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The effect of playground- and nature- based playtime interventions on physical activity and self-esteem in UK school children Jo Bartona, Gavin Sandercocka, Jules Prettya & Carly Wooda a School of Biological Sciences, University of Essex, Colchester, UK Published online: 12 May 2014.

To cite this article: Jo Barton, Gavin Sandercock, Jules Pretty & Carly Wood (2014): The effect of playground- and nature-based playtime interventions on physical activity and self- esteem in UK school children, International Journal of Environmental Health Research, DOI: 10.1080/09603123.2014.915020

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The effect of playground- and nature-based playtime interventions on physical activity and self-esteem in UK school children

Jo Barton, Gavin Sandercock, Jules Pretty and Carly Wood*

School of Biological Sciences, University of Essex, Colchester, UK

(Received 18 December 2013; final version received 10 March 2014)

School playtime provides opportunities for children to engage in physical activity (PA). Playground playtime interventions designed to increase PA have produced dif- fering results. However, nature can also promote PA, through the provision of large open spaces for activity. The purpose of this study is to determine which playtime interventions are most effective at increasing moderate-to-vigorous physical activity (MVPA) and if this varies by school location. Fifty-two children from an urban and rural school participated in a playground sports (PS) and nature-based orienteering intervention during playtime for one week. MVPA was assessed the day before and on the final day of the interventions using accelerometers. Intervention type (p < 0.05) and school location (p < 0.001) significantly influenced MVPA; with PS increasing MVPA more than nature-based orienteering. Urban children seemed to respond to the interventions more positively; however, differences in baseline MVPA might influence these changes. There was a positive correlation for fitness and MVPA during PS (r = 0.32; p < 0.05), but not nature-based orienteering (p > 0.05). The provision of PS influences PA the most; however, a variety of interventions are required to engage less fit children in PA.

Keywords: physical activity; playtime; urban; rural; nature

Introduction

Many UK school children aged 5–10 years (26–34 %) do not perform the recommended daily 60 min of moderate-to-vigorous physical activity (MVPA) (NHS Information Centre 2011). Regular physical activity (PA) during childhood is essential for good physical and psychological health (PH) (Department of Health 2011). In common with the adult data, a meta-analysis of paediatric exercise interventions conducted worldwide shows a similar, moderate effect size for changes in children’s self-esteem (SE) due to exercise (Ekeland et al. 2004). However, opportunities for children to be active are diminishing and children in the UK follow an increasingly sedentary way of life (Biddle et al. 2004). Time spent outdoors is a positive correlate of PA (Cleland et al. 2008), yet UK children spend less time outdoors than previous generations due to safety concerns, traffic and parental fear of crime (Bird 2007). Children are also drawn inside by the attraction of indoor alternatives such as TV and computer games (Biddle et al. 2004). Children of a lower socio-economic status (SES) are a group of particular concern, as they have greater access to sedentary activities but reduced access to portable play equipment such as bicycles, which facilitate PA (Tandon et al. 2012).

*Corresponding author. Email: [email protected]

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http://dx.doi.org/10.1080/09603123.2014.915020

School playtime provides an ideal opportunity to promote PA in an outdoor environ- ment (Ridgers et al. 2006). Children in the UK typically receive up to 55 min of school playtime each day, equating to 183 h per year. If all this time were used for PA, play- time would provide 50 % of the total amount required (Ridgers et al. 2006, 2007a). However, playtime currently only contributes 5–40 % towards the daily activity require- ment (Ridgers et al. 2006). There is large variation in the calculated contribution of school playtime due to differences in PA assessment methods and playtime durations.

Playtime interventions such as equipment provision and playground markings have successfully increased time spent in MVPA during school playtime by up to 60 % (Stratton 2000; Stratton & Mullan 2005; Verstraete et al. 2006; Ridgers et al. 2007b; Haug et al. 2010). However, some studies also suggest that playtime interventions such as playground markings do not significantly influence PA levels (Ridgers et al. 2007a; Haug et al. 2010; Ridgers et al. 2010). The sustainability of increases in PA over time is also questionable as short-term changes may be due to novelty effects of the interven- tions (Stratton 2000; Ridgers et al. 2006).

The location of playtime interventions may also impact upon their effectiveness. Natural environments provide large open green spaces for activity and can create more imaginative and inventive play than urban environments lacking natural features (Bird 2007). Individuals with access to natural, green environments are three times as likely to be active (Wells et al. 2007) and natural settings can improve concentration, cognitive function and social play (Wells 2000). In adults, performing PA whilst exposed to nature (green exercise) provides additive benefits for PH, largely through improvements in SE (Pretty et al. 2005; Barton & Pretty 2010). It is suggested that these additive benefits are enabled through the ability of natural environments to provide a distractor from daily stresses (Pretty et al. 2005; Reed et al. 2013). However, there is a paucity of green exercise studies in children and those simulating the experience using natural images have shown no additive benefit to SE (Wood et al. 2012).

The school environment may provide a vital opportunity for children to have contact with natural environments. Accessing green space and engaging in outdoor play during the school day is therefore a key component to the health, well-being and development of children (Ward Thompson et al. 2008). Yet, children spend much of their playtime on the concrete playground (Ridgers et al. 2006) and often have limited access to green spaces within the school environment. The primary purpose of this study was to deter- mine which type of playtime intervention is most effective at increasing PA levels and improving SE in UK school children. A secondary aim was to compare the effect of the interventions in children attending schools located in urban and rural settings.

Methodology

Participants

Fifty-two boys and girls aged 8.84 ± 0.45 years (mean ± SD) volunteered to participate in the study. Participants were recruited from two primary schools located in urban and rural areas in England (Colchester Borough Council 2004). The two areas were in the 20 % most socio-economically deprived in England for one or a combination of factors, such as housing, income and health, crime and living environment (Colchester Borough Council 2004). The participants in each school were derived from a year 5 class; the sample size was determined by the relative size of each class. Informed parental consent and individual assent were obtained for each child prior to the start of the study. Only

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children who returned consent forms participated. Institutional faculty ethical approval was granted for the study.

Procedure

At the start of the project, participants’ stature was measured with the participant bare- foot and to the nearest 0.1 cm (Seca 220 stadiometer) and mass measured to the nearest 0.1 kg (Seca 770 digital scale). Body mass index (BMI) and BMI z-scores (Cole et al. 1995) related to the individuals’ age and sex were also calculated. Cardiorespiratory fit- ness was determined using the 20 m shuttle run test (20 mSRT) (Léger et al. 1988). The 20 mSRT required participants to run between markers, 20 m apart, in time to pre- recorded beeps. The initial running velocity was 8.5 km h−1, increasing by 0.5 km h−1

each minute. The test was terminated due to volitional fatigue or when the participant failed to reach the marker at the beep on two consecutive occasions (Léger et al. 1988). The number of shuttles each participant completed was recorded and converted to run- ning speed (km h−1). 20 mSRT z-scores were then calculated from age and sex-related normative data (Olds et al. 2006). A positive or negative z-score indicates an above or below average score, respectively.

Two playtime interventions were then introduced into each of the schools during lunch playtime for one week between November and December 2009. The interventions were available for the whole 55 min duration of lunch playtime on five consecutive days. The weather did not prevent the children from accessing either of the interventions on any of the five days. A playground sports (PS) equipment intervention was imple- mented followed by a nature-based orienteering intervention. The order of the interven- tions was requested by the school due to circumstances out of our control. It would have been preferable for the order of the interventions to be randomised for each partici- pant in order to eliminate the effect of one intervention on the other and also any order effects. Time spent in MVPA was assessed prior to and on the final day of each inter- vention, whilst SE was assessed pre- and post-intervention. The interventions were implemented for a period of five days in order to determine whether they could influ- ence MVPA and SE in the short term.

Interventions

The PS intervention was performed on the playground and consisted of small pieces of equipment such as skipping ropes, bats and balls and Frisbees. The children could play with the equipment freely during all playtime periods. In both schools, the playground consisted of concrete areas surrounded by the school buildings. There were very few green features in view from the school playground.

The orienteering intervention was carried out on the school field and green areas surrounding the school buildings. Children were provided with a map of the school grounds and a course with markers to follow and locate. The course was altered on each day of the intervention. In both the urban and rural schools, the fields were surrounded by trees and green areas. At some points in both schools, the school buildings could be seen from the field; however, the dominant features of the environment were green.

The dimensions of the green and playground areas were comparable in both schools and all children participated fully in both interventions. The implementation of the inter- ventions was the same in both the urban and rural schools. The children received an

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explanation of each intervention and were provided with identical equipment and opportunity to take part in each of them.

Instrumentation

PA levels were monitored for one day prior to the start of the intervention and on the final day of each intervention using accelerometers (Actigraph GT1 M, MTI Health Ser- vices Inc.). Accelerometers were only worn on the final day of each intervention so as to minimise the disruption to the schools and daily lessons. Activity levels were moni- tored during the 55-min lunch break using a 1s epoch. Accelerometers were worn on a belt, over clothing, positioned on the right hip. Accelerometer data were downloaded using the Actilife programme (v4.4.1) and processed using ActiSci V0.99b5. The time spent in MVPA was determined using established cut points (Treuth et al. 2004), with an adjustment made for the accelerometer model (Corder et al. 2007).

SE monitoring took place immediately after lunch break, the day before each inter- vention and again at the same time on the final day of the intervention. SE was assessed using the one-page 10-item Rosenberg SE scale (Rosenberg 1965); the instruments test– retest correlations range from 0.82 to 0.99 and reported Cronbach’s α coefficients range from 0.77 to 0.88 (Blascovich & Tomaka 1991). The scale was slightly modified to ensure that the language could be understood by the age group of children involved. For example, participants are normally asked how they feel about themselves and whether they strongly agree, agree, disagree or strongly disagree with a list of 10 state- ments. This was amended to whether the participants thought the statements to be very true, true, not true or definitely not true. This change was made as it was thought that children would have a greater understanding of “true” and “not true”, as opposed to “agree” and “disagree” and that they would therefore be able to interpret the statements and provide responses more easily. Some statements were also modified to make them more comprehensible in terms of language, for example “I am able to do things as well as most other people” was changed to “I can do things as well as most other children”.

Data analysis

Two-way between ANOVA examined differences in anthropometric and fitness data according to sex and school location. Two-way mixed ANCOVA examined the changes in time spent in MVPA according to the intervention type and school location, with the pre-intervention MVPA, BMI z-score and 20 mSRT z-score being included in the analy- sis as covariates. Pearson’s correlation examined the relationship between fitness and the change in MVPA following the nature-based orienteering and PS interventions sepa- rately. Two-way ANCOVA also examined the effect of the intervention type and school location on the change in SE, with pre-intervention SE scores, BMI z-score and 20 mSRT z-scores being included in the analysis as covariates. Significance was accepted as p < 0.05 throughout the analysis.

Results

Two-way between ANOVA (using school location and sex as two independent variables) revealed a significant difference between urban and rural school children in age (F(1,44) = 4.75; p < 0.05), stature (F(1,44) = 9.17; p < 0.01), BMI (F(1,44) = 14.04; p < 0.001) and BMI z-score (F(1,44) = 14.47; p < 0.001). Participants in the rural school

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T ab le

1 .

D es cr ip ti v e st at is ti cs

(m ea n ± S D ) fo r u rb an

an d ru ra l sc h o o l ch il d re n .

A g e (y ea rs )

S ta tu re

(c m )

B o d y m as s (k g )

B M I (k g m

− 2 )

B M I (z -s co re )

2 0 m S R T (k m h − 1 )

2 0 m S R T (z -s co re )

U rb an

M al e

8 .7 8 ± 0 .3 8

1 .3 0 ± 0 .0 7

3 7 .9 ± 1 6 .7

2 2 .5 ± 9 .8

1 .3 2 ± 2 .0 0

1 0 .5 ± 1 .0

0 .4 9 ± 0 .9 0

F em

al e

8 .5 8 ± 0 .2 6

1 .3 0 ± 0 .0 6

3 8 .6 ± 1 2 .1

2 2 .8 ± 7 .2

1 .8 6 ± 1 .2 6

9 .7 ± 0 .3

0 .2 5 ± 0 .3 0

A ll

8 .7 3 ± 0 .3 6 a

1 .3 0 ± 0 .0 6 a

3 8 .1 ± 1 5 .5

2 2 .7 ± 9 .2 a

1 .4 5 ± 1 .8 5 a

1 0 .3 ± 0 .9

0 .4 3 ± 0 .8 0

R u ra l

M al e

9 .1 4 ± 0 .5 0

1 .3 9 ± 0 .0 7

3 3 .3 ± 5 .6

1 7 .3 ± 2 .3

0 .3 9 ± 1 .2 1

1 0 .4 ± 0 .9

− 0 .6 3 ± 3 .0 9

F em

al e

8 .8 0 ± 0 .4 8

1 .3 5 ± 0 .0 8

3 1 .4 ± 6 .4

1 7 .1 ± 2 .1

0 .2 7 ± 0 .9 6

9 .6 ± 0 .4

0 .1 5 ± 0 .5 6

A ll

8 .9 3 ± 0 .5 1

1 .3 7 ± 0 .0 8

3 2 .2 ± 6 .1

1 7 .2 ± 2 .1

0 .3 1 ± 1 .0 6

9 .9 ± 0 .7

– 0 .1 8 ± 2 .0 5

T o ta l

M al e

8 .9 1 ± 0 .4 5

1 .3 3 ± 0 .0 8

3 6 .2 ± 1 3 .7

2 0 .6 ± 8 .3

1 .0 0 ± 1 .8 1

1 0 .4 ± 1 .0

0 .1 0 ± 2 .0 0

F em

al e

8 .7 4 ± 0 .4 4 b

1 .3 4 ± 0 .0 7

3 3 .5 ± 8 .8

1 8 .8 ± 4 .9

0 .7 2 ± 1 .2 7

9 .6 ± 0 .4

b 0 .1 8 ± 0 .5 0

A ll

8 .8 4 ± 0 .4 5

1 .3 3 ± 0 .0 8

3 5 .1 ± 11 .9

1 9 .8 ± 7 .1

0 .8 8 ± 1 .6 1

1 0 .1 ± 0 .9

0 .1 3 ± 1 .5 6

a In d ic at es

a si g n ifi ca n t d if fe re n ce

fr o m

ch il d re n in

th e ru ra l sc h o o l (p

< 0 .0 5 ).

b In d ic at es

a si g n ifi ca n t se x d if fe re n ce s fo r al l ch il d re n .

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were older and taller, but had a lower BMI and BMI z-score than the urban school children. There were no differences (p > 0.05) between mass, 20 mSRT speed or 20 mSRT z-score in the urban and rural schools (Table 1). There was also a main effect for sex revealing significant sex differences in age (F(1,44) = 4.21; p < 0.05) and 20 mSRT speed (F(1,44) = 19.54; p < 0.001) for all children combined. Females were younger and reached a slower final speed on the 20 mSRT. There were no sex differences in stature, mass, BMI, BMI z-score or 20 mSRT z-score (p > 0.05). There were no significant effects for any of the variables due to the interaction of the school location and sex (p > 0.05).

Descriptive data according to school location and activity type are reported in Table 2. Two-way ANCOVA showed a significant main effect for the change in the time spent in MVPA due to the intervention type (F(1,74) = 5.78; p < 0.05) and school loca- tion (F(1,74) = 23.42; p < 0.001), but no effect due to the interaction of the intervention type and school location (p > 0.05). The PS intervention increased the time spent in MVPA more than the nature-based orienteering intervention and the urban school increased their time spent in MVPA to a greater extent than the rural school (Table 3). ANCOVA also revealed that there was a significant effect of pre-intervention time spent in MVPA on the change in the time spent in MVPA (F(1,74) = 18.97; p < 0.001) and also a significant effect of the BMI z-score on the change in the time spent in MVPA (F(1,74) = 6.85; p < 0.05). There was no effect of the 20 mSRT z-score on time spent in MVPA.

Table 2. Time spent in MVPA (min) and SE scores according to playtime activity and school environment (mean ± SD).

Urban Rural

MVPA (min) Self-esteem MVPA (min) Self-esteem

Sports Pre 11.28 ± 4.46 21.60 ± 7.69 7.72 ± 4.62 19.05 ± 6.29 Post 15.23 ± 4.24 18.89 ± 6.10 9.77 ± 5.65 18.36 ± 5.98 Total 13.33 ± 5.26 19.89 ± 7.49 8.75 ± 4.99 18.52 ± 5.86

Orienteering Pre 4.67 ± 2.46 18.00 ± 6.24 7.48 ± 4.11 16.82 ± 6.15 Post 9.27 ± 4.03 15.67 ± 6.73 7.50 ± 3.59 16.27 ± 5.19 Total 6.59 ± 3.95 17.00 ± 6.43 7.48 ± 3.82 16.29 ± 5.45

Total Pre 7.93 ± 5.14 19.91 ± 7.23 7.63 ± 4.25 17.75 ± 6.14 Post 12.60 ± 5.44 17.30 ± 6.90 8.58 ± 4.65 17.06 ± 5.37 Total 10.07 ± 5.75 18.61 ± 7.17 8.11 ± 4.46 17.39 ± 5.74

Note: A lower score = a better self-esteem.

Table 3. Change in the time spent in MVPA (min) due to the sports equipment and orienteering intervention in urban and rural school children (mean ± SD (95 % CI)).

Urban (min) Rural (min) Total (min)

Sports 4.16 ± 4.74 (0.68–5.84) 1.92 ± 5.43 (0.29–6.45) 3.07 ± 5.16 (2.54–5.08) Orienteering 4.60 ± 3.85 (1.95–6.94) 0.15 ± 3.62 (−1.71 to 1.37) 2.15 ± 4.31a (0.22–2.83) Total 4.36 ± 4.31 (3.69–6.35) 1.00 ± 4.6b (−0.97 to 1.59) 2.62 ± 4.75 (1.44–3.48)

aIndicates a significant difference between sports equipment and orienteering (p < 0.001). bIndicates a significant difference between schools (p < 0.05).

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Pearson’s correlation revealed a positive correlation for children of all fitness, deter- mined by the maximum speed achieved on the 20 mSRT, and time spent in MVPA dur- ing the PS intervention (r = 0.32; p < 0.05), but not during the nature-based orienteering intervention (p > 0.05).

Two-way ANCOVA revealed no significant main effects on the change in SE, due to either the type of intervention (p > 0.05), school location (p > 0.05) or interaction of both variables (p > 0.05) (Table 4). The pre-intervention SE score significantly affected the change in the SE score (F(1,77) = 25.09; p < 0.001). There was no effect of BMI z-score or 20 mSRT z-score on change in SE (p > 0.05).

Discussion

The primary aim of this study was to determine which type of playtime intervention is most effective at increasing PA levels and improving SE in UK school children. The results indicated that the PS intervention led to significantly greater increases in the time spent in MVPA compared to the nature-based orienteering intervention, irrespective of the school location. The time spent in MVPA following the PS intervention contributed 21 % towards the daily PA recommendation; whilst the time spent in MVPA following nat- ure-based orienteering only contributed 13.7 %. Previous studies support the finding that the provision of games equipment during playtime leads to increases in PA (Verstraete et al. 2006; Haug et al. 2010). However, no studies to date have documented the effects of a nature-based intervention on PA. Greater increases in PA might have been expected following the nature-based orienteering intervention as access to natural environments has been associated with increased levels of PA (Wells et al. 2007). On the other hand, the PS intervention may have encouraged more vigorous activity than the nature-based orienteer- ing, as orienteering requires cognitive thinking which may influence PA levels.

There was a positive relationship between fitness and time spent in MVPA for the PS intervention, suggesting that more fit children chose to engage more with the sports equipment than less fit children. There was no correlation between fitness and the time spent in MVPA during the nature-based orienteering, indicating that this type of intervention may be effective at engaging children of all fitness levels. PA in man-made settings is based on a hierarchy of physical strength and skill (Bird 2007), whereby the fittest and most able individuals dominate. Natural areas stimulate more diverse and creative play, providing opportunities for children of all abilities to take part (Bird 2007). The nature-based orienteering intervention was more inclusive than the PS intervention; thus nature-based interventions should be used as a tool to engage children of all abilities in PA during school playtime.

Both the PS and nature-based orienteering interventions led to improvements in SE; however, there were no significant differences in the change in SE due to the type of intervention. In adults, performing PA whilst exposed to nature has been demonstrated

Table 4. Change in SE scores due to the sports equipment and orienteering intervention in urban and rural school children (mean ± SD (95 % CI)).

Urban Rural Total

Sports 2.33 ± 6.69 (−0.65 to 3.66) 0.78 ± 5.18 (−1.68 to 2.46) 1.53 ± 5.94 (−0.51 to 2.41) Orienteering 2.16 ± 5.81 (0.68–5.16) 0.59 ± 3.33 (−0.97 to 3.19) 1.32 ± 4.66 (0.51–3.51) Total 2.25 ± 6.21 (0.63–3.79) 0.68 ± 4.31 (−0.75 to 2.25) 1.43 ± 5.32 (0.24–2.48)

Note: A positive change = an improved self-esteem.

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to provide synergistic benefits for PH (Pretty et al. 2005, 2007; Barton & Pretty 2010). In the children in the current study, interventions conducted in natural, green environ- ments did not affect SE differently to interventions conducted in concrete areas. The current generation of children spend significantly less time interacting with nature than previous generations (Bird 2007). As such, it is possible that they have become discon- nected from the natural environment in a way that limits them from receiving benefits for PH (Bratman et al. 2012). However, the effects of the nature-based intervention may have been limited by the duration of the orienteering, the type of activity and factors such as weather and temperature. Further investigation into the benefits of green exer- cise and activity requiring interaction with nature is warranted in children.

The secondary aim of this study was to compare the effect of the interventions in children whose schools were located in either an urban or rural setting. Environmental location may affect health risk factors. In this study, children attending the urban school had a significantly higher BMI (and BMI z-score) than those from the rural school and were more likely to be classified as either overweight or obese. SES may affect BMI, due to limited opportunities for PA and greater access to sedentary activities in more deprived individuals (Tandon et al. 2012). Whilst both of the schools within this study were within areas which were in the 20 % most socio-economically deprived in Eng- land, they were categorised as so for different reasons. The urban school was in an area deprived in terms of education, skills and training, income, crime and employment, whilst the rural school was only deprived in terms of housing and access to key services (Colchester Borough Council 2004). Poor income and a lack of employment are likely to prevent individuals from having bicycles or portable exercise equipment which provide opportunities for PA (Tandon et al. 2012), whilst having to travel to reach key services such as a supermarket or doctor are not.

In terms of MVPA, the urban school children responded to the interventions more positively than the rural school children. Whilst the urban children experienced increases in MVPA by 4.2 and 4.6 min due to the PS and nature-based orienteering interventions, respectively, the rural children only experienced 1.9 and 0.2 min increases, respectively. The urban children may have responded more positively to the playground intervention, as they may not have access to the equipment outside of the school environment. Fur- thermore, children living in a deprived urban area are less likely to have regular access to nature (Bird 2007). The interventions provided new and exciting opportunities for the urban children, but may have been more familiar to the rural children, thus leading to the disparities in their effects. The findings suggest a need for bespoke activity interven- tions informed by the school location, characteristics and fitness levels of the children. However, it should be noted that the differences between MVPA in two schools prior to the interventions might have impacted on the results.

The urban children experienced slightly greater improvements in SE following the playtime interventions; however, these differences were non significant. The urban chil- dren performed more MVPA during the interventions and seemed to engage with the interventions to a greater extent than the rural children; thus, the slightly more positive changes in SE might have been expected. Urban residing children also have less fre- quent opportunities for day-to-day contact with nature than rural children (Bird 2007), perhaps providing some explanation as to why they experienced a more positive enhancement in SE following nature-based orienteering. To date, this is the first known study to examine the effect of different playtime interventions on SE and to compare the effects in urban and rural school children.

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The present study has several limitations. Firstly, the lack of randomisation of the interventions may have impacted upon the results. Randomisation helps to control for the potential novelty effects of the interventions and prevents one intervention from impacting upon the other. Since the playground intervention was performed first and there was only a one week gap between the interventions, the playground intervention may have directly impacted upon the pre-nature-based orienteering MVPA. The timings of MVPA assessment post-intervention may also be considered as a limitation, as only one day of monitoring took place. Additional monitoring would provide a more thorough assessment of the impact of the interventions on PA. The study would also have benefited from a longer intervention period. The one-week period for which the interventions were implemented is unlikely to have influenced SE, thus accounting for the lack of statistically significant changes. Also, given that the interventions were performed in two different schools, it is possible that there may have been some dispar- ity between the interventions and their implementation, which might have impacted on findings.

Conclusion

This study indicates that whilst both nature- and playground-based interventions can increase the time spent in MVPA during playtime, the more traditional playground inter- ventions are more effective at increasing PA. Urban children seem to respond more pos- itively to playtime interventions than rural children; however, differences in activity levels prior to the interventions may limit the application of these findings. Children with lower fitness tend to be disengaged with the more traditional playground activities; thus, nature-based interventions may provide vital opportunities for PA in these groups of children. Playtime interventions can also promote improvements in SE; however, these do not significantly vary according to the type of intervention or the location of the school. This study demonstrates that it is essential that a multi-faceted approach be utilised in order to engage children in PA during school playtime, whilst also taking advantage of the numerous health benefits derived from playing in all areas of the school grounds. Nature-based interventions should be implemented alongside play- ground-based interventions to provide opportunities for children of all abilities to engage in PA during playtime. Thus, schools should allow children to have regular access to both the playground and natural areas of the school grounds in order to for all children to have opportunities to be active. Furthermore, PA and health policies should encour- age the use of natural environments in order to enable more children to meet activity guidelines and thus receive the well-documented health benefits.

Acknowledgement This work was supported by Heart Research UK [HHG/2968/08].

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https://www.researchgate.net/publication/262225742

Abstract
Introduction
Methodology

Participants
Procedure
Interventions
Instrumentation
Data analysis

Results
Discussion
Conclusion
Acknowledgement
References