Journal of Physical Activity and Health, 2016, 13 (Suppl 2), S251  -S255
http://dx.doi.org/10.1123/jpah.2016-0325© 2016 Human Kinetics, Inc.

ORIGINAL RESEARCH

Results From Scotland’s 2016 Report Card on Physical Activity
for Children and YouthJohn J. Reilly, Avril Johnstone, Geraldine McNeill, and Adrienne R. Hughes
Background: The 2016 Active Healthy Kids Scotland Report Card aims to improve surveillance of physical activity (PA), facilitate international comparisons, and encourage evidence-informed PA and health policy. Methods: Active Healthy Kids Canada
Report Card methodology was used: a search for data on child and adolescent PA and health published after the 2013 Scottish
Report Card was carried out. Data sources were considered for grading if based on representative samples with prevalence
estimates made using methods with low bias. Ten health behaviors/outcomes were graded on an A to F scale based on quintiles(prevalence meeting recommendations ≥80% graded A down to <20% graded F). Results: Three of the seven Health Behaviors
and Outcomes received F or F- grades: Overall PA, Sedentary Behavior, and Obesity. Active and Outdoor Play and OrganizedSport Participation could not be graded. Active Commuting to School was graded C, and Diet was graded D-. Family and Peer
Influence was graded D-; Perceived Safety and Availability of Space for PA as well as the National Policy Environment weremore favorable (both B). Conclusions: Grades were identical to those in 2013. Scotland has a generally favorable environmentfor PA, but children and adolescents have low PA and high sedentary behavior. Gaps in surveillance included lack of objectively
measured PA, no surveillance of moderate-to-vigorous PA in children, summary surveillance data not expressed in ways whichmatch recommendations (eg, for PA in young children; for screen-time), and no surveillance of Sport Participation, Active andOutdoor Play, or Sitting. Scottish policy does not include sedentary behavior at present.
Keywords: exercise, sedentary behavior, obesity, adolescent
A brief description of Scotland, and the rationale for an Active
Healthy Kids Scotland Report Card, distinct from report cards produced by the other UK nations, was provided in the report on the2013 Active Healthy Kids Scotland Report Card.1 Physical activity(PA) surveillance of children and adolescents in Scotland is basedlargely on the nationally representative Scottish Health Survey(SHeS2), which uses self/parent-report measures of PA. For many
years the SHeS has made the unlikely assumption that all reported
PA is of moderate-to-vigorous intensity PA (MVPA).2,3 Annually
collected SHeS data suggest that adherence to the 60 minutes/
day MVPA recommendation is very high in boys and girls duringchildhood, but falls dramatically in early adolescence, particularly
in girls. National PA strategy, based explicitly on SHeS data,4,5
targets adolescents, particularly adolescent girls. However, the only
validation study of SHeS methodology for measurement of PA inchildren found that MVPA was overestimated by 120 minutes/day
on average,3 and the estimates of PA from the SHeS questionnaire
were uncorrelated with accelerometer output in the same individuals.
Moreover, recent longitudinal studies suggest that MVPA probably
declines well before adolescence6,7. Current Scottish PA surveillance
therefore provides a misleading basis for national policy, and thereis need for a thorough critique of Scottish PA surveillance data, andScottish policy, in this area.

Reilly, Johnstone, and Hughes are with the Physical Activity for HealthGroup, School of Psychological Sciences and Health, University ofStrathclyde, Glasgow, Scotland. McNeill is Emeritus Professor of Public
Health Nutrition, Institute of Applied Health Sciences, University ofAberdeen, Aberdeen, Scotland. Hughes (adrienne.hughes@strath.ac.uk)
is corresponding author.

During 2013, the first Active Healthy Kids Scotland Report
Card was developed and launched in both short-form8and longform,9 as part of a Knowledge Translation project modeled closelyon the Active Healthy Kids Canada Report Cards,10 organized by
Active Healthy Kids Scotland (www.activehealthykidsscotland.
co.uk). As noted in the 2013 Active Healthy Kids Scotland Report
Card,1 child health in general, and PA in particular, has been a highpriority in Scottish government policy. Scottish policy since 2013
has used the hosting of a major international sporting event, the2014 Commonwealth Games, to promote PA among children andadolescents.4,5The primary aim of the present paper is to summarize the process and results of the Active Healthy Kids Scotland 2016 Report
Card. Secondary aims are to identify any changes in report card
grades since 2013, to critique Scottish PA and health surveillancedata for children and adolescents, and to critique any changes in
PA and health surveillance and policy since 2013.

Methods
The 2016 Active Healthy Kids Scotland Report Card was produced
by a RWG, based on the Canadian model10,11 which consisted of
the 4 authors of the current article. The RWG was advised by adiverse group of stakeholders from many sectors (academia; healthand education practice and policy; transport; sport; play), based on
the approach taken in the Canadian card12 and in the 2013 Scottish card.1,8,9 Members of the Stakeholder Group commented on a
draft version of the Scottish card. The 2016 Active Healthy Kids
Scotland Report Card was cofunded by grants from 2 Scottish
charities, The Robertson Trust (www.therobertsontrust.org.uk/) andInspiring Scotland (www.inspiringscotland.org.uk). The funders
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S252  Reilly et al

have particular interests in using evidence to inform policy, and thepromotion of child PA and health, but had no role in the content of
the report card, and no role in the current manuscript.
The Active Healthy Kids Scotland Report Card in 2016 had
the same 10 indicators (Table 1) as in 2013. Most of the indicators
were health behaviors, but, as in 2013, the Research Working Group(RWG) felt that it was important to retain at least 1 health outcome(obesity) among the indicators, and 1 non-PA behavior (diet). Obesity has been a high priority of Scottish government policy for sometime, and the inclusion of obesity provides an opportunity to increase
the usefulness of the report card in Scotland. As in 2013, for someof the indicators there were multiple sources of Scottish surveillancedata, and the aim was to base grades, where possible, on evidence
which met the following criteria: data should be recent, publishedafter the Active Healthy Kids Scotland Report Card in 2013; data
should be derived, where possible, from nationally representative
samples; data should be have minimal bias, obtained using methods
which do not lead to large overestimates or underestimates of theprevalence of the health behavior or outcome.
During March and April 2016 the RWG searched for relevant
evidence from Scotland, prioritizing nationally representative surveys as before.1 For the 10 indicators draft grades were assigned by
the RWG during April 2016, by comparison of the national survey
data against a relevant evidence-based recommendation (eg, 60
minutes MVPA/day, every day, for school-age children and adolescents) where this was available. The benchmark approach from theActive Healthy Kids Canada Report Cards10–12 was used: grade A(we are succeeding with ≥80% of children and adolescents); grade B(succeeding with 60 to 79%); grade C (succeeding with 40 to 59%);
grade D (succeeding with 20 to 39%); grade F (succeeding with<20%); and INC (incomplete data). Each indicator was assigneda ‘+’ if there was evidence that trends were improving since thelast report card in 2013 or a ‘-’ was assigned if there was evidenceof worsening time trends since the last report card, and/or goodevidence of marked socioeconomic inequalities for that indicator.
For each indicator we considered the probability of bias arisingfrom error in the measures used. Where the probability and magnitude of bias were both high the measure was not used. For example,
we declined to assign a grade to the SHeS surveillance measuresof PA for the reasons given above, but graded this indicator basedlargely on a measure of MVPA from the Health Behavior in School
Age Children (HBSC) 2014 Survey13 which has a much smaller
bias when used to assess adherence to PA recommendations.14,15
Decisions of this kind were made by the RWG, using a combinationof their methodological expertise in the area, reference to recent
reviews on biases in measurement of the various indicators,16–19 andthe consultation process with stakeholders.
Draft report card grades were considered by the Stakeholder
Group in May 2016. Stakeholders were asked to address the following questions, as before:9
Were any relevant Scottish data missed in the process of carddevelopment ?
Were any data misinterpreted or misunderstood by the RWG(eg, were the draft grades justified)?
Were any relevant stakeholder groups or individuals omitted?
Which indicators not included in the card should be includedin future cards?
The consultation process informed the final grades in the Active
Healthy Kids Scotland 2016 Report Card, launched in June 2016.

Consultation comments, and our responses to them, are available on
the project website (http://www.activehealthykidsscotland.co.uk).

Results and Discussion
The 2016 Active Healthy Kids Scotland Report Card grades are
summarized in Table 1, and the ‘cover story,’ the card theme of
Active and Outdoor Play, is summarized in Figure 1.The shortform report card, and a more detailed rationale for the indicatorsand grades,8,9 are both accessible from the project website (http://
www.activehealthykidsscotland.co.uk).
Five of the seven Health Behaviors and Outcomes Indicators(Table 1) could be graded with a combination of the availability of a
Table 1 Grades According to Physical Activity
Indicator in the 2016 Scottish Report Card on Physical
Activity for Children and Youth*
Indicator

GradesOverall Physical Activity Levels

F

Organized Sport Participation

INC

Active and Outdoor Play

INC

Active Transportation

C

Sedentary Behavior

F

Family and Peer InfluenceD-

Obesity

F-

Diet

D-

Community and the Built Environment

B

National Policies, Strategies and Investments

B

Note. The grade for each indicator is based on the percentage of children and youth
meeting a defined benchmark: A is 81% to 100%; B is 61% to 80%; C is 41% to60%, D is 21% to 40%; F is 0% to 20%; INC is Incomplete data combined withlack of an evidence-based recommendation.
* All 2016 grades identical to 2013 grades.

Figure 1 — Front cover of the 2016 Scottish Physical Activity Report Card.

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recommendation for that indicator, and a high degree of confidence
in the benchmark of the percentage of children and adolescents
meeting the guideline as noted above. The indicators Active andOutdoor Play and Organized Sport Participation could not be graded,in part because of a lack of an evidence-based recommendation forthese behaviors, and in part because available Scottish data werelimited or absent.9 Table 1 shows that the key health behaviors andoutcomes were generally assigned low or ‘fail’ grades.
Grades for the indicators of Influences on Physical Activity
and Health Behaviors and Outcomes were generally much better
than grades for health behaviors and outcomes (Table 1). For theindicator Family and Peer Influence on Physical Activity Behaviors and Outcomes, no direct evidence of family or peer influence
was available, and so proxy measures for the peer and adult healthbehaviors and outcomes had to be used, as in the 2013 report card.1
Scotland is characterized by obesity prevalence which is high,increasing, and socially patterned; adherence to adult PA recommendations is apparently moderate; adherence to dietary recommendations is low, socially patterned, and worsening over time.
The indicator Community and the Built Environment (perceived
safety, access to, and availability of space for PA) was graded B,
reflecting the evidence that access and availability of space appeared
to be generally favorable to PA, and perceived safety was moderately high. The indicator Policy referred to national policy only,
and was graded B on the grounds that Scotland has many national
government policies, strategies, and investments which target mostof the 7 health behaviors and outcomes included in the card (thenotable exception in 2016 being sedentary behavior, as in 20131).
Since the 2013 Scottish report card, national policy and strategy inthis area has arguably improved, or at least increased, with greater
recent emphasis on policy implementation including the signingof implementation agreements between national and local governments.5 In addition, recent Scottish policy in this area has sought totake advantage of the hosting of the 2014 Commonwealth Gamesto provide a population-wide PA ‘legacy.’4

Key Health Behaviors and Outcomes Related
to Physical Activity and Sedentary Behavior
For children and adolescents reported exposure to recreational
screen time was extremely high, well above the 2 hours per day
recommended internationally. The 2 data sources on recreational
screen time available for grading had reporting limitations: SHeS
surveillance of recreational screen time expresses the prevalenceof the child and adolescent population exceeding 4h/d, not the 2h/d
used in the screen-time recommendation;2 the HBSC data are summarized for different forms of recreational screen time (TV viewing;
gaming) separately, so estimating total recreational screen time forindividuals is problematic.13 The overall PA grade was based on adolescents only, using MVPA data from the HBSC 2014.13 These data
are based on a simple self-report method which has only a small bias
for the assessment of adherence to MVPA recommendations,14,15 andsuggest that around 30% of boys adhere to the recommendation atage 11, and 15% at 15; in girls 21% adhered at age 11 and 11% at
age 15.13 As noted above, surveillance of MVPA is not available forschool-age children in Scotland as it is not measured in the SHeS.
An additional problem identified by our critique of surveillance isthat the SHeS erroneously uses school-age recommendations for PA
when considering the adequacy of PA levels in preschool children.2
The low grades for the ‘headline’ report card indicators of
PA and sedentary behavior, and in fact all grades in 2016, were

the same as in 2013.1 The 2016 Active Healthy Kids Report Card
Scotland therefore provides no evidence for an improvement in
PA and health behaviors since the last report card, and there wassome evidence of a possible worsening of some of the indicators,
discussed briefly below.
The ‘cover story’ for the 2016 Active Healthy Kids Scotland
Report Card8,9 (Figure 1) was Active and Outdoor Play. The rationale for the cover story was that active and outdoor play represents
a potentially important opportunity to increase MVPA.20 Active
and outdoor play is a neglected domain of PA in PA promotion—
research and policy efforts have focused on school-based domains(notably PE, a high policy priority in Scotland)4,5 and no Scottish
data sources exist for active and outdoor play specifically. An
additional argument for surveillance of active and outdoor play,and consideration of this domain in PA policy, is that differencesin MVPA between children in high-income versus low-income
countries might be partially attributable to differences in the amountof time spent in active and outdoor play.21,22 In addition, recent systematic reviews suggest that the school-based domains (PE, recess,active commuting to school) which have been the focus of mostprevious research and policy effort may contribute relatively little topopulation MVPA at present.23–25 Comparisons of the likely effectof different interventions on population MVPA20,26 also suggest that
future efforts should extend beyond the school.
Scottish government surveillance and policy is based heavily on
the SHeS.4,5 The critique of SHeS data and data interpretation for thecurrent study has highlighted multiple weaknesses in the SHeS datacollection, data presentation, and data interpretation. For example,
Organized Sport Participation is not measured specifically by the
SHeS, despite the prominence of the potential CommonwealthGames legacy in policy. As noted above, the SHeS does not measure Active and Outdoor Play specifically. A serious weakness of
the SHeS data interpretation is that the survey attempts to measure
total volume of PA2 but data on total volume of PA are erroneously treated as time spent in MVPA when used in surveillance
and in evidence-based policy.4,5 As a result, apparent adherence to
MVPA recommendations based on this misinterpretation of SHeS
data are extremely high: 80% of boys and 73% of boys at age 11
to 12, with even higher apparent adherence in children according
to the SHeS.2,4,5 These estimates greatly exceed those for the sameage from the HBSC Surveys,13 as well as those from the othercountries in the UK,27–29 and suggest that typical levels of MVPA
among Scottish children are similar to those of children from rural
Mozambique.30 No objectively measured Scottish MVPA data wereavailable across the child and adolescent age range. Finally, SHeS
data on preschool children are compared against the MVPA recommendations for school-age children and adolescents in the SHeS2this is inappropriate, and the lack of distinction between preschooland school-age children is also inconsistent with the increasingemphasis on the early years in Scottish government policy.
Multiple sources of Scottish data were available, as before,1on active commuting (walking, cycling) to and from school, andthese data sources were highly consistent in suggesting that thataround 50% of Scottish primary school children normally commute
actively to school, and 40% to 45% of those at high school commute
actively, hence a C grade was assigned. New Scottish data on active
commuting to nursery became available since the 2013 report card,and this suggested that around half of preschool children commute
actively.8,9 Surveillance effort on active commuting to school/nursery in Scotland is substantial, based on multiple surveys, and

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S254  Reilly et alsome of the surveys are likely to be redundant. A gap identified by
the current study is that active commuting to other locations, on
the 160 or so days per year that children are not at school, is notincluded in current surveillance.

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Key Influences on Health Behaviors
and Outcomes
The D- grade for the indicator Family and Peer Influence on Physical
Activity Behaviors and Outcomes was limited to proxy data because
we were unable to find direct Scottish evidence of parental or peer
influence based on measures of PA or diet with minimal bias. The
proxy data indicates that Scottish children and adolescents develop
among adult norms of overweight and obesity, obesogenic diet, but
apparently moderately high levels of PA. Peer norms of low PA
and high exposure to screen time suggest that peer influences arealso unfavorable.
The B grade for the indicator Community and the Built
Environment was based on evidence8,9 that Scottish children andadolescents have high perceived access to/availability of space forPA, and perceived safety of such space was moderately high.1,8,9
The national policy environment was graded B. Many Scottish policies are relatively recent, and they may need greater time and/or
greater implementation efforts if they are to impact on the generally
unfavorable grades for the indicators in the Health Behaviors andOutcomes category. The emphasis on implementation of policy in
Scotland has increased since the last report card, with the recent
signing of implementation agreements between national and local
government.5 The major gaps in the national policy environment
were the absence of any policies on sedentary behavior, and the lackof emphasis on evaluation of policy implementation.

Obesity and Diet Indicators
Obesity prevalence (graded F-), as defined by BMI percentile, ismuch higher than in the past,1,8,9 is more prevalent among the moresocioeconomically deprived, and socioeconomic inequality in childand adolescent obesity appears to be widening. In addition, systematic reviews of obesity diagnostic studies have shown that obesity
prevalence estimates using BMI are highly conservative.18,19 Since
the 2013 Active Healthy Kids Report Card Scotland was published
new Scottish data (from the UK Diet and Nutritional Surveys
2008–201231) have become available on prevalence of overweight
and obesity among 2- to 3-year-olds: these estimates are based on
the WHO BMI standards32 and suggest very high prevalence (17%prevalence of obesity at age 2 to 3 years).
The 2014 Scottish Health Survey2 showed little change inchildren’s fruit and vegetable consumption which remained at an
average of 2.8 portions per day. Data for 2012/2013/2014 combined
showed that around half the children had nondiet soft drinks once a
day or more while over a third had potato chips once a day or more,with the highest proportions among children in the most socioeconomically deprived areas. Among adults there was no evidence
for improvement in diet over the period 2008 to 2014 and someevidence of widening socioeconomic disparities. Data for children
from 2003 to 2012/2013, however, suggest some gradual improvements in children’s diets (eg, with an increase in the frequency ofoily fish consumption and decrease in frequency of consumptionof potato chips). The UK-wide National Diet and Nutrition Survey
has recently released data for children in Scotland for the period
2008–2012 which show higher than recommended intakes of saturated fat and particularly of nonmilk extrinsic sugar (broadly similar

to added sugar) which was on average 15.8% of energy intake inboys and 14.9% of energy intake in girls (ie, the average is 3 times
higher than the recently revised recommended figure of 5% of foodenergy). As part of the critique of methods for the current study wenote that, while all dietary data methodology is limited, nutritionists
would generally have greater confidence in the methods used in the
National Diet and Nutrition Survey (prospective diet diaries) thanin the methods used in the SHeS (food-frequency questionnaires).

Strengths and Limitations
Grades assigned in the 2016 Active Healthy Kids Scotland Report
Card were based on an expert critique of the best (ie, most recent,most representative, least biased) available data using the robust
methodology developed for the Active Healthy Kids Canada Report
Cards.11,12 For a number of indicators grading was either problematicor impossible: high quality evidence was lacking in some cases(eg, MVPA of primary school age children not available), so thegrade was based largely on adolescent data, as in 2013; no evidence
was available for some indicators (eg, there was no evidence on
Organized Sport Participation8,9); indirect evidence had to be used
for grading in other cases (eg, for Family and Peer Influence as
noted above; for Active and Outdoor Play no specific surveillance
exists and no clear evidence-based recommendations exist for the
behavior). It is hoped that the identification and highlighting ofthese gaps and weaknesses in the evidence will lead to improved
PA and health surveillance in Scotland in future.

Conclusions
The 2016 Active Healthy Kids Scotland Report Card provides further evidence for the high-income nation paradox identified by thecomparison of Active Healthy Kids Report Cards from 15 nationsin 2014.21 Despite some limitations in the evidence it is clear that
Scotland has a generally favorable built and policy environment
for child and adolescent PA, but low child and adolescent PA.
In contrast, low-income nations generally have very unfavorable
environments, but higher levels of child and adolescent PA. Lessons
from such international comparisons should be helpful in Scottish
policy in this area in future.
Acknowledgments
The authors thank members of the Stakeholder Group for their varied andsubstantial contributions to the card. This work was supported by Knowledge Exchange Grants from Inspiring Scotland and The Robertson Trust.

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