and combined guidelines. Children who lived in rural areas were more likely to meet the sedentary behaviour (AOR\u0026thinsp;=\u0026thinsp;7.31; 95%CI: 3.93, 14.02), sleep (AOR\u0026thinsp;=\u0026thinsp;8.60; 95%CI: 3.55, 23.73) and combined (AOR\u0026thinsp;=\u0026thinsp;7.41; 95%CI: 4.04, 13.97) guidelines than those who lived in urban areas.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations between meeting the WHO guidelines and socio-demographic factors among Ethiopian preschool children (n\u0026thinsp;=\u0026thinsp;381).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSocio-demographic factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMeeting Physical activity guidelines\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMeeting Sedentary behaviour guidelines\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eMeeting Sleep guidelines\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eMeeting Combined guidelines\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP-values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild sex\u003c/p\u003e \u003cp\u003eBoys\u003c/p\u003e \u003cp\u003eGirls\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.37 (0.11, 1.10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.02 (0.63, 1.66)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.79 (0.43, 1.42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.430\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.85 (0.52, 1.38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild place of residence\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUrban\u003c/p\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.95 (0.23, 3.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.944\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e7.31 (3.93, 14.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e8.60 (3.55, 23.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e7.41 (4.04, 13.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParent educational level\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo formal schooling\u003c/p\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003cp\u003eSecondary school and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.20 (0.01, 1.41)\u003c/p\u003e \u003cp\u003e0.12 (0.00, 1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.77 (0.36, 1.63)\u003c/p\u003e \u003cp\u003e0.65 (0.25, 1.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1.12 (0.32, 3.68)\u003c/p\u003e \u003cp\u003e1.19 (0.30, 4.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.73 (0.37, 1.42)\u003c/p\u003e \u003cp\u003e0.44 (0.18, 1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eAbbreviation: OR: Odds Ratio, CI\u0026thinsp;=\u0026thinsp;Confidence Interval, * Indicates statistical significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSummary of the Main Findings\u003c/h2\u003e \u003cp\u003e Our study found that a high proportion of Ethiopian children met the WHO guidelines, adding a new insight from a low-income country\u0026rsquo;s context. Remarkably, over 90% of children met the physical activity and sleep guidelines, while more than half met the sedentary behaviour and combined guidelines. Children who lived in rural areas were more likely to meet the sedentary behaviour, sleep and combined guidelines than those who lived in urban areas. However, the differences between boys and girls in meeting the guidelines were small and not statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eAdherence to the WHO 24-hour movement behaviours guidelines\u003c/h2\u003e \u003cp\u003eA recent review highlighted the evidence gap in 24-hour movement behaviours among preschool children in Sub-Saharan Africa [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. To the author\u0026rsquo;s knowledge, no studies were found from Ethiopia to compare with our results. Our results were higher than other studies reported for meeting physical activity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], sleep [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and sedentary behaviour guidelines [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A possible reason for this might be lifestyle and environmental factors in Ethiopia [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Most children usually spent more time outdoors and engaged in unstructured play, which contributes to accumulating more physical activity [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] that may help them to sleep well because they are more physically tired [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Almost half of Ethiopian children had limited access to screen devices due to lack of electricity in the rural areas, which helped them to meet the sedentary behaviour guidelines. This may prevent or limit screen time before bed which would also support better sleep [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In contrast, the adherence to the sedentary behaviour guidelines was lower in our study than in the study reported from China (88.2%) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As suggested by Guan et al., (2020), the high levels of adherence to the sedentary behaviour guidelines among Chinese children may have been related to cultural differences. In addition, most Ethiopian parents traditionally count time by observing the position of their shadows based on the Sun\u0026rsquo;s movement, rather than relying on clocks or watches, which might affect the accuracy of estimates of children's screen duration. This should be considered when interpreting our findings. Our combined adherence to WHO guidelines was higher than other published studies [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A possible reason is that a higher proportion of Ethiopian children met the physical activity and sleep guidelines. These findings are consistent with earlier studies regarding compliance with physical activity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], sleep [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and sedentary behaviour guidelines [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Our study found that there was no significant difference between boys and girls in meeting the individual and combined WHO guidelines. These findings were consistent with several previous studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Conversely, our results were in contrast with some evidence reported for combined [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], physical activity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] and sleep [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. A possible explanation for the lack of difference between boys and girls in our study relates to the parenting rules [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] and cultural context in Ethiopia where boys and girls are free to play outside equally at preschool age unlike later age.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eAssociations between meeting the WHO guidelines and socio-demographic factors\u003c/h2\u003e \u003cp\u003e We found that children who lived in rural areas were over seven times more likely to meet the sedentary behaviour, sleep and subsequently the combined guidelines than those who lived in urban areas. Our findings related to rural/urban differences in adherence to sedentary behaviour guidelines was consistent with previous studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, our finding was different from a study conducted in South Africa, which reported that urban children were more likely to meet the sedentary behaviour guidelines than rural children [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Possible reasons could include limited access to screen devices in rural Ethiopia, which could be linked to the lack of availability of electric power in the setting. Our sleep adherence was inconsistent with the two studies conducted in South Africa, which reported no urban-rural difference in meeting the sleep guidelines [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and higher sleep adherence among urban children than their rural peers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Possible reasons for this contrasting finding might be due to country contexts. Most rural children in Ethiopia have less screen time before bed and spend considerable time active outdoors. These factors may contribute to better sleep quality and duration than in urban children [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Our study found that rural children were more likely to meet the combined guidelines than urban children. A possible explanation of this finding is that most rural children complied with the sedentary behaviour and sleep guidelines than urban children with further research needed to confirm differences between rural and urban children in meeting the combined guidelines.\u003c/p\u003e \u003cp\u003e However, our study did not show significant associations between meeting the physical activity guidelines and any socio-demographic factor. This finding differs from studies from Croatia, South Africa and Zimbabwe [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which showed that rural children were more likely to meet physical activity guidelines than their urban peers. Most Ethiopian children from urban and rural areas met the physical activity guidelines. This may be due to children\u0026rsquo;s participation in unstructured physical activities both in urban and rural areas. Also, Ethiopia has a low rate of private car ownership, which may encourage children to walk more to catch public transport, such as minibuses or small taxis to reach their destinations. This could help them to accumulate the required physical activity recommendations in both settings.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eOur findings contribute to bridging the evidence gap and laying the foundation for future advocacy, research, and surveillance on 24-hour movement behaviours in this age group to ensure healthy childhood development in Ethiopia. Our study suggests that interventions focused on reducing screen time and promoting healthy movement behaviours in urban areas are needed. This study provides the first evidence from a low-income country\u0026rsquo;s context, conducting the SUNRISE main study [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], which includes a nationally representative sample of 1,000 children, would provide a greater opportunity to determine the population prevalence of guidelines adherence across the regions of Ethiopia.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003e The strengths of this study include the use of device-measured physical activity and sleep data, providing quality evidence regarding adherence to the WHO guidelines and how this differed among boys and girls as well as urban and rural settings from a low-income country context. However, this study has some limitations. A convenience sampling was used to select kindergarten or rural kebele, which might limit the generalisability of the findings even if this approach is practical. Accurately estimating children\u0026rsquo;s screen time proved challenging for most parents, as they do not rely on watches, even if we followed the SUNRISE standardised protocol [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our sedentary screen time finding needs to be interpreted with caution.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study showed that a high proportion of Ethiopian children exhibit healthy levels of 24-hour movement behaviours. However, urban children showed a lower adherence in screen time, sleep and combined guidelines, suggesting a need for targeted support in these areas.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHICs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;High-income countries\u003c/p\u003e\n\u003cp\u003eLMICs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eMVPA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Moderate to Vigorous-intensity Physical Activity\u003c/p\u003e\n\u003cp\u003eREDCap\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Research Electronic Data Capture\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSTROBE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Strengthening the Reporting of Observational Studies in Epidemiology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTPA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Total Physical Activity\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organisation\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the University of Wollongong Human Research Ethics Committee, Australia (IHRERC/2018/044) and the Institutional Health Research Ethics Review Committee at Adama Hospital Medical College, Ethiopia (AHMC/SR/31/01/2022). Informed written consent was provided by parents/caregivers for their children and themselves before participating in the study. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData that support the findings of this study are available upon a reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCA is supported by a Higher Degree Research Scholarship funded by the University of Wollongong, Australia. The funder had no role in the conceptualisation, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCA conceptualised the study, processed and analysed data, interpreted results and was a major contributor in writing the manuscript. DC, KK and ADO conceptualised the study. KHC and DA were involved in data processing and interpreting the results. AD, SG and DT interpreted the results and edited the manuscript. All authors reviewed and approved to the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors expressed their gratitude to the University of Wollongong for granting a scholarship to Chalchisa Abdeta to conduct this study. We acknowledged the SUNRISE Study Coordinating Centre team (Penny Cross, Rebecca Calleia, Ajinkya Buva and Claudia Maddren) for their invaluable logistic and data management support provided during the data collection. The authors also grateful to Mr. Tadesse Tolera for his assistance in facilitating data collection in the rural area. We expressed our gratitude to our data collectors, Dr. Tsedey Shume and S/r Hermela Girma, for their hard work in collecting quality of data. We thank the parents/caregivers, educators and community health workers for their contribution to the success of data collection. Finally, we would like to extend our heartfelt thanks to the children who participated in this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age. Geneva: World Health Organisation. 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Screen use before bedtime: Consequences for nighttime sleep in young children. Infant Behav Dev. 2021;62:101522.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuerrero MD, Barnes JD, Chaput JP, Tremblay MS. Screen time and problem behaviors in children: exploring the mediating role of sleep duration. Int J Behav Nutr Phys Act. 2019;16(105).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristian H, Murray K, Trost SG, Schipperijn J, Trapp G, Maitland C, Divitini M. Meeting the Australian 24-Hour Movement Guidelines for the Early Years is associated with better social-emotional development in preschool boys. Prev Med Rep. 2022;27:101770.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoncalves WSF, Byrne R, de Lira PIC, Viana MT, Trost SG. Adherence to 24-hour movement guidelines among rural Brazalian preschool children: associations with parenting practices. Int J Behav Nutr Phys Act. 2022;19(1):133.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-activity-sedentary-and-sleep-behaviors","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jassb","sideBox":"Learn more about [Journal of Activity, Sedentary and Sleep Behaviors](https://jassb.biomedcentral.com/)","snPcode":"44167","submissionUrl":"https://submission.nature.com/new-submission/44167/3","title":"Journal of Activity, Sedentary and Sleep Behaviors","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Physical activity, Sedentary behaviour, Screen time, Sleep, Early childhood","lastPublishedDoi":"10.21203/rs.3.rs-4598823/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4598823/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe World Health Organisation (WHO) has called for more evidence on 24-hour movement behaviours from low- and middle-income countries. We examined the proportion of Ethiopian children aged 3.0-4.9 years who met the WHO guidelines on physical activity, sedentary behaviour and sleep for children under the age of five, and the associations between meeting the guidelines and socio-demographic factors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted in Adama and Lume Woreda, Ethiopia. Children were recruited through kindergartens in Adama and rural villages in Lume Woreda, Ethiopia. Physical activity and sleep were measured using ActiGraph accelerometer. Sedentary screen time and restrained sitting were parent-reported. Multivariable logistic regression models tested associations between meeting the individual and combined WHO guidelines and socio-demographic factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 430 children participated in the study (mean age 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 years). More than half the children (58.0%) met all the WHO guidelines. A higher proportion met the physical activity (96.1%) and sleep guidelines (91.9%) compared to the sedentary screen time guideline (63.5%). Children who lived in rural areas were more likely to meet the sedentary behaviour (84.6% vs 38.2%, AOR\u0026thinsp;=\u0026thinsp;7.31; 95%CI: 3.93, 14.02), sleep (98.6% vs 83.8%, AOR\u0026thinsp;=\u0026thinsp;8.60; 95%CI: 3.55, 23.73) and combined (81.3% vs 30.1%, AOR\u0026thinsp;=\u0026thinsp;7.41; 95%CI: 4.04, 13.97) guidelines than those who lived in urban areas.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e Children from rural Ethiopia were more compliant with the WHO guidelines than their urban counterparts. Strategies to reduce screen time and promote healthy movement behaviours in urban areas are needed. Further studies with a larger representative sample might provide better insight across the regions of the country.\u003c/p\u003e","manuscriptTitle":"Adherence to the WHO guidelines and associations with socio- demographic factors among Ethiopian preschool children: The SUNRISE study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-08 07:02:05","doi":"10.21203/rs.3.rs-4598823/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-22T07:43:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-17T16:39:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-07T12:27:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-27T21:01:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283947826949552636353660833578535079537","date":"2024-06-25T18:01:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"215579325870169355081395068885367765862","date":"2024-06-25T16:39:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176618888985532091870924709362838250906","date":"2024-06-24T10:58:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103014299065330948510950765839213321721","date":"2024-06-24T09:30:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-23T04:46:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-23T03:31:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T14:27:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Activity, Sedentary and Sleep Behaviors","date":"2024-06-18T09:14:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-activity-sedentary-and-sleep-behaviors","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jassb","sideBox":"Learn more about [Journal of Activity, Sedentary and Sleep Behaviors](https://jassb.biomedcentral.com/)","snPcode":"44167","submissionUrl":"https://submission.nature.com/new-submission/44167/3","title":"Journal of Activity, Sedentary and Sleep Behaviors","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c1a23d6-6855-4ce2-846d-e76729e0c642","owner":[],"postedDate":"July 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-08-21T02:02:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-08 07:02:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4598823","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4598823","identity":"rs-4598823","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}