A Policy-Based Intervention for Physical Activity and Screen Time in Childcare Outside School Hours

Importance Extended education programs reach tens of millions of children globally during discretionary hours when physical activity competes with screen use, yet scalable strategies to improve movement behaviors are limited. Objective To evaluate the effectiveness of Activated Outside School Hours Care (OSHC), a policy-based intervention to improve physical activity and screen time practices in extended education settings. Design, Setting, and Participants This cluster randomized clinical trial was conducted in Australia’s system of organized before- and after-school care in 3 Australian states (South Australia, New South Wales, and Western Australia) between August 1, 2022, and December 31, 2024, with assessments at baseline, 3 months, and 12 months. Intervention Activated OSHC is a web-based intervention offering voluntary accreditation to services aligning their policies with national physical activity and screen time guidelines through staff training. Services were randomized 1:1 to intervention or usual practice, in which services continued their typical programming. Main Outcomes and Measures The primary outcome was service-level adherence to OSHC sector physical activity and screen time guidelines. Secondary outcomes included staff physical activity–enabling behaviors, children’s moderate-to-vigorous physical activity and recreational screen time, and availability of physical activity equipment, assessed through direct observation. Intention-to-treat and per-protocol analyses were performed. Results Of 197 services (101 in the intervention group and 96 in the control group), 182 (92%; 90 in the intervention group and 92 in the control group) completed the 12-month follow-up. Of the 101 services in the intervention group, 48 (48%) achieved accreditation within 12 months. Intention-to-treat analyses showed no significant effects for guideline adherence or children’s activity levels. However, the services in the intervention group demonstrated greater staff physical activity–promoting behaviors during before-school care (odds ratio [OR], 1.72; 95% CI, 1.27-2.33) and greater availability of physical activity equipment during before- (OR, 1.21; 95% CI, 1.00-1.46) and after-school care (OR, 1.16; 95% CI, 1.04-1.30). In per-protocol analyses, accredited services were more likely than controls to meet all guidelines (OR, 7.35; 95% CI, 1.39-38.86), with improved after-school screen time adherence (OR, 5.63; 95% CI, 1.16-27.22). In per-protocol analyses, accredited services showed greater staff physical activity–enabling behaviors (OR, 3.00; 95% CI, 2.10-4.28), and children engaged in more physical activity during before-school care (incidence rate ratio, 1.23; 95% CI, 1.05-1.43) compared with controls. Conclusions and Relevance This randomized clinical trial found few population-level changes in intention-to-treat analyses. However, services achieving accreditation demonstrated consistent improvements in guideline adherence, staff behaviors relating to physical activity, and children’s physical activity. The intervention was effective when implemented, but limited uptake constrained population-level impact. The accreditation model is viable for practice improvement, but policy- or system-level strategies may be needed to drive widespread adoption. Trial Registration Australian New Zealand Clinical Trials Registry Identifier: ACTRN12622000393752