Project nature: promoting outdoor physical activity in children via primary care

Background Families face a range of barriers in supporting their children’s active play in nature including family circumstances, environmental constraints, and behavioral factors. Evidence-based strategies to address these barriers are needed. We aimed to develop and pilot test a primary care-based family-centered behavioral intervention to promote active outdoor play in 4–10 year-old children. Methods Project Nature, a provider-delivered intervention that provides informational resources and an age-appropriate toy for nature play, was initially developed for children ages 0–3. With stakeholder input, we adapted existing materials for 4–10 year-olds and conducted usability testing at an urban clinic serving families from diverse backgrounds. Subsequently, we conducted a mix-methods pilot study to evaluate intervention feasibility and acceptability. Parents of 4–10 year-olds completed pre- and post-surveys (n = 22), and a purposive subset (n = 10) completed qualitative interviews. Post-intervention, pediatric providers (n = 4) were interviewed about their implementation experiences. Results The majority (82%) of parents liked the information provided and the remaining (18%) were neutral. Qualitatively, parents reported that: the toy provided a tangible element to help children and parents be active, they did not use the website, and they wished the intervention emphasized strategies for physical activity during cold and wet seasons. Providers felt the materials facilitated discussion about behavior change with families. There were no statistically significant changes in PA and outdoor time pre- and post-intervention. Conclusions Project Nature was welcomed by providers and families and may be a practical intervention to promote outdoor active play during well-child visits. Providing an age-appropriate nature toy seemed to be a critical component of the intervention, and may be worth the additional cost, time and storage space required by clinics. Building from these results, Project Nature should be revised to better support active outdoor play during suboptimal weather and evaluated to test its efficacy in a fully-powered trial. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-024-02297-5.


Background
The health benefits of daily physical activity (PA) and time outdoors are well-recognized [1][2][3].For children, time outdoors is strongly associated with increased PA [1] and a range of other benefits including improved mental health, healthier weight status, and less myopia [3,4].The American Academy of Pediatrics and other experts recommend children and adolescents play outdoors daily and participate in moderate-to-vigorous PA (MVPA) 60 minutes/day to improve physical, mental, and cognitive health [5][6][7][8].In 2019 only 23% of U.S. youth met these recommendations, a percentage that has been declining over time [9] and especially since the COVID-19 pandemic [10].A growing body of evidence indicates that nature contact can confer both physical and mental health benefits for children of all ages.A recent systematic review of almost 300 studies concluded that the current literature supports a positive relationship between nature contact and children's health, and recommended advocating for strategies that promote equitable nature contact for children in places where they live, play, and learn [3].Parents have identified a range of barriers to supporting children's active play in nature including family circumstances (e.g., time, finances, single parenting), environmental constraints (e.g., access to safe outdoor play spaces, transportation, finding age-appropriate activities), and behavioral factors (e.g., previous experiences in nature, safety, weather concerns) [11].Many barriers stem from structural inequities rooted in historical, racial discriminatory practices such as "redlining" [12] that created disparities in parks access.
While addressing structural barriers to nature access is paramount to supporting equitable access to outdoor play [11,13], there is also opportunity for family-centered interventions [11,13].It is vital to establish active play habits early, as PA strongly tracks from early childhood to adulthood [14]."Prescriptions" to encourage time in nature [15][16][17][18] provide directive information about what families "should" do, but may not address context-specific barriers to outdoor play.A recent study conducted by our team found that parents of school aged children wanted information about opportunities for nature play near their homes, including how to access nature and support children's safe play under different weather conditions [11].Evidence-based primary care strategies to promote children's active play in nature and address existing barriers are needed.
Project Nature (PN), a provider-delivered intervention developed initially for children ages 0-3, addresses some of these limitations using an educational brochure (that describes benefits to active play in nature and activity ideas), a website (that shares local resources including parks, green spaces, and nature programs), and an age-appropriate nature toy (that can be used for outdoor play).The development of this intervention was guided by the WHO's Commission on Social Determinants of Health framework [19] and our formative work pointed to well-child visits as an appropriate setting to support children's outdoor play [11].Pediatric providers employing PN identified a need for a similar intervention aimed at older school-aged children.
The aims of this multi-phase study were to (1) conduct an adaptation needs assessment of the existing preschool age intervention, (2) adapt PN for school-aged children with parent and provider input, and (3) test the feasibility, acceptability, and preliminary efficacy of this adapted intervention.

Study design and personnel
This study was conducted in Seattle, WA from 2020 to 2023, and included three phases: (1) adaptation needs assessment, (2) material adaptation and usability testing, and (3) pilot evaluation.See Fig. 1 for a description with details of each component.The Seattle Children's Hospital Institutional Review Board approved the study.This report conforms to the Standards for Reporting Qualitative Research [20].Our multidisciplinary team included individuals with expertise in pediatrics (PT, DG), sports medicine (GG, LN), public health research (EK), anthropology and qualitative research (KS, CN), research coordination (KG), and data analysis (MB).Our team members identify across many disciplines, ethnicities, languages, and parenting experiences; these diversities and viewpoints informed study design, data collection and data analysis.We employed triangulation at many stages so data from each source contributed to our robust understanding of the phenomena.In this study we used an inclusive definition of "parent" as one of a child's primary guardians accompanying the child to their clinic visit.

Phase 1: adaptation needs assessment
A convenience sample of 14 (7 English-speaking and 7 Spanish-speaking) parents of children age 3-10 were recruited from pediatric clinics in Seattle that serve high proportions of patients with public insurance.We selected these clinics recognizing that outdoor play in nature is less accessible for families with resource constraints and those who face cultural barriers.14 pediatric providers were recruited via word of mouth and a message in the Washington Chapter of the American Academy of Pediatrics newsletter.Interviews with parents centered around family barriers to outdoor play and conversations about playing in nature with their pediatric provider (see Additional file 1), and were conducted by native speakers, professionally translated and transcribed, and then spot-checked by native speakers for accuracy.Focus groups with providers explored feasibility and acceptability of adapting PN for older children (see Additional file 2).

Phase 2: material adaptation and usability testing
Incorporating themes from the adaptation needs assessment, we systematically adapted the existing PN materials (designed for 0-3 year old children) for older children 4-10 years old.Proposed adaptations were brought to our multidisciplinary planning group for input on developmental appropriateness, consistency with the core components of PN, and considerations related to equity and inclusion.This feedback was: synthesized into an initial draft of a brochure, revised by a graphic designer, and reviewed by our full team.
Next, we conducted usability testing with the adapted intervention with a sample of English-and Spanishspeaking parents and clinic staff at one pediatric health clinic serving primarily publicly insured children in an economically and racially diverse neighborhood in Seattle.Spanish interviews were conducted by native speakers.A convenience sample of 20 (10 English-speaking and 10 Spanish-speaking) parents of 4-10 year-old children seeking care were invited to review PN materials and provide mixed method feedback on their acceptability and usability.5 staff members were interviewed (1 ARNP, 1 behavioral health therapist, 1 RN, 2 social workers).All participants verbally provided informed consent.We measured usability with Lyon et al. 's Usability Evaluation for Evidence-Based Psychosocial Interventions scale [21].Qualitative interviews were conducted with each of the participants.Interview guides can be found in the Additional file 3. Feedback was synthesized in the moment following each interview and taken back to the team.The results were used to finalize the age-adapted PN intervention components.

Sample and procedure
We held a meeting with interested providers at our partner clinic and provided a written guide for how providers can introduce and discuss PN with families.Providers could tailor conversations based on families' circumstances, needs and barriers.Printed brochures and nature toys were delivered to the clinic.
We recruited families with the following eligibility criteria were: (1) child scheduled for a 4-10 year-old wellchild visit with a participating healthcare provider, (2) parent spoke English, and (3) verbal consent obtained from a parent or guardian prior to the visit in person or via phone call.Parents were asked to complete quantitative surveys via email, phone call, or paper before the scheduled well-child visit.Three weeks post-intervention, parents were asked to complete a post-intervention survey.Surveyed parents were subsequently invited to complete qualitative interviews.After reviewing our initial 10 transcripts, we ascertained that data sufficiency had been achieved and data collection was complete.Postintervention, we held phone interviews with participating

Survey measures
Pre-and post-survey topics included: MVPA participation by child and parent independently for at least 20 minutes/day; co-participation in PA and outdoor time; and prior discussions with the child's healthcare provider about PA and outdoor time.Although the recommendation for children 6 and older is 60 minutes/ day of MVPA and 150 minutes/week for adults, the guidance for younger children is less concrete, so we chose the 20 minute/day mark to be able to capture some PA in an increment that may be more reasonably impacted by the PN intervention.The survey also inquired about barriers that may prevent the child from being physically active and demographics.The post-survey assessed perceptions of the intervention's feasibility and accessibility using Weiner et al. 's Acceptability of Intervention Measure, a validated 4-question self-report scale [22], as well as self-reported implementation of toy and brochure.The survey can be found in Additional file 4.

Qualitative measures
Using a phenomenological approach, our qualitative interview guides were developed according to study goals and adjusted as necessary per standard qualitative methodology [23,24].Individual interviews with parents focused on acceptability, feasibility and preliminary efficacy of the intervention.Interviews with providers addressed acceptability and feasibility of the intervention in the clinic setting.Parent and provider interview guides can be found in the Additional file 5 and 6.

Data analysis
Parent and child demographics were summarized descriptively.Mean and standard deviations were calculated for numeric outcomes pre and post intervention and compared statistically with paired t-tests.This was a Phase 1b behavioral study, and thus not powered to detect change quantitatively.
Interviews and focus groups (in Phase 1 and 3) were digitally recorded, professionally transcribed (and translated where appropriate), and spot checked by interviewers to ensure data integrity [25,26].In the results, quotes are identified by data set (where 1 = adaptation needs assessment, 2 = pilot evaluation), qualitative tool (IN = interview, FG = Focus group), parent versus provider (PA = Parent, PR = provider), language (EN = English, SP = Spanish) and participant number.
Data were uploaded into Dedoose Version 7.0.23 (Sociocultural Research Consultants, Los Angeles, California) for coding and thematic analysis following procedures outlined by Braun and Clarke [27].Steps to codebook development were as follows: initial codes were derived from study goals; codes were augmented by a reading of two transcripts; codes were tested on three additional transcripts by two coders; the codebook was edited until an exhaustive but manageable code list was reached.We used a multi-step approach to developing the codebook which allowed for both deductive codes (e.g., Perceptions and Usability of PN) extracted from study goals, instruments, frameworks, and inductive codes (e.g., Weather and Child unmotivated to go outside as barriers to do PA) emerging from review of transcripts.
Transcripts were open coded by two coders (KS, CN) who were blind to each other's coding and differences were resolved by discussion until 100% agreement was reached.During synthesis, coded excerpts were systematically summarized into themes and subthemes with associated quotes.

Adaptation needs assessment
Demographics for the Adaptation Needs Assessment can be found in Tandon et al. (2022) [11].Several key needs and key barriers for the adapted materials emerged from the pediatric provider focus groups and parent interviews, which are summarized in Tables 1 and 2 respectively.
Providers and parents emphasized the importance of the intervention being engaging, fun, and exciting.Both felt that concrete physical materials such as a toy and brochure can be particularly motivating.Images representing families from many different backgrounds would make the materials child-friendly and inclusive.It would also be important to consider family literacy and language barriers.There were concerns that it would be difficult for the intervention to address structural barriers to active play outside including transportation, expenses, and neighborhood safety.Other barriers, such as children preferring sedentary, indoor activities and suboptimal weather could potentially be addressed by the intervention.
Providers identified possible clinic-centered challenges to PN implementation including inadequate storage space, established clinic culture and habits inhibiting distribution and inventory of PN materials, and the limited length of well-child visits.

Demographics for the Material Adaptation & Usability
Testing are displayed in Table 3.The key needs highlighted by the needs assessment were used to adapt the core components of PN for 4-10 year-olds and to diverse families.from parents and clinic staff on the written materials and nature toy, which was incorporated into the final adapted materials.Parents wished for a varied selection of nature toys to match their children's diverse interests; the research team used parents' suggestions to finalize the following nature toy options: kite, jump rope, bubble wand, frisbee, colored chalk, bug catcher and magnifying glass, and shovel and seeds.When surveyed, parents and clinic staff who participated in usability testing described PN as appealing to use often, easy to understand, and easy to learn how to use.

Pilot evaluation
Demographics of participants who completed pre-and post-surveys are displayed in Table 5. 26 families received the intervention and 22 parents completed both pre-and post-intervention surveys.Of those 22, 10 completed qualitative interviews.Of the 6 pediatric providers who participated in the pilot, we interviewed 4 ARNPs.
Here we report our findings from the Pilot Evaluation organized by 1) feasibility and acceptability, and 2) preliminary efficacy.Qualitative feedback from providers and parents on their experience with the intervention is summarized in Table 6.

Feasibility and acceptability
Parents generally liked the information about PN discussed by their pediatrician, the toy, and the brochure (Table 7).The mean score on Weiner et al. 's validated 4-item Acceptability of Intervention measure was 4.3, SD = 0.8, out of a range of 1 to 5, where higher scores indicate greater acceptability.On average, participants endorsed a response of "agree" or "completely agree" to items about the acceptability of the intervention.82% of families who were given the PN kit by their provider reported using it.
Interviews confirmed that PN as a whole was wellreceived and welcomed by both parents and providers.
With few exceptions, parents perceived the nature toys to be fun and conveniently sized (e.g.portable and storable).Parents were pleased that toys matched their children's individual interests.Children did not show a predilection to choosing certain toys over others; the least expensive toys (e.g.chalk, bubble wand, and frisbee) were just as popular as the more expensive ones (e.g.seeds and shovel).
Some parents mentioned that their children were unmotivated to do PA, preferring screen-based and sedentary activities; the children enjoyed PA once they were outdoors, but the process of persuading them to go out could be hard.Parents liked that the PN toy reminded them to take their children outdoors for PA and provided more ideas for how to encourage their children to be active.Parents raised concerns about the toy durability; they observed that PN might not be sustainable long term because children were initially excited but lost enthusiasm over time or when toys broke.While the brochure was well-liked by parents in survey responses, the majority of parents interviewed did not remember using the brochure.Parents wished that the brochure included more ideas for activities to do when the weather is less favorable for outdoor play.Parents suggested changing the format (e.g. to activity book or calendar) and including more activities ideas besides those involving the PN toy (e.g.scavenger hunt).
Most parents were not aware of the website and therefore did not visit it.However, parents did express interest in visiting the website if they had known about it and suggested that providers should emphasize it more.Most of the providers did not remember talking about the website with parents.
There were barriers to families using the PN materials.In pre-and post-surveys, weather was the mostcommonly reported barrier to children's PA, followed by time.In interviews, parents raised concerns that the nature toys and activity ideas were practical only for warm, dry weather.Parents wished that providers spent time discussing strategies for PA during cold and wet seasons.Parents pointed out that feeling tired, being busy with work and lack of time were also barriers to consistently supporting their children's PA and time in nature.
Providers had mixed perceptions about the amount of time they had for PN during well-child visits; some felt the amount of time was sufficient, while others did not.Within the study context, providers found that not giving the intervention to all the patients seen each day led to forgetting to do the intervention with some of the participants that were enrolled in the study.

Preliminary efficacy
There were no statistically significant changes in PA and outdoor time pre-and post-intervention (Table 8).

Discussion
This study demonstrates how we successfully adapted PN for a diverse group of families with children aged 4-10 years old, through an iterative process of engaging stakeholders and implementing feedback.PN was welcomed by providers and families and may be a practical intervention to promote outdoor active play during wellchild visits.Pediatricians and other pediatric clinicians are uniquely positioned to encourage and support families in physical activity and nature contact but face some challenges in doing so.Building from these results, PN should be revised to better support active outdoor play during suboptimal weather and evaluated to test its efficacy in a fully-powered trial.
The nature toy was the most memorable aspect of the intervention for both providers and families and seemed to be a critical component of the intervention that may be worth the additional cost, time and storage space required by clinics.The toy facilitated activity that a parent and child could do together, in contrast to a parent watching their child play outdoors.While the current average cost of the nature toy is too high for scalability and potentially limits sustainability of the intervention, it is likely that the cost per toy would decrease when ordered in bulk.In primary care-based interventions     that employ a toy, it will be key to balance the durability and quality of the toys with the cost, versatility, and ageappropriateness.Future cost-effectiveness studies may be warranted.
In contrast to the toy, there were mixed results about the brochure and most parents were not even aware that a website existed.Many parents desired more information about other outdoor activities, local resources including parks, and ways to be active during cold and wet times of the year.While the brochure and website contained some of this information, families were not aware of it so providers may need to more intentionally reference those resources in their discussions with families.In particular, the website could be a platform that can be customized with local resources (i.e.park finder by zip code, links to upcoming events, places to get outdoor gear, etc.) and kept updated, which could be useful for scaling this intervention.The fact that parents did not remember using the brochure or website supports existing literature stating that knowledge provision alone does not reliably result in behavior change.
Some providers felt there was not enough time to adequately explain PN within the allotted well-child visit.We suspect that work-flow fluidity would improve in a nonresearch context or with a different study design where the intervention could be employed during all wellchecks.Moreover, parents wished that providers had spent more time directly motivating their children to be active and spend time in nature -especially during cold and wet times of the year.This has implications for how pediatric providers manage their time counseling during well-child visits and how other clinic staff may be able to support providers.Training providers to use PN materials by applying motivational interviewing strategies may help them incorporate PN more efficiently into their anticipatory guidance.It will also be important to consider how to help support parents to motivate their children to be active at home, such as through family-based activities.Positive reinforcement, reminders, and limiting sedentary behaviors and media use could be helpful strategies.Future studies could strive to learn from families that have successfully implemented behavioral changes.
There is a need for an adequately powered study to understand the impact of this intervention on behavioral outcomes including child PA as well as parent and child co-participation in physical activity.It will be important to evaluate how the intervention addresses barriers in larger studies -including the most-commonly cited barriers of weather and lack of time.Examining the core components of PN independently, and including provider counseling as an independent component of the intervention, will be helpful in prioritizing and allocating resources.We acknowledge that there is likely a synergistic effect of all the core intervention components, and that some may work better for individual families than others.
Limitations of our study include having a small sample of participants from one geographic area.This intervention was specifically adapted to address the barriers and meet the needs of the population of children who receive care at a single children's clinic in Seattle.While this clinic serves an urban, racially and ethnically diverse, lower income population, the families participating may not be representative of those served by other clinics.We had difficulty recruiting families in the study because many did not answer their phone before their appointment or did not want to participate in research, which may have contributed to selection bias.While this  version of PN has only undergone rigorous usability testing in English, next steps include adapting and testing the intervention to other languages to reach a broader population.Finally, evaluation of the efficacy of this intervention would need to include more rigorous and objective measures of outcomes such as PA.Overall, our findings lay the foundation for future studies evaluating the efficacy of the PN intervention, as an evidence-based strategy to decrease disparities in children's active play in nature.Ultimately, eliminating structural barriers to nature access through policy change and community investment will be necessary to improve equitable access to play and nature.We urge policy makers to implement plans to increase green space, fund improving the quality of green spaces that already exists in low-income communities, and consider less resourceintensive strategies such as adding gardens in childcare, school and community spaces [3].In the meantime, pediatric providers can play a pivotal role in encouraging and promoting outdoor play through individual encounters with children and families.

Fig. 1
Fig. 1 Study phases and components

Table 1
Table 4 summarizes iterative feedback Key needs for the adaptation as identified by providers and parents with relevant quotes • Toy is engaging for child … it kind of depends on the family because … that child -who' s 5 years old, whose BMI is not even on the chart -is just glued to his games and his parents iPhone.And I don't think giving him this would interest him at all….I think it also has to do with how much enthusiasm the parents bring with it.[1-FG-PR-EN-113]Ifeellikefamiliesrespondreallywelltogettingthat concrete thing, because when we're just telling them do this or do that, I feel like sometimes it' s just another item on the long list of things that various professionals have told them they should be doing that they're not doing.[1-FG-PR-EN-108]•InclusivevisualsThepicturesaregreatforkidstodothe scavenger.[1-FG-PR-EN-108]…includingkids of different racial and ethnic backgrounds, and including people in hijabs, and including people with mobility challenges or other types of disabilities -development disability, et cetera -I think including different types of families.[1-FG-PR-EN-108]Wehavealot of parents who don't read in any language, and so having printed materials, even if we can get different languages, is not super helpful.So, having something that' s very graphic and easy to explain.[1-FG-PR-EN-108]If it all of a sudden goes away that' s pretty disappointing, and so, it would be nice if it was something that we could sustain over a long period of time.[1-FG-PR-EN-105]N/A

Table 2
Key barriers for the of the intervention as identified by providers and parents with relevant quotes It' s amazing we live in this beautiful place with amazing outdoor resources, but … transportation can be a barrier, having to get somewhere, having to pay for parking … having things that are very neighborhoodbased that are pointing out the ways in which nature is available in small doses, even in your apartment complex, and ways to be able to encourage physical activity with things that are best done outdoors.[1-Neighborhood context and safety • The tool does not address structural barriers …how close are they to this source and how safe is it for them to -or does mom drive?Can mom get them there, or a parent, or whoever?And how safe is it for them to walk if nobody can drive them there?[1-

Table 3
Material adaptation & usability testing parent demographics

Table 4
Qualitative usability testing and PN adaptation

Table 5
Pilot evaluation parent and child demographics

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

Table 7
Parent perceptions about components of PN

Table 8
Physical activity and outdoor time pre-and-post interventionDuring the past week, on how many days did your child exercise, play a sport, or participate in physical activity for at least 20 min that made them sweat and breathe hard?During the past week, on how many days did you exercise, play a sport, or participate in physical activity for at least 20 min that made you sweat and breathe hard?During the past 7 days, on how many days did you go outside with your child for a walk or play near your home or in a park?