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Reilly, John and Dick, Smita and McNeill, Geraldine and Tremblay, MarkS (2014) Results from the Scottish report card on physical activity forchildren and youth. Journal of Physical Activity and Health, 11 (Supp 1).
S93-S97. ISSN 1543-3080 , http://dx.doi.org/10.1123/jpah.2014-0183
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Journal of Physical Activity and Health, 2014, 11(Supp 1), S93-S97
http://dx.doi.org/10.1123/jpah.2014-0183© 2014 Human Kinetics, Inc.

Official Journal of ISPAH
www.JPAH-Journal.com
BRIEF REPORT

Results From Scotland’s 2013 Report Card on Physical Activity
for Children and YouthJohn J. Reilly, Smita Dick, Geraldine McNeill, and Mark S. Tremblay
Background: The Active Healthy Kids Scotland Report Card aims to consolidate existing evidence, facilitate international comparisons, encourage more evidence-informed physical activity and health policy, and improve surveillance of physical activity.
Methods: Application of the Active Healthy Kids Canada Report Card process and methodology to Scotland, adapted to Scottish
circumstances and availability of data. Results: The Active Healthy Kids Scotland Report Card 2013 consists of indicators of
7 Health Behaviors and Outcomes and 3 Inluences on Health Behaviors and Outcomes. Grades of F were assigned to Overall
Physical Activity, Sedentary Behavior (recreational screen time), and Obesity Prevalence. A C was assigned to Active Transportation and a D- was assigned to Diet. Two indicators, Active and Outdoor Play and Organized Sport Participation, could not
be graded. Among the Inluences, Family Inluence received a D, while Perceived Safety, Access, and Availability of Spaces for
Physical Activity and the National Policy Environment graded more favorably with a B. Conclusions: The Active Healthy Kids
Canada process and methodology was readily generalizable to Scotland. The report card illustrated low habitual physical activity and extremely high levels of screen-based sedentary behavior, and highlighted several opportunities for improved physicalactivity surveillance and promotion strategies.
Keywords: exercise, sedentary behavior, obesity, diet, adolescent
Scotland is a developed northern European nation of 5.2 million people, occupying the northern third of the UK. Scotland has
its own legal system distinct from the remainder of the UK (England, Wales, and Northern Ireland), and has its own parliament
with responsibility for a number of powers devolved from the UK
including education, the environment, transport, roads, planning,sport, child policy, health care, and health policy.
Public health surveillance of physical activity in children andadolescents in Scotland is based currently on the Scottish Health
Survey (SHeS1) which uses parent-report measures of physicalactivity, and makes the assumption that all reported physical activity is moderate- to vigorous-intensity physical activity (MVPA).1,2
The SHeS data suggest that adherence to the 60 minutes per day of
MVPA recommendation3 is very high during childhood, and so thatchildhood is not the focus of physical activity policy at present.4
A direct comparison of the SHeS method against accelerometry
indicated that levels of MVPA in children are much lower thansuggested by the SHeS,2 while recent longitudinal studies showthat MVPA declines markedly during childhood.5,6 Current Scottish
physical activity surveillance is, therefore, somewhat limited andmisleading, and the Active Healthy Kids Canada Report Card7,8
seemed to represent a promising approach to achieving more robust
physical activity surveillance and an evidence-informed physicalactivity promotion strategy in Scotland.
Active Healthy Kids Scotland was created in 2013 (www.
activehealthykidsscotland.co.uk) to develop and launch an evidenceinformed knowledge synthesis ‘Report Card’ in both short9 andlong10 forms as part of a knowledge translation project modeled
Reilly (corresponding author: john.j.reilly@strath.ac.uk) is with the Physical Activity for Health Group, University of Strathclyde, Glasgow, Scotland.
Dick and McNeill are with the Institute of Applied Health Sciences, University of Aberdeen Medical School, Aberdeen, Scotland. Tremblay is with theChildren’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada.

closely on the Active Healthy Kids Canada Report Cards.11 The
primary purpose of this paper is to summarize the process and resultsof the Active Healthy Kids Scotland Report Card 2013. The reportcard is based on the best available recent evidence from Scottish
children and adolescents.

Methods
The Active Healthy Kids Scotland Report Card 2013 was produced
by a small Research Work Group (RWG), based on the Canadianmodel.7,8,11 The RWG consisted of the 4 authors of the current
paper. The RWG evidence review and synthesis was reviewed
by a small Project Steering Group consisting of 5 academic andpolicy stakeholders. Following approval by the Steering Group,
the work was reviewed by a larger and more diverse Stakeholder
Group representing a variety of relevant sectors: academia; healthand education practice and policy; transport; sport; play; and major
health charities. The wider Stakeholder Group helped identify relevant data and commented on a draft version of the Scottish card.
Funding for the Active Healthy Kids Scotland Report Card wasprovided by a grant from the Scottish Universities Insight Institute(www.scottishinsight.ac.uk), a consortium of Scottish Universities
dedicated to the advancement of knowledge translation. The funding
body had no role in the content or presentation of the report cardand in the current manuscript.
Since the Active Healthy Kids Scotland Report Card wasmodeled closely on the Active Healthy Kids Canada Report Card,it was our intention to harmonize indicators (health behaviors andinluences) with the Canadian Report Card as much as possible,
subject to the availability of suitable Scottish data. However,
Scottish public health surveillance data were available for somehealth outcomes and behaviors not included in the Canadian card,
but which are related to physical activity and sedentary behavior.
Prevalence of obesity and some aspects of diet were thus included
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Reilly et alin the Scottish card. The inal Scottish Report Card therefore had atotal of 10 indicators (Table 1), with several behaviors and outcomesfor some indicators.
During March and April 2013 the RWG searched for relevant
evidence from nationally representative surveys within Scotland, inwhich sampling was stratiied to take account of regional and demographic variation.1,12 Restricting the search to national surveys wasappropriate because several such surveys exist within Scotland, andbecause of the dearth of large nationally representative research studies (eg, birth cohort studies) with high quality measures of the healthbehaviors and outcomes of interest. Draft grades were assigned by the
RWG for the 10 indicators by comparison of the national survey data
against a relevant evidence-based recommendation where available(eg, 60 minutes MVPA/day for school-age children and adolescents)using the benchmark approach from the Active Healthy Kids Canada
Report Cards:7,8 grade A (we are succeeding with > 80% of children
and adolescents); grade B (succeeding with 60%–79%); grade C(succeeding with 40%–59%); grade D (succeeding with 20%–39%);and grade F (succeeding with < 20%). An indicator was assigned aplus (‘+’) if there was evidence that trends were improving and/or if
there was evidence of negligible disparities (by age, gender, ethnicity, socioeconomic status) and a minus (‘–’) if there was evidence ofworsening time trends and/or marked disparities for the indicator.
The probability and likely magnitude of bias arising from error in
the measures was also considered for each indicator (eg, in measurement of MVPA by parental report in the SHeS2 as noted above).
Where the probability and magnitude of bias were both high, themeasure was not used. For example, a grade was not assigned to the
SHeS surveillance measures of MVPA for the reasons given above;a measure from the Health Behavior in School Age Children 2010
Survey (nationally representative of Scotland12) which appears tohave a much smaller bias when used for the assessment of adherence
to physical activity recommendations14,15 was used instead to assign
a grade for this indicator. Decisions of this kind were made by the
RWG and Steering Group using a combination of their expertise in
the area, reference to recent reviews which summarized evidence on
biases in measurement of the various indicators,16–18 and consultation with stakeholders. Other factors considered were how the reportcard measure might be improved in the future (eg, by inclusion of ameasure currently missing from Scottish public health surveillance,or by inclusion of a better measure of that indicator), and how grades
might be improved in the future drawing largely on relevant Scottish
evidence-based guidelines.3,13
Draft report card grades were considered at a feedback meeting attended by the RWG, the Steering Group and the Stakeholder
Group in June 2013. Additional stakeholder feedback was obtainedusing a formal online consultation on the process and draft grades
over a 6-week period during June and July 2013. Stakeholders wereasked to address the following questions:

Results
The Active Healthy Kids Scotland Report Card 2013 is the irst of
its kind for the country (Figure 1) and is summarized in Table 1. For
the category of Health Behaviors and Outcomes, 5 of the 7 indicators
could be graded with a degree of conidence based on a combination of the availability of a recommendation and the benchmark of
the proportion of children and adolescents meeting the guideline.
Active and Outdoor Play and Organized Sport Participation could
not be graded due, in part, to a lack of an evidence-based guideline
for these behaviors and limited Scottish data.10 The key healthbehaviors and outcomes were generally assigned low grades and a
grade of F for Sedentary Behavior (recreational screen time) andOverall Physical Activity.
For the category Inluences on Physical Activity and HealthBehaviors and Outcomes, grade assignment was possible with adegree of conidence, but grades varied substantially (Table 1). The
indicator Family and Peer Inluence on Physical Activity Behaviors
and Outcomes was graded D-. The grade was informed by an obesity
prevalence which is high, increasing and socially patterned (adultdata); low adherence to physical activity recommendations; and low
adherence to dietary recommendations which is socially patterned
and worsening over time.
The indicator Community and the Built Environment, which
included perceived safety, access, and availability of space forphysical activity, was graded B, relecting the evidence that safety,
access and availability of space did not appear to be major barriers
to physical activity. The indicator Policy referred to national policy

Were any relevant Scottish data missed in the process of carddevelopment?
Were any data misinterpreted by the research working group?
(eg, were the draft grades justiied?)
Were any relevant stakeholder groups or individuals omitted?
Which indicators not included in the 2013 card should be
included in future cards?
This consultation process informed the inal grades in the short- andlong-forms of the report card9,10 published in October 2013. Bothare accessible from the project website www.activehealthykidsscotland.co.uk.

Figure 1 — Front cover of Active Healthy Kids Scotland Report Card2013.

Scotland’s 2013 Report Card

S95

Table 1 Grades in the Scottish Report Card on Physical Activity forChildren and Youth 2013
Indicator

GradesHealth Behaviors and Outcomes
Overall Physical Activity Levels
Organized Sport Participation
Active Play
Active Transportation
Sedentary Behavior

F
INC
INC
C
F

Obesity
Diet
Inluences on Health Behaviors and Outcomes
Community and the Built Environment
Family and Peer Inluence
National Policies, Strategies and Investments

FDB
DB

Note. The grade for each indicator is based on the percentage of children and youth meeting a deined
benchmark: A is 81%–100%; B is 61%–80%; C is 41%–60%, D is 21%–40%; F is 0%–20%; INC is
incomplete data combined with lack of an evidence-based recommendation.

only (including the national school curriculum and policy). It wasgraded B on the grounds that Scotland has many national government policies, strategies and investments which target most of the
7 health behaviors and outcomes included in the card (the notable
exception being sedentary behavior).

Discussion
Health Behaviors and Outcomes
The lowest grade possible (F) was assigned to both of the reportcard ‘headline’ indicators, Sedentary Behavior (deined here as
recreational screen time) and Physical Activity. The recreational
screen time grade was based on self-reported time spent viewing TV and gaming among 11- to 15-year-old participants in the
Health Behavior in School-Age Children Survey 2010:12 76%
reported more than 2 hours per day of TV alone, and 77% of boys
and 37% of girls reported 2 hours per day of gaming in addition
to TV viewing. Scottish13 and international19,20 recommendations
state that recreational screen-time for school-age children andadolescents should be limited to 2 hours a day, thus justifying the F
grade.
The overall physical activity grade was also based on Scottish
Health Behavior of School Age Children 11–15 years in 2010.12 Thedata were based on a simple self-report method which appears tohave limited bias for the assessment of adherence to physical activity
recommendations.14,15 Only 19% of boys and 11% of girls 11–15
years of age met the daily recommendation for 60 minutes MVPA.12
Neither objectively measured Scottish physical activity surveillance data nor parent-reported or objectively measured data foryounger children were available. Data were also not available forobjective measures of sedentary behavior or for types of sedentary
behavior other than recreational screen time, including constructs ofsedentary behavior now considered very important to later health,notably time spent sitting and breaks in sitting time.21
Multiple sources of Scottish data were available on active
commuting (walking, cycling) to and from school. These data
were highly consistent in suggesting that just over 50% of Scottish

primary school children and 40%–50% of high school students normally commute actively to school; hence, a C grade was assigned.
Both obesity (F-) and diet (D-) were dificult to grade; bothare health outcomes rather than health behaviors. Multiple sourcesof Scottish surveillance data indicated an estimated prevalence ofobesity that was much higher than at any time in the past, allowing
for conservative estimates based on the BMI.17 Obesity was alsosocially patterned with higher prevalence among the more socioeconomically deprived. Compliance with recommendations regarding
consumption of sugar, fruit and vegetables, and saturated fat among
Scottish children and adolescents was generally low, but dietary
survey data are not adequately summarized as the percentage ofthe survey sample meeting the recommendations. This complicates
grading with the Active Healthy Kids Canada scale. Compliancewith dietary recommendations was also strongly socially patterned. Further discussion of the grades for obesity, diet, and theother indicators is provided in the long-form of the Scottish reportcard.10

Influences on Health Behaviors and Outcomes
The D- grade for Family and Peer Inluence on Physical Activity
Behaviors and Outcomes indicates that Scottish children and adolescents develop in an environment which is unfavorable to physicalactivity and health as evident in adult overweight and obesity, lowphysical activity, and an ‘obesogenic’ diet.9,10 The available Scottish
evidence on the adult environment was a proxy for parental inluence, since no data on these behaviors were available for the parentsof school-age children and adolescents. Data on peer inluence on
physical activity and sedentary behavior were not available, and assuch could not be used to inform the grade.
The B grade for the indicator Community and the Built
Environment suggests that Scottish children and adolescents havemoderately high perceived safety, access, and availability of spacefor physical activity. Given the seemingly favorable environment
for physical activity, future research should focus on why levels ofphysical activity are so low and levels of recreational screen time
so high.

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Reilly et al

The national policy environment was also graded B, and appears
to be favorable to physical activity and health of Scottish children
and adolescents. Many of the relevant Scottish policies are relatively
recent and 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 and Outcomes category.
Moreover, most national policies have not been evaluated; theirimplementation and/or effectiveness may in fact be limited. The
major gap in the national policy environment was the absence ofany policies on sedentary behavior.

Strengths and Limitations
Although grades assigned in the Active Healthy Kids Scotland
Report Card 2013 were based on the best available data, the process of developing the report card highlighted a number of gaps in
Scottish surveillance of physical activity and health. The 2 mostglaring gaps were the absence of objective measures of physicalactivity and the lack of surveillance of sedentary behavior. The
potential for biases in the physical activity surveillance measuresused in Scotland, and limitations in their ability to identify seculartrends and disparities are critiqued in more detail elsewhere.10 For
some indicators in the Health Behavior and Outcomes category,there were no or only limited data for preschool children. For otherindicators, dificulty in assigning a grade arose from a combination of limitations in the surveillance data and the absence of anevidence-based recommendation against which to assess adherence.
The long-form of the Active Healthy Kids Scotland Report Card2013 offers a number of recommendations aimed at improving Scottish surveillance of physical activity and health among children andadolescents.10 If these recommendations are adopted, future Scottish
Active Healthy Kids Report Cards should be more comprehensive,
better informed by evidence, and more useful for informing policy
and monitoring trends over time.

Conclusions
Development of the irst Active Healthy Kids Scotland Report Cardin a relatively short period of time (7 months) and at relatively low
cost (total cost < £16,000 sterling (though with some support in kindfrom the funding body in the form of providing a venue for 2 meetings), suggests that the Active Healthy Kids Canada Report Card isa model of knowledge translation into public health which is readily
generalizable. The irst Scottish card shows that Scottish children
and adolescents have extremely high levels of recreational screen
time and low levels of MVPA, and develop in an adult environment
where poor diet, low physical activity and overweight or obesity
are the norm. However, the irst Scottish report card suggests thatmany of the environmental factors believed to inluence physicalactivity and sedentary behavior are favorable. Future issues of thereport card will be useful in assessing whether this favorable policy
and community/built environment is having the desired impact onimportant health behaviors and health outcomes for children andadolescents.
Acknowledgments
Research for this paper originated at The University of Strathclyde,
Glasgow, Scotland; The University of Aberdeen, Scotland; and The Children’s Hospital of Eastern Ontario Healthy Active Living and Obesity
Research Institute, Canada. The authors thank the following members of the
project Steering Group for their contributions to the 2013 Scottish Report

Card: Dr. Julie Armstrong, Dr. Tim Lobstein, Members of the ObesityGroup of the Scottish School of Public Health Research. The authors also
thank members of the Stakeholder Group for their varied and substantial
contributions to the card, and the Scottish Universities Insight Institute for
their administrative support. This work was supported by a Knowledge
Exchange Grant from the Scottish Universities Insight Institute.

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