Education outside the classroom as upstream school health promotion: 'adding-in' physical activity into children's everyday life and settings.

INTRODUCTION: It is central for public health to answer questions related to how to change health and wellbeing in populations through interdisciplinarity and health in all policies and sectors. For a school physical activity promotion initiative to be acceptable and thus feasible, the buy-in of teachers is fundamental. Therefore, school physical activity promotion should be integrated into and support teaching activities. AIMS: We discuss the use of education outside the classroom as a feasible pedagogical approach that integrates and promotes physical activity for school children. METHODS: We present and discuss theoretical arguments and empirical evidence to argue and illustrate that education outside the classroom is a promising approach for promoting physical activity. RESULTS: Education outside the classroom is characterised by regular curriculum-based experiential teaching activities outside the classroom with the inclusion of physical activity as a means to pedagogical ends. School subjects are taught outside the classroom drawing on problem-based learning and experiential education. Here, physical activity is integrated without compromising curriculum goals which increases teacher buy-in and thereby intervention acceptability and feasibility. Empirical evidence suggests that education outside the classroom increases boys' moderate to vigorous physical activity and girls' light intensity physical activity. We contend that the mechanisms are a mix of place, pedagogy and pupil motivations. CONCLUSIONS: Education outside the classroom is a feasible and acceptable approach to public health and physical activity promotion because it is integrated into children's everyday settings through curriculum time and applied broadly to child populations at a low cost. The practice of education outside the classroom is context-dependent and culturally bound, and practices therefore need to be adapted to the individual sociocultural context.

The Association between Education Outside the Classroom and Physical Activity: Differences Attributable to the Type of Space?

Education outside the classroom (EOtC) has become an attractive approach, not only for learning but also for health. This explorative, cross-sectional study investigated children's sedentary behaviours (SED), light physical activity (LPA) and moderate-to-vigorous PA (MVPA) on school days with an EOtC session in green space compared to school days with EOtC in other environments and without EOtC. Teachers from 17 Danish school classes practised EOtC for one school year on a weekly basis and self-reported the characteristics of the EOtC environment. The pupils' PA was device-measured for seven consecutive days in a random period during the school year with AX3 accelerometers. Across 617 pupils (age 9-13 years), PA intensity cases (N = 2264) on school days (8:10-14:00 h) with (n = 317) or without (n = 1947) EOtC were included in a mixed-effects regression analysis. Mean exposure to EOtC was 262 min per session. School days with green EOtC (e.g., parks, forests and nature schools) were associated with (mean, [95% CI]) -24.3 [-41.8, -7.7] min SED and +21.3 [7.7, 36.4] min LPA compared to school days with non-green EOtC (e.g., cultural and societal institutions or companies) and with +6.2 [-0.11, 11.48] min MVPA compared to school days with a school-ground EOtC. No sex differences were found. In conclusion, school days with green EOtC must be considered promising to counteract children's sedentary behaviours during school hours.

Mental, physical and social health benefits of immersive nature-experience for children and adolescents: A systematic review and quality assessment of the evidence.

In this systematic review, we summarised and evaluated the evidence for benefits of immersive nature-experience on children and adolescents' mental, physical and social health. An electronic search was performed for English language articles published between January 2004 and May 2017. Data were extracted from 84 publications that met the inclusion criteria. Study quality was assessed for a subset of the studies, i.e. controlled between- and within-subject studies, using a systematic assessment scheme, and the quality of the evidence was reviewed at an outcome level. Across heterogeneous types of immersive nature-experience, there was conditional support for benefits on self-esteem, self-efficacy, resilience and academic and cognitive performance. Correlational research evidenced higher levels of physical activity in natural environments than comparison conditions. Benefits for outcomes such as self-concept, problem solving, and mood were more inconclusive. In addition, social skill-oriented and behavioural indicators were improved, although the categories comprised different outcomes. Risk of bias, insufficient sampling methods and unsuited comparison groups were common study limitations.

Immersive Nature-Experiences as Health Promotion Interventions for Healthy, Vulnerable, and Sick Populations? A Systematic Review and Appraisal of Controlled Studies.

In this systematic review, we summarized and evaluated the evidence for effects of, and associations between, immersive nature-experience on mental, physical, and social health promotion outcomes. Immersive nature-experience was operationalized as non-competitive activities, both sedentary and active, occurring in natural environments removed from everyday environments. We defined health according to the World Health Organization's holistic and positive definition of health and included steady-state, intermediate, and health promotion outcomes. An electronic search was performed for Danish, English, German, Norwegian, and Swedish articles published between January 2004 and May 2017. Manual approaches, e.g., bibliographies from experts, supplemented the literature search. Data were extracted from 461 publications that met the inclusion criteria. To assess the status and quality of the evidence for health promotion effects of immersive nature-experience, we focused on the subset of studies based on controlled designs (n = 133). Outcome level quality of the evidence was assessed narratively. Interventions most often involved adventure-based activities, short-termed walking, and seated relaxation in natural environments. We found positive effects on a range of health promotion outcomes grouped under psychological wellbeing (n = 97; ≈55% positive; ≈13% mixed; ≈29% non-significant; 2% negative); psychosocial function (n = 67; ≈61% positive; ≈9% mixed; ≈30% non-significant); psychophysiological stress response (n = 50; ≈58% positive; ≈18% mixed; ≈24% non-significant), and cognitive performance (n = 36; ≈58% positive; ≈6% mixed; ≈33% non-significant; 3% negative); and social skills and relationships (n = 34; ≈70% positive; ≈7% mixed; ≈22% non-significant). Findings related to outcomes categorized under physical health, e.g., risk of cardiovascular disease, were less consistent (n = 51; ≈37% positive; ≈28% mixed; ≈35% non-significant). Across the types of interventions and outcomes, the quality of the evidence was deemed low and occasionally moderate. In the review, we identify, discuss, and present possible solutions to four core methodological challenges associated with investigating immersive nature-experience and health outcomes: (1) intervention and program complexity; (2) feasibility and desirability of randomization; (3) blinding of participants and researchers; and (4) transferability and generalizability. The results of the review have been published as a popular-scientific report and a scientific research overview, both in Danish language.

Are children participating in a quasi-experimental education outside the classroom intervention more physically active?

BACKGROUND: Education outside the classroom (EOtC) is a curriculum-based approach to teaching that has shown positive associations with children's physical activity and academic learning in small-scale case studies. The purpose of this large-scale quasi-experimental study was to determine if children who participate regularly in EOtC spend more time being physically active than children who do not. METHODS: In the 2014/2015 study TEACHOUT, classes were recruited in pairs such that each EOtC class had a non-EOtC comparison class at the same school and grade level. Participants in 17 EOtC classes and 16 comparison parallel classes across Denmark wore an Axivity AX3 accelerometer taped to the lower back for seven consecutive days. Data from 201 EOtC participants (63.3% girls, age 10.82 ± 1.05,) and 160 comparison participants (59.3% girls, age 10.95 ± 1.01) were analysed using an 'intention to treat' (ITT) approach. The amount of EOtC the participants were exposed to was monitored. Associations between time spent in different physical activity intensities and EOtC group and sex were assessed using generalised linear models adjusted for age. In a second analysis, we modified the sample using a 'per protocol' (PP) approach, only including EOtC and comparison class pairs where the EOtC class had >150 min and the comparison had <150 min of EOtC during the measured week. RESULTS: On average, EOtC participants spent 8.4 (ITT) and 9.2 (PP) minutes more in moderate-to-vigorous physical activity (MVPA) per day than comparison participants (p < 0.05). However, EOtC boys spent 18.7 (ITT) and 20.8 (PP) minutes more in MVPA per day than comparison boys (p < 0.01), while there were no significant between-group differences for girls. CONCLUSIONS: For boys, EOtC was associated with more daily time being spent moderately and vigorously physically active. No differences were observed for girls. Implementing EOtC into schools' weekly practice can be a time- and cost-neutral, supplementary way to increase time spent in PA for boys through grades three to six. TRIAL REGISTRATION: The Scientific Ethical Committee in the Capital Region of Denmark protocol number H-4-2014-FSP . 5 March, 2014.

Measuring Children's Physical Activity: Compliance Using Skin-Taped Accelerometers.

INTRODUCTION: Accelerometer-based physical activity monitoring has become the method of choice in many large-scale physical activity (PA) studies. However, there is an ongoing debate regarding the placement of the device, the determination of device wear time, and how to solve a lack of participant compliance. The aim of this study was to assess the compliance of Axivity AX3 accelerometers taped directly to the skin of 9- to 13-yr-old children. METHODS: Children in 46 school classes (53.4% girls, age 11.0 ± 1.0 yr, BMI 17.7 ± 2.8 kg·m) across Denmark wore two Axivity AX3 accelerometers, one taped on the thigh (n = 903) and one on the lower back (n = 856), for up to 10 consecutive days. Participants were instructed not to reattach an accelerometer should it fall off. Simple and multiple linear regressions were used to determine associations between accelerometer wear time and age, sex, BMI percentiles, and PA level. RESULTS: More than 65% had >7 d of uninterrupted, 24-h wear time for the thigh location and 59.5% for the lower back location. From multiple linear regressions, PA levels showed the strongest association with lower wear time (thigh: ß = -0.231, R = 0.066; lower back: ß = -0.454, R = 0.126). In addition, being a boy, being older (only for lower back), and having higher BMI percentile were associated with lower wear time. CONCLUSION: Using skin-taped Axivity accelerometers, we obtained 7 d of uninterrupted accelerometer data with 24-h wear time per day with a compliance rate of more than 65%. Thigh placement resulted in higher compliance than lower back placement. Achieving days with 24-h wear time reduces the need for arbitrary decisions regarding wear time validation and most likely improves the validity of daily life PA measurements.

A quasi-experimental cross-disciplinary evaluation of the impacts of education outside the classroom on pupils' physical activity, well-being and learning: the TEACHOUT study protocol.

BACKGROUND: Education Outside the Classroom (EOTC) is a teaching method that aims to promote schoolchildren's learning, physical activity (PA), social relations, motivation, and well-being. EOTC activities are characterized by teachers using the local environment in their teaching, and involve innovative teaching methods, child-led approaches to problem-solving, experimentation, cooperation, PA, and play. EOTC has become common practice for many teachers in Scandinavia; however, only case studies have evaluated its impacts. The TEACHOUT study aims to evaluate the impacts of EOTC on Danish schoolchildren's PA, social relations, motivation, well-being, and learning. METHODS: TEACHOUT is a quasi-experimental, cross-disciplinary study. Sixteen schools participated, containing 19 EOTC school classes and 19 parallel non-EOTC classes, with a total of 834 children aged 9 to 13 years. Measures of the children's social relations, motivation for school, well-being, and academic performance were collected at the beginning and end of the school year. Data on PA levels were collected over ten-day periods during the school year using accelerometers. The amount and characteristics of the actual EOTC provided in both EOTC and non-EOTC classes were monitored day-to-day throughout the school year, using an online teacher survey platform. The effects of EOTC are mainly analysed by comparing EOTC pupils to non-EOTC (i.e. control) pupils based on their scores on the outcome variables (i.e. school performance, well-being, motivation, and social relations) at the end of the school year, adjusting for the baseline values (from the beginning of the year). The impacts of EOTC on PA are evaluated by comparing the total as well as context-specific amounts of PA of children participating in EOTC to those of children in their parallel non-EOTC classes. Furthermore, the interdependencies between PA, social relations, well-being, motivation, and learning are explored using path analysis. To help describe and understand the processes that have led to the quantitative outcomes, qualitative case observations of children's practices and interactions in EOTC as well as classroom teaching were carried out and combined with qualitative interviews about children's perceptions of these practices. DISCUSSION: The TEACHOUT study represents a holistic multidisciplinary approach to educational and school health-promotion research through its study design and combination of scientific disciplines and methods, as well as its focus on the interdependent relations between learning, PA, social relations, well-being, and motivation. This will result in a comprehensive picture of school health promotion and children's health and well-being, which will broaden the understanding of the potential benefits of EOTC in school health promotion and primary education. These results can be used to inform and guide future policy and practice.