Barriers and facilitators to physical activity among ethnic Chinese children: a qualitative systematic review

ABSTRACT Objective: The review aimed to synthesize the barriers and facilitators from the available studies that explored physical activity among ethnic Chinese children and uncover any differences or similarities in these barriers and facilitators. Introduction: Physical activity promotes overall health, fitness, and well-being in children, yet prevalence of this has been low among ethnic Chinese children who reside in either Chinese and non-Chinese territories. Research has been conducted to explore the barriers and facilitators to physical activity among ethnic Chinese children. However, no qualitative systematic review has been conducted to synthesize these barriers and facilitators. Inclusion criteria: Studies were considered for inclusion if they explored the barriers and facilitators to physical activity among ethnic Chinese children aged six to 17 years in either Chinese or non-Chinese territories, or among people who had responsibility for them in school, home, and community settings. The review included studies that focused on their views, experiences, attitudes, understandings, perceptions, and perspectives. Studies were included if they focused on qualitative data including, but not limited to, designs such as phenomenology, ethnography, grounded theory and action research. In addition, the authors considered cross-sectional surveys to find any free text relating to the review question. Methods: MEDLINE, Embase, CINAHL, PsycINFO, BNI, AMED, Web of Science, Scopus, CNKI, Wanfang and VIP databases were searched to identify published studies. The search for unpublished studies included EThOS, OpenGrey, ProQuest Dissertations and Theses, CNKI and Wanfang. Databases were searched from their inception dates to 10 December 2018 and no language restrictions were applied. The JBI guidelines for qualitative systematic reviews were followed in conducting the review. The JBI process of meta-aggregation was used to identify categories and synthesize findings. Results: Out of 9460 records identified, 11 qualitative studies met the eligibility criteria and were included in the review. Using the JBI checklist for qualitative research (10 criteria), the critical appraisal scores of the majority of studies ranged from a moderate score of 6 (n = 1) to a high score of 7 and above (n = 9). Seven studies were from China, two from Australia, one each from the United Kingdom and the United States. The sample size ranged from 12 to 115 participants. A total of 56 findings were extracted and aggregated into 21 categories, based on the similarity of meaning. From studies conducted in the Chinese territories, four synthesized findings (personal, socio-cultural, environmental, and policy- and program-related barriers and facilitators) were aggregated from 37 extracted findings and 14 aggregated categories. From studies conducted in the non-Chinese territories, only two synthesized findings (personal and socio-cultural barriers and facilitators) were derived from 19 extracted findings and seven aggregated categories. Based on the ConQual scores, confidence in the synthesized findings was moderate. Conclusions: Four broad themes emerged from the participants’ accounts, namely personal, socio-cultural, environmental, and policy- and program-related factors. Barriers and facilitators at the personal and socio-cultural level (e.g., parents and teachers) were most frequently cited, reflecting the importance of children's self-influence and the role of adults. Future interventions are needed to address the identified barriers and enhance the facilitators. Systematic review registration number: PROSPERO CRD42018097124


Summary of Findings
Barriers and facilitators to physical activity among ethnic Chinese children Bibliography: Wang H, Swain S, Luo J, Blake H, Chattopadhyay K. Barriers and facilitators to physical activity among ethnic Chinese children: a qualitative systematic review. JBI Evid Synth 2020;18 (12)

Socio-cultural barriers and facilitators (Chinese territories):
The socio-cultural barriers and facilitators include interactions brought by people who have a connection with children (e.g., parents, peers). A child's physical activity participation may be facilitated when there is a dynamic involvement of parents and teachers. Children may be more likely to take part in physical activity when there are available opportunities/conducts provided by supportive teachers and parents. In contrast, perceived lesser parental value/utility of physical activity and time constraints may negatively influence their children's participation in physical activity.

Qualitative Remains unchanged
Moderate (Downgrade one level) Moderate Downgraded one level as there was a mix of unequivocal and credible findings Environmental barriers and facilitators (Chinese territories): A child's activity may be hindered by the unfriendly outer physical activity-related environmental characteristics, including environment structural elements (e.g., heavy transport), demographic characteristics (e.g., high population density), and physical activity resources (e.g., insufficient facilities). At the same time, having sufficient/physical activity-friendly resources within the community, including parks and playgrounds, may present opportunities for children's activity.

Qualitative Remains unchanged
Moderate (Downgrade one level) Moderate Downgraded one level as there was a mix of unequivocal and credible findings Policy-and program-related barriers (Chinese territories): The national policies and related programs are the outer structure influencing a child's physical activity environment. A lack of appropriate physical activity programs/structures and attractive program content may inhibit children's participation in physical activity.

Socio-cultural barriers and facilitators (non-Chinese territories):
The socio-cultural barriers and facilitators include interactions brought by people who have a connection with children (e.g., parents, peers). A child's participation in physical activity may be facilitated when there is dynamic involvement of parents and peers as well as their support. In contrast, unsupportive parenting and cultural beliefs may hinder children's participation in activity.

Qualitative Remains unchanged
Moderate (Downgrade one level) Moderate Downgraded one level as there was a mix of unequivocal and credible findings Introduction C hildhood is the most physically active period in a person's life and has been recognized as the most crucial period in promoting the uptake of and adherence to physical activity. 1-3 Physical activity promotes children's overall health and it can contribute to their sense of self, social well-being, and future health. 4 Moreover, it contributes to the quality of life in children with disabilities. 5,6 Physical activity in childhood may directly enhance body composition and skeletal health. It also helps prevent several chronic diseases such as obesity, type 2 diabetes, hypertension, and cardiovascular diseases. 7,8 In terms of psychological health, physical activity improves self-esteem, and promotes the establishment of social contacts and friendship. 6 Regular physical activity among children may boost learning abilities, including improvement in concentration power, memory, intellectual development, and academic performance. 4,6,8 In terms of economic benefits, it contributes to lower health care utilization and costs associated with physical inactivity-related diseases. 7,9,10 For instance, in Australia, around AU$43 million per year is spent on health care for overweight and obese children. 10 Childhood is also an important transition point where the physical activity level starts to decline as children grow into adolescence (at around 13 years of age). [11][12][13] Evidence suggests that children aged nine to 11 years spend more time participating in moderate-to-vigorous physical activity in schools than children aged six to eight years of age. 12 In other words, children start to take responsibility for their own participation in physical activity during this transition period. Hence, this transition period is critically important as health behaviors adopted at this stage could underscore both immediate and long-term health; for example, children who engage in physical activity are likely to have higher selfefficacy and less depression. 14 In contrast, children who do not engage in physical activity at this stage are likely to have more cardiovascular risk factors and increased incidences of being overweight or obese in adulthood. 11 According to the World Health Organization's physical activity guideline, children and adolescents (five to 17 years of age) should engage in at least 60 minutes of moderate-to-vigorous physical activity per day and reduce their sedentary time. 15 However, globally, physical activity levels remains low among children. In China, children's physical activity levels are significantly lower compared to high-income countries in Europe and North America. [16][17][18][19] For instance, physical active rates among children were 25% in Ireland and Finland,66.7% in Australia,and 25% in the United States. 17 In China, only 9% of children were physically active. 17 Additionally, around 25% of physically active children in China did not achieve the required intensity (moderate-tovigorous) of physical activity. 17 Available evidence has suggested that poor physical activity engagement may affect Chinese children's mental health and well-being. 20 It is reported that 15.4% of children have mental disorders and over 25% of children have experienced some form of mental or psychological disorder (such as poor dependability, mentality, and confidence) as a result of low rates of physical activity. In China, the combined percentages of children and adolescents who were overweight and obese reached 19.2% in 2010. 21,22 This was higher than that of US children and adolescents (16.9%) in 2009 to 2010. 23 Around 76% (>3 million) of obese and overweight Chinese children were reported to have at least one metabolic syndrome. 24 As a result, there is a need to investigate the issue of low physical activity among Chinese children and physical activity-related health problems.

Physical activity among ethnic Chinese children
Children's academic achievements are overemphasized in China and schools are usually evaluated based on their academic performances. As a result, schools prefer to allocate their resources (including time) to academic curriculum rather than physical activity. 25 Only 24.7% of Chinese children are reported to have participated in extracurricular physical activity throughout school compared to an average level around 60% in high-income countries. 17 In schools, health (physical) education and structured exercise programs are available and are delivered to children orally and/or in written format. Structured exercise sessions are run to achieve the recommended intensity and duration of physical activity. However, the development process of these programs remains questionable and most of these programs are not based on behavior change theories. [26][27][28] Ethnic Chinese children are less physically active compared to children of other ethnic origins in many high-income countries. 29,30 A study reported that around 45% of Chinese American children were not actively playing outdoor games and sports. 30 In these countries, ethnic Asian sub-groups are often aggregated as a homogenous group and the same generic physical activity promotion intervention is provided to all. 29,31 The intervention that works in children of other ethnicities may not have the same positive impact on ethnic Chinese children. This is also supported by previous studies demonstrating that the two main barriers to physical activity among ethnic Chinese children are insufficient time for physical activity and a competing emphasis on educational attainment. 32,33 As such, a ''shrinkage'' of available physical activity time for children has been reported at the school level, 34 as well as a consistent decrease in the physical fitness of ethnic Chinese children. 35 Additionally, the stereotypical views of ethnic Chinese (e.g., not being good at ball games such as football or basketball) make ethnic Chinese children self-exclude from the physical activity cultures of their adopted countries. 36 There are socio-cultural issues that hinder physical activity among ethnic Chinese children. Generally, parents of ethnic Chinese children are more concerned about their child's safety and academic achievements, which in turn promotes sedentary behavior and impedes physical activity. 37 These children spend more time on academic studies after school hours and on weekends than on physical activity. 25 Ethnic Chinese girls are also less likely to engage in physical activity than boys. 16 In many conservative Chinese societies, there is a huge sociocultural pressure on girls to avoid physical activity. The image of Chinese women is incongruent with being physically active, 29 so there is a need for a socio-culturally appropriate intervention for ethnic Chinese children, addressing their specific barriers to physical activity.

Rationale for this systematic review
Several studies have been conducted to explore the barriers and facilitators to physical activity among ethnic Chinese children. 29,30,[37][38][39][40][41][42][43][44] Although a few systematic reviews written in Chinese are available on this topic, they are extremely brief and limited in searching scope (i.e., only include Chinese databases) and their quality can be inconsistent. In these reviews, there are no details regarding the development of the search strategy or the procedures of screening, data extraction, synthesis, and quality appraisal. [45][46][47][48] Evidence shows that parents, guardians, and teachers play an important role in shaping children's health behaviors concerning areas such as physical activity. 46,49 Extensive research has been conducted to explore which factors those with responsibility for children (e.g., parents, guardians, and teachers), and the children themselves, perceive to be important for physical activity behavior, but no qualitative systematic synthesis of this growing body of evidence has been conducted until now. Exploring and integrating previous qualitative evidence will enhance understanding of the barriers and facilitators to physical activity among ethnic Chinese children. Moreover, it may also lead to the identification of potential avenues for intervention that those who are instrumental to children's physical activity behaviors believe to be important but that have yet to be explored by researchers and policy makers.
Ethnicity, cultural norms, and residence can have an impact on children's views, experiences, attitudes, understandings, perceptions, and perspectives regarding barriers and facilitators to physical activity. 50 In addition, the physical activity program-and policy-related differences between Chinese territories and non-Chinese territories can have influences on a child's physical activity behavior. In Chinese territories there are some unique influential factors including the state-run sports system, the ''one child'' policy, and tight control at the school level due to the fear of sports injuries and accidents. 45,47 In non-Chinese territories, ethnic Chinese children's physical activity behaviors may be influenced by the sports trend in the local community. 29,30 To uncover the particular views, experiences, attitudes, understandings, perceptions, and perspectives of ethnic Chinese children, this systematic review only included data that could be analyzed separately for ethnic Chinese children. In this systematic review, the repetition of bouts of physical activity over time is the focus, which includes exercise, sport, and physical education. 51

Review questions
What are the barriers and facilitators found in available studies that explore physical activity among ethnic Chinese children?

Types of studies
The review included studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, ethnography, grounded theory, and action research. The authors also included cross-sectional surveys where free-texts relating to the review question were collected using open-ended questions, as free-text data are suggested to be of intrinsic value and analysis enables the researcher to explore the important contextual value of participants' responses. 52,53 The free-text data could provide additional information that is examined beyond the surface-level analysis. 52,53 The importance of free-text data in experience surveys has been acknowledged for its qualitative utility and for improving the health services. 54,55

Methods
The systematic review followed the JBI methodology for systematic reviews of qualitative evidence. 56 It was conducted in accordance with an a priori protocol. 57 This systematic review was registered with PROSPERO (CRD42018097124). The process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 58

Search strategy
An initial limited search was carried out on MEDLINE and China National Knowledge Infrastructure (CNKI) databases using the initial keywords ''physical activity,'' ''barriers,'' ''facilitators,'' ''Chinese,'' and ''children.'' The titles and abstracts of the studies were screened for keywords, and the index terms used to describe the article were also identified. As some databases have specific hierarchical categorizations, the initial search terms were indexed differently (e.g., physical fitness, child) or not indexed (e.g., barriers and facilitators) in the databases. As such, the final search strategy used both initial search terms and specific index terms (e.g., MeSH terms in MEDLINE) where appropriate. The search results were inspected to ensure that the relevant articles were identified. Phenomenology, grounded theory, ethnography, or qualitative descriptive studies were explored using ''qualitative research'' in the search strategy (the full search strategies are detailed in Appendix I, which were developed for MEDLINE and then adapted for other databases in consultation with an information specialist/librarian).
The search spanned a range of sources to find both published and unpublished studies. The following databases were searched until 10 December 2018: MEDLINE (from 1946, Ovid), Embase (from 1947, Ovid), CINAHL (from 1937, EBSCO), PsycINFO (from 1806, Ovid), BNI (from 1993, EBSCO), AMED (from 1985, Ovid), Web of Science (from 1900), Scopus (from 1788), CNKI (from 1979), Wanfang (from 1995), VIP (from 1989), EThOS (from 1925), OpenGrey (from 1997), and ProQuest Dissertations and Theses (from 1980, ProQuest). The reference lists of all the identified reviews and studies selected for inclusion in the review were screened for additional studies. No language restrictions were applied, and translations from Chinese into English were sought where necessary. Whenever a translation was needed, two reviewers were independently involved in the translation and supplied comments. Consensus was reached through discussion between reviewers.

Study selection
Following the search, all identified citations were collated and uploaded into EndNote X8.2 (Clarivate Analytics, PA, USA), and duplicate citations removed. Titles and abstracts were screened for eligibility by two independent reviewers using the inclusion criteria. Studies identified as potentially eligible, or those without an abstract, had their full texts retrieved and their details were imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full texts of the studies were assessed against the inclusion criteria by two independent reviewers. Full-text studies that did not meet the inclusion criteria were excluded, and the reasons for exclusion reported. Any disagreements that arose between the reviewers were resolved through discussion or with a third reviewer.

Assessment of methodological quality
All studies selected for inclusion were critically assessed by two independent reviewers using the standardized critical appraisal tool for qualitative research incorporated within JBI SUMARI. 56 This tool uses a series of criteria that can be scored as being met, not met, or unclear or not applicable to that particular study. Two independent reviewers went through each criterion and commented on it. Any disagreements that arose between the reviewers were resolved through discussion or with a third reviewer. The critical appraisal results are presented in tabular form (Table 1). All studies, regardless of the results of their methodological quality, underwent data extraction and synthesis. A cut-off score was not used to include or exclude studies in this systematic review, as many studies are likely to be of poor quality. 56 Poor-quality studies can generate potentially valuable insights, 59 and can lead to a richer understanding of the research phenomenon.

Data extraction
Data were extracted from papers included in the review by two independent reviewers using the standardized data extraction tool incorporated within JBI SUMARI. Any disagreements that arose between the reviewers were resolved through discussion or by involving a third reviewer. In the first phase of data extraction, study characteristics were extracted: study period, design, location (territory [Chinese/ non-Chinese] and country), phenomena of interest, context (such as home, community and school), participant characteristics (such as age and gender), inclusion and exclusion criteria, sample size, recruitment method, data collection procedure and tool, data analysis technique, and authors' conclusion. In the second phase of data extraction, specific study findings were extracted: barriers and facilitators to physical activity among ethnic Chinese children. As suggested by previous qualitative studies and crosssectional surveys, a structure was agreed on by the reviewers to extract findings. [38][39][40][41][42][43][44][45] This consisted of four aspects: i) personal (relating to physical, emotional, or mood-associated factors of children), ii) socio-cultural (relating to people with whom the child would come in contact, such as parents/guardians and teachers), iii) environmental (relating to structural elements such as facilities and transport) and iv) policy-and program-related (relating to programs, organizations, and staff). In addition, illustrations from the text that support these findings were extracted (one illustration per finding). The findings and illustrations were the actual verbatim words of the study participants and the authors. The credibility of each finding was assessed unequivocal (the finding is accompanied by an illustration that is beyond a reasonable doubt and is not open to challenge), credible (the finding is accompanied by an illustration that is lacking a clear association with it and is open to challenge) or not supported (when neither unequivocal nor credible can be applied and when the most notable findings are not supported by the data). 56

Data synthesis
Study findings from all qualitative studies were pooled using JBI SUMARI with the meta-aggregation approach. 60 This involved the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. 56 These categories were then subjected to a synthesis in order to produce a single comprehensive set of synthesized findings. 56 Any free text from cross-sectional surveys was intended to be pooled together with qualitative data from qualitative studies; however, this process was not required due to the nature of the data extracted.
In order to uncover any associated differences or similarities in the views, experiences, attitudes, understandings, perceptions, and perspectives regarding barriers and facilitators to physical activity, the data from the Chinese and non-Chinese territories were synthesized separately. In addition, the data from the children and parents/guardians and teachers were synthesized separately based on the pre-defined structure (i.e., personal and sociocultural). Specifically, the findings relating to children and parents/guardians and teachers were assembled and synthesized under personal and socio-cultural aspects, respectively. In addition, specific themes relating to children, parents/guardians and teachers were separated on the basis of similarity in meaning of included findings and the interpretation illustrated in the included studies. The identification of themes relating to barriers or facilitators was based on the similarity in meaning of the included findings. The identification of barriers or facilitators was cross-checked by the two independent reviewers and consensus was reached in case of differences.

Assessing confidence in the findings
The final synthesized findings were graded according to the ConQual approach for establishing confidence in the output of research synthesis and presented in the Summary of Findings. 61 The Summary of Findings included the major elements of the review and details of how the ConQual score was developed. The table included the title, population, phenomena of interest, and context for the specific review. Each synthesized finding from the review was then presented along with the type of research informing it, a score for dependability, a score for credibility, and the overall ConQual score.

Study inclusion
The comprehensive literature search returned 12,533 records through database searching and 13 through additional resources, resulting in 12,546 potentially relevant records.
Following the removal of duplicates (n ¼ 3086), the titles and abstracts of the remaining records were assessed (n ¼ 9460). A further 9281 of these records were excluded with reasons, leaving 179 records in the full-text screening. All 179 papers were retrieved for a full review, following which, 168 were excluded (see Appendix II). No disagreements arose during the screening. The remaining 11 papers were critically appraised and included in the review. 29,32,36,38,[62][63][64][65][66][67][68] See Figure 1 for the full study selection process.

Methodological quality
The critical appraisal results of 11 included studies are presented in Table 1. 29,32,36,38,[62][63][64][65][66][67][68] The results for most studies were 6 and above out of 10. Only one study had a score of 4 out of 10. 65 Nine of the 10 quality appraisal questions achieved a high proportion of ''yes'' ratings; however, question 7 (Is the influence of the researcher on the research, and vice versa, addressed?) had a significantly lower proportion of ''yes'' ratings. The issue of reporting of methodologies was identified in the majority of the included studies (except two studies conducted in Australia). It also highlighted a lack of reporting on the impact the researchers had on the studies. Despite this, the score of all 11 studies ranged between six and 10 on the JBI Critical Appraisal Checklist for Qualitative Research and, therefore, none were excluded for reasons of quality.

Characteristics of included studies
The characteristics of the included studies are presented in Appendix III. All included studies used qualitative methods to investigate the perspectives of the participants. Of all 11 studies, seven were from China, 38,62-67 two from Australia, 36,68 one from the United Kingdom, 32 and one from the United States. 29 Only one study was written in Chinese and a translation of the findings was conducted. 65 Among the seven studies from China, four were from Hong Kong 38,62,66,67 and three were from mainland  Out of 11 studies, seven were conducted in schools, 36,38,[62][63][64][65][66] two in communities 29,67 and two in both schools and communities. 32,68 Only one study was an unpublished thesis. 65 All studies were published between 2007 and 2017, with most (eight of 11) being conducted since 2014. 29,32,36,38,63,65,66,68 There were more studies exploring the experience of barriers and facilitators to physical activity from the perspective of children than that of parents and teachers. Two studies were conducted with both children and parents, 62,63 one with both children and teachers, 65 two with parents only 32,67 and six included children only. 29,36,38,64,66,68 Two papers originated from the same study. 36,68 Time constraints and other priorities were identified among both children's and parents' accounts as barriers to physical activity. [62][63][64]66,67   The number of study participants ranged from 12 to 115 and one study (conducted among teachers) did not mention the number of participants. 65 In exploring the methodological aspects of the 11 studies, two made specific commitments to a critical and interpretive ethnographic methodology, 36,68 while methodology was unspecified in the other nine. 29,32,38,[62][63][64][65][66][67] The data collection methods used were primarily semi-structured interviews, carried out in person 29,62,65,66 or by telephone. 29,62,67 Focus group discussion was used in two studies, 32,63 and two studies only mentioned using interviews, 36,68 of which one also used field observation. 36 Specifically in two studies, alternative qualitative methods were used including self-completion education 64 and nominal group technique. 38 Regarding the trustworthiness of these qualitative approaches, it is considered that interviews are better for investigating experience compared to quantitative methods. 69 Interviews are extremely helpful for in-depth exploration instead of broad surveys of surface patterns. A previous study reported that interviews could produce sufficient and trustworthy contributions when exploring children's perceptions compared to focus group discussion. 70 In terms of field observation, it is an effective qualitative approach to study the meaning of behavior, language, and the interactions of the group. However, this approach may not be appropriate to identify the barriers and facilitators to physical activity, as observation mainly entails looking at the individuals' behavior rather than their attitudes and opinions. 71 In addition, observation is less appropriate to identify infrequent events, which might be of significance for physical activity.
The data analysis techniques were thematic analysis, 29,36 inductive analysis, 32 framework analysis, 63 and content analysis. 64,66,68 Two studies did not state the specific analysis but only stated using coding analysis, 62,67 whilst no data analysis methods were specified in one study. 65 All of these analytical approaches were considered to be suitable for answering the question. However, thematic analysis and inductive analysis were seen to be better for  comprehensively capturing all the themes of findings. This was because these approaches did not cautiously measure the frequency of different themes as a proxy for significance (i.e., content analysis) or identify categories using the pre-existing concepts/ frameworks (i.e., framework analysis). 72,73 As such, thematic and inductive analysis may be more appropriate to comprehensively evaluate each finding and avoid missing the potential barriers and facilitators that may have been neglected previously.

Review findings
As mentioned in the protocol, a standard structure with four themes was used to categorize all the extracted findings using the meta-aggregative approach. 57 Findings related to the participants of interest (i.e., children, parents/guardians and teachers) were aggregated under personal (relating to physical, emotional, or mood-associated factors of children) and socio-cultural themes (relating to people with whom the child would come in contact with, such as parents/guardians and teachers). The findings from these two themes were aggregated into two specific synthesized findings looking at the barriers and facilitators to ethnic Chinese children's physical activity. In addition, findings related to structural elements (such as facilities and transport) and policies and programs (such as organizations and staff) were aggregated into environmental and policy-and program-related themes. All 11 studies included in this review explored the barriers and facilitators to physical activity among ethnic Chinese children. A total of 56 findings were extracted, of which 41 were assessed as unequivocal and 15 as credible (see Appendix IV).
Among all the extracted findings, a total of 37 findings were extracted from the studies conducted in the Chinese territories, of which 24 were graded as unequivocal and 13 as credible. Specifically, the 37 findings were grouped into 14 categories and further aggregated into four synthesized findings. The first synthesized finding had 15 findings and six categories, of which 12 findings were unequivocal and three were credible. The second synthesized finding had 10 findings and three categories, of which eight findings were unequivocal and two were credible. The third synthesized findings had eight findings and three categories, of which one finding was unequivocal and seven were credible. The fourth synthesized finding had four findings and two categories, of which three findings were unequivocal and one was credible.
Among studies conducted in the non-Chinese territories, 19 extracted findings (17 unequivocal and two credible) were grouped into seven categories that were aggregated into two synthesized findings. The first synthesized finding had seven findings and three categories. Of these, six findings were assessed as unequivocal and one as credible. The second synthesized finding had 12 findings and four categories, of which 11 findings were unequivocal and one was credible.
The confidence of all synthesized findings was graded based on ConQual approach (see Summary of Findings). This ranking system allowed the findings of individual studies to be downgraded based on their dependability and credibility. Downgrading for dependability occurred when the five criteria for dependability were not met across the included studies. 61 Where four or five of the responses to these questions were ''yes'' for an individual finding, then the finding remained at its current level. If two or three of these responses were ''yes'', it moved down one level (i.e. from high to moderate). If zero or one of these responses was ''yes'', it moved down two levels (from high to low, or moderate to very low). The synthesized finding then would be downgraded based on the aggregate level of dependability from across the included findings. In terms of credibility, it would be downgraded if the synthesized findings were not all unequivocal findings. Specifically, the synthesized finding would be downgraded one, two, three, or four levels if it contained a mix of unequivocal/credible findings, only credible findings, a mix of credible/unsupported findings or no supported findings, respectively. 61 For all synthesized findings, the majority of studies received four ''yes'' responses on the ConQualidentified criteria for dependability; therefore, the level of confidence remained unchanged. The findings included a mix of unequivocal and credible ratings, necessitating downgrading one level, resulting in a credibility score of moderate. This represented a ConQual rating of moderate confidence in these qualitative synthesized findings and was supported by the evidence of sufficient quality.

Results from Chinese territories
Of the studies conducted in the Chinese territories, the barriers and facilitators to a child's physical activity were identified and synthesized into four broad findings, including personal, socio-cultural, environmental, and policy-and program-related aspects. Both barriers and facilitators were identified in personal, socio-cultural, and environmental factors, while only barriers were identified in the policyand program-related factors.

Synthesized finding 1: Personal barriers and facilitators
Personal barriers and facilitators include physical, emotional, and motivational factors that may determine children's choices and participation in physical activity. A child's perceived interest in, enjoyment in, and active pursuit of physical activity may increase their physical activity level. In contrast, factors such as individuals who place a lower value or perceived utility on physical activity, and time constraints may negatively influence a child's participation in physical activity. This synthesized finding was derived from 15 findings, which merged into six categories (see Figure 2).
Personal facilitators Category 1.1: Fun. Children generally had experience in physical activity and their positive feelings (e.g., fun, enjoyment, happiness) from those experiences were cited as important in facilitating physical activity participation. 62,66 ''Doing physical activity is fun and when I see other people playing, I want to be one of them. . . . My parents also encouraged me. They would spend time jogging with me and I still remember we had so much fun. '' 62(p.390) ''I feel satisfied when I can shoot a basketball into the ring. . . . and usually I am able to hit the shuttlecock with a swift sound and therefore I feel really happy and have fun playing with it. . . . When I play badminton, I think the sound of "Academic-focused" school environment seemed to be a major barrier for PA participation (U) Finding Category Synthesized finding 1 Families are an important factor in their physical activity participation (C) Physical activity was not useful in relation to entering a better secondary school (U) Having the positive outcomes for academic and/or career future (U) Improving on their health (U) High attainment value and high utility in physical activity (U) As they grew up, time spent on a particular physical activity increased (U) Feeling happy and competent and enjoying the sport and movement (U) Low intrinsic values of physical activity among children were cited as a barrier inhibiting physical activity participation. Children stated that the negative feelings or experiences around physical activity delimited their motivation to be active; this included the perceived feeling of frustration, loneliness, and tiredness while doing or after physical activity. 66 ''I do not feel any differences or improvements and I think it is boring. I am always like that, not a bit better. '' 66(p.392) ''I always do sport alone by myself and this is why sport is not interesting to me. I do not like it because there is no one to compete or compare with me. There is no one to encourage me and I do not feel happy when doing sport. '' 66(p.392) ''I need to put in too much effort in sport. I do not like the feeling of tiredness after doing sport.'' 66(p.391) Category 1.6: Time constraints. Lack of time was one of the most cited and particular barriers to a child's physical activity, and it was identified mainly because of the long school day and heavy study burden (e.g., assignments) for ethnic Chinese children who reside in China.  ''The most frequently mentioned disadvantage, 'will take too much time,' was mentioned by 40.6% of the students. '' 64(p.43) ''The most frequently mentioned barrier, 'having too many assignments,' was mentioned by about half (48.4%) of the students. Additionally, 'time' was the second most frequently mentioned circumstance; 14.2% of the students mentioned having more time as a facilitator and 18.8% mentioned not having enough time as a barrier. '' 64(p.43) Similarly, parents also cited that their child's low participation in physical activity was a result of insufficient time being provided them, which may indicate the ''academic-focused'' school environment. 63 ''The environment now is so different from the environment of my childhood. My kid is sitting there all day studying and no time for exercise. It seems that he does not like exercise at all, and when he has spare time, he watches TV. '' 63(p.894) Synthesized finding 2: Socio-cultural barriers and facilitators. The socio-cultural barriers and facilitators include interactions between children and people who have a connection with them (e.g., parents, peers). A child's participation in physical activity may be facilitated when there is dynamic involvement by parents and teachers. Children may be more likely to take part in physical activity when there are available opportunities or examples provided by supportive teachers and parents. In contrast, perceived lower value or utility of physical activity by parents and time constraints may negatively influence their children's participation in physical activity. This synthesized finding was derived from 10 findings, which merged into three categories (see Figure 3).

Socio-cultural facilitators
Category 2.1: Parental support. Parents were commonly identified as important people with regards to the approval and disapproval of children's engagement in physical activity. 64 Particularly, fathers were cited as responsible for creating physical activity opportunities for their children. 62 ''Clearly, most of the salient referents for this behavior were family members, including parents, others, fathers, and grandparents.'' 64(p.43) ''Interestingly, within the group we interviewed, only fathers provided actual facilitation of their children's physical activity. One of them acted as an assistant coach regularly in his boy's rugby team, while a few attended their children's sports competitions, such as badminton and swimming during their leisure time, and two parents assisted with transporting children to playgrounds. '' 62(p.338) In addition, parental knowledge, as well as their understanding of the importance of physical activity in the betterment of physical health and academic performance, were cited as facilitators to children's participation in physical activity. 62 ''Students in Hong Kong, as far as I know, are not doing much sports and exercise. I'm sure exercise can help my son to be fit and maintain a good shape and weight. '' 62(p.341) ''PE [physical education] is important because it makes my son healthier. . . . good health may help him study better. '' 62(p.342) Category 2.2: Teachers' actions, behaviors, or concerns. While at school, a child's physical activity mostly took place at physical education class, and therefore physical education teachers were able to facilitate and encourage children to be active. Physical education teachers believed that the establishment of proper teaching goals and a harmonious teacherstudent relationship positively influenced children's physical activity. 65 ''We should combine the collective goal with an individual goal. Each student's physical quality and individual ability are different. We should fully consider the individual difference of each student when setting the teaching goal. When setting the collective teaching goal, we should make the goal has a certain range of fluctuation, because the requirement is universal for each student. We should ensure that for students whose sports learning ability are not strong enough can improve their sports achievements through hard work and their interest in sports learning can be increased due to the establishment of motivation in sports learning. In the other way, this goal should also apply to those who have higher sports learning abilities. '' 65(p.24) ''The PE [physical education] teachers should respect and care about students rather than criticize students at will. Teachers should equip a positive attitude and be the role model so that the students will feel the equality between themselves and teachers. In addition, they may be attracted to the class. With the establishment of a harmonious relationship between students and teachers, students will thus take the teachers as examples and change their behavior. '' 65(p.25) Socio-cultural barriers Category 2.3: Physical activity is not part of the family's priorities. Although parents did acknowledge the beneficial effects of physical activity, a child's educational attainment and academic development were considered to be the universal priorities among Chinese parents. 62,67 ''I know doing more physical activity is good for my child, but I'd rather have her study first and only allow her to play for a while if she could finish her school work. You know, too much play will negatively affect her academic performance. '' 62(p.338) ''My son is now in the soccer team and he practices for many days a week . . .he comes back home at 7 pm and I think soccer is distracting him from studying well. . . I'm so afraid that he'll get hurt and I'm thinking not let him play anymore. I usually let him do whatever he wants in sports but if the exam is near, I'd advise him to play less basketball, I think it's better for him to spend more time studying than on playing. '' 67(p.42) ''There was a time a basketball club invited me to join them, and I know this was a chance for me to play in a professional level. However, my mother opposed my decision, and I did not dare to argue with her. '' 62(p.340) It was also reported that the work commitment may be a barrier that restricted parents of ethnic Chinese children who reside in Chinese territories to accompany their children to physical activities. 67 ''Both of us need to work six days a week, well. . .we're not rich and we must work for the money for the family. Sometimes we would go out with the kids on Sundays and we usually go shopping or dining out. '' 67(p.41) Synthesized finding 3: Environmental barriers and facilitators A child's physical activity may be hindered by environmental characteristics, including environmental structural characteristics (e.g., heavy transport), demographic characteristics (e.g., high population density) and physical activity resources (e.g., insufficient facilities). This synthesized finding was derived from eight findings, which merged into three categories (see Figure 4).

Environmental facilitator
Category 3.1: Accessibility and proximity of facilities. The perceived physical activity-friendly environment was identified as a facilitator of physical activity. Specifically, it was identified that a child's engagement in physical activity was positively associated with the accessible facilities (''recreation grounds, parks'') and the proximity of facilities (''convenient transportation, subway station''). 38(p.50) Environmental barriers Category 3.2: Care concerns. A common consideration mentioned by both parents and children was safety. 38,67 Parents stated that they worried that a child could get hurt doing certain types of activities while children identified their consciousness of neighborhood safety.
''Some dangerous activities, like skating, it's not too safe for my girl to play. Children usually can't decide what is dangerous for them. They just play for fun but neglect the importance of safety. For example, I won't let him go climbing hills or rock. . .it's too dangerous. I've seen quite a lot of accidents happened in people climbing, it's definitely not suitable for children, especially girls, it's just not right for her to play such rough sport and Hong Kong don't have much safe climbing places for younger ones and there is a lack of qualified teachers. '' 67(p.42) A child's physical activity was also related to an individual's perception of safety in the local environment, specifically through expressions of fear of surrounding safety (''afraid of being taken or hurt at  '' 38(p.4) and the awareness of danger (''few cars on roads [traffic]'') 38(p.5) were cited by the children as barriers that delimited their activity.
Category 3.3: The unique condition in the Chinese mainland. Three unique environmental barriers were mentioned by children who reside in China, which were pollution-related barriers, population density, and insufficient facilities. The air quality (''fresh air'') and extent of noise (''too much noise'') acted as barriers to children's engagement in activity. 38(p.5) In addition, the large population density (''too many people in recreation grounds'') was also cited as responsible for hindering a child's engagement in activity. 38(p.5) The insufficient facilities were cited as a complaint by children for restricting their physical activity. 62 ''Other negative feelings, expressed by both boys and girls, included too many students in a class (40-45 students sharing one basketball court). '' 62(p.343) Synthesized finding 4: Policy-and programrelated barriers The national policies and related programs are the outer structure influencing a child's physical activity opportunities. A lack of appropriate physical activity programs or attractive program contents may inhibit children's participation in physical activity. This synthesized finding was derived from four findings, which merged into two categories (see Figure 5).
Category 4.1: Lack of opportunities to participate. Physical education class was mentioned as the main physical activity opportunity provided to Chinese children. However, children cited that they had limited opportunity to participate in their activity of interest in the class. One possible reason was that physical education was only set up to help children pass the mandatory physical education component of the high school entrance examination (i.e., commonly known as ''Zhongkao'' in Chinese). 63

Results from non-Chinese territories
Unlike the synthesized findings from studies conducted in the Chinese territories, only personal and socio-cultural barriers and facilitators to physical activity were extracted and synthesized from the studies conducted in non-Chinese territories.

Synthesized finding 1: Personal barriers and facilitators
The personal barriers and facilitators include both physical and psychological factors that may determine children's choices and participation in physical activity. A child's physical activity interests and positive attitude may facilitate their participation, while negative interpersonal influences may hinder their participation. This synthesized finding was derived from seven findings, which merged into three categories (see Figure 6). ''I just think they [Europeans] think they are better, my other friends, they used to be in the A team, but then they are too inside, they don't express much things in schools, they don't talk to other people, they're just not used to it, that's why they don't pass the ball to them. '' 36(p.450) ''Like back in primary school, you don't notice that much, since your English is not good enough, you won't know what they're saying, but when your English gets better, sometimes, you hear stuff, sometimes in playing sport, they'll say you're Asian and you can't play sport, they like to start things like that.'' 36(p.450)

Synthesized finding 2: Socio-cultural barriers and facilitators
The socio-cultural barriers and facilitators include interactions with people who have a connection with children (e.g., parents, peers). A child's participation in physical activity may be facilitated when there is dynamic involvement by parents and peers as well as their support. Unsupportive parenting and cultural beliefs may hinder children's participation in activity. This synthesized finding was derived from 12 findings, which merged into four categories (see Figure 7).  to lead a physically active lifestyle and become positive active role models within the family.

Socio-cultural facilitators
''Because our nation requires us to pursue all kinds of development including moral, intellectual and physical aspects. '' 32(p.1010) However, this cultural ethos was also identified as the cultural barrier to physical activity participation for children. In general, a child's educational attainment or academic success was given more emphasis by parents and children. 32,68 This belief, in turn, delimited participation in physical activity for ethnic Chinese children.
''You will understand how to balance and you will make your children have sport, for activities, and have time for study too. '' 32(p.1010) ''Academics is important because if I don't do well at school, I would let down my Mum and Dad, coz I mean what would it feel like if you were the parent of your child, others will say, oh my god, that person is so dumb, that child is so stupid, you know what I mean? I don't wanna feel that way or have my parents looked down upon by others like that. '' 68(p.1053) These attitudes also highlighted the traditional familiar power relationship in the Chinese family. A child was culturally legitimized to value filial piety, including adopting parental discourse without questioning, which makes ethnic Chinese children feel obligated to excel in academic performance as expected by their parents. 68 ''Pretty stilted, I mean they don't know what to do with me, my problems, like the Asian thing. Basically, to be Asian daughter, it's like I need to get Aþ and everything, though they say they don't mind me getting a B in English. . .Chinese kids wouldn't ask to go out, they'd be too busy studying. I'm meant to like learning, I'm supposed to take what they say without questions, you know, and to look after my sister, just basically be a model daughter. . .I'm different from this model, I think I'm reasonably ok, because I don't go out and party and drink and stuff like that, a lot of other people do. I'm ok. I mean I'm not ashamed of myself. '' 68(p.1059) Category 2.4: Parental concerns. The perceived negative impacts of physical activity by parents were commonly cited as barriers to a child's participation in physical activity. Four parental concerns were identified: academic concerns, aesthetic concerns, safety concerns, and weight concerns. 68 ''My parents don't really like me doing fencing. . .My parents are like whenever I ask to join a new sport, they're like What's the point of that? Are you going to get world champion? Are you going to get number one like gold medal in sailing? If not, I don't think you should do it, coz it's not going to get you any money and it's not going to get you an OP1. '' 68(p.1056) ''. . .all I got was getting tanner and tanner and tanner in my sport and my Dad starts complaining, like oh my gosh, you look like you're getting darker, no no no! They prefer me to be Whiter. . . they don't really want me to get tanner coz they think it's like the marine people. They just don't want me to be dark, not like a chocolate. '' 68(p.1055) ''Sometimes when I go outside, I ride my bike but my parents don't want me to ride outside, coz there's more cars in the place where I lived before, the place I lived before was like a circuit. '' 68(p.1056) ''For example if a child is already fat, that means he will have less interest in sport. '' 32(p.1009)

Discussion
This systematic review explored qualitative evidence relating to barriers and facilitators to ethnic Chinese children participating in physical activity, and uncovered the similarities and differences in these barriers and facilitators. This is beneficial to researchers working in the fields of physical activity as it could provide novel information about the barriers and facilitators to ethnic Chinese children's physical activity behaviors. The included 11 studies resulted in 41 unequivocal and 15 credible findings that were grouped into 21 categories. Four synthesized findings emerged from the data: personal, socio-cultural, environmental (only in the Chinese territories), and policy-and program-related barriers and facilitators (only in the Chinese territories).
The synthesized findings described barriers and facilitators to ethnic Chinese children's physical activity in school, home, and community settings. For many identified barriers and facilitators, the constructs were similar and were particularly dependent on the presence or absence of that factor. Overall, the identified personal and socio-cultural facilitators were consistent in both Chinese and non-Chinese settings; however, there were some differences regarding the barriers in the four synthesized findings. It is important to critically assess the barriers distinctive to ethnic Chinese children in the Chinese and non-Chinese territories. This systematic review identified personal barriers and facilitators similar to those identified by previous Chinese quantitative systematic reviews on this topic. 46,47,74 Specifically, children's participation in physical activity was associated with a child's physical activity preferences, motivation, self-perceived physical activity value, and experience of participating previously, regardless of residence (in the Chinese or non-Chinese territories). 29,36,62,66 It was highlighted that children who experienced enjoyment and happiness while doing physical activity were more likely to participate in physical activity. 36,62,66 In contrast, negative feelings (e.g., tiredness) about physical activity would inhibit their future participation in physical activity. 66 Children's motivations for physical activity increased when they perceived that benefits could be gained by engaging in physical activity. 66 In this systematic review, parents were consistently identified as integral ''gatekeepers'' in providing ethnic Chinese children with physical activity opportunities, in line with previous Chinese quantitative systematic reviews on this topic. 29,32,45,68,74 Regardless of whether children resided in the Chinese or non-Chinese territories, their parents were aware of the responsibility to provide opportunities for their child to be active, such as going out at weekends. 29,32,62,64 However, parents were generally seen to be overemphasizing children's educational attainment. 62,67,68 Their perception that physical activity was a factor negatively influencing their child's academic performance was presented as a barrier inhibiting children from participating in physical activity. 62,67,68 On the other hand, parental support and willingness to provide greater opportunities for children to participate in physical activity resulted in higher physical activity levels in their children. 29,32,62 Beyond parental influences, the role of peers and teachers in shaping a child's physical activity behavior was reported to be an important facilitator. In Chinese and non-Chinese territories, children were likely to participate in physical activity if they had peers to play with. Additionally, their interest in physical activity increased when they had experiences of better performance than their peers in certain physical activities. 62 As only one Chinese study involving teachers was included, it was not possible to distinguish the similarities or differences relating to teachers between the two settings. In Chinese territories, it was identified that physical education lessons that demonstrated a good approach to teaching (e.g., ''set appropriate goals,'' ''establish an equal and harmonious relationship between teachers and children'') led to an increase in children's physical activity levels. 65 This may be potentially related to the social support from engaging in physical activity that is perceived by children. 75 Children spent the majority of their time at school, and social interaction was a considerable factor in their decision to participate in sports. Children were more likely to engage in physical activity when teachers and peers were encouraging and supportive.
Specific to children in Chinese territories, a lack of time was identified as a personal barrier to being active. 63,64 Children commonly expressed interest in engaging in physical activity, yet they had very little leisure time as they spent the majority of time at school or working on assignments. 63,64 This was also consistent with other Chinese quantitative systematic reviews, suggesting that children who reside in Chinese territories commonly experience a great burden of academic study that limits the amount of time they have available for physical activity. 66,74 A previous study shows that the school hours for primary school children in Chinese territories are nine hours on average. 76 Children normally arrive at school around 7:30 a.m. to 7:55 a.m. and leave school around 4:30 p.m. to 5:30 p.m., which is significantly longer than the school periods in the United States and the United Kingdom (e.g., approximately 8:30 a.m. to 3:30 p.m.). [76][77][78][79][80] Experiences of exclusion, overt racism, and/or gender inequality were specific socio-cultural barriers that emerged among children in non-Chinese territories. 36 In general, ethnic Chinese children had the feeling of being purposely excluded and discriminated against by peers while doing certain types of sports (e.g., touch football) due to their ethnicity. The stereotypical perceptions of Chinese (Asians) as being quiet and not good at sports negatively influenced ethnic Chinese children's participation in physical activities. The general idea that girls are less competitive and strong compared with boys was identified as a barrier to girls being physically active and led to them self-excluding from participation in physical activity. 36 Gender inequality was also reflected in the scenario where captains always picked teammates from the boys over girls first at physical education. Given the difficult experience of being a migrant, it is important for ethnic Chinese children who reside in non-Chinese territories to be aware of the impact of these stereotypes on individuals and not to perpetuate them through their own internalized physical activity behaviors.
An interesting socio-cultural barrier was identified among Chinese female children who reside in non-Chinese territories who claim that their physical activity is hindered by pressure from their parents to maintain ''white'' skin, as traditional Chinese culture considers ''whiter'' skin to be associated with higher social classes, while darker-skinned people (or those who are tanned) indirectly represent a low socio-economic status, as it implies working outside under the scorching sun. 70,81 Although the preference for fair skin remains in Chinese culture, it was only identified as a barrier to physical activity in ethnic Chinese children who reside in non-Chinese territories, which may suggest conflicts in values between the first migrant generation and their descendants. It is important for parents of ethnic Chinese children who reside in non-Chinese territories to be aware of the cultural differences relating to preferences for skin color and not restrict children's participation in physical activity as a result of this belief.
In addition to personal and socio-cultural barriers and facilitators, the synthesized findings of environmental and policy-and program-related barriers and facilitators were only identified in children who reside in Chinese territories. This may suggest that children's physical activity levels may have more complex and multifaceted barriers and facilitators in Chinese settings compared to non-Chinese settings. Environmental barriers and facilitators in relation to safety and convenience of physical activity environments were identified in this review, and were consistent with previous Chinese quantitative systematic reviews on this topic. 46,47,74 Children's participation in physical activity may be hindered by poor neighborhood safety (e.g., crime) and traffic, but can be facilitated by an exercise-friendly environment (e.g., available equipment and resources for physical activity). 38,62,67 Air quality and population density were additionally identified as barriers relating to environmental sanitation among ethnic Chinese children who reside in Chinese territories, 31 and poor air quality and high population density negatively impacted children's motivation to be physically active. Evidence suggests that children have different physical activity patterns compared with adults, such as playing outdoors, playing close to the ground, and engaging in more contact activities. These two sanitary barriers may inhibit children's participation in physical activity, particularly for ethnic Chinese children who reside in the Chinese territories. 82 Being aware of the unique Chinese environmental barriers to children's physical activity and involving public health policymakers in promoting physical activity may help to increase the physical activity levels in ethnic Chinese children who reside in Chinese territories. 83 In terms of policy-and program-related barriers, ethnic Chinese children who reside in Chinese territories were repeatedly prevented from doing physical activity as a result of insufficient opportunities for participation in their preferred physical activity in physical education lessons. 29,62,63,66 In Chinese territories, children are required to take a sports test before entering high school, which means physical education lessons are generally used as (examination-oriented) training by schools and, therefore, children lack opportunities to do their preferred physical activity at school. 63 In addition, the overly skill-oriented nature (e.g., ball games, track and field) and time provision (e.g., most of the class time allocated to do warm-up or stretching) of physical education lessons negatively influenced a child's motivation to engage in physical activity. 62,66 Several previous Chinese quantitative systematic reviews reported that physical education lessons in Chinese territories were not attractive to children (i.e., a lack of intriguing curriculum content/structure), and they are simply delivered by organizing children to do free self-practice. 47,74 A child's physical activity may be determined by their preferences and they will allocate more time to specific activities as they grow up, so age-specific physical activity guidance could assist in engaging children more broadly. It may be more appropriate to offer young children general and interesting physical activities while providing more skill-oriented sports for older children. Strategies to improve the content and structure of physical education lessons, as well as a focus on physical activity policy adherence in schools, are warranted. The use of surveillance systems to monitor the implementation performance of physical education in schools could be considered in order to support school policy adoption. 84

Strengths and limitations
To the best of the authors' knowledge, this is the first qualitative systematic review to synthesize the barriers and facilitators to physical activity in ethnic Chinese children between six and 17 years of age. This review applies rigorous JBI review methods, an extensive search strategy, and included all papers regardless of language or type of publication (i.e., published or unpublished). It is acknowledged that the synthesized findings cannot be generalized as this is a qualitative systematic review; however, the included studies were carried out across four countries (China, Australia, United States, and United Kingdom) and included children from different age groups, ranging from nine to 16 years, and various participant groups including children, teachers, and parents. These qualitative studies provided useful insights in the contexts of home, school, and community in which barriers and facilitators are experienced by children and perceived by parents and teachers. The studies also provided narrative illustrations from all the participants, which give a better understanding of the specific needs from the perspective of children, parents, and teachers. In addition, this review categorized the extracted findings using a similar structure to that of previous reviews, which could help uncover the similarities and differences of perceived barriers and facilitators to physical activity when compared with other systematic reviews on this topic conducted among participants of different age groups, settings, or countries.
A limitation of this review is that publication bias cannot be ruled out, as a non-peer reviewed thesis was included in this review, possibly lowering the methodological quality and the credibility of synthesized findings The confidence of the recommendations may be compromised due to the poor quality of the included thesis based on the JBI critical appraisal tool; however, none of the identified theses or dissertations were left out in the process of screening. The majority of studies were not written in Chinese, which may lead to the conclusions being biased by a general view on Chinese territories held by Western society. One study was in Chinese and a translation of extracted findings was conducted by reviewers; however, the credibility of synthesized findings may be reduced due to language bias and the accuracy of the translation.
This review did not stratify the barriers and facilitators specific to children of different ages and genders because the participants included children, teachers, and parents, and the majority of included studies did not report the barriers and facilitators according to children's gender. The perceived barriers and facilitators to physical activity may differ between younger and older children as well as between boys and girls, so future research may benefit from reporting the barriers and facilitators to children of different ages and genders independently.
The review data offered limited insights into barriers and facilitators to physical activity specifically for ethnic Chinese children who reside in the non-Chinese territories, since the synthesized findings were drawn from just four research studies that met the inclusion criteria. Of the seven studies conducted among children who reside in Chinese territories, only six were published peer-reviewed studies, and these studies were generally conducted in large Chinese cities, such as Beijing and Hong Kong. Considering the limited number of included studies and the social differences between different jurisdictions it is not possible to claim a universal understanding of barriers and facilitators for children residing in Chinese territories.

Conclusions
The reasons for physical inactivity in ethnic Chinese children are complex and multi-factorial. A range of personal, social, environmental, and policyand program-related barriers and facilitators have been identified that influence their participation in physical activity. Particularly, barriers and facilitators at the personal and socio-cultural level (e.g., parents and teachers) were most frequently cited, reflecting the importance of children's selfinfluence and the key role adults play in shaping children's physical activity behaviors. There are fewer qualitative studies on this topic conducted with Chinese children who reside in non-Chinese territories than in the Chinese territories. It is important that future research examines this topic given there is a large population of ethnic Chinese children living outside Chinese territories and the differences noted regarding the barriers to physical activity among ethnic Chinese children in different countries. The focus on identified barriers and facilitators to physical activity in ethnic Chinese children will assist parents, health professionals, teachers, and policymakers in developing successful programs to encourage and increase participation in physical activity within this population.

Recommendations for practice
Using the JBI guidance for recommendations, development implications for practice have been identified and recommendations made. 85 Grade A recommendations are strong and Grade B recommendations are weaker. On the strength of the ConQual Summary of Findings, it is recommended that future physical activity promotion practice needs to consider the children's, parents', and teachers' concerns as well as the unique Chinese social, cultural, environmental, and policy-and program-related influences. Specific recommendations are listed in Table 2.

SYSTEMATIC REVIEW
Children and their parents participated in eight semistructured focus groups in Beijing (North China) and Nanjing (South China). Each site conducted two focus groups with children and two focus groups with parents.

Framework analysis
In conclusion, the children selected from Beijing and Nanjing, two major cities in China, one in the North and one in the South, reported that they chose food often based on flavor. Their consumption of unhealthy snacks was prevalent.  (2007) Beijing, China One class ranking high and one class ranking low (with respect to the average academic grades) was selected from two schools respectively. All the students from each of the four classes were invited to participate in the study; all students who were asked agreed to participate in this study.

Qualitative study
Identify salient consequences, referents, and circumstances about PA as perceived by middle school students and to provide suggestions for interventions and quantitative research School Children (98%) were aged 13-15 years and half were male and half were female 155 Participants were students selected from four classes of two middle schools. In Beijing, middle school or junior high school consists of three grades: Grade 1, 2 and 3.
The self-completion instrument was administered during PE class by two members of the research team who were not associated with the school.

Content analysis
The results of this qualitative study suggest that student perceptions of the relationship between their participation in PA and their school work might be more important factors underlying their decisions to participate in PA than their beliefs about the health benefits. Programs to increase PA should address the social and environmental factors underlying these perceptions with the goal of strengthening student engagement in PA and improving learning potentials. Quantitative studies with a larger and representative sample and with close-ended items based on the qualitative research are needed to more fully understand middle school students' decisions to engage in daily PA. In addition, given the role of the parents as a social referent and the students' perception of the connection between PA and academic performance, research is needed to understand the views of parents, teachers, and school administrators.

12
The participants were selected purposefully for this qualitative interview study from three government-funded schools that had participated in a larger mixed method study.
The semi-structured interviews were conducted in Cantonese by two Chinese Hong Kongborn female researchers who were familiar with the study and primary school contexts. Each interview lasted for approximately 30 minutes to an hour and was conducted in a classroom environment. Consents were sought from the principals, the young people, and their parents. All agreed and gave consent for the young people to participate in the interview.

Content analysis
The deeply rooted capitalistic economy and the philosophy of Confucianism that act hand-in-hand in shaping the PA values and expectancy beliefs of contemporary Hong Kong Chinese young people. Experience as misrecognition/less recognition in HPE and school sport-problematic (U) ''Well, when I was skinny, I just look(ed) so fragile that I'll be pushed over by wind, and now when I'm not that skinny, people just assume that I don't do much exercise anyways. . . . they just don't pick me first'' (p.449) Experience as misrecognition/less recognition in HPE and school sport-adaptive (U) ''I don't really study, because I hate studying, it's boring, I like to have fun. . . . I'm having fun and feeling good. I like sports but I'm not good at it because I'm not as fast as everyone else, and I can't swim that well either. I'd like to join an AFL club but I haven't found a club yet that I like. AFL is fun'' (p.451) Physical activity inequity (U) ''Yeah, well I guess in PE, the captain chooses the boys first, like you know, they are the stronger players, and he kind of chooses the girls last. . . . Some of the girls are strong as well, but coz the boys always want those who's able to kick and able to goal. Well, in HPE class, not many girls participate in it, coz like we're girls, we don't want to do it, and the teachers is like, you can walk around the field and do nothing'' (p.449) Overt forms of racism (U) ''Like back in primary school, you don't notice that much, since your English is not good enough, you won't know what they're saying, but when your English gets better, sometimes, you hear stuff, sometimes in playing sport, they'll say you're Asian and you can't play sport, they like to start things like that'' (p.450) Exclusion experiences (U) ''I just think they [European] think they are better, my other friends, they used to be in the A team, but then they are too inside, they don't express much things in schools, they don't talk to other people, they're just not used to it, that's why they don't pass the ball to them'' (p.450) Child and parental perspectives on diet and physical activity decisions: implications for childhood obesity prevention in China. Asia Pac J Clin Nutr. 2017;26 (5) ''Interestingly, within the group we interviewed, only fathers provided actual facilitation of their children's physical activity. One of them acted as an assistant coach regularly in his boy's rugby team, while a few attended their children's sports competitions, such as badminton and swimming during their leisure time, and two parents assisted with transporting children to playgrounds'' (p.338) Families are an important factor in their physical activity participation (C) ''Doing physical activity is fun and when I see other people playing, I want to be one of them. . . . My parents also encouraged me. They would spend time jogging with me and I still remember we had so much fun'' (p.390) As they grew up, time spent on a particular physical activity increased (U) ''I play Circumstances that make physical activity easy and circumstances that make it difficult (C) ''Many of the circumstances (e.g., assignments, time, and weather) were mentioned both as circumstances that make physical activity easy and as circumstances that make it difficult. The most frequently reported facilitator of physical activity, ''having fewer assignments'', was mentioned by 27.7% of the students. The most frequently mentioned barrier, ''having too many assignments'', was mentioned by about half (48.4%) of the students. Additionally, ''time'' was the second most frequently mentioned circumstance; 14.2% of the students mentioned having more time as a facilitator and 18.8% mentioned not having enough time as a barrier. These data also suggest that ''having fun activities'', ''having others to participate with'', ''approval from others'' and ''making facilities more available'' operate as facilitating and hindering circumstances" (p. Strengthen the teaching and management regulation (U) ''The PE teachers should respect and care about students rather than criticize students at will. Teachers should equip a positive attitude and be the role model so that the students will feel the equality between themselves and teachers. In addition, they may be attracted to the class. With the establishment of a harmonious relationship between students and teachers, students will thus take the teachers as examples and change their behavior'' (p.25) Make tailored objectives for students (U) ''We should combine the collective goal with an individual goal. Each student's physical quality and individual ability are different. We should fully consider the individual difference of each student when setting the teaching goal. When setting the collective teaching goal, we should make the goal has a certain range of fluctuation, because the requirement is universal for each student. We should ensure that for students whose sports learning ability are not strong enough can improve their sports achievements through hard work and their interest in sports learning can be increased due to the establishment of motivation in sports learning. In the other way, this goal should also apply to those who have higher sports learning abilities'' (p.24) HPE, health and physical education; PA, physical activity; PE, physical education