We identified three potential barriers to children’s physical activity in child care from this qualitative study: (1) safety and injury concerns, (2) economic and budgetary issues, and (3) a focus on “academics,” even in the preschool setting. Several of these themes interacted with one another. For example, a center’s tight budget limited its ability to offer expensive outdoor equipment, thus centers prioritized things they felt mattered most to the parents: more time, space, and materials in the classroom. Unless parents valued and prioritized outdoor time (and several participants felt many parents did not), children would not have opportunities to be physically active. Out of concern for potential injury, some parents requested their child not participate in outdoor activities, and “read a book instead.” This solution addresses all three themes—book reading is safer than outdoor play, books are significantly cheaper than purchasing and maintaining outdoor play equipment, and reading a book is seen as more of a learning experience than outdoor play. Because children spend long hours in care and many lack a safe place to play near their home, these barriers to physical activity in child care may limit children's only opportunity to engage in physical activity.
One seemingly novel finding was that a heightened societal focus on safety resulted in twin outcomes: child care playgrounds had been modified to prevent child injury, but the modifications also rendered them less challenging and interesting for children. It is not clear if these playground “improvements” have caused children to be less active on playgrounds over time, although others have found children to be less active on child care playgrounds with more pieces of fixed equipment.47,48
Our findings resonate with studies of older children, who have been reported to lose interest in playground equipment that is not sufficiently challenging or varied.49,50
Another surprising finding was that a societal focus on “academics” extended even to the preschool-aged group. Several commented that parents wanted to know what their child “learned” that day, but were not interested in whether they had gone outside, or had mastered fundamental gross motor skills. Participants felt that academics were valued by both low- and upper-income parents, and thus were motivated to demonstrate a “purpose” for gross motor time so that the children would not be seen as just “running around.” Some felt pressure from state learning standards and local kindergarten-readiness initiatives. Participants discussed ways of incorporating lessons about numbers or letters on the playground, and thus potentially meet both learning and physical activity standards. Recent successful interventions have integrated activity throughout the day in the classroom.51–53
It is unknown to what extent these initiatives or parental pressure for academics have contributed to restricting children’s time outdoors in child care, because children’s outdoor playtime has not been systematically studied. More research is needed to examine cognitive and physical activity outcomes in concert, because participants noted that the 2 are interconnected in this age group.
Participants also noted economic barriers to physical activity in child care: that playground equipment was expensive and that programmatic budgets were usually dedicated to classroom materials and instruction (ie, focus on academics). It is unknown, however, to what extent budgetary issues actually impede children’s physical activity, for example, if children attending centers with the majority of children on tuition assistance are any less active than children attending centers that do not accept children on tuition assistance. These questions warrant additional investigation.
Our findings highlight potential areas for additional research and targets for intervention. Although participants recognized the interconnections between physical and socioemotional development, they did not think many parents understood this. This presents an educational opportunity for pediatric clinicians, who interact regularly with families, to guide children’s healthy development. Recognizing that school readiness is a prevalent concern, pediatricians may need to highlight for parents the many learning benefits of outdoor play (better concentration, learning about science, negotiation with peers), and reassure parents that active time does not need to come at the expense of time dedicated to “academics” and “learning.” Because we have previously reported that children sometimes are dressed unsuitably for active play,41
pediatricians can remind parents about the importance of “dressing for success,” which in preschool would be dressed for active play. The pediatric visit (more common in early years than in older childhood) is also an excellent opportunity to dispel myths parents may believe about the chances their child will get sick when exposed to cold or damp weather, because we have also reported this is a prevalent concern.42
Last, in dispensing injury prevention advice, pediatricians should be careful not to reinforce messages that physical activity is inherently dangerous. Pediatricians can balance these safety messages with an equal dose of health promotion messages about the crucial importance of daily physical activity for both physical and mental health; and for the motor, socioemotional, and cognitive development of young children.
There may have been selection bias in that those who chose to participate tended to view children’s physical activity more favorably, and may have been more attuned to the interconnections between physical and cognitive development in this age group in comparison with the “typical” child care provider. Our findings should be interpreted as exploratory, because this was a qualitative study of child care providers within a single county in Ohio. The primary purpose of qualitative research is to probe phenomena in-depth, not to generalize the results to other populations. Yet the barriers participants discussed—concerns about safety, budgets, and academics— potentially characterize other geographic areas. Although we tried to recruit participants of different ethnicities, there were no Latino participants, which partially reflects local demographics (<1% of county residents are Latino). We recruited a heterogeneous sample in terms of center program philosophy, years of experience, and sociodemographics of children served, yet it is not possible through qualitative research to make inferences on demographic predictors of participants’ attitudes or behaviors, nor is it possible to derive prevalence estimates of the ideas expressed. Future studies are needed to investigate the generalizability of these findings.
In promoting optimally safe, healthy, and enriched learning environments for young children, there may be a need to reset the balance between the salient priorities of injury prevention and kindergarten readiness with those that have not received as much recent attention, that is, physical activity promotion. Child advocates must think holistically about potential unintended consequences of policies designed to protect children’s safety (eg, licensing codes that have rendered climbers uninteresting, or early learning standards that encourage child-care providers to cut time dedicated for outdoor play). Given that childhood obesity is quickly eclipsing childhood injury as a leading cause of morbidity, and that time in child care may be the child’s only opportunity for outdoor play, licensing standards may need to explicitly promote physical activity in as much detail as is devoted to safety. The third edition of the American Academy of Pediatrics and American Public Health Association’s health and safety standards for child care (“Caring for Our Children,” third edition54
) do just this, and are the first to include explicit guidelines and practical tips for promoting physical activity in child care.