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Many (56%) US children aged 3–5 years are in center-based childcare and are not obtaining recommended levels of physical activity. In order to determine what child-care teachers/providers perceived as benefits and barriers to children’s physical activity in child-care centers, we conducted nine focus groups and 13 one-on-one interviews with 49 child-care teachers/providers in Cincinnati, OH. Participants noted physical and socio-emotional benefits of physical activity particular to preschoolers (e.g. gross motor skill development, self-confidence after mastery of new skills and improved mood, attention and napping after exercise) but also noted several barriers including their own personal attitudes (e.g. low self-efficacy) and preferences to avoid the outdoors (e.g. don’t like hot/cold weather, getting dirty, chaos of playground). Because individual teachers determine daily schedules and ultimately make the decision whether to take the children outdoors, they serve as gatekeepers to the playground. Participants discussed a spectrum of roles on the playground, from facilitator to chaperone to physical activity inhibitor. These findings suggest that children could have very different gross motor experiences even within the same facility (with presumably the same environment and policies), based on the beliefs, creativity and level of engagement of their teacher.
The alarming rise of childhood obesity rates over the past three decades [1, 2] has prompted medical and public health professionals to call for increased prevention efforts, particularly among elementary and preschool-aged children, where such efforts may hold the most promise [3–8]. In the same time frame, the proportion of preschool-aged children being cared for outside of their home has escalated. Recent estimates are that 75% of US children aged 3–6 years are in some form of childcare and 56% of those children attend child-care centers .
Obesity is related to lower physical activity levels and greater sedentary behaviors [10–16]. Moreover, like the risk for obesity [17–19], physical activity habits are established early in life and track over time [20, 21]. Thus, it is imperative to promote physical activity among preschool-aged children, for both obesity prevention and for establishing lifetime healthy physical activity habits.
For preschool-aged children, physical activity also allows for the development of fundamental gross motor skills [22–24]. Children who develop motor skills earlier are more apt to be active, and thus, these behaviors are mutually reinforcing . Physical activity has also been associated with numerous other long-term health benefits, including improved blood pressure, blood cholesterol profiles and increased bone mineral density [26–31], as well as mood and cognitive benefits such as decreased anxiety, depression and aggression and improved attention [31–36], self-esteem, mood [26, 31, 37] and social interaction skills .
In spite of the importance of physical activity for preschoolers, many of these young children are not obtaining adequate levels of moderate and vigorous physical activity in child-care settings [6, 7, 39–42], perhaps contributing to the increasing rates of obesity among US children [3, 10, 43, 44]. In fact, recent studies have found that in child-care children are only vigorously active for 2–3% (12–46 min) of their 6 hours day excluding naps and meals and sedentary for most (70–83%) of their time [6, 7, 39]. We have reported that center schedules for outdoor gross-motor play vary widely (range 17.5–120 min), that this time can be substantially curtailed due to inclement weather and that individual teachers sometimes make decisions about what constitutes inclement weather . Others have reported that children in child-care centers obtain varying amounts of physical activity, and the amount is primarily dependent on the aspects of the individual center the child attends [7, 39, 46, 47]. The question of why activity levels vary so much across different child-care centers is currently an area of scientific inquiry. Recent studies have highlighted the importance of environmental factors at the child-care center, including time spent outdoors [46, 48, 49], the amounts and types of playground equipment [47, 49, 50], playground size and surfaces [47, 51], integration of shrubbery into the playground  and children dressed inappropriately for play . Several studies have illuminated the importance of teachers’ behaviors toward children’s physical activity on the playground, including positive or negative prompts and modeling [6, 54, 55] but these studies have not explored the teachers’ underlying attitudes about children’s physical activity or the playground. A better understanding of teachers’ underlying attitudes that contribute to their behavior around children’s physical activity, including perceptions of benefits and barriers to children’s physical activity, may provide insight about potential ways to increase children’s physical activity levels. This is particularly important if individual teachers make daily decisions about when and how long to use the playground.
The purpose of this qualitative study was to determine what child-care teachers/providers perceived as the primary benefits and barriers to children’s physical activity in child-care centers. We chose qualitative inquiry to allow us to uncover and describe the underlying practices and beliefs of current child-care staff. This formative research was undertaken in order to generate hypotheses that could be tested in a subsequent observational study about the primary environmental determinants of children’s physical activity in childcare.
We conducted nine focus groups with 49 child-care teachers/providers between August 2006 and June 2007, and 13 one-on-one interviews in the spring of 2008; nine interviews were member-checks with former focus group participants, four interviewees were new—they were recruited in the original sample for the focus groups but were unable to attend any of the sessions. We used maximum variation sampling [56, 57] and utilized the assistance of several community agencies in order to recruit a heterogeneous convenience sample of child-care teachers, thereby securing a small sample of great diversity. Specifically, we targeted recruitment of teachers from different ethnic backgrounds and with a range of years of experience. Moreover, we recruited those who worked in both suburban and urban centers, those which served both low-income and upper-income children and incorporated a range of philosophies and affiliations (e.g. Montessori, Head Start, church-affiliated, YMCA, worksite- or University-affiliated and corporate/for-profit centers). Child-care providers were eligible to participate if they currently worked or had worked in a full-day child-care center in Hamilton County (Cincinnati area), Ohio within the past 3 years. Furthermore, no more than one participant per child-care center was eligible to attend each focus group, so that minimized the chances that certain focus group members knew one another, which could make other focus group members feel uncomfortable and hamper the free-flow of ideas . Of the 49 focus group participants, 27 (55%) identified themselves as black/African American, 48 (98%) were female and 44 (90%) had at least some education beyond high school. Participants had worked in child-care settings an average of 13 ± 9 years (range <1 year to 37 years). Focus group participants came from 34 centers that were well distributed geographically throughout the county including 13 centers located in low-income US Census tracts (median income less than 50% of median income for the local metropolitan statistical area). The types of child-care centers were also diverse, including five Montessori, six Head Start, two church-affiliated, two YMCA, four worksite-affiliated and three corporate/for-profit centers. The four interview participants who had not been able to participate in the focus groups came from three additional centers.
All focus groups were led by a trained focus-group moderator (S.N.S.), attended by the lead investigator (K.A.C.) and were audio-recorded and transcribed verbatim. They lasted on average 1.5 hours. The focus group topic guide (Table I) used a balanced set of broad open-ended questions to probe participants’ perceptions of both the benefits and barriers to children’s physical activity in child-care centers. The focus group topic guide was modified slightly after each session, which allowed for exploration of new themes and clarification of items brought up in each previous group. A consensus was reached by two investigators (K.A.C. and S.N.S.) that thematic saturation had been reached by the end of the ninth group (no new themes or ideas were emerging from the sessions) [56, 58], thus sampling was discontinued.
Data analysis of the focus group transcripts proceeded in a collaborative reflective style. We used an inductive approach  whereby we looked for patterns, themes and categories in our data, without applying any pre-conceived constructs, hypotheses or theories to the process of interpretation. Thus we identified, categorized, coded and labeled the primary patterns of ideas that emerged from the verbatim comments contained in the transcripts of our focus groups. Transcripts were systematically read and reviewed independently by three investigators (K.A.C., S.N.S. and C.A.K.) trained in qualitative analytic methods and from different fields (pediatrics, social science research and child-care center employment). The three investigators agreed on an initial set of codes and organizing framework (codebook). Next, this set of codes was used to analyze and code transcripts from the focus groups. Three investigators independently coded the transcripts, meeting after each one to resolve any differences in coding by consensus.
To enhance the completeness and credibility of the data analysis and interpretation of the findings, 13 individual interviews were conducted subsequent to the focus group transcript analysis. The use of member checking methodology provided an additional round of data collection and analytical triangulation. Each interviewee was asked a series of questions about physical activity at their center and also was asked to critique the list of themes generated from the analysis of the focus groups and/or to provide additional insights and supporting experiences. Interviews were held in a private room either in the subject’s home or workplace, lasted on average 1 hour, were audio-recorded, and led by either S.N.S. or K.A.C. The audio recordings of the personal interviews were reviewed to assess the degree of substantiation of the preliminary interpretation of the findings, disagreement with the inclusion of particular themes, and identification of any new themes. This step allowed participants to assess the accuracy and completeness of the data analysis . All interviewees provided written informed consent to participate. This study was approved by Cincinnati Children’s Institutional Review Board and all participants received $25 remuneration.
A total of four overarching themes related to physical activity and outdoor play in childcare were identified by group consensus, including: (i) benefits, (ii) disadvantages, (iii) facilitators and (iv) barriers. These overarching themes were subdivided into those that related to children, parents, teachers, structural, policy and societal factors. Results related to the primary disadvantage of active and outdoor play—children getting injured or dirty—and barriers associated with children and parents, including inappropriate children's clothing, have been reported elsewhere . Themes related to structural, societal and policy benefits and barriers to physical activity and outdoor play will be presented in a separate paper. This paper will report on the three broad categories of findings related to teachers, namely their (i) perceived benefits of physical activity and outdoor play, (ii) perceived disadvantages/barriers to physical activity and outdoor play and (iii) decisions regarding outdoor play and their roles on the playground.
One-on-one interviews conducted during the member-checking component of this study did not produce any additional or conflicting information related to barriers and benefits of physical activity. Interviewees corroborated the preliminary interpretation of the findings including the inclusion of all preliminary themes, and no disconfirming evidence was found. To eliminate over-reporting of themes or over-representation of comments from the nine participants that participated in both interviews and focus groups, only quotations from the focus group transcripts are used in the reporting of our results.
Participants noted numerous benefits of physical activity, outside time and fresh air (Table II). Benefits fell into two broad categories that were often inter-related physical and socio-emotional. For instance, they noted that the energy expenditure associated with physical activity could help prevent childhood obesity (¶A1,¶A2) (a physical benefit) and could also provide a ‘stress-relief’(¶A4) and improve children’s mood (¶A5) (emotional benefits). They noted that structured activities (¶A6) and regular physical activity help build healthy habits (¶A1, ¶A3) and could help them calm the classroom down (¶A6, ¶A7).
Sometimes the socio-emotional benefits were seen as integrated with or consequences of the physical benefits. For instance, most participants felt that physical activity was important in the preschool age group for developing individual gross motor skills, such as climbing, ball skills, coordination, pedaling and hopscotch (¶A8, ¶A9, ¶A10). Several participants noted that children who master gross motor skills at an early age tend to become more self-confident than other children. Mastery of gross motor skills fostered feelings of self-efficacy (¶A12, ¶A14) and ultimately improved self-esteem (¶A13, ¶A14). Similarly the converse was true: some participants had encountered a few children who never learned to perform fundamental skills such as skipping, climbing or throwing a ball (¶A15, ¶A18). Children who cannot perform these skills may begin to feel embarrassed and discouraged (¶A15, ¶A16, ¶A18) and have difficulty with their peers. Without the opportunity to practice, failure to learn these skills at an early age could place children on a trajectory in which they never feel comfortable doing physical activities (¶A17). Participants noted that in contrast to exercising indoors in a gross motor room, going outside provided additional physical benefits of more room to run and expend energy (¶A19, ¶A20, ¶A21). This increased freedom to run was also interpreted on a socio-emotional level, as participants noted that children felt freer to raise their voices and express themselves (¶A21, ¶A24, ¶A27) outdoors and that children seemed more creative outdoors compared with indoors (¶A25, ¶A26). Playground schedules that allowed children to interact with children from other classrooms helped to foster children’s new friendships and social development (¶A27, ¶A28, ¶A30). Participants also remarked that the limited quantity of playground equipment such as balls or slides could facilitate the development of children’s problem-solving skills as they must negotiate shared usage of items in limited supply (¶A29, ¶A30). Lastly, participants found that even brief exposures to the outdoors seemed to help children nap better later (¶A22, ¶A23).
An additional important quality of outside time mentioned was ‘fresh air’. Fresh air conveyed both the physical benefit of escaping germs, which were seen as being more prevalent indoors especially during the winter (¶A31, ¶A32, ¶A33, ¶A34, ¶A35) and the emotional benefits of improved mood for both teachers and children (¶A36, ¶A37, ¶A38). In summary, the benefits of being outdoors exceeded those of indoor active play for all the realms discussed gross motor skill development, socialization, health and mood. Further, being outdoors allowed for greater energy release, more vigorous activities, freedom and creativity and social interaction.
While participants listed many benefits of physical activity and outdoor time, they also noted a few disadvantages and several barriers to children getting physical activity (Table III). One disadvantage to outdoor time was the perception that children could get sick (¶B1, ¶B2, ¶B3), especially if improperly dressed for cold or wet weather, although participants said this belief was more common among parents than teachers.
Adverse weather conditions—which could include precipitation, cold, extreme heat or smog warnings—were cited by virtually all participants as a common and important barrier to children’s outside time (¶B4). Yet most participants went on to say that teachers’ perceptions of the weather conditions were more important than actual conditions in determining whether children were permitted outdoors and how long they spent outdoors (¶B5, ¶B6, ¶B7, ¶B13). In fact, many participants acknowledged that it was usually the adults (teachers or parents) and not the children that were bothered by most adverse weather conditions (¶B11, ¶B12, ¶B13). Individual teachers’ preferences or beliefs about weather conditions (e.g. not being a cold weather person (¶B8), not liking the rain (¶B9), or associating dampness with getting sick (¶B1, ¶B10)) could keep children indoors.
Other less frequently mentioned reasons for teachers avoiding the outdoors included not liking the outdoors, (¶B14), getting dirty or sweaty (¶B15), insects (¶B16) and the chaos and noise on the playground (¶B17, ¶B18). Several commented on how much work it was to take children outdoors, including helping children put on coats and mittens (¶B19), administering sunscreen (¶B20), setting up and properly stowing portable equipment on the playground (¶B21, ¶B22) or supervising a challenging playground structure.
Lastly participants mentioned their own ailments, such as allergies and asthma (¶B23, ¶B24, ¶B25) or being overweight (¶B22, ¶B26), as possible impediments to taking the children outdoors and encouraging their physical activity. Many had worked with colleagues they perceived as ‘lazy’ (¶B27, ¶B28). Participants suggested that some teachers may feel self-conscious about their bodies or their physical activity skills and/or lack the self-efficacy to effectively encourage children’s physical activity and their confidence to participate in children’s games (¶B29). A few suggested that perhaps this was due to a negative experience the teacher had had on the playground as a child (¶B30).
Participants weighed both the benefits and barriers to outdoor play in making the decision whether to take children outdoors (Table IV). Most said it was up to the individual teacher whether or not children went outside (¶C1, ¶C2, ¶C3).
Because teachers were empowered to make this decision based on individual preferences, teachers perceived that they could and did serve as gatekeepers to outdoor play. Below a participant describes the ‘pull’ (¶C4) a teacher can have in deciding not to go outside for personal reasons. Another two participants describe how a teacher can override the center’s schedule for personal reasons (¶C5, ¶C6). Assistant or junior teachers often deferred to senior teachers (¶C7). In extreme cases, participants described keeping children indoors for an entire winter season (¶B8 Table III, ¶C8 below) or school year (¶C9) due to personal preferences and concerns about the weather.
Teachers could also act as gatekeepers by blocking off specific parts of the playground, for safety or personal reasons (¶C10, ¶C11, ¶C12). Participants suggested that these restrictions teachers place on children's activities may have been motivated out of fear (¶C11) or a previous bad experience (¶C12).
Participants described a spectrum of roles (¶C13) that teachers could play on the playground, ranging from actively participating in play with children (teacher as facilitator), to supervisory only (chaperone), to being distracted or disengaged.
The following quotes exemplify teachers who see their role on the playground as a facilitator (¶C14, ¶C15, ¶C16) to children’s activity. Participants discussed their role in promoting children’s gross motor skill development and encouraging all children to engage in physical activities (¶C14).
Many participants felt their primary responsibility on the playground was to keep children safe and saw their primary role as a chaperone (¶C17, ¶C18). Several cautioned against too many teacher-led activities (¶C19, ¶C20).
Lastly, participants suggested that sometimes teachers may inhibit children’s physical activity by not engaging with the children while on the playground (¶C21, ¶C22), as many had worked with colleagues who disengaged when going on the playground—either to socialize with other teachers or take a break (¶C22, ¶C23, ¶C24) or because they didn't see facilitation of active play as part of their responsibility. A few participants stated that they had seen colleagues talk or text on their cell phones (¶C24) while they were supposed to be supervising the children outside.
Participants noted numerous benefits to children’s physical activity in general and outdoor time in particular that have been cited in the health and education literature, including obesity prevention, gross motor skill development and self-efficacy, stress relief, improved mood and attention. While others have reported that child-care providers recognize these benefits , among our participants there was a pointed awareness of the integrated physical and psychosocial benefits of physical activity, particularly for this age group and particularly when done outside. Participants pointed out an unintentional social benefit of limited access to portable play equipment—that it fostered individual children’s negotiation and problem-solving skills. In addition, both short-term (e.g. better napping and attention later in the day) and long-term (e.g. obesity prevention) benefits were noted. Of note, many of the short-term benefits were not only for the children but were beneficial to the care staff (e.g. easier nap time, behavior management). However, participants also noted numerous barriers to going outside, many of which were related to their personal preferences or beliefs. Some barriers (e.g. weather and teachers’ personal health or circumstances) have been identified in other focus group work with child-care providers . Other barriers, such as not being a cold weather person, not enjoying the noise and chaos outdoors or the amount of work involved in preparing children to go outdoors, appear to be novel.
Participants recounted that for many teachers the barriers outweighed the benefits, and because the decision of whether or not to take the children outside ultimately resided with the teacher, teachers perceived that they were the primary gatekeepers to the playground. Their perceived role as gatekeeper was cast in three ways: (i) deciding whether or not to go to the playground, (ii) deciding what equipment and parts of the playground would be accessible or off-limits and (iii) deciding what level of engagement to have with the children. Many participants had encountered colleagues who disengaged on the playground by sitting, standing by the fence or socializing. There was less consensus about what a teachers’ role on the playground should be (activity facilitator versus safety chaperone) and to what extent should children’s outdoor time be structured versus unstructured. These findings suggest that children could have very different gross motor experiences even within the same facility (with presumably the same environment and policies), based on the beliefs, attitudes, creativity and level of engagement of their teacher. Our findings that teachers perceive themselves to be gatekeepers to the playground appear to be novel but are consistent with the Health Belief Model and the Theory of Reasoned Action and Theory of Planned Behavior  in that teachers’ attitudes and beliefs influence their behaviors, and that more experienced teachers’ actions may establish the normative behavior for newer teachers. In this case, however, teachers’ attitudes and beliefs are also influencing the behaviors of the children they care for, as these preschool-aged children are entirely dependent on their caregivers for opportunities to be active.
Our findings about the importance of teachers’ attitudes, level of engagement with the children and modeling behaviors are consistent with other quantitative studies that have examined their association with children’s objectively measured physical activity [6, 42, 54, 55, 62]. Dowda et al.  and Bower et al.  both found that higher levels of teacher training were associated with higher center-levels of physical activity. Brown et al. [6, 55] have reported that teachers rarely encouraged children’s physical activity or used structured games. Yet when instructed on how to incorporate brief structured activities during outdoor play  or throughout the day , teachers can have a tremendous impact on increasing children’s activity levels. Fees et al.  found that family child-care home providers felt they lacked training in planning and implementing structured activities to enhance children’s specific motor skills. Our findings suggest a potential mechanism for why focused teacher training may be an effective strategy for increasing children’s physical activity in childcare.
The importance of the role of teacher as gatekeeper to the playground may be profound. Even if the center’s schedule calls for two daily outdoor active opportunities , participants described instances in which the teacher could override the schedule. Assistant or junior teachers did not feel comfortable challenging lead or experienced teachers’ decisions. Thus children who have a teacher who is not a ‘cold weather,’ ‘hot weather’ or ‘outdoor person’ may rarely have opportunities to go outside. While on the playground, teachers recognized that they served in various roles that could influence the amount of physical activity in which children engaged. The importance of the level and type of engagement of the teacher on the playground (e.g. chaperone versus facilitator) and the extent to which they do not restrict elements of the playground may partly explain recent conflicting findings [46–49] about whether or not providing increased outdoor time can increase children’s physical activity in childcare. Specifically, if children are under the care of a disengaged or overly restrictive teacher, increasing children’s outdoor time will not necessarily increase their physical activity.
Our study relied on self-report and proxy-report, we did not observe teachers’ actual behaviors. The extent to which individual teachers’ beliefs and attitudes influence their behaviors or children’s active opportunities cannot be determined from a qualitative study. Our purpose was to generate hypotheses about why children’s activity level varied across different centers. Although we tried to recruit participants with a range of experiences participation was voluntary and there may have been a selection bias; i.e. those who chose to participate seemed to view children’s active opportunities generally favorably. We asked participants to reflect both on their own behaviors as well as the behaviors of their present or past colleagues and found generally positive reflections of their own behaviors on the playground as facilitators, while stories about teachers as inhibitors of activity were mostly proxy descriptions of co-workers. Almost all of the participants were female, and either Caucasian/white or African-American/black, which is reflective of the child-care work force  and the predominant ethnic/racial groups in Hamilton County. Future studies are needed to better understand teacher-related barriers to children’s physical activity that may vary by region, state or cultural group.
A strength of undertaking this study in Cincinnati is that the city is located in a temperate zone with distinct seasons. Previous studies in more moderate climates such as in coastal California  may not have had the variability in weather to study the potential effect of weather or teacher’s attitudes toward weather.
There are important implications to our findings. Because of the crucial role of the teacher in children’s active opportunities, a center could have an exemplary playground with gracious amounts of space and equipment but still have very low levels of physical activity if the teachers rarely bring children outside for active play. Alternatively, a center could have no playground on-site and/or minimal equipment but with highly creative and activity-oriented teachers, the center could still achieve very high levels of physical activity for children through improvised races, games and activities in an empty parking lot or during nature walks.
A central conclusion or policy recommendation that emerges from this research is that in order to increase children’s physical activity in child-care centers, interventions must target and support the key decision-makers—the gatekeepers to the playground—teachers. Interventions could involve teacher training on age-appropriate structured games, and focus on improving teachers’ self-confidence and efficacy on the playground. Interventions may also need to address common teacher-perceived barriers to going outdoors, including beliefs and preferences about weather and the amount of work involved in taking children outdoors. Such interventions are crucial with parents working long hours and/or children living in unsafe neighborhoods, as their time in childcare may be their only opportunity to be active.
The National Heart Lung and Blood Institute at the National Institutes of Health through a Career Development Award (K23HL0880531); The Robert Wood Johnson Foundation Physician Faculty Scholars Program; Dean’s Scholar Program at the University of Cincinnati College of Medicine.
The authors would like to thank Leslie Kemper, who assisted with recruitment and scheduling of focus groups, and 4C for children, the local child-care resource and referral agency who assisted with recruitment for focus groups. We are also grateful to all of the directors and teachers who contributed their time and thoughtful comments to this study.