Physical Activity and Sedentary Behaviour Surveillance in Czech Children and Adolescents: A Scoping Review of the Literature from the Past Two Decades

Background: This study aimed to map the available evidence related to physical activity (PA) and sedentary behaviour (SB) in Czech children and adolescents and suggest future directions and improvements to strengthen surveillance on PA and SB in the Czech Republic. Methods: The search of studies published between January 2000 to December 2020 included the Medline and Medvik databases and a hand search in eight Czech journals related to the topic. This review followed the "Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews". Results: Out of 350 identied studies, 79 met the selected criteria. The majority of studies were cross-sectional (89%), approximately two-thirds of the studies (61%) examined only PA, and half of the studies (51%) employed device-based assessments. Approximately 47% of studies reported the prevalence of physical inactivity based on inconsistently dened recommendations. Approximately, 14%, 23%, and 10% of studies focused on active transport, organized PA (including physical education or leisure-time PA), and parent-child PA, respectively. Conclusions: Future studies need to focus on longitudinal design and interventions, randomly selected samples, a mix of devised-based and self-reported methods, and recognition of health-related 24-h time-use patterns. This review advocates the governmental-supported development of a national surveillance system helping to the reduction of insucient PA and excessive SB.

Speci cally, time spent using a device such as a computer, television, or games console, which is called "screen time" (ST), is a more speci ed component of total SB with several negative effects on health [10].
Achieving a required level of PA and SB offers signi cant health bene ts and mitigates health risks which have been recently highlighted by the World Health Organization (WHO) in the last edition of "WHO Guidelines on Physical Activity and Sedentary Behavior" [1].
WHO also announced national surveillance on PA as an essential part of the global initiatives for the reduction in the global prevalence of insu cient PA by providing a means to assess compliance with PA and SB guidelines and subsequently serving for monitoring progress over time [11]. Moreover, the national data could help to adopt global PA and SB recommendations with adequate adjustment to the social, cultural, and environmental conditions of the state. In the Czech Republic, the national surveillance system, as well as country-speci c recommendations for children and adolescents' PA, are lacking. The inadequacy in the area of PA research is seen in a recently published systematic review of global, regional, and national trends and patterns in PA research since 1950 where the Czech Republic with a total of 105 papers is in nineteenth place among high-income European countries [12]. Likewise, no study has summarized and reviewed existing research on PA and SB in Czech children and adolescents. Such a comprehensive analysis describing up-to-date surveillance and main ndings is critical ahead of further steps which could lead to the development of a national surveillance system and recommendations.
Therefore, the purpose of this study was to systematically review the best available evidence on PA and SB in Czech children and adolescents published in the last two decades. Speci cally, we aimed to (1) summarize the descriptive characteristics and main conclusions of the available evidence and (2) suggest future directions and improvements to strengthen surveillance on PA and SB in Czech children and adolescents.

Methods
The search strategy This scoping review conforms to the "Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews" (PRISMA-ScR) [13]. The checklist was followed to report this study (Supplementary le 1). The search included the Medline (via Ovid) and Medvik databases. We searched for studies published from January 2000 to December 2020 but only studies whose data were obtained during this period were included in the review. The search strategy was arranged in three sets of terms that cover the target population (i.e., school-aged children), movement behaviors (i.e., PA and SB), and country (Czech Republic). The search strategy builds mainly on the Medical Subject Heading (MeSH) terms. Subsequently, selected free-text terms were included in the search strategy to increase the sensitivity of the search. The complete search strategy in electronic databases is presenting in Supplementary le 2. The search results were imported into the EndNote programme (Version X7; Thomson Reuters, San Francisco, CA, USA), all duplicates were deleted, and an online Excel spreadsheet was produced for screening purposes. The nal database included several unique identi ers for each study and several pieces of bibliographic information (article identi er, authors, year of publication, study title, abstract and journal title).
Then, the title and abstract of the studies were screened by two independent evaluators. The studies were divided into three groups: relevant, irrelevant, and potentially relevant studies. In the case of potentially relevant studies, their full-texts were analyzed, and then the studies were included or excluded. In the event of a disagreement between the evaluators concerning the relevance of a particular study, the nal decision as to inclusion or exclusion was made by a third person.
In addition to searching the databases mentioned above, the authors performed a hand search in the references of studies included in the review. A hand search was also carried out in main Czech journals related to the topic of interest and which were not indexed in the Medline and Medvik databases during part or the whole period of past 20 years. Namely, we performed the hand search in Tělesná kultura, Acta Gymnica, Česká Kinantropologie, Studia Kinanthropologica, Medicina Sportiva Bohemica et Slovaca, Tělesná výchova a sport mládeže, Acta Universitatis Carolinae -Kinanthropologica, Studia Sportiva.

Study inclusion and exclusion criteria
Studies with any research design were included in this scoping review if they: a) targeted Czech children and adolescents aged 6-19 years, b) reported PA, SB, or both, c) were written in English or Czech language, d) were published between 2000 and 2020, and e) were published as a peer-reviewed journal article. The international studies without a clearly de ned Czech sample were excluded. The minimal sample size was set at least 50 participants for cross-sectional studies and was not set for longitudinal studies.

Data extraction
The basic characteristics about included studies (design, primary outcomes, and main ndings) and descriptive characteristics of the study samples (sample size, percentage of girls, age category or average age, and region of Czech Republic) were extracted. We also extracted information on the use of methods in measurement (self-reported, device-measured) and dealt with more detailed information on PA and SB. Finally, we summarized the main ndings and results of the included studies.

Data extraction procedure and bibliographic characteristics
In the Medline and Medvik databases, a total of 316 studies were identi ed based on the search strategy, and 34 studies were identi ed by hand search (Figure 1). After the removal of duplicates, the exclusion of studies based on predetermined criteria was done. Out of 160 full-text articles assessed for eligibility, there was a disagreement between the evaluators concerning the relevance of a particular study in 8 studies, and the nal decision as to inclusion or exclusion was made by a third person. Although these papers were related to PA and SB of Czech children and adolescents, the main reasons for exclusions were: a) impossibility to separate Czech results from results of other countries [14], b) PA and SB results related to very speci c samples (with different mental load or academic achievement) without clear summary ndings [15][16][17], and c) speci c studies examined test-retest reliability [18,19].
The nal sample included 79 studies, the overview of which is shown in Table 1. Sixty-one papers were published in the English language and 18 were published in the Czech language. Out of 79 studies, 18 studies [20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] were part of international surveys with clearly identi ed results related to PA and/or SB in Czech children and adolescents. The agreement between preferred and PA actually undertaken was associated with higher odds for meeting the weekly PA recommendations and higher levels of well-being both in boys and girls. 58% of children used AT for commuting to and from school. Children actively commuted more often in schools which had formally processed health promotion objectives than in school without these goals. In addition, children who had a school in the same village or city had a higher chance for AT than children who had a school elsewhere than in the place of residence. A longer duration of total PA in daughters, sons and their fathers and mothers was related to a shorter daily period of time spent sitting. A longer time spent daily in sitting in parents was associated with a longer time spent sitting in their children. Children, both daughters and sons, and their mothers, who participate in organized PA twice or more times a week, showed a signi cantly longer time spent performing VPA than children whose mothers are without any participation in organized PA.

SB (ST)
Despite the different mother-/father-child behavioral associations, daily step counts of parents were positively associated with daily step counts of their children. For both overweight/obese and non-overweight children, the odds of reaching the recommended daily step counts were increased by their regular participation (≥twice per week) in OLTA and nonexcessive entertainment ST (≤2 h per day) in the motherchild and nuclear family triads. studies on adolescents, and 7 studies on both. The age of the study participants ranged between 6 and 19 years. The intervention studies employed only children aged 6-9 years. Girls represented more than 50% of the study sample in most of the studies and boys have not been included in 4 studies [41][42][43][44].
Out of all 79 studies, the randomly selected representative samples were identi ed in 28 studies.
In cross-sectional studies, the sample size varied from 55 [42] up to 30,966 participants [45]. Longitudinal studies employed samples with 9 to 176 participants.
This scoping review identi ed data on PA and SB of Czech children and adolescents in 18 international and 61 national studies. Some of the national studies narrowed their selection only to speci c regions: 12 studies from the Olomouc region [26, 39, 43, 46-54], 2 studies from the Hradec Králové region [39,49], three studies from the Moravia region [41,55,56], two studies from the North-western Bohemia region [57,58], one study from the Plzeň [59] and Opava region [42].

Weekdays versus weekend days
In all studies, a greater PA level was found for weekdays compared to weekend days. Moreover, this was con rmed in longitudinal studies [43,51] which revealed that across all months and seasons, children and adolescents achieved notably more minutes in MVPA or steps on weekdays than on weekends, with Sunday being the least active day [43,50,51,62]. Conversely, weekend days seem to be the "risk time" for excessive ST and insu cient PA level [40,62,66,74,80,85].

Active transport
Out of 11 studies examining AT, 9 studies focused on active commuting to and from school including walking, cycling, and riding a scooter or skateboard. The proportion of children and adolescents using actively commuting to school ranged between 22.5% and 74.3% across studies [29,36,39,63,75,[86][87][88][89]. Living within a 20-minute walking distance to school [75], a place of residence being in the same municipality as the school [63, 87], high walkable areas [39], and attending schools with policies and programs promoting AT [87,88] were positively associated with active commuting to school. Based on one study [21], AT accounted for 22.5% and 24.9% of the weekly PA of Czech boys and girls, respectively.
A long-term decrease in AT of Czech adolescents was found in two studies. One study [39] [43,44,51]. In intervention studies [52][53][54], PE lessons as a part of the school PA program performed in the compatible active environments were found to have a vital role in obesity and overweight reduction among younger pupils.
The proportion of children and adolescents who participated in OLTA ranged between 41-81% across studies [90][91][92][93] and was decreasing with age [58,91]. More speci cally, 62% of Czech children and adolescents took part in sports club activities [37]. Moreover, OLTA was positively associated with better physical and mental health [93], lower occurrence of repeated substance use and truancy, and inversely with higher odds for physical ghts and injuries [91], higher school engagement, lower levels of schoolrelated stress, and better academic achievement [92], and a lower prevalence of obesity [82]. Longitudinal engagement in OLTA increased daily PA, regardless of the month and season [50]. In contrast, 34-37% of Czech children and adolescents were not engaged in any OLTA [29,90]. However, the involvement in peeroriented unstructured activities was strongly associated with an increased risk of smoking, getting drunk, experience with sexual intercourse, and worse academic achievement in 34% of adolescents [90].
For example, boys were more likely to cycle to school [86] and the association between school policies and programs and AT was stronger in boys compared to girls [80]. On the other hand, a higher rate of AT was signi cantly associated only with higher well-being in girls [21]. Girls had signi cantly lower odds of adherence to the combined movement guidelines [64], appeared to be more in uenced by social motives [61] and their participation in leisure-time PA was decreasing with age more than in boys [58]. PA preference differed between boys and girls and was longitudinally more stable for boys than for girls [23].
In SB studies, the results related to sex differences were not so clear. In some device-based studies, girls were found to be more sedentary [38,56,67,71], while in others, time spent in SB was higher in boys compared to girls [45,58,65,80,83]. Moreover, in self-reported studies, boys reported higher overall ST [58,83], computer use [32,45,80], or TV watching [45] than girls. On the contrary, chatting online was more common among girls [80]. The sex-speci c SB was found also in the device-based study [55], where boys spent on average 9.9 min/day less in short sedentary bouts and 7. Zealand [101] or Thailand [102]. Within this review, the lack of Czech studies focusing on health-related time-use patterns and covering all daily behaviours in children and adolescent populations has been recognized.
Consistent, understandable assessments of prevalence and trends in PA (ideally relative to other behaviours) are necessary to guide the development of policies and programs to increase activity levels and to reduce the burden of non-communicable diseases associated with physical inactivity and elevated SB. In this review, 37 studies investigating the percentage of Czech children or adolescents who achieved PA or SB recommendations were cross-sectional with 62% not having a representative sample.
This review also identi ed several studies that examined trends in PA or SB or meeting recommendations for these behaviours. Such studies with randomly selected samples suggested the negative trends which were found in other countries [5], such as increased sedentary time, decreasing percentage of children and adolescents meeting PA guidelines, and using AT. However, these studies employed self-reported assessments of PA and SB that could be prone to both inaccurate reporting and reporting bias [103].
Moreover, accelerometers were found more accurate in the characterization of the entire activity pattern in school-aged children [104]. On the other hand, the domain and type-speci c differences in PA and SB (e.g., AT, ST) advocate the importance of assessing movement behaviours using the combination of selfreported and device-based methods. Furthermore, the variety of tools used to assess PA and SB, the way how were the data processed (especially in accelerometers) as well as the different de nition of su cient level of PA and SB in the studies may explain the inconsistency of ndings related to sex-speci c PA and SB or prevalence of su cient PA.

Strengths and limitations of the study
This is the rst comprehensive study systematically reviewing available evidence related to PA and SB in Czech children and youth. Moreover, within this review, we provide suggestions for future directions of the national surveillance system on these behaviours.
Several limitations have to be mentioned. Firstly, the search strategy does not cover "grey literature". This could lead to publication bias as we might miss some valuable data published in conference proceedings, Master or Doctoral thesis, or reports. On the other hand, our search strategy ensured that all studies found for this review underwent a peer-review process and demonstrate at least satisfactory methodological quality standards. Last and not least, within this scoping review we described the study designs, samples, and methods of PA and SB assessments and the main ndings of the selected studies.
However, an assessment of methodological quality which could help in comparison of outcomes of the studies was not carried out. Although we reviewed 79 studies, the uni ed national surveillance was not recognized. This review identi ed limitations including the large proportion of cross-sectional studies, the limited sample size in longitudinal studies, the lack of studies using a mix of devised-based and self-reported methods, and focusing on health-related 24-h time-use patterns.

Conclusion And Recommendations
In agreement with global calls [11,105], the result of this review advocates the necessity of the governmental-supported development of a national surveillance system that would incorporate a combination of standardized device-based measures, such as those derived from accelerometers, and self-reported domain and type-speci c assessments. Such a national surveillance system on movement behaviours which would allow to systematically assess the recommended amount of these behaviours is needed to reduce decreasing of su cient PA and hence, improve health or reduce the risk of different non-communicable diseases in Czech children and adolescents.
With respect to the "WHO Global action plan on physical activity 2018-2030" call [11] and based on this review of the best available evidence, we identi ed several issues which might serve as a recommendation for future directions in Czech research and policy and were inspiring for other Central European countries lacking a national surveillance system: We advocate the development of a national surveillance system on 24-h movement behaviours that The ow of information through the different phases of the review.

Figure 2
The overview of included studies considering their year of publication and primary outcomes. Note. PA = Physical activity; SB = Sedentary behaviour.