The effect of increasing risk and challenge in the school playground on physical activity and weight in children: A cluster randomised controlled trial (PLAY)
Open accessAbstract
Background To investigate whether changing the play environment in primary schools to one that includes greater risk and challenge increases physical activity and reduces body mass index (BMI).Subjects/methods A 2-year cluster randomised controlled trial was undertaken in 16 New Zealand schools (years 1-8). Intervention schools (n=8) redesigned their play environments to encourage imaginative and independent free play by increasing opportunities for risk and challenge (for example, rough-and-tumble play), reducing rules and adding new playground components (for example, loose parts). Control schools (n=8) were asked to not change their play environment. A qualified playworker rated all school play environments at baseline and 1 year. Primary outcomes were moderate-to-vigorous physical activity (7-day accelerometry) and BMI z-score, collected in 840 children at baseline, 1 and 2 years. Data were analysed using generalised estimating equations.Results Multiple changes were made to the school play environments resulting in a significant difference in overall play evaluation score between intervention and control schools of 4.50 (95% confidence interval: 1.82 to 7.18, P=0.005), which represents a substantial improvement from baseline values of 19.0 (s.d. 3.2). Overall, schools liked the intervention and reported many benefits, including increased physical activity. However, these beliefs did not translate into significant differences in objectively measured physical activity, either as counts per minute (for example, 35 (-51 to 120) during lunch break) or as minutes of moderate-to-vigorous physical activity (0.4, -1.1 to 2.0). Similarly, no significant differences were observed for BMI, BMI z-score or waist circumference at 1 or 2 years (all P>0.321).Conclusions Altering the school play environment to one that promoted greater risk and challenge for children did not increase physical activity, nor subsequently alter body weight. Although schools embraced the concept of adding risk and challenge in the playground, our findings suggest that children may have been involved in different, rather than additional activities.
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In addition to the 22 studies included in the original review, eight further studies were identified as eligible.
“In addition to the 22 studies included in the original review, eight further studies were identified as eligible.”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
Among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from -0.2% to 66.6%.
“For example, among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from –0.2% to 66.6%.”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
The risk of attrition was assessed as unclear in six studies, as insufficient information regarding the loss of schools and treatment of missing data were provided.
“The risk of attrition was assessed as unclear in six studies, as insufficient information regarding the loss of schools and treatment of missing data were provided [26, 37, 41, 42, 54, 57].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
Seventeen of the included studies were assessed as high risk of detection bias.
“Seventeen of the included studies were assessed as high risk [26, 28, 37, 41, 43, 44, 46–49, 52, 54–56, 58, 66, 67] and seven studies were assessed as low risk of detection bias [27, 42, 51, 53, 60, 62, 63].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
For risk of bias due to baseline imbalances, the majority of studies (n = 11) were assessed as low risk as studies accounted for imbalances by making adjustments for baseline differences during analyses, stratifying by school characteristics or through random allocation of schools to experimental groups.
“For risk of bias due to baseline imbalances, the majority of studies (n = 11) were assessed as low risk as studies accounted for imbalances by making adjustments for baseline differences during analyses, stratifying by school characteristics or through random allocation of schools to experimental groups [37, 38, 41, 46, 47, 55, 56, 58, 60, 64, 67].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
Two studies were classified as high risk for selective reporting as the implementation outcome was not previously registered in the available protocol or trial registration.
“Two studies were classified as high risk for selective reporting as the implementation outcome was not previously registered in the available protocol or trial registration [37, 41].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
Seven studies were assessed as unclear for potential risk of recruitment to cluster.
“Seven studies were assessed as unclear [26, 37, 38, 41, 42, 46, 67], whilst the remaining study [27] was assessed as high risk of bias due to randomization occurring prior to recruitment and a lack of blinding of recruiters.”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
Among studies that assessed changes in the implementation of a physical activity policy, practice, or program, effects were modest with median effect sizes ranging from no change (-0.2%) in Farmer et al. to a change of almost 20% in Sutherland et al.
“Among studies that assessed changes in the implementation of a physical activity policy, practice, or program [27, 41, 60, 64], effects were modest with median effect sizes ranging from no change (–0.2%) in the study by Farmer et al. [41] to a change of almost 20% in the Australian randomized trial by Sutherland et al. [60].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [41]
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The Effects of the LiiNK Intervention on Physical Activity and Obesity Rates among Children
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Physical Activity Opportunities During School Recess
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Outdoor Recreation - Physiological and Psychological Effects on Health
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Schoolyard-Redesign Strategies and Outcomes in Children and Adolescents: A Systematic Review
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Exploring long-term follow-up of effective implementation trials in schools: a secondary review
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- Authors
- Farmer, V. L., Williams, S. M., Mann, J. I., Schofield, G., McPhee, J. C., & Taylor, R. W.
- Affiliations
- University of Otago (NZ)
- Auckland University of Technology (NZ)
- Corresponding author
- Taylor, R W
- Venue
- International Journal of Obesity
- Published
- 2017-02-10
- Volume
- 41
- Issue
- 5
- Pages
- 793-800
- ISSN
- 0307-0565 (ISSN-L)
- 1476-5497
- OpenAlex
- W2587636309
- Cited by
- 60
- References
- 43
- Citations by year
- 2026: 5 · 2025: 7 · 2024: 9 · 2023: 2 · 2022: 4 · 2021: 6 · 2020: 14 · 2019: 7 · 2018: 1 · 2017: 5
- FWCI
- 5.46
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- International Journal of Obesity (publishedVersion)
- PubMed (publishedVersion)
- Otago University Research Archive (University of Otago) (submittedVersion)
- Funders
- Lottery Health Research
- Health Research Council of New Zealand
- Topics
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Social Sciences › Psychology › Developmental and Educational Psychology › Children's Physical and Motor Development
- Keywords
- play spaces, physical activity, body mass index, childhood obesity, elementary school students, free play, rough-and-tumble play, loose parts, waist circumference
- MeSH terms
- Body Weight, Child, Child Behavior, Environment Design, Female, Health Promotion, Humans, Male, New Zealand, Play and Playthings, School Health Services, Schools, Exercise, Body Mass Index, Cluster Analysis, Accelerometry, Pediatric Obesity
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