Table 6 Relevant quotes by domain, subdomain, data source, respondent

Feasibility

Clinic-centered challenges:

• Storage

• Clinic culture & staffing

• Visit duration

It doesn’t take long to give a toy out and to explain like part of the project and give them the brochure. I didn’t necessarily read the whole brochure to them or anything, but I was available for any questions…. [2-IN-PR-EN-03]

N/A

Patient-centered challenges:

• Language/ literacy

• Sustainability

The only downside I could think of is if it’s not in a language that the patient can read or if the family can read, then it’s not really beneficial for them. …. [2-IN-PR-EN-04]

One time maybe a few days later, I reminded him we had it, and he picked it up and took it, and went outside, but it didn’t last very long. [2-IN-PA-EN-03]

Seven days straight. And then he gave up on it..[2-IN-PA-EN-08]

Acceptability

TOY

Likable aspects:

• Fun & exciting

• Portable & storable

Disappointing aspects:

• Quality

• Durability

Oh, they loved the toy. And they gave them the option of like what toys they wanted. Yeah, most of them were really, really happy with the choices that were allowed. [2-IN-PR-EN-04]

I always thought it was lightweight and small, and I could pack it somewhere. [2-IN-PA-EN-02]

… [My son] was really excited to get bugs in this jar and look at them. And then [my daughter] was excited to see her sunflower seeds grow. [2-IN-PA-EN-05]

I know it’s hard because you’re working with a budget, but I think having better quality or more durable toys would see better results and actually changing behavior. [2-IN-PA-EN-03]

BROCHURE

Helpful aspects:

• Child-friendly

• Accessible formatting

Suggestions for improvement:

• Include ideas for cold/wet weather

• Consider formatting as a calendar

… it was helpful in framing conversation and I think that it’s helpful for parents to have something in their hands to remember what we talked about …. But I felt like overall, it was pretty easy to read and interact with. [2-IN-PR-EN-01]

It’s very easy to, like, have ideas to do things outside when the weather’s nice, but giving ideas of what to do when the weather is not so good. [2 IN-PA-EN-02]

If there was something like … here’s a …calendar of like -- here’s the activities. Mark off, like on the calendar, what was done. Kind of the way the libraries do, like the reading calendars over the summer. [2-IN-PA-EN-09]

WEBSITE:

• Parents unaware of website

• Reliant on providers to advertise

N/A

I don’t know if it was emphasized enough that there was another tool to go along with the brochure and the participation toy with the study. Maybe emphasize it a little more. [2-IN-PA-EN-06]

Barriers to using PN

Transportation & expense (toolkit does not address structural barriers)

I’m just thinking about how a good number of our families at Odessa Brown do live in apartments…it’s just not as easily accessible for them to go outside. [2-IN-PR-EN-03]

I think really having like resources for families who, you know, might not be able to, you know, attain the ability to attend these kinds of activities. Us, you know, as working parents do have to go to work and provide for a family. [2-IN-PA-EN-06]

Neighborhood context & safety (toolkit does not address structural barriers)

They’d have to go down the stairs, you know, like find a safe place. And so I think depending on where they actually live, it will affect how frequently they use like their outdoor tool, I guess, or toy. [2-IN-PR-EN-03]

N/A

Children tired & prefer sedentary activities

N/A

Sometimes the kids after school, they are just sort of burned out and they’re tired and they want to just have like downtime. Unfortunately, I think like TV and iPads… if you gave them a choice, they would choose that over going outside sometimes. But once they get outside, they’re always happy to do that. [2-IN-PA-EN-09]

Parent energy, time, & absence

N/A

I work overtime because my shift is like from 7:00 to 3:30, but sometimes I work until 5:00. In that case, we don’t have time for other activities. She has to go to back sleep at 7:00. So, we only have like an hour or two to do her homework. [2-IN-PA-EN-09]

Weather (summer toys not applicable during winter)

I think simple toys … like jump rope…are fun and good in the summer time, but tend to be a little bit messier and cold, … there’s the majority of the winter in the Seattle area. [2-IN-PR-EN-03]

I recall wondering, you know -- oh, what the like -- you know, it’s very easy to do stuff outside with [my daughter] when the weather’s nice, but it kind of turns super rainy. What, like, what are some ideas of what to do then? [2-IN-PA-EN-02]

Efficacy

Contributors to efficacy:

• Concrete, tangible object was motivating to parents AND children

• Facilitated conversations & play

• Provided ideas

I thought that families liked the intervention. It was acceptable to them and it facilitated conversations about specific ways that kids could engage in outside play. [2-IN-PR-EN-03]

I liked that it gave me an idea of another fun activity to do with her outside at the park instead of just playing at the playground…. [2-IN-PA-EN-02]

… I’m not that active as her… So that [kite] makes me run, too, because I have to start it for her to fly. So, it was kind of interesting that it really made me open my eye too. [2-IN-PA-EN-01]

Limitations to efficacy:

• Dependent on compatibility

• Dependent on engagement

They really loved picking out the activities or the little kind of things that we had available to them at the clinic. And then they were pretty motivated to try to do some more things outside. [2-IN-PR-EN-04]

I thought it was cute, because she actually, she likes plants. She likes seeing how they come up. She likes looking at all different kinds of plants. The colors is just something that she likes doing. So, I was pretty proud of her that she picked something that she was interested in. [2-IN-PA-EN-07]