Science & Sports (2011) 26, 72—82

ORIGINAL ARTICLE

Preschool outdoor play environment may combine

promotion of children’s physical activity and sun
protection. Further evidence from Southern Sweden
and North Carolina夽
Les aires de jeux extérieures en école maternelle peuvent associer
promotion de l’activité physique et protection solaire. Nouveaux
arguments de Suède du Sud et de Caroline du Nord

C. Boldemann a,∗, H. Dal a, F. Mårtensson b, N. Cosco c, R. Moore c,

B. Bieber c, M. Blennow d, P. Pagels e, A. Raustorp e,f, U. Wester g,
M. Söderström h,i,j

a
Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden
b
Department of Work Science, Business Economics and Environmental Psychology, Swedish University of Agricultural Sciences,
Alnarp, Sweden
c
The Natural Learning Initiative, College of Design, North Carolina State University, Raleigh, NC, USA
d
Karolinska Institutet, Department of Clinical Science and Education and Sachs’ Children’s Hospital, Söder Hospital, Stockholm,
Sweden
e
Linnaeus University, School of Sport Sciences, Kalmar, Sweden
f
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
g
The Swedish Radiation Safety Authority, Stockholm, Sweden
h
The Section of General Practice, Department of Public Health and The research Unit for General Practice, University of
Copenhagen, Copenhagen, Denmark
i
Department of Clinical Sciences in Lund, University of Lund, Lund, Sweden
j
Department of Primary Health in Region Scania, Sweden

Received 10 February 2010; accepted 15 May 2010

Available online 5 March 2011

KEYWORDS Summary
Physical activity; Objective. — To study the impact of preschool outdoor environments on children’s physical
activity and solar ultraviolet (UV) exposure at different latitudes and countries.

夽 Présenté au 1er congrès européen sur l’activité physique et la santé des tout-petits (0—6 ans), Épinal, 28—29 mai 2010.
∗ Corresponding author.
E-mail address: cecilia.boldemann@ki.se (C. Boldemann).

0765-1597/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.scispo.2011.01.007
Outdoor play environment and promotion of children’s physical activity 73

Methods. Outdoor environments of 11 preschools (two in Raleigh NC, USA, Lat.36◦ N, nine in
Sun exposure; Malmö, Sweden, Lat.55◦ N) were scored (OPEC) regarding space, vegetation, hilly terrain and
Outdoor level of integration between open spaces, vegetation and play structures. Free sky (%) was
environment; determined by imaging. Physical activity was measured by pedometers and solar UV-exposure by
Preschool children polysulphone dosimeters during 5 days in spring 2009, and individual background data gathered
by questionnaires and anthropometric measurements. Global UV radiation was measured and
available individual UV radiation (%) computed.
Results. — In Malmö, mean step count/minute was 21.2 in preschools with high-scored environ-
ment vs. 17.6 in low-scored environments, and UV-exposure lower, 26% vs. 43% of available UV
during outdoor stay. In Raleigh, step count/minute was 12.3 and UV-exposure of available UV
27% during outdoor stay.
Conclusions. — Step count/minute was lower in Raleigh than in Malmö, but in Malmö children
at low-scored environments ran a higher risk of sunburn than in Raleigh. Trees and shrubbery
integrated in children’s playscape trigger both physical activity and sun-protective behaviour in
Sweden, and previous measurements in Stockholm were confirmed. Such outdoor environment
should be recommended, but the role of season and climate needs to be further explored.
© 2011 Elsevier Masson SAS. All rights reserved.

Résumé
MOTS CLÉS Objectifs. — Étudier l’impact de l’environnement extérieur d’écoles maternelles sur l’activité
Tout-petits ; physique et l’exposition au rayonnement solaire ultraviolet (UV) à deux latitudes et dans deux
Exposition solaire ; pays.
Environnement Méthodes. — Les éléments extérieurs de 11 écoles maternelles (deux à Raleigh NC, États-Unis,
extérieur ; Lat. 36◦ N et neuf à Malmö, Suède, Lat. 55◦ N) ont été combinés par le score OPEC : espace, végé-
Activité physique tation, relief du terrain et degré d’intégration entre l’espace, la végétation et les structures de
jeu. L’activité physique a été mesurée par podomètres et l’exposition solaire par dosimètres
à film de polysulfone pendant cinq jours au printemps 2009. Les données individuelles ont été
recueillies par questionnaires et anthropométrie.
Résultats. — À Malmö, le nombre moyen de coups/minute était de 21,2 chez les enfants évoluant
dans un environnement à score élevé et de 17,6 dans les environnements à score bas. Les
expositions solaires étaient respectivement de 26 et 43 % lors des séjours en extérieur. À Raleigh,
les coups/minutes ne différaient pas selon l’environnement : 12,3 et l’exposition solaire non
plus : 27 %.
Conclusions. — L’activité physique est moindre à Raleigh, mais à Malmö, les enfants qui évoluent
dans un environnement extérieur à score peu élevé courent un plus haut risque d’érythème
solaire qu’à Raleigh. Les arbres et arbustes intégrés dans les aires de jeu des enfants augmentent
l’activité physique et les comportements de protection solaire. Le rôle des saisons et du climat
doit être précisé.
© 2011 Elsevier Masson SAS. Tous droits réservés.

1. Introduction stay protects from harmful overexposure on sunny days but

Outdoor preschool environment is important for health pro-
motion in Western societies as a rising number of preschool
children spend most of their waking hours at preschool.
Immediate access to varied preschool environment with
proximity to vegetation in play areas may serve several tar-
gets of health promotion: physical activity, sun-protective
behaviour and general health and well-being [1,2]. A lack
of physical activity and overexposure to solar ultraviolet
radiation (UVR) with its consequences are global health
concerns [2—5] with short- and long-term implications for
health as part of a developing lifestyle. Too little self-
triggered physical activity in daily life may cause ‘‘physical
activity deficiency’’ i.e. affect physical activity below lev-
els required to maintain health [6—8]. Further, 80—90% of
skin cancers in Western societies are caused by overexpo-
sure to solar UVR [4,5,9], in preschool children commonly
occurring inadvertently during outdoor stay and play. Indoor
restrains physical activity. Studies at preschools indicate
the relevance of active intervention policies to increase
physical activity [10], and to reduce sun exposure [7]. How-
ever, by environmental change it is possible to achieve
long-term positive impact on both physical activity and
sun exposure without recurrent intervention. Green outdoor
environments facilitate physically active play [1,3,11] and
shelter from excessive UVR due to a substantial cut in UV-
exposure during free play [1,12]. Abundant, low-reflectant
greenery yields sun protection [13,14] as part of a play
behaviour typical of outdoor settings in which children tend
to move in between different places surrounded by vege-
tation [2,15]. In Stockholm County children with access to
green outdoor environments with high such play potential
increased their physical activity and had a low risk of sun-
burn in spite of long outdoor stay [1]. It was unknown if
these findings would also apply to other climates and lati-
tudes than those of Stockholm County (Lat. 59◦ —60◦ N) which
74
is a segmented coastal metropolitan area, characterized by
rocky topography and pine forests in a continental climate
zone between the mid-latitude and subarctic regions [16].
In spring 2009 preschool children’s physical activity and
sun exposure was studied at nine public preschools in Malmö
(Lat. 55◦ N), an urban area with parks and surrounded by
agricultural land in a coastal climate. Six preschools were
situated in downtown medium-high income districts, and
three preschools in a low-income district 5 km from the city
center (Fig. 1).
Variation in the play potential of outdoor environments
within socio-economic areas was considered taking into
account the size, layout and content of nature and if popular
play locations were shaded or sun-exposed. The selection
of sites was based on the examination of aerial/satellite
photography (e.g. Google Earth) and inspection in situ.
A pilot study (convenience sample) was also carried out
in subtropical Raleigh, (Lat.36◦ N) and run at two corpo-
rate preschools attended by children from affluent society.
In both studied areas the prevalence of preschool atten-
dance is high [17,18]. In NC 80% of the children aged 3—5
years are enrolled in child care, usually in private/corporate
preschools [18]. In Sweden 96% of their peers attend
preschool, of which 82%are run by the local authorities
[17]. The prevalence of overweight and obesity among
preschool children is 15—20% in both locations [19,20]. Life-
time prevalence rates of sunburn in young white children
in Sweden and US range between 28 and 53% [21,22]. The
aim was to explore the generalizability of the salutogenic
potential in outdoor preschool environment across different
regions.
2. Methods
Permissions for study were granted by the Stockholm
Regional Ethics Committee, the local authorities and
preschools (Malmö) and the Internal Review Board at North
Carolina State University (Raleigh), and by parental written
informed consent. In Malmö 172/253 (68%) of eligible chil-
dren aged 3—5,9 years participated (non-response, n = 76,
declined participation = 5). All children with parental con-
sent except one wanted to participate. Two children were
absent during fieldwork, leaving 169 children in the analysis.
In Raleigh, parental consent was obtained for 33/58 eligible
children who all participated.
Malmö and Raleigh are geographically close to the
respective northern and southern borders of the earth’s
mid-latitude region. Taking into account the latitudinal dif-
ference, the study periods at the two respective sites were
chosen for seasonal comparability in terms of spring-time
vegetation and noon-time solar UV-intensity at clear sky
conditions (Fig. 2). Fieldwork was carried out during five
consecutive workdays, with similar sun elevation above the
horizon and sunburn risk, and stage of leafing (Raleigh March
30—April 3, Malmö May 4—8).
No site was understaffed during fieldwork (one
workforce/5—6 children). Arrivals, out- and indoor
stays, extramural activities, departure and absence
were clocked all days for each child. Inter-site attendance
in Malmö ranged between 75 and 96%. Of the children,
78% were measured ≥4 days, 95% ≥3 days. In Raleigh,
C. Boldemann et al.
attendance was 96 and 93% at the two sites respectively.
Absence depended on parent’s part-time job, holiday and
illness.
2.1. Scoring of the outdoor preschool environment
Ordinal outdoor play environment categories (OPEC) scores
were applied to assess the play potential [1,2], scored 1, 2
and 3 considering:
A) Total outdoor area (scoring adapted to typical size ranges
for outdoor environments of Southern Sweden and North
Carolina): 1 = < 1200m2 , 2 = 1200—3000m2 , 3 = > 3000m2 ;
B) Amount of trees, shrubbery and hilly terrain:
1 = little/non-existent, 2 = < half of area, 3 = > half
of area;
C) Integration between vegetation, open areas and play
structures:
1) No integration. Play areas, vegetation and open areas in
separate parts of environment,
2) Either of the following characteristics:
a) Trees or shrubbery adjacent to the play areas or the
play areas located inside areas with the character of
wild nature,
b) Open spaces located in between play areas,
3) Area fulfils 2a and 2b.
The sum of scores per site, divided by 3, was applied in
analysis. For records of shade and vegetation vs. free sky and
its relation to mean UV-exposures, the sky view factor (SVF),
i.e. the fraction (%) of visible free sky was determined by
fish eye photography of the sky [23] from favoured places as
determined by a behaviour mapping procedure to document
children’s positions [24]. Mean SVFs per site were applied in
analysis.
2.2. Measures, anthropometrics and parental
questionnaire
The children’s weights and heights were measured, and
body mass index (BMI) classified as normal, overweight and
obese [25]. The parents answered a questionnaire based
on a previous version [1,26], modified to be applicable in
both countries (non-response 20%, mostly due to immigrant
parents’ language difficulties at sites M4 and M9), asking
for child’s appraisal of preschool (feeling very comfort-
able/comfortable/less comfortable/uncomfortable), num-
ber of adults in the household, leisure time activities
involving physical activity, outdoor space at home, being
outdoors without adult company (Yes or No-questions), time
spent outdoors on Sundays (hours), regular attendance at
preschool (days/week, hours/day), regular bed- and wake-
up time (clock-time), prematurity (weeks), chronic disease
(defined as medication greater or equal to 3 months per
year), parental education and occupation (responses from
Raleigh questionnaires transposed) [27].
Outdoor play environment and promotion of children’s physical activity 75

Figure 1 Representative photos and matching representative sky view images of each preschool site (in order of increasing OPEC-
scores). (a) Malmö, May 2009. (b) Raleigh sites (convenience sample), April 2009. The terrain of both sites is flat, but vegetation
integrated in play space. At site 1, free mobility was restricted, at site 2 SVF lower due to free mobility, and due to the forest
bordering on the fence to the south.
76
Figure 2 Variation of solar UVR at noon with latitude and sea-
son (Wester and Josefsson, 1997). Dots inserted for fieldwork
(Raleigh Lat. 36◦ N, March 30—April 3, Malmö Lat. 55◦ N, May
4—8), 2009.
2.3. Weather conditions, pedometry and
dosimetry
In Raleigh, the skies were clear or thinly overcast during days
1—3 and day 5; day 4 was rainy. Meteorologically reported
peak temperatures were 18.3 — 25.6 ◦ C. In Malmö, days 2
and 3 were cold, windy and rainy, days 1, 4 and 5 partly
overcast with intermittent sunshine, and peak temperatures
13.0 — 18.0 ◦ C. Weather conditions during fieldwork were
recorded a.m. and p.m.
The children carried shake-tested Yamax Digiwalker SW-
200 pedometers above the right hip-bone, sealed to elastic
belts for optimal security and fixation [28,29]. Step count
in young children has been successfully validated for mea-
surement of physical activity under laboratory and field
conditions [30—32]. For individual measurement of solar
UV-exposure, polysulphone (ps) dosimeter badges were
pinned to the top of the right shoulder. PS-dosimetry is
an established technique to measure personal erythemal
UV-exposure [13,33—35]. The accuracy of ps-dosimetry has
been tested and confirmed for a similar study [1,36]. The
dosimeters accumulated individual UV-exposure during each
whole study period, and 94% were returned intact for anal-
ysis. Pedometers and badges were applied upon arrival and
taken off at leaving time, step counts recorded and pedome-
ters reset.
For diurnal measurement of global UVR, three dosimeters
were mounted on rooftops with free horizon within 15 km
(Raleigh) and 5 km (Malmö) of the preschools for daily aver-
ages, and changed each night. Temporal diurnal variation
of UVR was measured each day to calculate the fraction
of available global UV-exposure that the children received
outdoors, as recorded by the children’s individual dosime-
ters. Solar radiation data were obtained per 5-minute epoch,
in Raleigh by a UV-sensor from Safecast Davis Instruments,
in Malmö by a pyranometer (Kipp&Zonen CM21) monitor-
ing total solar radiation in a near-by city (Lund, 15 km) and
operated by SMHI (Swedish Meteorological and Hydrological
Institute). Data from the Raleigh sensor were normalized to
the rooftop dosimeter readings from Raleigh. Data from the
SMHI-instrument were normalized to the rooftop dosime-
ter readings from Malmö and also validated against SMHI’s
C. Boldemann et al.
on-line radiation transfer model for near-real time solar
UV-irradiance data, based on actual weather parameters
(www.smhi.se/strang). The UV-sensor readings were used
for computation of relative UV-exposure (hereafter ‘‘UV
fraction’’).
2.4. Evaluation and statistical analysis
Pedometer counts were expressed as step count/minute to
control attendance. Faulty day-counts (<5 steps/minute)
[37] were eliminated (5% of day-counts). The pattern and
frequency of faulty counts did not vary significantly between
days or between sites. Individual dosimeter UV-exposures,
expressed as erythemally effective Joule/m2 (J/m2 ) were
related to available global UVR during outdoor stay at
preschool (UV fraction). UV fraction and fraction of out-
door time (hereafter ‘‘outdoor fraction’’) were computed
per child, and per site (mean values). For the Malmö sam-
ple intra-class correlation coefficients were calculated in
order to estimate the influence from factors at preschool
level upon step count/minute and on UV fraction. For bivari-
ate analysis of variables’ association vs. step count/minute
the following tests were applied: t-test (environment cate-
gory of preschool, gender, dichotomized BMI, being outdoors
without adult company at home, leisure time activities
involving physical activity, outdoor education at preschool),
Kendall’s tau-b correlation coefficient (surface of preschools
in- and outdoors, age 3.0—5.9 years by 6-month periods,
attendance at preschool days/week, time spent outdoors
on usual Sundays, child’s health as stated by parent,
child’s socio-economic standard by mother’s education, and
by highest of parents’ education), and Pearson’s correla-
tion coefficient (BMI, outdoor stay, inter-site attendance,
individual attendance). Significantly associated variables
were jointly tested in linear mixed model analysis, i.e.
entered into the equation and sequentially removed (crite-
rion for removal p ≥ 0.05) by highest p-value. Significance
of differences in step count/minute and UV fraction vs.
dichotomized OPEC categories (scores >2 high, ≤2 low) were
determined by t-tests (significance level p < 0.05). The PASW
18.0 statistical software was applied.
3. Results
3.1. Malmö
After assessment of the participating preschools’ outdoor
play areas according to the OPEC-tool, six out of nine were
classified as low-score and three as high-score environments
(Tables 1A and 1B).
3.1.1. Sociometrics and anthropometrics
The children were 3.0—5.9 years old at measurement. Four-
teen per cent (23/163) were overweight/obese. Sixty per
cent attended all 5 days of fieldwork, 5% less than 3 days.
In 19% of the households, one or both parents were non-
Scandinavians from other parts of Europe and the Middle
East. Fifty-three per cent of the mothers had postgradu-
ate education and either parent in 68% of the households,
i.e. more than in the studied area (49%). Six per cent lived
in single-parent households, all children except four were
Outdoor play environment and promotion of children’s physical activity 77

reported to sleep ≥ 10 h/night, eight were born pre-term,

and eight had diseases requiring medication. All children
except eight were reported to feel comfortable or very com-
fortable at preschool, one in two engaged in leisure time
activities involving physical activity, and all stayed outdoors
more than one hour on Sundays. Only nine children were
allowed outdoors on their own at home, due to young age.
Other indicated causes were perilous traffic environment,
and fear of crime.

3.1.2. Step count

Of individual variance in step count, 23% was explained
by factors at preschool level. Outdoor area (m2 ) was non-
significant for step (linear mixed model). Step count/minute
was 20.5 in boys (range 9.3—37.7), and 17.4 in girls (range
7.3—30.1) (p < 0.001). High-OPEC environment added 3.7
steps/minute to physical activity, being 21.2 at high-OPEC
and 17.5 at low-OPEC sites (22% higher). The difference was
more pronounced in boys (18.8 vs. 24.3, 29%) than in girls
(16.4 vs. 18.6, 13%) (Table 3). In bivariate analysis, age and
outdoor stay, and leisure time activities involving physical
activity were significantly related to step count/minute, but
none of the other variables (sleep duration, attendance at
preschool days/week, and hours/day, time spent outdoors
on usual Sundays, being outdoors without adult company,
BMI, child’s health according to the parent, pre-term birth,
disease requiring medication, socio-economic status from
mothers education and by highest of parents’ education).
After joint analysis (linear mixed model) gender and outdoor
stay remained significant.
3.1.3. UV-exposure
Available diurnal UVR (whole period) amounted to 5264 J/m2
(daily variation 516—1600 J/m2 ). SVFs were 22—56% in
high-OPEC (score > 2), and 26—81% in low-OPEC environ-
ments (score ≤2) (Table 1). Of individual variance in
relative UV-exposure (UV fraction), 67% was explained
Figure 3 Correlation between Sky View Factor and relative
UV-exposure (UV fraction), considering selection of UV images
upon behaviour mapping, Raleigh, NC in March-April and Malmö,
Sweden, in May 2009. Triangles: Raleigh sites.
by factors at preschool level, and 29% explained by
OPEC (score dichotomized high/low-OPEC). The correla-
tion between mean UV-exposures (UV fractions) and SVFs
was r2 = 0.8 (p < 0.001) (Fig. 3). In bivariate analysis, OPEC
(dichotomized) and SVF were both significantly related
to UV-exposure (p < 0.001). After joint analysis (linear
mixed model), SVF remained significant (<0.001). Mean
daily UV-exposures ranged between 12—371 J/m2 and were
not correlated to age or gender, and exceeded in 20
cases (20%) >200 J/m2 erythemally effective UVR, (equiv-
alent of one minimal erythema dose for sun-sensitive
skin). Thirteen of these children attended preschools
with much time spent outdoors, predominantly high-OPEC
sites. Mean UV fraction was 26% (range 16—34%) at high-

Table 1A Data of preschool sites, and the participating children’s step counts/minute and UV-exposures, ranges and confidence
intervals, 95% confidence intervals (CI). Malmö, Sweden, 2009, and Raleigh, NC (convenience sample), 2009.

Preschool Socio- Outdoor SVF Girls (n =) Boys (n =) All (n =)

site economic play envi- (mean) (%)
status of ronment
recruitment category
area (score)

Malmö
M2 High 1.0 61 4 10 14
M3 High 1.3 81 7 10 17
M1 High 1.7 63 8 8 16
M6 High 1.7 26 5 7 12
M4 Low 2.0 57 17 18 35
M7 Low 2.0 61 5 4 9
M5 High 2.3 22 17 11 28
M8 High 2.7 56 9 13 22
M9 Low 2.7 43 10 6 16
Raleigh
pilot
R1 High 1.7 50 8 7 15
R2 High 1.7 42 9 9 18
78 C. Boldemann et al.

Table B Data of preschool sites, and the participating children’s step counts/minute and UV-exposuresa , ranges and confidence
intervals, 95% confidence intervals (CI). Malmö, Sweden, 2009, and Raleigh, NC (convenience sample), 2009.

Preschool site Step count/min, Step count/min, Dosimeter mean Outdoor stay (Fraction UV fraction (%)b ,
mean (range) mean exposure/day J/m2 %) at preschool, mean
(CI) (range) mean mean (range)
Girls (CI) (range) (range) (CI)
Boys (CI) (CI) All
Alla Alla

Malmö
M2 11.7 18.7 43 17 48
(8.6—14.7) (15.8—21.6) (12—69) (8—25) (27—79)
(7.2—16.3) (11.9—26.4) (34—52) (15—20) (40—57)
M3 17.5 17.1 186 35 67
(11.4—20.0) (15.1—19.0) (78—370) (19—56) (45—92)
(14.8—20.2) (13.2—20.8) (145—227) (29—40) (61—74)
M1 14,2 17.6 86 25 53
(9.4—24.1) (13.3—22.0) (51—176) (19—37) (39—71)
(10,0—18,3) (10.1—24.3) (70—103) (22—28) (48—59)
M6 12.9 17.9 54 38 21
(7.6—21.5) (11.9—23.9) (33—81) (29—48) (10—32)
(3.1—22.7) (12.4—30.2) (34—73) (34—42) (13—39)
M4 20.1 20.0 114 42 33
(11.1—30.1) (18.0—22.0) (17—297) (33—58) (8—66)
(17.4—22.8) (14.1—29.8) (96—133) (40—44) (29—38)
M7 13.0 17.2 103 39 33
(7.3—17.2) (12.5—21.8) (44—157) (29—52) (20—44)
(8.5—17.6) (14.7—20—6) (77—130) (33—46) (26—40)
M5 18.2 22.8 119 94 16
(7.8—29.8) (18.3—27.3) (49—234) (85—100) (5—35)
(15.4—21.9) (10.3—33.2) (97—142) (92—96) (14—19)
M8 20.2 28.2 200 76 34
(13.4—29.5) (25.2—31.1) (66—370) (47—98) (16—58)
(15.8—24.6) (18.5—37.7) (161—239) (69—84) (29—40)
M9 17.9 18.7 115 46 29
(10.9—27.0) (12.7—24.8) (38—206) (17—75) (14—61)
(14.7—21.1) (9.3—26.5) (85—144) (37—56) (23—35)

Raleigh pilot 9.3 12.1 57 15 27

(7.7—11.3) (8.2—16.2) (34—81) (9—20) (20—38)
(8.4—10.2) (9.3—14.9) (51—64) (13—17) (24—30)
R1 13.1 14.5 83 19 26
(7.9—19.7) (11.4—19.2) (48—122) (14—25) (18—36)
(10.116.1) (12.4—6.6) (73—92) (17—21) (24—29)
R2
SVF: Sky view factor.
a No difference in UV-exposure or outdoor stay was observed between girls and boys.
b Exposure fraction based on 8608 J/m2 (sites R1 and R2), and 5264 J/m2 (sites M1—M9).

OPEC, 43% (range 33—67%) at low-OPEC sites in Malmö 3.2. Raleigh

(site means, Table 1).
3.1.4. OPEC vs. SVF, step count, UV-exposure and
outdoor stay
Preschool OPEC-scores and SVFs were significantly corre-
lated (r = .34, p < 0.05). Crude mean step count/minute was
17.6 and mean UV fraction 43% at low-OPEC sites vs. the
values of 21.2 and 26% respectively at high-OPEC sites.
Outdoor fraction was 76% at high-OPEC, and 30% at low-
OPEC sites. All differences were highly significant (p < 0.001)
(Table 2).
According to the OPEC-tool, both outdoor environments
were scored as low-OPEC sites. Physical surroundings and
choices of places seemed to result in sun protection.
3.2.1. Sociometrics and anthropometrics
The children were aged 3.4—5.7 years at measurement, 9%
(3/32) being overweight/obese, 85% attended all 5 days of
fieldwork, one child attended 3 days. All mothers had post-
graduate education, two children lived in a single-parent
Outdoor play environment and promotion of children’s physical activity 79

Table 2 Variables with a significant bivariate association with step count/minute (significance level 5%), including variables
with a significant association for only one gender. Mean step count/minute, number of children (n) and 95% confidence intervals
(CI) for all children and by gender, Malmö, Sweden, 2009.

Step count/minute, mean (n, 95% CI)

All children Girls Boys

Independent variable: Preschool level

High environment category 21.2 (65, 19.6—22.9) 18.6 (35, 16.9—20.4) 24.3 (30, 21.8—26.8)
Low environment category 17.6 (101, 16.6—18.2) 16.4 (44, 14.7—18.0) 18.5 (57, 17.3—19.6)
Variables related to individual
Gender, girls 17.4 (79, 16.2—18.6)
Gender, boys 20.5 (87, 19.2—21.7)
Age, <3.5 years 15.2 (20, 12.9—17.6) 13.4 (9, 9.9—16.9) 16.7 (11, 13.3—20.2)
Age, ≥3.5 — <4 years 16.6 (28, 14.9—18.1) 15.5 (18, 13.4—17.6) 18.4 (10, 15.8—21.0)
Age, ≥4 — <4.5 years 17.8 (30, 15.9—19.7) 15.7 (11, 13.0—18.5) 19.0 (19, 16.5—21.5)
Age, ≥4.5 — <5 years 20.4 (38, 18.7—22.1) 18.3 (19, 16.0—20.6) 22.5 (19, 20.2—24.8)
Age, ≥5 — <5.5 years 22.1 (25, 19.1—25.1) 21.5 (10, 17.4—25.5) 22.5 (15, 17.9—27.1)
Age, ≥5.5 21.5 (24, 19.2—23.7) 20.8 (11, 17.1—24.6) 22.3 (13, 18.9—25.1)
Outdoor stay (%) ≥ median value (42,4)a 21.1 (83, 19.8—22.4) 19.1 (46, 17.5—20.6) 23.2 (46, 21.2—25.2)
Outdoor stay (%) < median value (42,4)a 16.9 (83, 15.8—17.9) 15.4 (41, 13.7—17.2) 18.0 (41, 16.8—19.3)
a Association with step count/minute was calculated with outdoor stay (%) as continuous variable.

household, no child except one slept less than10 h/night,
two were reported as born pre-term, and four had diseases
requiring medication. All children except one were reported
to feel comfortable/very comfortable at preschool, one in
two engaged in leisure time activities involving physical
activity, and all were reported to stay outdoors more than
one hour on ordinary Sundays. No child was allowed outdoors
on their own at home due to young age, traffic environment,
fear of crime, and dangerous wildlife.
3.2.2. Step count and UV-exposure
Mean step count/minute was 13.4 in boys (range 8.2—19.2),
and 11.3 in girls, (range 7.7—19.7) (non-significant) (for boys
45% lower than at high-OPEC sites and 30% lower than at
low-OPEC sites of Malmö, for girls 30% and 18% lower respec-
tively). Available diurnal UVR (whole period) amounted to
8608 J/m2 (daily variation 475—2510 J/m2 ). The children’s
daily UV-exposures ranged between 34—122 J/m2 , i.e. far
below the threshold limit for sunburn risk in fair, untanned
skin (200 J/m2 ). Mean UV fraction was 27% (range 18—38%).
4. Discussion
The main finding of this study was that high-OPEC
preschools trigger children’s physical activity and sun
protection, confirming previous observations from Stock-
holm County further north that, promotion of physical
activity and sun protection did not conflict. Green out-
door environments with high play potential during 7 h/day
add 1500—2000 steps, combined with 35—40% lower UV-
exposure, enabling long outdoor stay without sunburn,
compared with preschools without these qualities. OPEC
and outdoor stay (and hence outdoor stay and step
count/minute) were highly correlated and could not be sep-
arated in analysis. The inclusion of the outdoor site M5
(high-OPEC) may have strengthened this relationship. It has
been shown that adults are more prone to take children
outdoors at preschools in attractive, green surroundings
which is relevant for health promotion [26]. This was not
observed in Stockholm County though, possibly due to dif-
ferent weather conditions (heat wave during more than 50%
of the measurement period) [1]. Present findings support the
idea that green and varied outdoor environments increase
children’s physical activity per se, but also through the poli-
cies of longer outdoor stay that tend to evolve at such sites.
The significant negative correlation between OPEC and chil-
dren’s UV-exposure indicates that OPEC may be a tool also
for sun protection. In green and varied outdoor settings chil-
dren’s own choice of place and playful use of the physical
surrounding actually seems to result in sun protection.
Raleigh sites combined UV fractions similar to those of
Malmö high-OPEC sites with considerably lower physical
activity than at comparable Malmö sites. Raleigh children
napped from noon to 2 p.m., which their Malmö peers
seldom did. But even subtracting nap hours prior to compu-
tation did not change this significant difference. Fences
segmenting preschool outdoor areas for safety or practical
reasons may restrict free mobility and thereby reduce step
counts and also children’s ability to seek shade if vegeta-
tion is not within reach due to barriers inside the preschool
area. This needs to be discussed in view of the advan-
tages of free mobility and the possibility for children to
seek shade. Observations at R1 indicated that vegetation
sheltered children’s play from overexposure to UVR due
to the abundance of trees and bushes integrated in the
behaviour settings, even though physical activity did not
increase. At site R2, free mobility may have contributed
to low UV fractions as deciduous forest bordering on the
southern fence attracted the children to its proximity even
though it was beyond the preschool ground (Fig. 2, R2).
Green shade reduces UVR by 50—70% [14], and makes e.g.
a UV index of 10 to 3—4, with little risk of sunburn. Green-
ery integrated with play space is attractive to children, and
80
would enable long outdoor stay with decreased sunburn risk
in Raleigh in spite of low latitude (Fig. 2), in contrast to
naked environment at high latitudes. Overall, UV fractions
were 37% higher at Malmö than at Raleigh sites. The results
indicate that in theory greenery integrated in play spaces
could yield sufficient ‘‘inadvertent’’ sun protection during
prolonged play outdoors without sunscreen, hats or clothing
from early fall until spring at latitudes between the 40th par-
allel to the tropic, and enable outdoor play all year round
without risk of sunburn North of the 40th parallel [38]. Sun-
protective behaviour other than physical environment by
proxy (clothes, hats and sunscreen) was not studied, as the
protective potential of the physical environment was the
aim of the study.
4.1. Limitations
Ground surface was not assessed which may be a minor
shortcoming in spring and summer. Ground reflectance for
UVR may vary, and soft or solid ground impact physical activ-
ity. At the sites in this study sand, soil and grass dominated.
Asphalt was less common and occurred on the front side at
sites M2 and M8, one high- and low-OPEC each. Due to the
modest variation of ground surface in this sample effects
could be expected to be marginal.
The established upper limit of valid step count is less
than or equal to 30 steps/minute [39] which one third of the
boys at site M8 exceeded. As malfunction of the pretested
pedometers was unlikely, but rather reflected high gen-
uine physical activity, also confirmed by observation, we
applied a threshold value of 40 steps/minute in our analysis.
Increased step count due to reactivity was unlikely [40], and
would have affected children at all sites in the same way.
Sun-protective behaviour defined as seeking shade was
not explicitly recorded by behaviour mapping, but so were
the favourite locations for play from which the sky views
were photographed. However, the choice of play locations
may vary depending on the weather, which complicates
interpretation of data. Physical activity did decrease dur-
ing cold and rainy weather and followed the same pattern
at low- and high-OPEC sites. For increased comparability of
SVFs, the dates for fieldwork were set considering seasonal
sun elevation and the leafing progress. Yet, leafing was late
in Raleigh and early for the season in Malmö. Hence, Raleigh
SVFs were probably overestimated compared to Malmö.
4.2. Suggestions for future study
The dependence on policies to engage staff to actively pro-
mote children’s physical activity [10], and sun-protective
behaviour [26] has been documented, as the association
between green outdoor environment and specific play pat-
terns among children [2,15]. In extension, the result of such
free mobility in green outdoor settings would be increased
physical activity and sun protection without the children
having to be told to seek shade, as they are attracted to
using trees and bushes in their play. Our aim was by objec-
tive measurement to assess these ‘‘inadvertent’’ behaviours
as a response to the environment. The integration of varied,
green terrain and elaboration of many minor play spaces
may be particularly important in confined spaces. This issue
C. Boldemann et al.
should be further investigated as being relevant for improve-
ment of preschool environment in densified urban areas with
limited opportunities of expanding outdoor space.
In Malmö, different socio-economic areas were rep-
resented, but not the countryside or any pronounced
immigrant district. The affluent part was therefore over-
represented. The corporate preschools in Raleigh were
attended by children predominantly representing affluent
society. Investigating preschools in disadvantaged areas —
with the greatest concerns regarding obesity and lack of
opportunities for physical activity — is highly warranted.
Intervention for improved health and health promotion
among disadvantaged children has been shown to have
greater impact on their health compared to children in
affluent areas [41]. Recent data from Alabama, USA, report
extremely low physical activity (approx. six steps/minute) in
children attending preschools in deprived areas with outdoor
environment of poor quality [42]. So the impact of cultu-
ral differences (e.g. private/corporate or public preschools,
barren or lush outdoor environment) on saluto-synergetic
impact on the children needs investigation.
Our finding that outdoor environment with vegetation
integrated in play may promote both physical activity and
sun protection during spring and summer in the North, but
seemingly only sun protection at southern mid-latitude, is
possibly due to the season of the chosen study periods. In
winter there is too little rather than too much solar UV
in Northern countries while much further south this is not
so pronounced (Fig. 2). Preschool children’s outdoor physi-
cal activity at Southern mid-latitude may well exceed that
of children’s in Northern regions with snow and sometimes
very cold weather. From a health perspective, step counts
during all seasons around the year need to be considered.
During field work, the air temperatures peaked at 26 ◦ C in
Raleigh, on average 5 ◦ C higher than in Malmö a month later.
Discomfort of direct sunlight may promote sun-protective
behaviour but is unlikely to spur physical activity in combina-
tion with high humidity in NC. However, in this investigation
childrenı̌s thermal comfort was not explicitly measured.
In Malmö, the weather was very rainy and cold which
made exposure during short periods of sunshine likely, and
hence explain high UV fractions. Further study of rela-
tive UV-exposure vs. weather, season, climate and latitude
is warranted, as is the significance of environments adja-
cent to outdoor preschool areas, such as forests close to
southern borders as was observed at site R2 (Raleigh).
The role of thermal comfort in terms of ambient temper-
ature, humidity and air pollution on both physical activity
and UV-exposure deserves exploration, as well as longitu-
dinal studies to explore impact of seasonality on children’s
physical activity and sun exposure. Also, there are obser-
vations that outdoor play in childhood may be protective
against malignant melanoma [43]. Apart from the potential
of increasing physical activity, this aspect of UV-exposure
would make it important to encourage outdoor stay all year
round.
5. Conclusion
The same findings were made at two different latitudi-
nal and climatological locations in Sweden, i.e. vegetation
Outdoor play environment and promotion of children’s physical activity
integrated in play space at preschool mediated by play
behaviour yields physical activity and sun protection by
automation. Handy tools for inexpensive assessment as part
of upgrading and selecting preschool land should be further
elaborated and adapted to mid-high latitudes. In Raleigh,
children’s step count/minute was lower than at compara-
ble sites in Malmö. However, at low-latitude Raleigh long
outdoor stay with low or no sunburn risk seems to be
more likely than in a barren environment at high latitudes
in Sweden. Considering the combined impact of preschool
outdoor environment upon physical activity and sun expo-
sure the role of climate and varying policies of outdoor
stay and play needs to be further explored across the
world.
Conflict of interest statement
None.
Acknowledgments
The study was funded by the Swedish Council for Environ-
ment, Agricultural Sciences and Spatial Planning. We also
want to acknowledge Bertil Forsberg and Chris Jordan for
giving access to rooftops at estate Kronprinsen in central
Malmö and NCSU campus for global UV measurement, Jill
Sindholt and Sarah Andersson for assistance in behaviour
mapping, Fredrik Olsson for assistance in processing sky view
images, and Thomas Carlund at SMHI for supplying pyra-
nometer data from Lund. Above all, we want to express our
gratitude to the children, their parents, and the preschool
staff.
References
[1] Boldemann C, Blennow M, Dal H, Martensson F, Raustorp A,
Yuen K, et al. Impact of preschool environment upon children’s
physical activity and sun exposure. Prev Med 2006;42:301—8.
[2] Martensson F, Boldemann C, Soderstrom M, Blennow M, Englund
JE, Grahn P. Outdoor environmental assessment of atten-
tion promoting settings for preschool children. Health Place
2009;15:1149—57.
[3] Licence K. Promoting and protecting the health of children and
young people. Child Care Health Dev 2004;30:623—35.
[4] WHO. Protection against exposure to ultraviolet radiation.
Geneva: WHO/EHC/UNEP; 1995.
[5] Armstrong BK. How sun exposure causes skin cancer: an epi-
demiological perspective. In: Hill D, Elwood JM, English DR,
editors. Prevention of skin cancer. Dordrecht Kluwer Academic
Publishers; 2004. p. 89—119.
[6] Blair SN, Brodney S. Effects of physical inactivity and obesity on
morbidity and mortality: current evidence and research issues.
Med Sci Sports Exerc 1999;31:S646—62.
[7] Stanton WR, Saleheen HN, O’Riordan D, Roy CR. Environmen-
tal conditions and variation in levels of sun exposure among
children in child care. Int J Behav Med 2003;10:285—98.
[8] US Department of Health and Human Services (USDH). Physical
activity and health: a report from the Surgeon General. Atlanta
GA: Center for Disease Control and Prevention, National Cen-
ter for Chronic Disease Prevention and Health Promotion;
1996.
[9] Armstrong BK, Kricker A. How much melanoma is caused by sun
exposure? Melanoma Res 1993;3:395—401.
81
[10] Dowda M, Pate RR, Trost SG, Almeida MJ, Sirard JR. Influences
of preschool policies and practices on children’s physical activ-
ity. J Community Health 2004;29:183—96.
[11] Fjörtoft I. Landscape as playscape. Learning effects from play-
ing in a natural environment on motor development in children.
Oslo: Nowegian University of Sport and Physical education;
2000.
[12] Boldeman C, Dal H, Wester U. Swedish pre-school children’s
UVR exposure - a comparison between two outdoor envi-
ronments. Photodermatol Photoimmunol Photomed 2004;20:
2—8.
[13] Diffey BL, Larko O. Clinical climatology. Photodermatol
1984;1:30—7.
[14] Parsons PG, Neale R, Wolski P, Green A. The shady side of solar
protection. Med J Aust 1998;168:327—30.
[15] Mårtensson F. The landscape in children’s play. A study of
outdoor play in preschools. Swedish University of Agricultural
Sciences; 2004.
[16] KGWCC. Koeppen-Geiger World Climate Classification map.
http://www.koeppen-geiger.vu-wien.ac.at/.
[17] NAE. Follow-Up Systems. Stockholm: National Agency for Edu-
cation; 2007.
[18] Capizzano JM, Main R. Many young children spend long hours
in child care (Snapshot of America’s Families III No. 22). Wash-
ington DC: Urban Institute; 2005.
[19] U.S.N.C. North Carolina- NPAS.S. http://www.
eatsmartmovemorenc.com. 2008.
[20] Thorgren-Jerneck K. Overweight and obesity in preschool
children. http://www.vardalinstitutet.net/documentarchive/
1168/1411/3463/5247.pdf?objectId=8527. 2010.
[21] Rodvall YE, Wahlgren CF, Ullen HT, Wiklund KE. Factors related
to being sunburnt in 7-year-old children in Sweden. Eur J Can-
cer 2010;46:566—72.
[22] Hall HI, McDavid K, Jorgensen CM, Kraft JM. Factors associated
with sunburn in white children aged 6 months to 11 years. Am
J Prev Med 2001;20:9—14.
[23] Grimmond CSB, Potter SK, Zutter HN, Souch C. Rapid meth-
ods to estimate sky view factors applied to urban areas. Int J
Climatol 2001;21:903—13.
[24] Cosco NG, Moore RC, Islam MZ. Behavior mapping: a method
for linking preschool physical activity and outdoor design. Med
Sci Sports Exerc 2010;42:513—9.
[25] Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a stan-
dard definition for child overweight and obesity worldwide:
international survey. BMJ 2000;320:1240—3.
[26] Soderstrom M, Martensson F, Grahn P, Blennow M. The outdoor
environment of day care centers. Its importance to play and
development. Ugeskr Laeger 2004;166:3089—92.
[27] ESeC. European socio-economic classification ISCO, 1988.
[28] Crouter SE, Schneider PL, Karabulut M, Bassett Jr DR. Validity
of 10 electronic pedometers for measuring steps, distance, and
energy cost. Med Sci Sports Exerc 2003;35:1455—60.
[29] Schneider PL, Crouter SE, Bassett DR. Pedometer measures of
free-living physical activity: comparison of 13 models. Med Sci
Sports Exerc 2004;36:331—5.
[30] Cardon G, De Bourdeaudhuij I. Comparison of pedometer and
accelerometer measures of physical activity in preschool chil-
dren. Pediatr Exerc Sci 2007;19:205—14.
[31] Eston RG, Rowlands AV, Ingledew DK. Validity of heart rate,
pedometry, and accelerometry for predicting the energy cost
of children’s activities. J Appl Physiol 1998;84:362—71.
[32] Kilanowski CK, Consalvi AR, Epstein LH. Validation of an elec-
tronic pedometer for measurement of physical activity in
children. Ped Exerc Sci 1999;11:63—8.
[33] Davis A, Deane GH, Diffey BL. Possible dosimeter for ultraviolet
radiation. Nature 1976;261:169—70.
[34] Diffey B. Personal ultraviolet radiation dosimetry with polysul-
phone film badges. Photodermatol 1984;1:151—7.
82
[35] Herlihy E, Gies PH, Roy CR, Jones M. Personal dosimetry of
solar UV radiation for different outdoor activities. Photochem
Photobiol 1994;60:288—94.
[36] Polysulphone and spore-film UV-dosimeters compared to two
radiation transfer models and an instrument that measures
the UV index - an evaluation for a UV-dosimetry study of
preschool children in Stockholm.Wester U, Slusser JR, Schäfer
K, Camerón A, editors. Remote sensing of clouds and the atmo-
sphere XI. Stockholm, Sweden: SPIE Bellingham; 2006.
[37] Rowe D, Mahar M, Raedeke T, Lore J. Measuring physical activity
in children with pedometers: reliability and replacement of
missing data. Ped Exerc Sci 2004;16:343—54.
[38] Boldeman C, Sinclair C. Sun protection at school. In: Rind-
borg U, Brandbert Y, Brietbart E, Griener R, editors. Skin
cancer prevention. New-York: Informa Healthcare; 2007.
p. 389—406.
C. Boldemann et al.
[39] Tudor-Locke C, Ainsworth BE, Thompson RW, Matthews CE.
Comparison of pedometer and accelerometer measures of free-
living physical activity. Med Sci Sports Exerc 2002;34:2045—51.
[40] Ozdoba R, Corbin CB, Le Masurier G. Does reactivity exist in
children when measuring activity levels with unsealed pedome-
ters? Ped Exerc Sci 2004;15:158—66.
[41] Evans GW, English K. The environment of poverty: multiple
stressor exposure, psychophysiological stress, and socioemo-
tional adjustment. Child Dev 2002;73:1238—48.
[42] Robinson LE, Wadsworth DD, Peoples CM. Correlates of school-
day physical activity in preschoolers. Res Quarterly Exerc Sport
2010; (accepted for publication, in press).
[43] Kaskel P, Sander S, Kron M, Kind P, Peter RU, Krahn G. Out-
door activities in childhood: a protective factor for cutaneous
melanoma? Results of a case-control study in 271 matched
pairs. Br J Dermatol 2001;145:602—9.