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. 2026 May 10;52:e70288. doi: 10.1111/cch.70288

International Study of Movement Behaviours in the Early Years (SUNRISE): A Pilot Study From Ecuador

José Francisco López‐Gil 1,✉, Emily Cisneros‐Vásquez 1, José Adrián Montenegro‐Espinosa 1, Camila Miño 1, Fiorella Quiroz‐Cárdenas 1,2, Daniela Celi‐Lalama 3, Aida Lorena Soria‐Vizcaino 4, Josefa María Panisello Royo 5, Rodrigo Yáñez‐Sepúlveda 6, Jorge Olivares‐Arancibia 7, Héctor Gutiérrez‐Espinoza 8, Anthony D Okely 9
PMCID: PMC13158317  PMID: 42108506

ABSTRACT

Background

This study aimed to determine the proportion of Ecuadorian preschool children meeting the World Health Organization (WHO) 24‐hour movement behaviour guidelines for physical activity, sedentary behaviour and sleep, to examine differences by sex and geographic location and to evaluate the feasibility and acceptability of the International Study of Movement Behaviours in the Early Years (SUNRISE) protocol.

Methods

In this pilot study, a total of 108 children aged 3–4 years from kindergartens in Quito (Ecuador) participated in 2024. Physical activity, sleep and sedentary behaviour were evaluated using accelerometry (ActiGraph wGT3x‐BT). Gross and fine motor skills were evaluated using validated tasks, and executive functions were assessed via the Early Years Toolbox.

Results

Only 11.8% of children met all three WHO recommendations of 24‐hour movement behaviours, while 16.1% did not meet any. Boys showed higher compliance with the physical activity guidelines compared to girls, and urban children demonstrated slightly better adherence to the screen time guideline. A total of 100% of participants completed anthropometric, executive function and motor skill assessments, respectively. Additionally, 86.1% of children provided at least one valid day of accelerometer data, and 75.9% accumulated three or more valid days, supporting the feasibility and acceptability of the SUNRISE study protocol in this population.

Conclusion

This pilot study demonstrated the feasibility and acceptability of the SUNRISE study methods among Ecuadorian children. Given the low proportion of children meeting the WHO movement guidelines, long‐term strategies are needed to promote healthier lifestyles from early childhood in Ecuador.

Keywords: executive functions, motor skills, movement behaviours, obesity, physical activity, preschool children, screen time, sedentary behaviour, sleep

Summary

  • Few Ecuadorian preschool children met all three WHO 24‐hour movement guidelines.

  • Boys were more likely to meet physical activity recommendations, while urban children showed better adherence to screen‐time guidelines.

  • The SUNRISE protocol proved feasible in Ecuador, with high completion rates and acceptable accelerometer compliance.

  • Many children failed to meet one or more movement guidelines, highlighting the need for early preventive strategies.

  • These findings support the need for surveillance and policy actions to promote healthy movement behaviours in early childhood.

1. Introduction

Childhood obesity is expanding at an alarming rate worldwide (Kerr et al. 2025). According to World Health Organization (WHO) estimates, approximately 37 million children under the age of five were overweight globally in 2022, corresponding to a prevalence of 5.6%, compared with 5.0% in 1990 (World Health Organization 2024). In Latin America and the Caribbean, the prevalence is even higher, reaching 8.6% in 2022, equivalent to around 4.2 million affected children, while in South America specifically, the prevalence was estimated at 9.7% (United Nations Children's Fund 2023). In Ecuador, a systematic review and meta‐analysis reported pooled obesity prevalences of 8.1% among preschool children (< 5 years), 10.7% among school‐aged children (5–11 years) and 10.5% among adolescents (12–18 years) (Hajri et al. 2021). Moreover, nationally representative data from the Encuesta Nacional de Salud y Nutrición (ENSANUT)‐2018 survey indicated an obesity prevalence of 12.7% among children aged 5–17 years (López‐Gil, Chen et al. 2025). Childhood obesity substantially increases the risk of premature mortality and the early onset of noncommunicable diseases, including cardiovascular disease, type 2 diabetes, liver disorders and cancer (Biro and Wien 2010; Reilly and Kelly 2011; Simmonds et al. 2016; World Health Organization 2024).

Twenty‐four‐hour movement behaviours have emerged as an important framework for understanding lifestyle factors related to childhood obesity (López‐Gil et al. 2023). This concept integrates physical activity, sedentary behaviour and sleep within a 24‐hour period, emphasizing their interdependence and combined influence on health outcomes (Pedišić 2014; Pedišić et al. 2017). The WHO guidelines for physical activity, sedentary behaviour and sleep for children under 5 years helped establish this approach globally (World Health Organization 2019). However, the development of these recommendations relied largely on evidence from high‐income countries, highlighting the limited availability of research from low‐ and middle‐income countries (LMICs).

Growing evidence suggests that adherence to the 24‐hour movement guidelines is associated with multiple health benefits in children and adolescents (Rollo et al. 2020). These include better mental health outcomes, such as lower odds of depression and suicidality (De Lannoy et al. 2023; López‐Gil, Solmi, et al. 2025; López‐Gil et al. 2024), improved psychosocial health and health‐related quality of life (De Lannoy et al. 2023; López‐Gil, Tremblay, et al. 2022; López‐Gil, Roman‐Viñas, et al. 2022), higher physical fitness and healthier dietary patterns (Tapia‐Serrano et al., 2023), improved cognitive outcomes (Bao et al. 2024) and healthier body composition (López‐Gil et al. 2023). Furthermore, adherence to these guidelines during adolescence has been associated with lower risks of obesity, hypertension, type 2 diabetes, depression, suicidality and mortality later in adulthood (García‐Hermoso et al. 2022, 2023, 2025; López‐Gil, Ezzatvar and García‐Hermoso 2025). Given that early childhood represents a critical developmental period during which behaviours are more easily shaped, understanding movement behaviours at this stage is particularly important (Carson et al. 2017). Nevertheless, evidence focusing specifically on preschool‐aged children remains limited.

Since the publication of the WHO guidelines, there has been increasing interest in examining children's adherence to the 24‐hour movement recommendations. However, most evidence comes from high‐income countries (Rollo et al. 2020; Tapia‐Serrano et al. 2022). For instance, a systematic review including data from 23 countries reported that only 11.3% of preschool children met all three guidelines, whereas 8.8% did not meet any of them (Tapia‐Serrano et al. 2022). Similarly, an analysis of 33 countries found that only 14.3% of children aged 3–4 years adhered to all WHO recommendations (Chong et al. 2024). In South America, compliance with the integrated guidelines ranges from 2.9% to 17.5% across studies, with available evidence mainly from Brazil, Chile and Colombia (Tapia‐Serrano et al. 2022), and only Brazil included in the more recent multicountry analysis (Chong et al. 2024). Importantly, no studies to date have examined adherence to the 24‐hour movement guidelines among preschool children in Ecuador.

The International Study of Movement Behaviours in the Early Years (SUNRISE) aims to establish a global surveillance system for monitoring movement behaviours in preschool‐aged children, with particular emphasis on LMICs (Okely et al. 2021). Before implementing nationally representative studies, pilot studies are conducted to assess feasibility, acceptability and methodological adequacy in each country. Pilot studies have already been completed in several countries, including South Africa, Japan, Sweden, Bangladesh, Zimbabwe, Vietnam, Bosnia and Herzegovina, Ethiopia, Tanzania, Mongolia, Iran, Mexico and Tunisia (Draper et al. 2020; Tanaka et al. 2020; Delisle Nyström et al. 2020; Hossain et al. 2021; Munambah et al. 2021; Kim et al. 2022; Užičanin et al. 2024; Abdeta et al. 2024; Nusurupia et al. 2024; Byambaa et al. 2024; Zarghani et al. 2024; Argumedo et al. 2025; Ltifi et al. 2025). Ecuador is a middle‐income country in northwestern South America with approximately 17.8 million inhabitants, of whom about 64% live in urban areas (World Bank Group 2025). Therefore, the aims of this study were as follows: (1) to determine the proportion of Ecuadorian preschool children meeting the WHO 24‐hour movement behaviour guidelines; (2) to assess differences according to sex and geographic location; (3) to analyze differences in anthropometric characteristics, motor skills and executive functions; and (4) to evaluate the feasibility and acceptability of the SUNRISE study protocol in Ecuador.

2. Material and Methods

This pilot study with a cross‐sectional study included a convenience sample of 100 children aged 3–4 years (n = 50 each in rural and urban areas) and was considered adequate to evaluate the feasibility and acceptability of the study, in accordance with the SUNRISE study protocol (Okely et al. 2021). Children were recruited from kindergartens (‘Educación Inicial ’) in Quito and surrounding areas (Pichincha, Ecuador). Following the SUNRISE protocol, no more than 20 children were recruited per kindergarten. Given that not all kindergartens had sufficient eligible children, additional centres were progressively included using a snowball sampling strategy until reaching the target sample size of approximately 100 participants, with roughly equal representation from urban and rural settings. Finally, a total of 11 kindergartens were examined in this study. As a result of this progressive recruitment strategy, a total of 108 children were enrolled, slightly exceeding the initial target of 100 participants.

In Ecuador, preprimary education is not compulsory but is widely accessible for children aged 3 and 5 years. According to national data, approximately 86% of children in this age group are enrolled in early childhood education programs, primarily in public institutions (Ministerio de Educación, Deporte y Cultura 2023). In this context, the term ‘preschool’ refers to educational services provided to children aged 3–5 years, prior to the start of compulsory primary education. ‘Kindergarten’ (‘ Educación Inicial ’ in Spanish) is commonly used to describe these early education settings in Ecuador (United Nations Children's Fund 2024).

Data collection was conducted between September and December 2024. The directors of the selected kindergartens were initially approached and invited to take part in the study. Upon receiving their agreement, parents or primary caregivers of enrolled children were invited to attend informational meetings with the research team at the kindergartens, scheduled outside regular working hours or conducted virtually when necessary to accommodate parents' availability. During these meetings, the study procedures were explained and interested parents received an information sheet and a consent form. Consent was primarily obtained through signed paper forms. However, in some cases, electronic consent was used, whereby parents were provided with a secure link to review the study information and indicate their consent. Eligible participants were children aged 3–4 years who regularly attended the kindergarten. Participation was open to all children, including those with disabilities or health conditions, to ensure inclusivity. However, children who were unable to complete the device‐based measurements or motor and executive function tests were excluded from the respective analyses. Only children whose parents or caregivers provided written informed consent were included in the study.

A team of experienced researchers, with expertise in education, sports sciences, paediatrics, public health, epidemiology and nutrition, carried out the data collection. Before data collection, all researchers were trained in the study protocol by the SUNRISE Coordinating Center. All study materials, including consent forms, questionnaires, information and log sheets, were translated into Spanish. Data were collected during school hours at each kindergarten and entered using Research Electronic Data Capture (REDCap) software (Vanderbilt University, Nashville, Tennessee, USA) (Harris et al. 2009).

For the SUNRISE study, ethical approval was obtained from the Human Research Ethics Committee (HREC) of the University of Wollongong (UOW), Australia (ID 2018/044; ID 2019/378). Additional ethical clearance was granted by the Comité de Ética de Investigación en Seres Humanos of Universidad Espiritu Santo (CEISH‐UEES), Ecuador (ID C‐UEES‐25‐13).

2.1. Measurements

All measurements were in accordance with the SUNRISE study protocol published elsewhere (Okely et al. 2021).

2.1.1. Anthropometrics

Height and weight measurements were taken using a portable height measuring board (SECA 213, GmbH & Co. K, Hamburg, Germany) and calibrated scales (SECA 876, GmbH & Co. K, Hamburg, Germany) according to WHO protocol (World Health Organization 2008). Two measurements were obtained for weight and height, and a third was collected if differences exceeded 0.25 kg or 0.5 cm, respectively. BMI z‐scores were calculated using WHO AnthroPlus (Version 1.0.4) and applied to determine children's weight status in accordance with WHO growth standards (World Health Organization 2006).

2.1.2. Twenty‐Four‐Hour Movement Behaviours

Twenty‐four‐hour movement behaviours, including physical activity, sleep and sedentary behaviour, were objectively measured using accelerometers (R. W. Taylor et al. 2018). Children were fitted with waist‐worn ActiGraph wGT3X‐BT devices (ActiGraph LLC), programmed to initiate data collection at a sampling rate of 30 Hz starting from midnight on the day of distribution. Children were instructed to wear the accelerometers continuously for seven consecutive days, removing them only for bathing, swimming or water‐based activities. Compliance was supervised by teachers during kindergarten hours and by parents or caregivers outside of school hours. Raw accelerometry data were downloaded and processed using ActiLife software (Version 6.12.1), reintegrated into 15‐s epochs and filtered with a low‐frequency extension. A recording was considered valid if it included at least one full day with six or more hours of waking wear time, verified through manual inspection (Bingham et al. 2016). A standardized wake period (8:00 am to 10:20 pm), according to reported wake and sleep times, was used to isolate waking behaviour. Nonwear time was defined as any period consisting of at least 20 consecutive minutes with zero counts and excluded from analysis (Cliff et al. 2009). Validated intensity thresholds classified activity as sedentary (< 800 counts per minute [CPM]), light‐intensity physical activity (LPA; 800–1679 CPM), moderate‐to‐vigorous‐intensity (MVPA; ≥ 1680 CPM) and vigorous‐intensity (VPA; ≥ 3368 CPM) (Pate et al. 2006, 2015).

In addition to accelerometer‐based measurements, sleep duration and screen time were evaluated using a self‐administered questionnaire fulfilled by parents or primary caregivers (Okely et al. 2021). Participants were provided with printed copies of the questionnaire, which they were asked to complete at their convenience; alternatively, a digital version was also made available for those who preferred to complete it online. Once completed, the questionnaires were returned to the teachers, who then delivered them to the research team. Sleep duration was evaluated with the following question: ‘How many hours of sleep does this child get in a typical 24‐hour day (including naps)?’ Screen time was evaluated by asking: ‘In a 24‐hour period over the past week, how much time did the child participating in this study spend using electronic devices such as a smartphone, tablet, video game, or watching television or internet videos while sitting or lying down?’ Parents were instructed to report the duration as accurately as possible, rounded to the nearest minute. The WHO 24‐hour movement guidelines were considered as three behavioural domains: physical activity, sedentary behaviour, and sleep (World Health Organization 2019). For children aged 3–4 years, the physical activity domain was defined as accumulating at least 180 minutes per day of total physical activity (TPA), of which at least 60 minutes should be MVPA. The sedentary behaviour domain was defined as no more than 1 hour per day of screen time and not being restrained, or sitting, for more than 1 hour at a time. The sleep domain was defined as 10–13 hours of good‐quality sleep per day, including naps. Because the physical activity and sedentary behaviour domains include more than one operational component, we distinguished between component‐level criteria and domain‐level adherence. Physical activity adherence required meeting both the TPA and MVPA criteria; sedentary behaviour adherence required meeting both the screen time and restrained/prolonged sitting criteria; and sleep adherence required meeting the sleep‐duration criterion. Integrated adherence was defined as meeting all three behavioural domains.

2.1.3. Executive Functions

Executive functions, specifically working memory and inhibitory control, were evaluated using two tasks from the Early Years Toolbox (https://www.eytoolbox.com.au) (Howard and Melhuish 2017). Both tasks were previously translated into Spanish for the study. Working memory was examined using the standardized ‘Mr. Ant’ task, in which children identified the positions of coloured stickers on a cartoon figure. Once the stickers had disappeared, children had to recall and indicate their original positions. Participants received one point for each level where they correctly identified the sticker positions in at least two trials, with total scores ranging from 0 to 8. Inhibitory control was assessed using the ‘Go/No‐Go’ task, where children were instructed to tap the screen during ‘go’ trials (when a fish appeared) and to refrain from tapping during ‘no‐go’ trials (when a shark appeared). Scores ranged from 0 (no correct responses) to 1 (perfect performance on both trial types).

2.1.4. Motor Skills

Motor skills, including functional mobility, postural control, dexterity and upper and lower body strength, were evaluated using validated assessments from the National Institutes of Health Toolbox (Reuben et al. 2013).

2.1.4.1. Fine Motor Skills

Dexterity was measured using the nine‐hole pegboard test. Each child completed the test with both hands, performing one practice attempt followed by one trial. Children placed nine pegs into the holes and then replaced them, one by one and in any order. The time required for each hand was recorded, where shorter times denoted greater dexterity.

2.1.4.2. Gross Motor Skills

Functional mobility was assessed through the supine‐timed up and go test. Children began lying on their backs with their feet positioned at a start line located three meters from a wall. After observing a demonstration by the researcher, children were instructed to get up, run to touch a marked target on the wall and return as quickly as possible to the start line. The time to complete the task was recorded, with faster times indicating better functional mobility. One practice and two‐timed trials were conducted.

Postural steadiness was evaluated using a one‐leg standing balance test. Children were asked to stand unassisted on each leg for up to 30 s. Longer standing times indicated better balance. After a demonstration and a practice attempt, the time for each trial was recorded.

Upper body strength was assessed with a handgrip dynamometer (TKK5825, Grip‐A, Takei, Tokyo, Japan). Grip strength was measured to the nearest 0.5 kg, with higher values indicating greater strength. Each child completed two trials with each hand, and the dynamometer setting was adjusted according to the hand size of each participant.

Lower body strength was measured using the standing long jump test. Children placed their feet behind a line and jumped forward as far as possible, landing on both feet. The distance jumped, measured in centimetres, represented lower body strength, with greater distances indicating higher strength. At least one practice trial and two recorded trials were completed.

2.2. Feasibility and Acceptability of the Study

The feasibility of implementing the SUNRISE study protocol and assessments in Ecuador was assessed by monitoring adherence to study procedures and gathering qualitative feedback from parents and kindergarten staff via focus group discussions.

Recruitment feasibility was assessed by the ability to enrol a balanced sample with respect to geographic location (urban and rural areas) and sex distribution (boys and girls). Success criteria included the following: (1) enrolling approximately 100 children, with a target of around 20 participants per kindergarten, and (2) completing data collection for at least 90% of children.

Measurement feasibility was determined by evaluating adherence to the study protocol by both participants and research staff. For accelerometry, successful completion was defined as obtaining at least 24 hour of valid data, with a minimum of 6 hour of waking wear time per day, in at least 80% of children who wore the devices.

To assess acceptability, focus groups involving parents and staff were conducted across the 11 participating early childhood education centres. In most centres, separate sessions were held for parents and staff; however, in one centre, a single mixed session was conducted. Although 11 parent groups and 11 staff groups were initially planned, the final number of focus groups was 21. Each group included between two and five participants, and discussions lasted approximately 15–30 minutes. Focus groups were conducted on the last day of data collection at each centre, following semistructured guides tailored to participant role. Staff groups addressed the following five main topics: the presence of the data collection team, children's engagement with study activities, experiences with accelerometer use, feedback on motor skill and iPad‐based activities and general comments or suggestions. Parent groups explored the following four main topics: experiences with the caregiver questionnaire, children's enjoyment and engagement in the study, feedback on accelerometer use at home and general comments or suggestions. Specific questions included: ‘Did the children enjoy participating?’, ‘Was there anything the children did not enjoy or that could be improved?’, ‘How did you find your child/the children adapted to wearing the accelerometer for seven days?’, ‘Were there any difficulties encountered? If so, could you describe them and suggest possible improvements?’, and ‘Do you have any additional comments?’ Sessions were audio‐recorded when feasible; otherwise, structured notes were taken by the research team. All notes were subsequently translated into English and entered into the REDCap database for analysis (Okely et al. 2021).

2.3. Statistical Analyses

Statistical analyses were conducted via R statistical software (Version 4.4.1) from the R Core Team in Vienna, Austria, and RStudio (2024.09.0+375) from Posit in Boston, Massachusetts, USA. The normality of continuous variables was assessed using quantile–quantile (Q–Q) plots, density plots and the Shapiro–Wilk test. Homogeneity of variances was verified with Levene's test. Descriptive statistics were calculated to identify participant's characteristics, 24‐hour movement behaviours, motor skills and executive functions. Categorical variables are expressed as numbers and percentages. Continuous variables are presented as mean (standard deviation) for normally distributed data and median (first quartile, third quartile) for nonnormally distributed data. Comparisons between sexes and between urban and rural participants were performed using Student's t‐test for continuous variables with normal distribution and the Wilcoxon rank‐sum test for nonnormally distributed variables. Differences in categorical variables were assessed using Pearson's chi‐squared (χ2) test or Fisher's exact test when expected cell counts were less than five. A threshold of p < 0.05 was used to determine statistical significance.

3. Results

Table 1 presents the descriptive characteristics of the Ecuadorian children examined. A total of 108 children were enrolled and included in the analyses (57.4% girls; 50.9% urban). The median BMI‐for‐age z‐score was 0.7 (IQR: 0.2, 1.3), with no significant differences by sex (p = 0.166) or geographic location (p = 0.278). Based on BMI status, 61.1% of children had normal weight, 31.5% overweight and 7.4% obesity, with no significant differences between sexes (p = 0.708) or between urban and rural areas (p = 0.907). Regarding body composition, boys showed higher fat‐free mass than girls (median 14.2 vs. 13.1 kg; p < 0.001) and lower body fat percentage (14.5% vs. 17.3%; p < 0.001). No significant differences were observed in fat‐free mass, fat mass or body fat percentage between urban and rural participants.

TABLE 1.

Descriptive data of the study participants.

Variable Total sample Sex Geographic location
N = 108 a Male n = 46 a Female n = 62 a p b Urban n = 55 c Rural n = 53 c p b
Age (years) 4.0 (3.5, 4.3) 4.0 (0.5) 3.9 (0.6) 0.337 3.8 (0.5) 4.1 (0.5) 0.035
Sex 0.579
Male 46 (42.6%) — — — 22 (40.0%) 24 (45.3%)
Female 62 (57.4%) — — — 33 (60.0%) 29 (54.7%)
Geographic location 0.579
Urban 55 (50.9%) 22 (47.8%) 33 (53.2%) — — —
Rural 53 (49.1%) 24 (52.2%) 29 (46.8%) — — —
Height (cm) 98.9 (96.0, 102.1) 99.6 (4.8) 98.4 (5.3) 0.222 98.5 (5.2) 99.3 (5.0) 0.459
Weight (kg) 16.0 (14.5, 17.6) 16.6 (14.9, 18.1) 15.8 (14.0, 17.2) 0.067 15.8 (14.2, 17.3) 16.5 (14.7, 17.7) 0.300
Height‐for‐age (z‐score) −0.8 (−1.5, −0.1) −0.8 (0.8) −0.8 (1.0) 0.988 −0.7 (0.9) −0.9 (0.9) 0.237
Weight‐for‐age (z‐score) 0.0 (−0.7, 0.5) 0.1 (0.8) 0.0 (1.0) 0.500 0.1 (0.9) 0.0 (0.9) 0.799
BMI‐for‐age (z‐score) 0.7 (0.2, 1.3) 1.0 (0.8) 0.7 (0.9) 0.166 0.8 (0.8) 0.9 (0.9) 0.278
BMI status c 0.708 0.907
Normal weight 66 (61.1%) 26 (56.5%) 40 (64.5%) 35 (63.6%) 31 (58.5%)
Overweight 34 (31.5%) 16 (34.8%) 18 (29.0%) 16 (29.1%) 18 (34.0%)
Obesity 8 (7.4%) 4 (8.7%) 4 (6.5%) 4 (7.3%) 4 (7.5%)
Fat free mass (kg) 13.5 (12.7, 14.6) 14.2 (13.2, 15.2) 13.1 (12.1, 14.0) < 0.001 13.4 (12.7, 14.6) 13.6 (12.9, 14.6) 0.551
Fat mass (kg) 2.6 (1.9, 3.1) 2.3 (1.7, 3.0) 2.6 (2.0, 3.3) 0.089 2.3 (1.7, 3.0) 2.6 (2.0, 3.3) 0.123
Body fat (%) 15.7 (12.5, 18.4) 14.5 (11.1, 16.5) 17.3 (14.4, 19.7) < 0.001 15.3 (11.6, 17.6) 16.4 (12.9, 18.9) 0.109
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a

Mean (standard deviation) or median (first quartile, third quartil), and number (percentages).

b

p values for continuous variables were obtained using the Wilcoxon rank sum test (for nonnormally distributed variables) or the Student's t‐test (for normally distributed variables: age, height, height‐for‐age, weight‐for‐age and body mass index‐for‐age). For categorical variables, p values were obtained using Pearson's chi‐squared (χ2) test (or Fisher's exact test when expected cell counts were < 5).

c

According to the World Health Organization criteria.

Abbreviation: BMI, body mass index.

Table 2 summarizes the 24‐hour movement behaviours of the study participants. Children spent a mean of 102.4 minutes/day in LPA, 58.4 minutes/day in moderate physical activity (MPA), 13.4 minutes/day in VPA and 73.0 min/day in MVPA. Boys accumulated significantly more LPA (p = 0.039), MPA (p = 0.002), VPA (p = 0.001) and MVPA (p = 0.001) than girls, while no significant differences were found by geographic location (p > 0.05 for all). Total sedentary time was 489.8 minutes/day, with no significant differences by sex (p = 0.436) or area (p = 0.284). However, sitting time differed between urban and rural children (p = 0.003), with urban children spending more time sitting. Children spent a median of 120 minutes outdoors on weekdays and 180 minutes on weekends, with no significant differences by sex or area. Total sleep time measured by accelerometry was 706.8 minutes/day, with girls sleeping longer than boys (726.6 vs. 683.7 minutes/day; p = 0.010). Sleep time based on parent‐reported questionnaires showed no significant differences.

TABLE 2.

Twenty‐four‐hour movement behaviours in the overall sample and stratified by sex and area of residence.

Variable Total sample Sex Geographic location
N = 108 a Male n = 46 a Female n = 62 a p b Urban n = 55 a Rural n = 53 a p b
LPA time (min) 102.4 (21.3) 107.4 (22.2) 98.1 (19.7) 0.039 101.4 (19.2) 103.5 (23.5) 0.567
Missing 15 3 12 7 8
MPA time (min) 58.4 (44.1, 71.3) 65.1 (53.1, 81.0) 52.5 (38.9, 66.5) 0.002 57.6 (42.9, 69.5) 59.7 (45.5, 74.1) 0.933
Missing 15 3 12 7 8
VPA time (min) 13.4 (8.4, 22.6) 17.5 (11.7, 27.6) 11.3 (7.4, 17.0) 0.001 14.7 (8.7, 24.0) 12.8 (7.9, 19.8) 0.316
Missing 15 3 12 7 8
MVPA time (min) 73.0 (53.1, 93.8) 86.4 (65.2, 105.2) 64.2 (46.1, 82.9) 0.001 72.0 (52.2, 96.3) 73.0 (54.2, 92.7) 0.664
Missing 15 3 12 7 8
TPA time (min) 181.4 (144.5, 200.9) 188.7 (167.3, 220.4) 165.5 (130.1, 190.7) 0.003 179.6 (144.4, 198.2) 181.8 (144.5, 210.0) 0.896
Missing 15 3 12 7 8
Time spent outdoors (weekdays) (min) 120.0 (60.0, 240.0) 120.0 (60.0, 240.0) 120.0 (60.0, 180.0) 0.299 120.0 (60.0, 180.0) 120.0 (60.0, 240.0) 0.907
Missing 1 1 0 1 0
Time spent outdoors (weekends) (min) 180.0 (120.0, 270.0) 240.0 (90.0, 300.0) 180.0 (120.0, 240.0) 0.274 180.0 (120.0, 270.0) 180.0 (90.0, 240.0) 0.319
Missing 1 1 0 1 0
Sedentary time (min) 489.8 (62.0) 493.8 (59.0) 486.2 (64.9) 0.436 482.0 (56.1) 498.0 (67.5) 0.284
Missing 15 3 12 7 8
Sitting time (min) 90.0 (60.0, 120.0) 60.0 (60.0, 120.0) 120.0 (60.0, 120.0) 0.250 120.0 (60.0, 180.0) 60.0 (40.0, 120.0) 0.003
Missing 1 1 0 1 0
Time spent sitting in a vehicle (weekdays) (min) 30.0 (20.0, 60.0) 30.0 (30.0, 60.0) 30.0 (20.0, 60.0) 0.136 30.0 (20.0, 60.0) 30.0 (15.0, 60.0) 0.692
Missing 1 1 0 1 0
Time spent sitting in a vehicle (weekends) (min) 60.0 (30.0, 120.0) 60.0 (30.0, 120.0) 60.0 (30.0, 90.0) 0.598 60.0 (30.0, 120.0) 60.0 (30.0, 60.0) 0.693
Missing 1 1 0 1 0
Total sleep time (min) c 706.8 (89.2) 683.7 (73.3) 726.6 (97.4) 0.010 708.0 (84.0) 705.5 (95.5) 0.612
Missing 15 3 12 7 8
Total sleep time (min) d 660.0 (600.0, 690.0) 660.0 (610.0, 690.0) 660.0 (600.0, 710.0) 0.591 660.0 (600.0, 675.0) 660.0 (600.0, 705.0) 0.518
Missing 1 1 0 1 0
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a

Mean (standard deviation) or median (first quartile, third quartile).

b

p values for continuous variables were obtained using the Wilcoxon rank sum test (for nonnormally distributed variables) or the Student's t‐test (for normally distributed variables: moderate, vigorous, and moderate‐to‐vigorous physical activity time [accelerometer], sedentary time [accelerometer] and total sleep time [accelerometer]).

c

Measured with an accelerometer.

d

Measured with a parent questionnaire.

Abbreviations: LPA, light physical activity; MPA, moderate physical activity; MVPA, moderate‐to‐vigorous physical activity; TPA, total physical activity; VPA, vigorous physical activity.

Table 3 presents the proportion of children meeting the 24‐hour movement guidelines and component‐level criteria. Overall, 68.8% met the MVPA guideline, 50.5% met the TPA guideline, 47.7% met the screen time guideline, 59.8% met the restrained sitting guideline, and 64.5% met the sleep guideline based on accelerometer data. Boys were significantly more likely than girls to meet the MVPA (p = 0.004) and TPA (p = 0.028) guidelines. A higher proportion of meeting with the screen time guideline was identified among rural children compared to urban children (p = 0.026). When considering compliance with all five component‐level criteria (accelerometer‐based sleep), only 11.8% of children met all criteria. Boys were significantly more likely than girls to meet a greater number of guidelines (p = 0.043). Using parent‐reported sleep data, 11.8% of children also met all five component‐level criteria, with similar patterns by sex (p = 0.035) and no differences by geographic location.

TABLE 3.

Number and proportion of children meeting each of the 24‐hour movement component‐level criteria in the overall sample and stratified by sex and area of residence.

Variable Total sample Sex Geographic location
N = 108 a Male n = 46 a Female n = 62 a p b Urban n = 55 a Rural n = 53 a p b
MVPA guideline 0.004 0.378
No 29 (31.2%) 7 (16.3%) 22 (44.0%) 13 (27.1%) 16 (35.6%)
Yes 64 (68.8%) 36 (83.7%) 28 (56.0%) 35 (72.9%) 29 (64.4%)
Missing 15 3 12 7 8
TPA guideline 0.028 0.602
No 46 (49.5%) 16 (37.2%) 30 (60.0%) 25 (52.1%) 21 (46.7%)
Yes 47 (50.5%) 27 (62.8%) 20 (40.0%) 23 (47.9%) 24 (53.3%)
Missing 15 3 12 7 8
ST guideline 0.164 0.026
No 56 (52.3%) 20 (44.4%) 36 (58.1%) 34 (63.0%) 22 (41.5%)
Yes 51 (47.7%) 25 (55.6%) 26 (41.9%) 20 (37.0%) 31 (58.5%)
Missing 1 1 0 1 0
Restrained sitting guideline 0.244 0.608
No 43 (40.2%) 21 (46.7%) 22 (35.5%) 23 (42.6%) 20 (37.7%)
Yes 64 (59.8%) 24 (53.3%) 40 (64.5%) 31 (57.4%) 33 (62.3%)
Missing 1 1 0 1 0
Sleep guideline c 0.064 0.989
No 33 (35.5%) 11 (25.6%) 22 (44.0%) 17 (35.4%) 16 (35.6%)
Yes 60 (64.5%) 32 (74.4%) 28 (56.0%) 31 (64.6%) 29 (64.4%)
Missing 15 3 12 7 8
Sleep guideline d 0.460 0.176
No 15 (14.0%) 5 (11.1%) 10 (16.1%) 10 (18.5%) 5 (9.4%)
Yes 92 (86.0%) 40 (88.9%) 52 (83.9%) 44 (81.5%) 48 (90.6%)
Missing 1 1 0 1 0
All 24‐h component‐level criteria e 0.043 0.837
None 2 (2.2%) 0 (0.0%) 2 (4.0%) 1 (2.1%) 1 (2.2%)
One 14 (15.1%) 2 (4.7%) 12 (24.0%) 8 (16.7%) 6 (13.3%)
Two 19 (20.4%) 10 (23.3%) 9 (18.0%) 10 (20.8%) 9 (20.0%)
Three 26 (28.0%) 13 (30.2%) 13 (26.0%) 15 (31.3%) 11 (24.4%)
Four 21 (22.6%) 10 (23.3%) 11 (22.0%) 8 (16.7%) 13 (28.9%)
Five 11 (11.8%) 8 (18.6%) 3 (6.0%) 6 (12.5%) 5 (11.1%)
Missing 15 3 12 7 8
All 24‐h component‐level criteria f 0.035 0.583
None 2 (2.2%) 1 (2.3%) 1 (2.0%) 1 (2.1%) 1 (2.2%)
One 8 (8.6%) 0 (0.0%) 8 (16.0%) 4 (8.3%) 4 (8.9%)
Two 17 (18.3%) 7 (16.3%) 10 (20.0%) 10 (20.8%) 7 (15.6%)
Three 29 (31.2%) 15 (34.9%) 14 (28.0%) 18 (37.5%) 11 (24.4%)
Four 26 (28.0%) 12 (27.9%) 14 (28.0%) 10 (20.8%) 16 (35.6%)
Five 11 (11.8%) 8 (18.6%) 3 (6.0%) 5 (10.4%) 6 (13.3%)
Missing 15 3 12 7 8
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a

Data expressed as number (percentages).

b

p values obtained using Pearson's chi‐squared (χ2) test (or Fisher's exact test when expected cell counts were < 5).

c

Measured with an accelerometer.

d

Measured with a parent questionnaire.

e

Moderate‐to‐vigorous physical activity, total physical activity and sleep guidelines measured with an accelerometer; screen time and restrained sitting guidelines measured with a parent questionnaire.

f

Moderate‐to‐vigorous physical activity and total physical activity guidelines measured with an accelerometer; screen time, restrained sitting and sleep guidelines measured with a parent questionnaire.

Abbreviations: MVPA, moderate‐to‐vigorous physical activity; ST, screen time; TPA, total physical activity.

Figures 1 and 2 show the proportion of children meeting all or none of the 24‐hour movement guidelines in the overall sample and stratified by sex and geographic location. In the total sample, 11.8% of children met all three guidelines. Compliance with all recommendations was higher among boys (18.6%) compared to girls (6.0%), and slightly higher in urban (12.5%) than rural children (11.1%). In contrast, 16.1% of the total sample did not meet any guideline, with a higher proportion among girls (26.0.6%) and rural children (15.6%) compared to boys (4.7%) and urban children (16.7%).

FIGURE 1.

FIGURE 1

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Compliance with physical activity, sleep and screen time guidelines in the total sample of Ecuadorian children aged 3–4 years.

FIGURE 2.

FIGURE 2

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Compliance with physical activity, sleep and screen time guidelines according to sex and geographic location in Ecuadorian children aged 3–4 years.

Table 4 summarizes motor skills and executive function performance. Boys achieved significantly longer distances in the standing long jump (p = 0.021) and slower times in the left‐hand nine‐hole pegboard test (p = 0.027) compared to girls. Girls, in turn, performed higher in inhibitory control tasks (p = 0.019). No significant differences by sex were observed for balance, handgrip strength, supine‐timed up and go or working memory. Regarding geographic location, rural children performed higher in the right‐hand nine‐hole pegboard test (p = 0.047), while no significant differences were found for other motor or cognitive outcomes.

TABLE 4.

Motor skills and executive functions in the overall sample and stratified by sex and area of residence.

Variable Total sample Sex Geographic location
N = 108 a Male n = 46 a Female n = 62 a p b Urban n = 55 a Rural n = 53 a p b
Left leg standing balance test (s) 2.9 (1.9, 3.9) 2.7 (1.9, 4.0) 3.1 (2.0, 3.8) 0.462 3.0 (2.1, 3.7) 2.9 (1.8, 4.4) 0.975
Right leg standing balance test (s) 2.6 (1.7, 4.1) 2.3 (1.7, 3.7) 2.7 (1.9, 4.5) 0.267 2.8 (1.6, 4.3) 2.3 (1.8, 3.7) 0.733
Standing long jump (cm) 53.3 (19.6) 58.6 (21.5) 49.3 (17.2) 0.021 51.5 (20.3) 55.1 (18.9) 0.313
Supine‐timed up and go (s) 6.0 (5.1, 6.9) 5.9 (4.9, 7.4) 6.1 (5.4, 6.9) 0.677 6.0 (5.1, 7.2) 6.0 (5.4, 6.6) 0.946
Force right hand (kg) 4.5 (3.0, 6.0) 4.9 (3.0, 7.0) 4.5 (3.0, 5.5) 0.266 4.5 (3.5, 6.0) 4.5 (3.0, 6.0) 0.990
Force left hand (kg) 4.5 (3.0, 5.5) 4.5 (3.0, 6.0) 4.3 (3.0, 5.3) 0.361 4.5 (3.0, 5.5) 4.5 (3.0, 5.5) 0.600
Left hand 9‐hole peg‐board test (s) 41.7 (35.9, 48.8) 44.1 (37.3, 53.4) 39.6 (33.8, 43.6) 0.027 42.9 (38.0, 48.5) 38.8 (33.5, 49.2) 0.083
Right hand 9‐hole peg‐board test (s) 37.6 (32.5, 45.7) 39.6 (34.9, 46.0) 35.7 (31.4, 43.8) 0.066 42.0 (33.5, 46.7) 35.0 (32.2, 41.0) 0.047
Inhibitory (total score) 0.5 (0.4, 0.7) 0.4 (0.3, 0.7) 0.6 (0.4, 0.7) 0.019 0.6 (0.3, 0.7) 0.5 (0.4, 0.7) 0.606
Working memory (total score) 2.0 (1.0, 2.3) 2.0 (1.0, 2.0) 2.0 (1.3, 2.3) 0.365 2.0 (1.0, 2.0) 2.0 (1.3, 2.3) 0.103
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a

Mean (standard deviation) or median (first quartile, third quartile), and number (percentages).

b

p values for continuous variables were obtained using the Wilcoxon rank sum test (for nonnormally distributed variables) or the Student's t‐test (for normally distributed variables: standing long jump).

Regarding feasibility, compliance with accelerometer wear time criteria was achieved by 93 out of the 108 participating children (86.1%), who provided at least one valid day of data (defined as at least 6 hour of valid wear time during the waking period). Among these, 82 participants (75.9%) accumulated three or more valid days. Regarding executive function assessments, 100% of children completed the working memory task and the inhibitory control task. For physical fitness assessments, 100% completed the standing long jump test and the handgrip strength tests for both hands. In motor skill tests, 100% of participants completed the balance and supine‐timed up and go assessments. These results support the feasibility of implementing the SUNRISE study protocol in Ecuadorian preschool children.

In relation to acceptability, thematic analysis revealed common patterns across the 11 centres. Regarding the caregiver questionnaire, participants in four out of 11 centres noted repetitive questions (especially in the sleep module), three centres considered it lengthy and three described it as clear and understandable. Concerning the accelerometer, parents in six out of 11 centres reported discomfort during sleep, four highlighted children's acceptance and three expressed concerns about water exposure. Additionally, two accelerometers were lost during the study period. Staff from five out of 11 centres recommended reducing wear time, four observed good device acceptance and three valued the accelerometer as an observation tool. Staff in six out of 11 centres described the presence of the data collection team as positive and enriching, and four centres emphasized good interactions with the children. In five centres, children were reported to enjoy the motor and iPad‐based tasks, although in two centres, staff had limited opportunity to observe activities. Regarding children's overall engagement, both parents and staff described children as motivated and enthusiastic in six out of 11 centres, willing to participate again in four and verbally expressing positive comments in three. In five centres, parents confirmed that children perceived the experience as playful and enjoyable. Parents in four out of 11 centres expressed interest in receiving individual feedback, while staff in five centres offered commendations and showed interest in participating in future research. Minor logistical suggestions to improve coordination and reduce waiting times were also noted by both groups.

4. Discussion

4.1. Main Findings

This study provides a comprehensive overview of 24‐hour movement behaviours, body composition, motor skills and executive functions among Ecuadorian preschool children. We found that a small proportion of children met all movement behaviour guidelines, with boys and urban children showing slightly higher adherence than girls and rural children. Physical activity levels were generally higher among boys, while sedentary time and sleep duration did not differ significantly by sex or area. In terms of body composition, boys had higher fat‐free mass and lower body fat percentage than girls. Regarding motor skills, boys demonstrated higher performance in physical strength and gross motor tasks, whereas girls performed better in inhibitory control. These findings highlight notable sex‐ and area‐based disparities across movement behaviours, physical fitness and cognitive outcomes in early childhood.

4.2. Twenty‐Four‐Hour Movement Guidelines

Overall adherence to the WHO 24‐hour movement guidelines was low in this population, with only a small proportion of children meeting all three recommendations. Consistent with previous research (Chong et al. 2024; Tapia‐Serrano et al. 2022), physical activity was the guideline most frequently achieved, whereas screen time showed the lowest compliance. Sex and place‐of‐residence differences were also evident, with boys more likely to meet physical activity recommendations and urban children more likely to comply with screen time limits. Importantly, a notable subgroup of children did not meet any of the guidelines. The proportion of preschool children in our study meeting all three WHO 24‐hour movement guidelines aligns with international patterns (Chong et al. 2024; Tapia‐Serrano et al. 2022), but provides the first available data for Ecuador. Although individual compliance with some individual guidelines (i.e., PA and sleep time) recommendations was relatively high, screen time guideline and integrated adherence remained low. Particularly concerning is that approximately one in five girls failed to meet any of the guidelines, signaling a critical gender disparity that emerges early in life (Chong et al. 2024; Tapia‐Serrano et al. 2022).

4.3. Anthropometric

Most Ecuadorian preschool children had a BMI‐for‐age within the normal range, with 31.5% having overweight and 7.4% obesity. These figures are comparable to previous national estimates (Hajri et al. 2021; López‐Gil, Chen, et al. 2025). More specifically, these findings are in line with those reported by Hajri et al. (2021), who found an obesity prevalence of 8.1% among children under five in Ecuador. Collectively, these findings reinforce concerns about the growing burden of overweight and obesity from early childhood in the country (Kerr et al. 2025). No significant differences in BMI status were observed by sex or area of residence. Boys had significantly higher fat‐free mass and lower body fat percentage compared to girls, reflecting early sex differences in body composition. These findings are consistent with previous research showing that sex differences in body composition, characterized by higher fat‐free mass and lower body fat percentage in boys compared to girls, are evident from early childhood (Taylor et al. 1997). No differences were observed between urban and rural children in body composition indicators.

4.4. Gross and Fine Motor Skills and Executive Functions

Concerning gross motor skills, boys performed better than girls in the standing long jump test, indicating superior gross motor strength. Research focusing on the standing long jump test revealed that boys aged 3–5 years outperformed girls, indicating superior lower‐body muscular strength during these early developmental stages (Cadenas‐Sanchez et al. 2019). Concerning fine motor skills, boys showed higher performance in the pegboard test than girls, which is in line with the literature (Veldman et al. 2018). These differences are likely attributable to early developmental and social and environmental factors, including influences from family, peers, teachers and cultural context, rather than inherent biological or physiological causes or hormonal differences (Thomas and French 1985). In many Latin American contexts, including Ecuador, gendered play patterns may already emerge during the preschool years, where boys are often encouraged towards more vigorous outdoor play while girls may be directed towards quieter or sedentary activities (Barnett et al. 2016). Such differences in daily movement opportunities could contribute to early disparities in motor skill development (Hinkley et al. 2008). Despite this fact, no significant sex differences were observed in other motor skills. However, these findings should be interpreted with caution given the study's limitations, including the small sample size and the lack of sample representativeness. Future research with larger samples is warranted to clarify these associations.

In relation to executive functions, girls demonstrated higher inhibitory control, suggesting early cognitive advantages in executive functioning. This is in line with the literature that has consistently shown that girls tend to outperform boys on tasks measuring inhibitory control (Silverman 2021), a key executive function during the preschool years. For instance, a meta‐analysis covering 102 studies with more than 21 000 children aged 1–9 years found that girls demonstrated a significant advantage in delay‐of‐gratification tasks, with a small but consistent effect size (Hedges' g = 0.25–0.26) (Silverman 2021). In Latin American contexts, a study conducted in Ecuador with a representative sample of preschoolers from nine cities reported that girls achieved significantly higher scores in inhibitory control assessments even at the youngest evaluated age groups (López‐Vallejo et al. 2024). Conversely, no significant differences by sex were observed in working memory, which aligns with the findings by López‐Vallejo et al. (2024) in Ecuador suggesting that working memory follows a relatively stable developmental trajectory in early childhood and is less susceptible to sex‐related or environmental variations.

On the other hand, no significant geographic differences were generally observed in gross motor skills or executive functions, including balance, handgrip strength, inhibitory control and working memory. However, these findings should be interpreted with caution due to certain limitations of the study. The relatively small and nonrepresentative sample size, along with the assessment of participants from a single city, may limit the generalizability of the results. In this context, the proximity between urban and rural areas within the city might have attenuated potential geographic disparities. Contrary to our results, one study conducted in Nigeria pointed out that rural preschool children had higher physical activity levels and better gross motor skills compared to urban children (Oginni et al. 2025). Supporting this notion, a study conducted in Brazil found that rural preschoolers outperformed their urban counterparts in executive function tasks (Freitas et al. 2022). Possible reasons for these discrepancies could be related to greater access to open spaces and opportunities for unstructured play (Freitas et al. 2022; Oginni et al. 2025). Therefore, future research with larger and more geographically diverse samples is warranted to clarify these associations.

4.5. Feasibility and Acceptability of the Study

The feasibility and acceptability of the SUNRISE study protocol among Ecuadorian preschool children were supported by the high completion rates across assessments. Nearly all participants completed the anthropometric measurements, motor skill tests and executive function tasks. Additionally, most children provided three or more days of valid accelerometer data, fulfilling the minimum requirements for physical activity, sedentary behaviour and sleep assessments. These results indicate that the SUNRISE study procedures are feasible and well accepted within the Ecuadorian context, encompassing both urban and rural settings. Nevertheless, strategies to further enhance compliance with accelerometer wear time, such as improved parent engagement, clearer instructions and child‐friendly communication materials, should be considered in future larger‐scale studies.

4.6. Strengths and Limitations

Strengths of this study include the use of objective methods to assess movement behaviours through accelerometry, and the application of standardized and validated protocols for the evaluation of motor skills and executive functions. Additionally, the sample comprised both urban and rural children, allowing for the exploration of geographical differences. Moreover, to our knowledge, this is the first study conducted in Ecuador to provide data on compliance with the WHO 24‐hour movement behaviour guidelines among children under the age of five. However, several limitations should be acknowledged. The cross‐sectional design limits the ability to infer causality between movement behaviours and developmental outcomes. Although the sample size was appropriate for assessing feasibility and providing descriptive insights, larger and more representative samples will be necessary to generalize the findings to the broader Ecuadorian preschool population. Missing data, particularly in accelerometry and questionnaires, may have introduced bias. Furthermore, parent‐reported measures, such as sleep and screen time, are subject to social desirability bias and recall bias, which may result in inaccurate estimates of these behaviours. Finally, although the sample included children from both urban and rural settings based on national criteria, all participants were recruited within the province of Pichincha (Quito). Thus, the geographical differences observed may not fully capture the broader urban–rural disparities present across the country, given the relative proximity between the participating kindergartens.

5. Conclusions

This pilot study provides novel insights into 24‐hour movement behaviours, body composition, motor skills and executive functions among Ecuadorian preschool children. Only a small proportion of children met all WHO movement behaviour guidelines, with notable disparities by sex. These findings underscore the urgent need for early interventions promoting healthy movement behaviours among preschoolers, with special attention to girls. Future research using larger, nationally representative samples is needed to confirm these results and to better inform targeted public health strategies in Ecuador.

Author Contributions

Josefa María Panisello Royo: supervision, visualization, resources, writing – review and editing. José Adrián Montenegro‐Espinosa: investigation, writing – review and editing. Aida Lorena Soria‐Vizcaino: writing – review and editing. Camila Miño: investigation, writing – review and editing. Fiorella Quiroz‐Cárdenas: investigation, writing – review and editing. José Francisco López‐Gil: conceptualization, formal analysis, investigation, data curation, methodology, validation, supervision, funding acquisition, visualization, project administration, writing – original draft, resources, software. Emily Cisneros‐Vásquez: investigation, writing – review and editing, project administration. Daniela Celi‐Lalama: writing – review and editing. Jorge Olivares‐Arancibia: writing – review and editing. Anthony D. Okely: conceptualization, methodology, software, validation, supervision, visualization, project administration, resources, writing – review and editing. Héctor Gutiérrez‐Espinoza: project administration, writing – review and editing. Rodrigo Yáñez‐Sepúlveda: writing – review and editing.

Funding

This work was supported by the Universidad de Especialidades Espíritu Santo (UEES) (2025‐MED‐009).

Ethics Statement

The general study protocol and the main study received ethical approval from the Human Research Ethics Committee (HREC) of the University of Wollongong (UOW), Australia (ID 2018/044; ID 2019/378). Additional ethical clearance was granted by the Comité de Ética de Investigación en Seres Humanos of Universidad Espíritu Santo (CEISH‐UEES), Ecuador (ID C‐UEES‐25‐13).

Consent

Consent was primarily obtained through signed paper forms from parents/caregivers.

Acknowledgements

We sincerely thank the parents, caregivers, teachers and directors of the early childhood education centres who participated in this study for their valuable time and contribution of essential information. We also wish to acknowledge Lina América Sánchez Charcopa, María Paula Zalamea Delgado, Martina Jared Masache Cruz, Evelin Nataly Estrella Flores, Monica Elizabeth Castillo Miñaca and Juan Carlos Palacios Mora for their support during the data collection process in the pilot phase of the study. We acknowledge the SUNRISE Coordinating Centre at the University of Wollongong, Australia, for their technical support in adapting the protocol to the Ecuadorian context.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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