An Intervention to Increase Outdoor Play in Early Childhood Education Centers (PROmoting Early Childhood Outside): Protocol for a Pilot Wait-list Control Cluster Randomized Trial

Rachel Ramsden, Christina S Han, Dawn Mount, Janet Loebach, Adina Cox, Susan Herrington, Anita Bundy, Amber Fyfe-Johnson, Ellen Beate Hansen Sandseter, Michelle Stone, Mark S Tremblay, Mariana Brussoni, Rachel Ramsden, Christina S Han, Dawn Mount, Janet Loebach, Adina Cox, Susan Herrington, Anita Bundy, Amber Fyfe-Johnson, Ellen Beate Hansen Sandseter, Michelle Stone, Mark S Tremblay, Mariana Brussoni

Abstract

Background: Participation in outdoor play has been extensively documented as beneficial for the health, well-being, and development of children. Canadian early childhood education centers (ECECs) are important settings in young children's lives and provide opportunities to participate in outdoor play. However, there are barriers to the provision of outdoor play opportunities at ECECs, such as adverse weather conditions, poorly designed outdoor spaces, outdoor time policies, and early childhood educator comfort levels.

Objective: The PROmoting Early Childhood Outside (PRO-ECO) study is a wait-list control cluster randomized trial that evaluates the impact of the PRO-ECO intervention, an innovative outdoor play intervention, on children's outdoor play behavior. The purpose of this paper was to provide a detailed overview of the pilot study protocol and the methods that will be used to develop, implement, and evaluate the PRO-ECO intervention.

Methods: A total of 8 ECECs delivering licensed care to children aged 2.5 to 6 years in the Greater Vancouver region of British Columbia, Canada, and operated by the YMCA of Greater Vancouver (YMCA GV) are included in this study. Using a wait-list control cluster randomized trial design, we randomly allocated ECECs to either the PRO-ECO intervention arm (n=4) or the wait-list control arm (n=4). The primary outcome measures include changes in the proportion and diversity of observed outdoor play behavior during dedicated outdoor times at the ECECs as measured through observational behavior mapping. Secondary outcome measures include changes in educator attitudes; quality of ECECs' outdoor play space; and children's psychosocial strengths, physical activity levels, and social behaviors. A process evaluation of the acceptability of the PRO-ECO intervention in the 8 YMCA GV ECECs will also be assessed. Outcome data will be collected at baseline, 6-month follow-up, and 12-month follow-up. Mixed effect models will test the effect of the PRO-ECO intervention on quantitative outcomes. Baseline and postintervention data will be included in the analysis, controlling for the cluster design. Qualitative data will support quantitative findings and provide evidence for the acceptability of implementation.

Results: Participant recruitment for this study began in August 2021, and baseline data collection was completed at all 8 ECECs in November 2021. As of April 2022, a total of 130 children have been recruited to participate in this study.

Conclusions: The PRO-ECO pilot study will develop, implement, and evaluate the PRO-ECO intervention within 8 YMCA GV ECECs in the Vancouver region of British Columbia, Canada. The findings of this study will be useful for early childhood educators, ECEC providers, and policy makers to consider means for enhancing outdoor play provision and assessing the sustainability of the intervention in ECEC settings.

Trial registration: ClinicalTrials.gov NCT05075580; https://ichgcp.net/clinical-trials-registry/NCT05073380.

International registered report identifier (irrid): DERR1-10.2196/38365.

Keywords: RCT; behavior mapping; built environment; early childhood education and care; intervention studies; outdoor play; pedagogy; preschool; randomized controlled trial.

Conflict of interest statement

Conflicts of Interest: None declared.

©Rachel Ramsden, Christina S Han, Dawn Mount, Janet Loebach, Adina Cox, Susan Herrington, Anita Bundy, Amber Fyfe-Johnson, Ellen Beate Hansen Sandseter, Michelle Stone, Mark S Tremblay, Mariana Brussoni. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 12.07.2022.

Figures

Figure 1
Figure 1
Wait-list control cluster randomized trial flow diagram: PROmoting Early Childhood Outside (PRO-ECO) pilot study. ECEC: early childhood education center.

References

    1. Outdoor play glossary of terms. Outdoor Play Canada. 2022. [2022-03-20].
    1. Pellegrini AD, Dupuis D, Smith PK. Play in evolution and development. Develop Rev. 2007 Jun;27(2):261–76. doi: 10.1016/j.dr.2006.09.001.
    1. Pellegrini AD, Smith PK. The development of play during childhood: forms and possible functions. Child Psychol Psychiatr Rev. 1998 May 01;3(2):51–7. doi: 10.1017/s1360641798001476.
    1. Ginsburg K, American Academy of Pediatrics Committee on Communications. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics. 2007 Jan;119(1):182–91. doi: 10.1542/peds.2006-2697.119/1/182
    1. Bento G, Dias G. The importance of outdoor play for young children's healthy development. Porto Biomed J. 2017;2(5):157–60. doi: 10.1016/j.pbj.2017.03.003.
    1. Tremblay M, Gray C, Babcock S, Barnes J, Bradstreet C, Carr D, Chabot G, Choquette L, Chorney D, Collyer C, Herrington S, Janson K, Janssen I, Larouche R, Pickett W, Power M, Sandseter E, Simon B, Brussoni M. Position statement on active outdoor play. Int J Environ Res Public Health. 2015 Jun 08;12(6):6475–505. doi: 10.3390/ijerph120606475. ijerph120606475
    1. Brussoni M, Gibbons R, Gray C, Ishikawa T, Sandseter E, Bienenstock A, Chabot G, Fuselli P, Herrington S, Janssen I, Pickett W, Power M, Stanger N, Sampson M, Tremblay M. What is the relationship between risky outdoor play and health in children? A systematic review. Int J Environ Res Public Health. 2015 Jun 08;12(6):6423–54. doi: 10.3390/ijerph120606423. ijerph120606423
    1. Kemple KM, Oh J, Kenney E, Smith-Bonahue T. The power of outdoor play and play in natural environments. Childhood Educ. 2016 Oct 27;92(6):446–54. doi: 10.1080/00094056.2016.1251793.
    1. Thomas F, Harding S. Outdoor Provision in the Early Years. Thousand Oaks, California: SAGE Publications; 2011. The role of play: play outdoors as the medium and mechanism for well-being, learning and development.
    1. Kellert S. Children and Nature: Psychological, Sociocultural, and Evolutionary Investigations. Cambridge, Massachusetts: The MIT Press; 2002. Experiencing nature: affective, cognitive, and evaluative development in children.
    1. Little H, Wyver S. Outdoor play: does avoiding the risks reduce the benefits? Australasian J Early Childhood. 2008 Jun 01;33(2):33–40. doi: 10.1177/183693910803300206.
    1. Wells NM, Evans GW. Nearby nature: a buffer of life stress among rural children. Environ Behav. 2016 Jul 26;35(3):311–30. doi: 10.1177/0013916503035003001.
    1. Baldwin D, Rudge S. The role of serotonin in depression and anxiety. Int Clin Psychopharmacol. 1995 Jan;9 Suppl 4:41–5. doi: 10.1097/00004850-199501004-00006.
    1. Levandovski R, Pfaffenseller B, Carissimi A, Gama CS, Hidalgo MP. The effect of sunlight exposure on interleukin-6 levels in depressive and non-depressive subjects. BMC Psychiatry. 2013 Mar 05;13(1):75. doi: 10.1186/1471-244x-13-75.
    1. Santer J, Griffiths C, Goodall D. Free Play in Early Childhood A Literature Review. London: National Children's Bureau; 2007.
    1. Fyfe-Johnson A, Hazlehurst M, Perrins S, Bratman G, Thomas R, Garrett K, Hafferty KR, Cullaz TM, Marcuse EK, Tandon PS. Nature and children's health: a systematic review. Pediatrics. 2021 Oct;148(4):e2020049155. doi: 10.1542/peds.2020-049155.peds.2020-049155
    1. Absoud M, Cummins C, Lim MJ, Wassmer E, Shaw N. Prevalence and predictors of vitamin D insufficiency in children: a Great Britain population based study. PLoS One. 2011 Jul 22;6(7):e22179. doi: 10.1371/journal.pone.0022179. PONE-D-11-07891
    1. Lester S, Russell W. The SAGE Handbook of Play and Learning in Early Childhood. London: SAGE Publications; 2014. Children's right to play.
    1. Clements R. An investigation of the status of outdoor play. Contemporary Issues Early Childhood. 2016 Jul 20;5(1):68–80. doi: 10.2304/ciec.2004.5.1.10.
    1. Charles C, Louv R, Bodner L, Guns B. Children and Nature 2008: a Report on the Movement to Reconnect. Children & Nature Network. 2008. Jan, [2022-06-22]. .
    1. Rivkin M. “Happy Play in Grassy Places”: the importance of the outdoor environment in Dewey's educational ideal. Early Child Educ J. 1998;25:199–202. doi: 10.1023/A:1025613413109.
    1. Ulset V, Vitaro F, Brendgen M, Bekkhus M, Borge AI. Time spent outdoors during preschool: links with children's cognitive and behavioral development. J Environ Psychol. 2017 Oct;52:69–80. doi: 10.1016/j.jenvp.2017.05.007.
    1. Zhang S, Garner R, Heidinger L, Findlay L. Parents’ use of child care services and differences in use by mothers’ employment status. Statistics Canada. [2021-11-28]. .
    1. Copeland KA, Khoury JC, Kalkwarf HJ. Child care center characteristics associated with preschoolers' physical activity. Am J Prev Med. 2016 Apr;50(4):470–9. doi: 10.1016/j.amepre.2015.08.028. S0749-3797(15)00518-8
    1. Dietze B, Kashin D. Perceptions that early learning teachers have about outdoor play and nature. Learn Landscape. 2019 May 31;12(1):91–105. doi: 10.36510/learnland.v12i1.981.
    1. Wagner SL, Forer B, Cepeda IL, Goelman H, Maggi S, D’Angiulli A, Wessel J, Hertzman C, Grunau RE. Perceived stress and Canadian early childcare educators. Child Youth Care Forum. 2012 Sep 25;42(1):53–70. doi: 10.1007/s10566-012-9187-5.
    1. Sandseter EB, Cordovil R, Hagen TL, Lopes F. Barriers for outdoor play in early childhood education and care (ECEC) institutions: perception of risk in children’s play among European parents and ECEC practitioners. Child Care Pract. 2019 Nov 22;26(2):111–29. doi: 10.1080/13575279.2019.1685461.
    1. Community care and assisted living act CHILD CARE LICENSING REGULATION. Government of British Columbia. [2022-03-20]. .
    1. Director of licensing standards of practice safe play space. Government of British Columbia. 2007. [2022-03-20]. .
    1. Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to creating active living communities. Annu Rev Public Health. 2006 Apr 01;27(1):297–322. doi: 10.1146/annurev.publhealth.27.021405.102100.
    1. Sugiyama T, Okely AD, Masters JM, Moore GT. Attributes of child care centers and outdoor play areas associated with preschoolers’ physical activity and sedentary behavior. Environ Behav. 2010 Dec 17;44(3):334–49. doi: 10.1177/0013916510393276.
    1. Cheng T, Brussoni M, Han C, Munday F, Zeni M. Perceived challenges of early childhood educators in promoting unstructured outdoor play: an ecological systems perspective. Early Years. 2022 Feb 26;:1–17. doi: 10.1080/09575146.2022.2034140.
    1. Messing S, Rütten A, Abu-Omar K, Ungerer-Röhrich U, Goodwin L, Burlacu I, Gediga G. How can physical activity be promoted among children and adolescents? A systematic review of reviews across settings. Front Public Health. 2019 Mar 19;7:55. doi: 10.3389/fpubh.2019.00055. doi: 10.3389/fpubh.2019.00055.
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013 May;50(5):587–92. doi: 10.1016/j.ijnurstu.2012.09.010.S0020-7489(12)00306-9
    1. Stone MR, Houser NE, Cawley J, Kolen AM, Rainham D, Rehman L, Turner J, Kirk SF. Accelerometry-measured physical activity and sedentary behaviour of preschoolers in Nova Scotia, Canada. Appl Physiol Nutr Metab. 2019 Sep;44(9):1005–11. doi: 10.1139/apnm-2018-0683.
    1. Tucker P, Vanderloo LM, Johnson AM, Burke SM, Irwin JD, Gaston A, Driediger M, Timmons BW. Impact of the Supporting Physical Activity in the Childcare Environment (SPACE) intervention on preschoolers' physical activity levels and sedentary time: a single-blind cluster randomized controlled trial. Int J Behav Nutr Phys Act. 2017 Sep 07;14(1):120. doi: 10.1186/s12966-017-0579-7. 10.1186/s12966-017-0579-7
    1. Campbell MK, Piaggio G, Elbourne DR, Altman DG, CONSORT Group Consort 2010 statement: extension to cluster randomised trials. BMJ. 2012 Sep 04;345(1):e5661. doi: 10.1136/bmj.e5661.
    1. Chan A, Tetzlaff JM, Altman DG, Dickersin K, Moher D. SPIRIT 2013: new guidance for content of clinical trial protocols. Lancet. 2013 Jan 12;381(9861):91–2. doi: 10.1016/S0140-6736(12)62160-6.S0140-6736(12)62160-6
    1. YMCA Member Associations. YMCA Canada. 2021. [2021-05-05]. .
    1. In J. Introduction of a pilot study. Korean J Anesthesiol. 2017 Dec;70(6):601–5. doi: 10.4097/kjae.2017.70.6.601.
    1. Research Randomizer. Social Psychology Network; [2021-08-30].
    1. Bartholomew L, Markham C, Ruiter R, Fernandez M, Kok G, Parcel G. Planning Health Promotion Programs: An Intervention Mapping Approach, 4th Edition. Hoboken, New Jersey, United States: John Wiley & Sons; 2016.
    1. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1–26. doi: 10.1146/annurev.psych.52.1.1.52/1/1
    1. Brussoni M, Han CS, Jacob J, Munday F, Zeni M, Walters M, Cheng T, Schneeberg A, Fox E, Oberle E. A web-based risk-reframing intervention to influence early childhood educators' attitudes and supportive behaviors toward outdoor play: protocol for the OutsidePlay study randomized controlled trial. JMIR Res Protoc. 2021 Nov 18;10(11):e31041. doi: 10.2196/31041. v10i11e31041
    1. Brussoni M, Han C, Jacob J. OutsidePlay. What is outdoor play? [2021-11-18].
    1. Loebach J, Cox A. Tool for observing play outdoors (TOPO): a new typology for capturing children's play behaviors in outdoor environments. Int J Environ Res Public Health. 2020 Aug 04;17(15):5611. doi: 10.3390/ijerph17155611. ijerph17155611
    1. Innovative Approaches to Researching Landscape and Health. Milton Park, Abingdon-on-Thames, Oxfordshire, England, UK: Routledge; 2010. Using behaviour mapping to investigate healthy outdoor environments for children and families: conceptual framework, procedures and applications.
    1. Cox A, Loebach J, Little S. Understanding the nature play milieu: using behavior mapping to investigate children's activities in outdoor play spaces. Child Youth Environ. 2018;28(2):232. doi: 10.7721/chilyoutenvi.28.2.0232.
    1. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951 Sep;16(3):297–334. doi: 10.1007/BF02310555.
    1. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86(2):420–8. doi: 10.1037//0033-2909.86.2.420.
    1. Teacher tolerance of risk in play scale (T-TRiPS): evaluating the psychometric properties of a new measure. Colorado State University. 2021. [2021-11-29]. .
    1. Herrington S, Lesmeister C. The design of landscapes at child-care centres: seven Cs. Landscape Res. 2006 Jan;31(1):63–82. doi: 10.1080/01426390500448575.
    1. Brussoni M, Ishikawa T, Brunelle S, Herrington S. Landscapes for play: effects of an intervention to promote nature-based risky play in early childhood centres. J Environ Psychol. 2017 Dec;54:139–50. doi: 10.1016/j.jenvp.2017.11.001.
    1. Ayala G, Elder J. Qualitative methods to ensure acceptability of behavioral and social interventions to the target population. J Public Health Dent. 2011;71 Suppl 1:S69–79. doi: 10.1111/j.1752-7325.2011.00241.x.
    1. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017 Jan 26;17(1):88. doi: 10.1186/s12913-017-2031-8. 10.1186/s12913-017-2031-8
    1. Levin H, Schwartz H. What is the cost of a preschool program? University of Pennsylvania. 2007. Mar 23, [2022-03-20].
    1. Goodman R. Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatry. 2001 Nov;40(11):1337–45. doi: 10.1097/00004583-200111000-00015.S0890-8567(09)60543-8
    1. Stone LL, Otten R, Engels RC, Vermulst AA, Janssens JM. Psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire for 4- to 12-year-olds: a review. Clin Child Fam Psychol Rev. 2010 Sep;13(3):254–74. doi: 10.1007/s10567-010-0071-2.
    1. Puhl J, Greaves K, Hoyt M, Baranowski T. Children's Activity Rating Scale (CARS): description and calibration. Res Q Exerc Sport. 1990 Mar;61(1):26–36. doi: 10.1080/02701367.1990.10607475.
    1. Crick NR, Casas JF, Mosher M. Relational and overt aggression in preschool. Develop Psychol. 1997;33(4):579–88. doi: 10.1037/0012-1649.33.4.579.
    1. van Dijk-Wesselius JE, Maas J, van Vugt M, van den Berg AE. A comparison of children's play and non-play behavior before and after schoolyard greening monitored by video observations. J Environ Psychol. 2022 Apr;80:101760. doi: 10.1016/j.jenvp.2022.101760.
    1. Loebach J, Cox A, Little S. The Routledge Handbook of Designing Public Spaces for Young People. New York: Routledge; 2020. Behavior mapping to support the development of youth-friendly public outdoor spaces.
    1. Barnett W. The Perry Preschool Program and Its Long-Term Effects: A Benefit-Cost Analysis. High/Scope Early Childhood Policy Papers, No. 2. Ypsilanti: High/Scope Educational Research Foundation; 1985.
    1. Barnett S. Lives in the Balance: Age-27 Benefit-Cost Analysis of the High/Scope Perry Preschool Program. Monographs of the High/Scope Educational Research Foundation, Number Eleven. Ypsilanti: High/Scope Educational Research Foundation; 1996.
    1. Belfield C, Nores M, Barnett WS, Schweinhart L. The High/Scope Perry preschool program: cost-benefit analysis using data from the age-40 followup. J Human Resources. 2006;41(1):162–90. doi: 10.3368/jhr.xli.1.162.
    1. Muennig P, Schweinhart L, Montie J, Neidell M. Effects of a prekindergarten educational intervention on adult health: 37-year follow-up results of a randomized controlled trial. Am J Public Health. 2009 Aug;99(8):1431–7. doi: 10.2105/ajph.2008.148353.
    1. Schweinhart LJ. The value of high-quality full-day preschool. JAMA. 2014 Nov 26;312(20):2101–2. doi: 10.1001/jama.2014.15124.1938540
    1. Heckman JJ, Moon SH, Pinto R, Savelyev PA, Yavitz A. The rate of return to the high/scope perry preschool program. J Public Econ. 2010 Feb 01;94(1-2):114–28. doi: 10.1016/j.jpubeco.2009.11.001.
    1. Gortmaker SL, Long MW, Resch SC, Ward ZJ, Cradock AL, Barrett JL, Wright DR, Sonneville KR, Giles CM, Carter RC, Moodie ML, Sacks G, Swinburn BA, Hsiao A, Vine S, Barendregt J, Vos T, Wang YC. Cost effectiveness of childhood obesity interventions: evidence and methods for CHOICES. Am J Prev Med. 2015 Jul;49(1):102–11. doi: 10.1016/j.amepre.2015.03.032.S0749-3797(15)00154-3
    1. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008 Apr;62(1):107–15. doi: 10.1111/j.1365-2648.2007.04569.x.JAN4569
    1. Braun V, Clarke V, Hayfield N, Terry G. Handbook of Research Methods in Health Social Sciences. Singapore: Springer; 2019. Thematic analysis.
    1. Washington becomes first in the nation to license outdoor, nature-based child care. Washington State Department of Children Youth and Families. [2022-03-20]. .
    1. McKenzie T. Physical Activity Assessments for Health-related Research. Champaign, IL: Human Kinetics; 2002. Use of direct observation to assess physical activity.

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