Pediatric health care providers can play a larger role in encouraging play in nature to promote children’s healthPediatricians can play an important role in encouraging families to engage in active play in nature (APN). Well-child visits are an ideal opportunity for pediatricians to help parents understand how active outdoor play is central to children’s health; however, little is known about how health care providers incorporate guidance about nature contact into well visits. Additionally, many economically disadvantaged families face structural barriers that restrict children’s opportunities for APN. An improved understanding of the factors that limit children’s APN are needed to inform healthcare interventions and strategies to encourage health promoting time in nature. This study offers a qualitative exploration of: 1) the barriers to children’s APN in families with low resources, and 2) the barriers pediatric providers face in promoting APN.
The study was conducted during the COVID-19 pandemic, in Seattle, Washington, US. Fourteen pediatric providers (12 pediatricians, one sports medicine pediatrician, and one pediatric physical therapist) and 14 parents of children (ages 3-10 years) who had public insurance were selected to participate in the study. The pediatric providers participated in six focus groups via Zoom. The focus groups examined the pediatric providers’ experiences of discussing APN with parents. Each parent participated in an individual interview. Half of the interviews were conducted in English and the other half in Spanish. The interviews aimed to clarify barriers to outdoor play, both before and during the pandemic. The interviews also examined whether parents had discussed APN with their pediatrician. Data was analyzed using qualitative coding methods. Analysis was grounded in the World Health Organization’s (WHO) Commission on Social Determinants of Health (CSDH) Conceptual Framework, which recognizes the broader structural context of health inequities.
Key barriers to APN identified by the study were aligned with the CSDH Framework and focused on material circumstances, psychosocial factors, behaviors of the family, and attributes of the health system. According to parents, a variety of material circumstances, which were exacerbated by the pandemic, restricted children’s APN, including time, finances and family situations. Parents reported that work commitments limited their time and energy to encourage children’s APN, especially amidst the demands of online learning. Parents indicated that their children wanted to play outside but needed an adult to bring them to nature and supervise their play. Families did not always know where to access nature. Neighborhood conditions, such as limited access to safe play areas, and pandemic-related concerns, including fear of infection and playground closures, also constrained engagement in APN. Behavioral factors that limited APN included children being tired after school, busy with extracurriculars, or engaged in screen time. Psychosocial factors reported by parents revealed that weather was a barrier to APN, and families often lacked the appropriate outdoor gear for cold or wet conditions. Additionally, several health system factors were revealed<em>. </em>Pediatric providers indicated that they were motivated to talk about APN during well child visits and felt it was important to educate parents about APN, however, short visit times greatly limited these conversations. Parents reported that APN was rarely discussed during their child’s well visits. Providers also highlighted a need for materials to support parents, with some providers indicating “that there are no easy-to-use and up-to-date APN resources for patients.” Further, providers often recognized that parents were dealing with more pressing issues. In cases where “parents were stressed, unable to support their children’s APN, living in unsafe neighborhoods, unable to pay for organized sports or experiencing large systematic barriers,” providers indicated that they “did not feel like it was appropriate to bring up APN.”
The study provides an improved understanding of parent and health care provider perspectives on APN and how it is approached during pediatric well child visits. Although APN was perceived to be valuable, parents reported a range of barriers and pediatricians indicated a need to focus on other priorities. Importantly, the study reveals that pediatric health care providers can play a larger role in encouraging APN to promote children’s health. “At the same time, these findings caution about the various barriers families face in engaging in APN, and the structural origins of these challenges that make them potentially difficult to modify through intervention in the healthcare setting.” In addition to the need to eliminate structural barriers that constrain nature access, the study also calls attention to the need for materials that support providers in discussing APN with their patients as well as strategies to address the barriers that limit APN. Approaches such as nature prescriptions, where pediatricians “prescribe” time in nature and provide resources to encourage visits to local parks, are a strategy that may help to support APN.
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