BACKGROUND AND OBJECTIVES: Three-fourths of US preschool-age children are in child care centers. Children are primarily sedentary in these settings, and are not meeting recommended levels of physical activity. Our objective was to identify potential barriers to children’s physical activity in child care centers.
METHODS: Nine focus groups with 49 child care providers (55% African American) were assembled from 34 centers (inner-city, suburban, Head Start, and Montessori) in Cincinnati, Ohio. Three coders independently analyzed verbatim transcripts for themes. Data analysis and interpretation of findings were verified through triangulation of methods.
RESULTS: We identified 3 main barriers to children’s physical activity in child care: (1) injury concerns, (2) financial, and (3) a focus on “academics.” Stricter licensing codes intended to reduce children's injuries on playgrounds rendered playgrounds less physically challenging and interesting. In addition, some parents concerned about potential injury, requested staff to restrict playground participation for their children. Small operating margins of most child care centers limited their ability to install abundant playground equipment. Child care providers felt pressure from state mandates and parents to focus on academics at the expense of gross motor play. Because children spend long hours in care and many lack a safe place to play near their home, these barriers may limit children's only opportunity to engage in physical activity.
CONCLUSIONS: Societal priorities for young children—safety and school readiness—may be hindering children’s physical development. In designing environments that optimally promote children’s health and development, child advocates should think holistically about potential unintended consequences of policies.
What’s Known On This Subject:
Three-fourths of US preschool-age children are in child care; many are not achieving recommended levels of physical activity. Daily physical activity is essential for motor and socioemotional development and for the prevention of obesity. Little is known about physical-activity barriers in child care.
What This Study Adds:
Injury and school-readiness concerns may inhibit children’s physical activity in child care. Fixed playground equipment that meets licensing codes is unchallenging and uninteresting to children. Centers may cut time and space for gross motor play to address concerns about school readiness.
The prevalence of high BMI increases as children age and has remained steady over the past 10 years,1 despite numerous public health efforts to curb the childhood obesity epidemic. Recent guidance2 based on empirical evidence suggests targeting prevention and interventions in the earliest age groups to address the epidemic,3–5 as by the time children are school-aged, 19% are already obese, and sedentary habits have already been established.6,7
Seventy-five percent of US children aged 3 to 5 years are in child care; 56% are in centers, including nursery schools, preschools, and full-day centers.8 Epidemiologic evidence suggests that children are not getting enough physical activity in these settings,9–14 even though it is a key strategy for preventing excessive weight gain.15–21 Children spend most (70%–83%) of their time being sedentary in child care—even when excluding time spent in naps and meals—and only spend 2% to 3% of the time in vigorous activities.9–11 This is particularly concerning, because daily physical activity is not only essential for healthy weight maintenance, but also for practicing and learning fundamental gross motor skills22–25 and socioemotional and cognitive skills.26–34
In the United States, child care facilities are licensed by individual states. The primary purpose of state licensing codes is to protect the health and safety of children. Thus, most of the language in the codes regarding physical activity relates to elements of playground safety, for example, maximum heights of climbing equipment, the size of fall-zones, and the types and depths of approved fall-zone surfaces. Individual centers may choose to implement center policies that are more promoting of physical activity, as long as they comply with the state’s minimum health and safety standards, as well as state and/or federal standards (eg, Head Start) for early learning. Licensing guidelines related to physical activity promotion vary widely among states35; only nine states specify a minimum amount of time to be spent in outdoor play.36
Children obtain vastly different amounts of physical activity in child care among states,37,38 which may in part be due to weather-related differences across regions.39 Surprisingly, however, children’s physical activity levels are highly variable among child care centers even within the same geographic region, and this variability is explained primarily (27%–47%)9,10,40 by individual center characteristics, rather than by child characteristics (3%–10%).9,10
The purpose of this qualitative study was to understand why children’s physical activity may vary among child care centers, and to identify barriers that might prevent children from obtaining adequate amounts of physical activity while in centers. This work was undertaken to generate hypotheses that could be tested in future quantitative studies to identify important barriers to children’s physical activity in child care and inform future policy-, facility-, or teacher-related interventions to increase children’s physical activity in child care. We have previously reported some of the barriers identified in this work related to children’s clothing,41 inadequate facilities,39 weather-related policies,39 and teachers’ attitudes and behaviors.42 This article presents additional findings, particularly regarding the impact of parents’ values and input that affects children’s center-based activity, highlighting those that are particularly relevant to pediatric clinicians, policy makers, and applied-pediatric researchers.
A detailed description of the methods used in this study and the demographics of the sample has previously been reported.41,42 We conducted 9 focus groups with child care teachers/providers between August 2006 and June 2007 to explore their perceptions of facilitators and barriers to children’s physical activity in centers, and to elicit child care providers’ normative beliefs.43,44 We then conducted 13 one-on-one interviews in the spring of 2008 to assess the credibility of our focus group findings (“member checks”).45 Participants were recruited through fliers and the local child care resource and referral agency, and assigned randomly to a focus group session that met their schedule. No more than 1 participant per child care center was eligible to attend each focus group, so that there was heterogeneity of experiences in each group.44,46 Participants were eligible if they currently worked or had worked in a full-day center in Hamilton County, Ohio within the past 3 years. Of the 49 focus group participants, 27 (55%) identified themselves as African American, 48 (98%) were female, and 44 (90%) had some post-high school education. Participants had worked in child care an average of 13 ± 9 years (range, <1–37 years). Focus group participants came from 34 urban and suburban centers including 5 Montessori, 6 Head Start, 2 church-affiliated, 2 Young Men’s Christian Associations, 4 worksite- or university-affiliated, and 3 corporate/for-profit centers. This study was approved by the institutional review board at Cincinnati Children’s Hospital Medical Center; all participants provided verbal informed consent to participate and received $25 remuneration.
Focus groups lasted an average 1.5 hours, were moderated by an experienced focus group facilitator (S.N.S.), and attended by the principal investigator (K.A.C). Discussions were audio-recorded and transcribed verbatim. The semistructured focus group guide included questions on benefits and barriers to children’s activity at the child, parent, teacher, center, institutional, policy, and societal levels. Open-ended questions were followed by more specific probes to clarify and extend responses. Prompted by pictures of typical child care center playgrounds, participants were asked to describe what they and the children enjoyed and did not like about their playgrounds. Examples of questions from the topic guide that contributed to the themes in this article are listed in Table 1. By consensus, 2 investigators (K.A.C. and S.N.S.) modified the focus group topic guide in an iterative fashion to explore new issues raised in previous focus group sessions and concluded after the ninth focus group that no new information was emerging from discussions. As theoretical saturation43,44 was achieved, recruitment for focus groups was terminated.
By using an inductive editing approach,46 3 investigators (K.A.C., S.N.S., and C.A.K.) trained in different disciplines (pediatrics, social science research, and child care) independently read each of the transcripts, identified emergent themes, and then as a group defined and categorized a codebook. The 3 investigators independently coded each transcript, and then met as a group to resolve any differences in coding by consensus. Nvivo (QSR International version 7) was used to record coding decisions and to manage the data.
The themes elicited from the focus groups were reviewed with 13 interview participants, 9 of whom had participated in the focus groups (“member checks”), and 4 of whom could not participate because of scheduling conflicts. Interviewees were encouraged to expand on or question each of the themes. Interview participants provided additional insights and supporting experiences, which were used to further analyze the findings, but did not differ with the investigators’ original analysis and interpretations. All quotes presented in this article are from the original 9 focus groups.
Time in Child Care May Be the Only Opportunity for Physical Activity and/or Outdoor Play
An overarching theme was that many participants expressed concern that the time in child care may be the child’s only opportunity for outdoor play (Table 2). Because many of the children were in care for such long hours, there was little free time for outside activities (¶1, ¶2). This was particularly the case for parents that worked multiple jobs (¶3), and/or did not earn sufficient income to afford outside extracurricular activities (¶4). Participants noted that some children may lack a safe place to play near their home (¶5), and several suspected that physical activity and trips to a safe park were not a “value” of the parents (¶6). This made the time in nonparental care even more critical for obtaining physical activity.
Concerns About Injury and a Focus on Safety Limits Children’s Physical Activity
Although participants acknowledged the importance of physical activity, they also acknowledged that vigorous activity and outdoor play presented a risk—that children could get injured. The child’s safety was cited as a main concern of both parents and teachers. Participants relayed pressure from parents not to allow their children to get injured while under their watch (¶7), and at times were asked to keep children from participating in vigorous activity to keep them from being injured (¶8, ¶9, ¶10).
Participants appreciated having state inspections of their playground and strict licensing codes, which helped them feel confident about the safety of the equipment, yet several worried that the guidelines had become so strict that they might actually be limiting rather than promoting children’s physical activity. Several participants discussed how overly strict standards had rendered climbers unchallenging and uninteresting to the children, thus hampering children’s physical activity (¶11, ¶12, ¶13). The new play equipment that was safe per these standards soon became boring to the children (¶11, ¶12) because they quickly mastered it. To keep it challenging, teachers noted that children would start to use equipment in (unsafe) ways for which it was not intended (¶14) (eg, walking up the slide), because participants noted that children were “wired” to seek out challenges (¶15). Some noted that preschool-aged children were drawn to more challenging “school-aged” equipment that the state had deemed was only appropriate for children over age 8 (¶16).
Last, participants cited crime-related safety concerns in the neighborhood where the center was located (¶17) as potentially inhibiting children’s physical activity. In summary, participants cited societal and adult concerns about children’s safety, and licensing guidelines designed to prevent childhood injury, both as potential obstacles to children’s physical activity opportunities in child care.
Financial Issues Limit Physical Play Space and Available Equipment
Several participants cited budgetary reasons for why their centers could not offer children optimal physical activity opportunities (¶18). Most centers had tight operating margins, and thus could not afford extensive equipment offerings (¶19, ¶20), which was cited by one participant as costing >$10 000 per climber.
Participants lamented that with budgetary constraints, and given parental concern about a focus on “academics” (discussed below), classroom and curricular activities took precedence over gross motor play offerings (¶21, ¶22). Many did not have a dedicated indoor gross motor room where children can be active during inclement weather (¶21, 22). Participants’ distaste for their inadequate play spaces sometimes caused them not to use them, thus children’s active play opportunities could be curbed even when spaces were available (¶23, ¶24).
Physical Activity versus Academics
A common theme expressed by many participants was that they felt pressure to prioritize academic classroom learning (eg, shapes, colors, prereading skills) over outdoor and active play time. Several felt this pressure directly from parents, including both upper-income (¶25, ¶26) and lower-income (¶27) families. Some participants felt this pressure from state early-learning standards (¶28, ¶29). Many teachers agreed with this goal in principle and sought to always ensure that, when it did occur, there was a purpose to physical activity so that children were not just “running around” (¶29, ¶30). Teachers felt the need to teach cognitive concepts when outside, such as numbers or one-to-one correspondence (¶31), to ensure that children were not practicing and learning only gross motor skills. At the same time, participants recognized that children learned through play, and, in particular, active play. Several commented that the energy release and creative stimulation of outdoor activities helped place children in a better mindset to learn and concentrate later, either indoors or outdoors (¶32, ¶33). Some even felt that children learned best through movement (¶34).
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.
This work was supported by the National Heart, Lung, and Blood Institute at the National Institutes of Health through Career Development Award K23HL0880531, a grant from The Robert Wood Johnson Foundation Physician Faculty Scholars Program, and by the Dean’s Scholar Program at the University of Cincinnati College of Medicine.
We thank 4C for Children, the local child care resource and referral agency that assisted with recruitment for focus groups. We also thank all of the directors and teachers who contributed their time and thoughtful comments to this study.
- Accepted October 5, 2011.
- Address correspondence to Kristen Copeland, MD, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 7035, Cincinnati, OH 45229. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Funded by the National Institutes of Health (NIH).
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