Table 2 Characteristics of observational studies (n = 17) and associations of (pre)school playgrounds with children’s health

PRESCHOOLS

Boldemann, 2006 [58]

11 preschools

Play potential/outdoor play environment score (sum of scores, divided by 3 and dichotomized into high if >2 and low if <2):

PA during school time (steps/min) [pedometer]

Significant increase of step count by 3.6 steps/min (p < .001)^a

Sweden

197 children (age 4–6; 43% girls)

Total outdoor area (small if <2000 m², medium if 2000–6000 m², large if >6000 m²) [Department of Infrastructure, Stockholm Royal Institute of Technology, survey]

9

Overgrown surface (trees, shrubbery) and broken ground (little/nonexistent, <half of area, >half of area) [observation]

Integration of play structures with vegetation

Brown, 2009 [37, 47]

24 preschools

Outdoor activity contexts [OSRAC-P]¹

Sedentary activity, MVPA on school playground (% of intervals in which sedentary activity, MVPA is performed) [OSRAC-P]¹

Compared to sociodramatic props, a child is significantly more likely to engage in MVPA if playing with balls/objects (OR = 3.21; 95% CI = 2.54-4.05)^b, playing in open space (OR = 2.57; 95% CI = 2.08-3.16)^b, and playing with fixed equipment (OR = 1.31; 95% CI = 1.06-1.62)^b

US

476 children (age 3–5; 49% girls)

Presence of balls/objects

Compared to sociodramatic props, a child is significantly more likely to engage in sedentary activity if playing with balls/objects (OR = 2.51; 95% CI = 2.15-2.91)^b, playing in open space (OR = 2.29; 95% CI = 2.02-2.59)^b, and playing with fixed equipment (OR = 2.41; 95% CI = 2.03-2.87)^b

8

Presence of open space

Fixed equipment

Presence of sociodramatic props

Presence of wheel toys

Cardon, 2008 [57]

39 preschools

Playground features [observation]:

PA levels during recess (step counts/min)

Girls:

Belgium

783 children (age 5.2; 47% girls)

Children/m²

[pedometer]

Significant association of number of children/m²(β =-5.411; SE=2.163), number of supervising teachers (β =-0.526; SE=0.239), and recess duration (β =-0.001; SE=0.000) with PA levels during recess

7.5

Supervision (number of teachers)

Boys:

Aiming equipment (count)

Significant association of number of children/m²(β = −4.635; SE = 2.104), recess duration (β = −0.001; SE = 0.000) with PA levels during recess

Playing equipment (count)

Recess duration

Soft surface (0–1)

Markings

Vegetation

Height differences

Toys availability (0–1)

Dowda, 2009 [45]

20 preschools

Fixed and portable equipment (count) [observation]

Sedentary activity on week and weekend days (min/h) [accelerometer]

Significant fewer sedentary time (p = 0.05)^c and more time spent in MVPA (p = 0.03)^c in schools wherein PA is promoted if more than 1 piece of portable equipment available

US

299 children (age 3-5; 50% girls)

Playground size (feet²) [measured]

Time spent in MVPA (min/h) [accelerometer]

Significant fewer sedentary time (p < 0.01)^c and more time spent in MVPA (p = 0.02)^c in schools wherein PA is promoted if less fixed playground

5

Significant fewer sedentary time (p = 0.02)^c and more time spent in MVPA (p = 0.02)^c in schools wherein PA is promoted if larger playgrounds

Gubbels, 2012 [60]

9 preschools

Portable and fixed equipment (count) [EPAO]²:

Outdoor PA level during school time (1–5) [OSRAC-P]¹

Significant association of portable jumping equipment (β = 0.36), portable slides (β = −0.55), fixed structured track (β = 0.53), fixed sandbox (β = −0.49), fixed swinging equipment (β = −0.41), and age (β = 0.13) with outdoor PA levels

The Netherlands

175 children (age 2.6; 49% girls)

Portable: balls, climbing structures, floor play equipment, jumping equipment, push/pull toys, riding toys, slides, sand/water toys, twirling equipment

Significant association of fixed structured track with outdoor PA levels (β = 0.23)^d

8.5

Fixed: structured track, merry-go-round, climbing structures, see-saw, slides, tunnels, balancing surfaces, sandbox, swinging equipment

PRIMARY, SECONDARY, MIXED SCHOOLS

Colabianchi, 2011 [40, 46]

20 primary schools

Playground features on renovated schoolyards [EAPRS]³:

PA levels on school grounds (% active, vigorously active and moderately active) [SOPLAY]⁴

No significant association of any of the play features with PA levels on school grounds^e

US

185 children (47% girls)

Total unique types of play equipment (0–10)

9

Number of play features (0-∞)

Overall condition (1–3)

Overall cleanliness (1–3)

Overall quality (0–1)

Overall safety (0–1)

Presence of benches (0–1)

Presence of trash cans (0–1)

Coverage/shade for resting features (0–3)

Renovated (0–1)

Fairclough, 2012 [50]

8 primary schools

Playground area (m²/student)

Daily PA levels (count/min, min spent in MPA, min spent in VPA)

Significant positive association of playground area with MPA before school (β = 0.15; SE = 0.06), lunchtime MPA (β = 0.5; SE = 0.2), and school time MPA (β = 0.8; SE = 0.3)

UK

223 children (age 10.7; 56% girls)

PA levels at school time, out of school, before school, during class time, during recess, during lunchtime, after school (min spent in MPA, min spent in VPA) [accelerometer]

Boys:

9

Engagement of greater MPA during recess than girls (β = 1.4; SE = 0.5)

McKenzie, 2010 [48]

13 primary schools

Potential areas for PA with:

PA during play and leisure (% sedentary, walking, vigorous and MVPA) [SOPLAY]⁴

Significant association of no supervision with walking (boys: OR = 0.49; 95% CI = 0.36,0.66, girls: OR = 0.25; 95% CI = 0.15,0.41) and engaging in MVPA (boys: OR = 0.31; 95% CI = 0.21,0.47, girls: OR = 0.56; 95% CI = 0.38,0.82) compared to supervised areas

US

36,955 children (54% girls)

Supervision (0–1)

Significant association of areas with play equipment and engaging in MVPA (boys: OR = 9.27; 95% CI = 6.07,14.15, girls: OR = 2.94; 95% CI = 2.04,4.24)

7.5

Available equipment (0–1)

Boys:

Organized activities (0–1)

Engaged in greater MVPA compared to girls in unsupervised areas (boys: OR = 0.31; 95% CI = 0.21,0.47, girls: OR = 0.56; 95% CI = 0.38,0.82)

Time period (before school, recess, lunch)

Engaged in greater MVPA compared to girls in areas with play equipment (see main results above)

Girls:

Engaged in less MVPA compared to boys in areas with organized activities (boys: OR = 0.59; 95% CI = 0.41,0.85, girls: OR = 0.54; 95% CI = 0.37,0.81)

Nielsen, 2010 [55]

7 primary schools

Playground surface area (m²) [measuring tape]

PA levels at home, during school time and total (% time spent in MPA, VPA, MVPA, average counts/min) [accelerometer]

Significant association of number of play facilities and both total PA and school time PA in average counts/min (OR = 1.038; 95% CI = 1.025,1.051) (OR = 1.027; 95% CI = 1.012,1.041)^f

New Zealand

417 children (age 5–12; 48% girls)

Number of permanent play facilities [self-report]

Significant association of number of play facilities and school time spent in VPA (OR = 1.101; 95% CI = 1.072,1.132)^f

9

Significant association of number of play facilities and total time spent in both MVPA and VPA (OR = 1.102; 95% CI = 1.066,1.139) and (OR = 1.034; 95% CI = 1.015,1.054)^f

Nielsen, 2012 [59]

18 pre/primary schools

Permanent play facilities (number)

School time and total PA (average counts/min, min/day in MPA or MVPA, % active < 1 hour/day,% vigorously active <1.5 hours/day) [accelerometer]

Preschools:

Denmark

Time point 1:

Playground area (m²)

Significant association of an increase of permanent play facilities with school time PA (average counts: OR = 1.0139; 95% CI = 1.0093,1.0186, time in MPA: OR = 1.0257; 95% CI = 1.0186,1.0328, time in MVPA: OR = 1.0257; 95% CI = 1.0186,1.0351)^g

7.5

594 children (age 6–7; 48% girls)

Significant association of an increase of play facilities with total PA (average counts: OR = 1.0069; 95% CI = 1.0043,1.0106, time in MPA: OR = 1.0067; 95% CI = 1.0023,1.0116, time in MVPA: OR = 1.0077; 95% CI = 1.0046,1.0116)^g

Time point 2:

Primary schools:

518 children (age 9–10; 49% girls)

Significant association of an increase of permanent play facilities with school time PA (average counts: OR = 1.0261; 95% CI = 1.0199,1.0324, time in MPA: OR = 1.0194; 95% CI = 1.0124,1.0257, time in VPA: OR = 1.0373; 95% CI = 1.0239,10.513, time in MVPA: OR = 1.0238; 95% CI = 1.0131,1.0295)^g

Significant association of an increase of play facilities with total PA (average counts: OR = 1.0094; 95% CI = 1.0054,1.0134, time in MPA: OR = 1.0093; 95% CI = 1.0035,1.0139, time in MVPA: OR = 1.0093; 95% CI = 1.0041,1.0133)^g

Ridgers, 2010 [30, 49]

8 primary schools

Playground characteristics [Google Earth Pro software]:

PA levels during recess (% time spent in sedentary, moderate and vigorous activity levels) [SOCARP]⁵

Significant association of equipment provision with sedentary activity

UK

128 children (age 9–10; 61% girls)

Playground size (m²)

(β = −8.15; 95% CI = −16.28,-0.02)^h and moderate activity (β = 6.91; 95% CI = 0.21,13.61)

6.5

Play space (number of children per m² during recess)

Significant association of play space with sedentary activity (β = −2.70; 95% CI = −3.88,-1.52)ⁱ and vigorous activity (β = 2.02; 95% CI = 1.20,2.84)^j

Fixed equipment (count)

Girls:

Playground markings (count)

Engaged in greater sedentary activity and less vigorous activity (β = 13.83; 95% CI = 7.14,20.5)^k(β = −8.22; 95% CI = −12.49,-3.95)^l

Seating (count)

Supervision (number of adults)

Recess duration (min)

Taylor, 2011 [56]

21 primary schools

Number of permanent play facilities (playground count: 30–135) [observations]

PA in recess, at school, at home and total (average counts/min, min of MVPA/day) [accelerometer]

Significant association of number of playground facilities and PA during recess (average counts: β = 3.2; 95% CI = 0.0,6.4, MVPA: β = 8.3; 95% CI = 0.8,16.3)^m

New Zealand

441 children (age 8; 47% girls)

Significant association of number of playground facilities and PA at home (average counts: β = 5.6; 95% CI = 3.5,7.7, MVPA: β = 10.5; 95% CI = 5.5,15.7)^m

7.5

No significant association of number of playground facilities and PA at school

Willenberg, 2010 [51]

23 primary schools (governmental, independent, religious and special development)

Playground characteristics [observation]:

PA before school, in recess and after school on school playground (% time spent in sedentary, MPA and VPA) [SOPLAY]⁴

Significant association of loose equipment and teacher supervision with time spent in VPA

Australia

3006 children (50% girls)

Loose equipment (0–1)

Significant association of fixed play equipment, court markings/goals and play markings with time spent in MPA

5.5

Supervision (0–1)

Surface type (grass-bitumen)

Fields (no improvements-with boundary lines/goals)

Fixed play equipment (0–1)

Bitumen (no improvements-with boundary lines/goals-with play markings)

Zask, 2001 [52]

18 primary schools

Playground characteristics during recess and lunch [CAST]⁶:

PA levels in school break times (% engaged in MVPA and VPA) [CAST]⁶

Significant association of school size and MVPA and VPA levels (MVPA: coefficient = −0.121; SE = 0.053, VPA: coefficient = −0.164; SE = 0.063)

Australia

3912 children (age maximum 6)

Equipment availability/use

Significantly lower MPVA and VPA levels during recess than during lunch periods (MVPA: coefficient = −0.149; SE = 0.076, VPA: coefficient = −0.296; SE = 0.097)

9.5

Teacher presence/behavior

Significant (one-tailed) association of balls-to-child ratio and VPA levels (coefficient = 0.019; SE = 0.010)

Girls:

Engaged in less MVPA and VPA than boys (MVPA: coefficient = −0.413;SE = 0.053, VPA: coefficient = −0.552; SE = 0.081)

Haug, 2008 [54]

68 secondary schools

Playground facilities:

Participation in recess PA (1–5) [self-report]

Significant association of playground facilities with recess PA (OR = 4.49; 95%CI = 1.93,10.44)ⁿ

Norway

1347 children (age 13; 48% girls)

Environmental index (comprised a set of 16 natural or built characteristics of indoor school area, schoolyard or school neighborhood)

Significant association of open fields (OR = 4.31; 95% CI = 1.65,11.28), outdoor obstacle course (OR = 1.78; 95% CI = 1.32,2.40), and playground equipment (OR = 1.73; 95% CI = 1.24,2.42) with recess PA

8

Haug, 2010 [53]

Characteristics of school environment (present yes/no) [self-report]:

PA level during recess [self-report]

In secondary schools:

Norway

130 schools (80 primary; 21 secondary; 29 combined)

Soccer field

Significant association of larger number of outdoor facilities with PA levels for boys and girls at secondary level compared to children in schools with fewer facilities (OR = 2.69; 95% CI = 1.21,5.98 and OR = 2.90; 95% CI = 1.32,6.37)

8.5

16,471 children (age 8–15)

Areas for other ball games

Boys:

Areas for hopscotch/skipping rope

Significant association of areas for hopscotch/skipping rope (OR = 2.53; 95% CI = 1.55,4.13), with a soccer field (OR = 1.68; 95% CI = 1.15,2.45), with playground equipment (OR = 1.66; 95% CI = 1.16,2.37), and with a sledding hill (OR = 1.70; 95% CI = 1.23,2.35) with higher PA levels compared to children in schools with fewer facilities

Playground equipment

Girls:

Outdoor obstacle course

Significant association of a sledding hill with PA levels (OR = 1.58; 95% CI = 1.11,2.24)

Sledding hill

No significant associations were found in primary schools.

Green spaces/forest areas

Areas for boarding skating

Outdoor facility index (0–1)

Sallis, 2001 [44]

24 middle schools

Characteristics of activity areas [observation]:

MVPA (% spent in MVPA) before school, during school, during lunch, after school [SOPLAY]⁴

Girls:

US

25,944 children

Area type (courts space with permanent markings, open field space with no markings, indoor activity space including multipurpose rooms and gymnasiums)

Significant more time spent in MVPA when equipment was available (F = 4.68)^o

5.5

Area size (m²) [measurement]

Significant more time spent in MVPA when school environments had high levels of improvements and supervision (F = 15.15)^o42% of the variance in MVPA explained by environmental variables

Permanent improvements (number of basketball hoops, tennis courts, baseball diamonds and football/soccer goals)

Boys:

Equipment (0–1)

Significant more time spent in MVPA when supervision was present (F = 3.11)^o and if equipment was available (F = 11.91)^o

Supervision (0–1)

Significant more time spent in MVPA when areas had high levels of both improvements and supervision (F = 12.01)^o

59% of the variance in MVPA explained by environmental variables