Thinking inside the box: the future of young children’s physical activity and the home environment

Abstract

Parrish et al.’s (2021) investigation of caregiver perceptions of preschoolers’ physical activity (PA) within the home environment posits important opportunities for public policy to consider space and available opportunities for PA for preschoolers. This study uncovered qualitative themes on preschoolers’ PA in the home, referencing the use of indoor and outdoor spaces, adaptations within the home, interplay between space and caregiving, and variability in child’s PA. This work sparks a discussion into the current understanding of the home environment for preschooler PA and future research directions. We propose three main areas to bring forward physical activity and public health research, including 1) role of policies and community (e.g., societal norms) on the home environment and child physical activity, 2) reimagination of the home environment beyond the physical components as a complex system, and 3) advanced measurement of child physical activity using modern technology. Merging these new opportunities with past efforts may help design and facilitate healthier PA and movement patterns for preschoolers now and into the future.

Introduction

One in four preschoolers (children ages 3 to 5 years) in the United States (U.S.) are meeting international guidelines for adequate physical activity amongst the COVID-19 pandemic and disrupted home environments (Kracht et al., 2021). The recent study by Parrish et al., 2021 investigated parent and grandparent perceptions of preschoolers’ physical activity within the home environment using semi-structured qualitative interviews conducted in the northwestern U.S. from years prior to the COVID-19 pandemic (Parrish et al., 2021). Interview questions were grounded in the materialities of care framework, which focuses on the interplay between material objects and environmental space in the context of caring for children (Buse et al., 2018). The authors identified four themes from these interviews, including caregiver views on outdoor vs. indoor spaces for children’s physical activity, adapting the home setting to allow for physical activity, considering the interrelationships among space and caregiving (such as family routines) as it relates to children’s physical activity, and considering the variability of children’s physical activity including low intensity physical activity. From their results, the authors posit opportunities for public policy to create sufficient space and identify opportunities for physical activity for preschoolers. Past research has predominantly focused on creating activity space and opportunities for school-aged children in the formal school environment, and this prior work should be expanded to consider the needs of younger children and their caregivers, including the creation and adaptation of physical activity practices and environments at home. Indeed, the home environment has been largely ignored by researchers and policymakers and remains an untapped opportunity as a venue to promote physical activity for young children.

The implications and recommendations of this study are timely given the recent World Health Organization (WHO)’s adoption of guidance on movement across the 24-hour day with the Guidelines on physical activity, sedentary behaviour, and sleep for children under 5 years of age (Ansari, 2019). The Parrish study also brings to light important topics facing the scientific and public health community, including the role of policy and community, comprehensive assessment of the family, and modern measurement in terms of the home environment and child physical activity. To clarify the importance of these areas and provide context, we will give a brief background of the knowledge base on preschooler physical activity to date and expand upon three future research areas projected from this paper, including high-level influences on home and child physical activity, exploration of the home environment, and advancing measurement.

Current State of the Science

Physical activity is well recognized for its importance across all ages for physical and mental development (Carson et al., 2016, Janssen and Leblanc, 2010). Physical activity prior to formal school entry (around 6 years of age) is different than other ages as young children move in more sporadic patterns with shorter bursts across the spectrum of physical activity from light to moderate- to vigorous-intensity activity. This movement is different compared to older children and adolescents who may have more structured physical activity opportunities at specific intensity levels, such as sports practice after school, and potentially a recess period in the day, but otherwise spend their day sitting. One main setting where young children may spend a large part of their waking hours during the week are formal childcare settings (Corcoran et al., 2017), and physical activity research in preschoolers has been conducted almost exclusively within these settings (Sisson et al., 2016, Larson et al., 2011). Since preschoolers are more active when outdoors compared to indoors, (Truelove et al., 2018, Jones et al., 2019) physical activity and outdoor time have evolved to become synonymous terms among both childcare teachers and researchers (Ott et al., 2019, Hinkley et al., 2018). Recent randomized controlled trials within childcare centers have experimented with various ways to increase outdoor time (Razak et al., 2018), thereby physical activity, by working with centers to modify their schedules and empower childcare teachers to participate in physical activity with children (Tucker et al., 2017).

Accordingly, as described in a recent systematic review, most interventions to increase preschooler physical activity have occurred predominately in childcare settings (47%, n=16 studies), with some including a childcare setting with a home component (32%, n=11 studies), but few were only within the home (21%, n=7 studies) (Hnatiuk et al., 2019). Amongst those conducted in the home, only one study showed favorable results on child physical activity (Cottrell et al., 2005). One potential explanation for the lack of change in children’s physical activity in the home setting is that a multitude of factors within the home environment may influence and possibly limit child physical activity. Another systematic review by Hesketh et al., found parental support, parental physical activity knowledge, and maternal role modelling were related to preschooler physical activity (Hesketh et al., 2017b). Improving upon these points, Hesketh et al. explored barriers and facilitators of preschooler physical activity in a systematic review of qualitative studies using a socio-ecological framework to capture macrosystem, microsystem, and child level factors (Hesketh et al., 2017a). This review included qualitative studies amongst parents, childcare staff, and other caregivers (Hesketh et al., 2017a). Specific to the home, Hesketh et al. found evidence that parental physical activity knowledge and appropriate scheduling may be facilitators to preschooler physical activity, while concerns around space and play in the home physical environment may be barriers to physical activity (Hesketh et al., 2017a). Opportunities to obtain quantitative evidence within these areas were proposed (Hesketh et al., 2017a), but explorations of the home as a multifaceted area that influences preschooler physical activity are still limited.

The home environment received renewed interest over the past years, with modern guidance on physical activity and the COVID-19 pandemic. A major development in recent years was a shift to focusing on movement throughout the 24-hour day, including physical activity, sedentary behavior, and sleep. Informal guidelines on physical activity came about in the early 2010s (Pate and O’Neill, 2012), but it was not until the past few years that guidelines were formalized. Though proposed in other venues, these guidelines came to prominence amongst a proposal of 24-Hour Movement Guidelines to create the 24-Hour Movement Guidelines for the Early Years (ages 0–4 years). These guidelines were first proposed by a Canadian group (Tremblay et al., 2017) along with an Australian group (Okely et al., 2017). The Canadian and Australian guidelines are similar, including ≥3 hours/day of total physical activity (light, moderate, or vigorous activity), with ≥1 hour/day of specifically MVPA for preschoolers (Tremblay et al., 2017). The other guidelines include ≤1 hour/day of sedentary screen-time and 10–13 hours/day of sleep for preschoolers (Tremblay et al., 2017). Incorporating multiple behaviors within the same day was a monumental step forward for public health and began the conversation of how children spend their day in totality, and the interaction of physical activity with other health behaviors. These guidelines received global attention and were eventually adopted by the WHO in 2019 (Ansari, 2019). Considering preschoolers obtain most of their sedentary screen-time and sleep outside of childcare settings (Kracht et al., 2019, Kracht et al., 2020), these guidelines also created a renewed focus on the role of the home environment in child movement patterns. Recent reports suggest only around 15% of preschoolers meet all three guidelines (Cliff et al., 2017, Kracht et al., 2019), as most meet the physical activity guideline but not the sedentary screen-time or sleep guideline.

Blending past research and these guidelines, a consensus statement by Rhodes et al. came about to address the role of family in child movement behaviors (Rhodes et al., 2020). Similar to Hesketh et al,(Hesketh et al., 2017a) the consensus statement approached the home environment as a macrosystem (larger influence of culture, policies and media, community, and social influences), microsystem (family and home environment), and the child behavior (Rhodes et al., 2020). The family environment level includes parent preferences and characteristics, parenting practices, home physical environment, and family demographics (Rhodes et al., 2020). Other considerations include family functioning, family structure, and family members which may span multiple levels of influence. In the consensus statement, these components were described mainly in reference to sleep and screen-time in preschoolers, but few studies in these areas included preschooler physical activity (Rhodes et al., 2020).

In the same year as the Rhodes et al. publication (Rhodes et al., 2020), the COVID-19 pandemic began across the globe. As initial lockdowns ensued, the home environment received renewed attention and the prevalence of meeting all three guidelines plummeted to less than 5% in the preschool population (Kracht et al., 2021). Multiple calls to action suggested a renewed focus on the home environment and child health behaviors within these settings (Guan et al., 2020, Tulchin-Francis et al., 2021). Recent reports found a significant increase in body mass index amongst 3–5 year olds in the U.S. when comparing before and during the pandemic (Lange et al., 2021). It is timely that the Parrish et al. 2021 study was submitted during the COVID-19 pandemic even with data collected prior to the pandemic (2011), as many in the physical activity community began to turn their attention toward the home environment. Though childcare teachers continued and even increased outdoor time as it allowed for social distancing practices (Lafave et al., 2021), many children spent additional time at home amongst a chaotic period in history. This unprecedented period created an opportunity for us to return to our “box” of thinking and revisit preschooler physical activity.

Considering prior research, the stimulus of the 24-hour movement guidelines and COVID-19 pandemic, along with the Parrish study bring into question our understanding and definition of the home environment as a dynamic and multi-faceted system. Guided by the socio-ecological framework and past research (Rhodes et al., 2020, Hesketh et al., 2017a), we present opportunities to improve our understanding and definition of the home environment.

1. Understanding the larger influence of policies and community on the home environment

The Parrish study and the new emphasis on preschooler physical activity at home brings forward questions on our own fundamental thinking of physical activity and how policies and communities influence our ability to be active. The Parrish study proposes policy should catch up to recent guidance on preschooler physical activity through design and development of home-based spaces (Parrish et al., 2021). A notable quote within the Parrish study was that the home environment was large enough for the child to be physically active as a toddler, but they outgrew it in the preschool years. As stated within the article, by one father “When they were toddlers and up to two, the apartment’s a pretty big area. But when you got a five-year-old that can ride a bike to [a nearby town] and back, you need some space and an apartment can’t cut it” (Parrish et al., 2021). Though physical activity before school entry is important, this may also pose the question of the preschooler outgrowing any large-scale modifications to the home environment or outdoor domicile area (e.g., playground) as they grow as well. This is another reminder that the home environment should allow for physical activity, regardless of age, from young to old. As all ages were confined to their home spaces during the COVID-19 pandemic, decreases in physical activity were seen across the age spectrum (Burkart et al., 2021, Fearnbach et al., 2021).

Specific to policy, there is limited guidance on home indoor design. Thus, adopting policies in the outdoor area may provide additional options at the macrosystem level for preschoolers to be active. Active urban living areas and accessible environments near living areas as stated in the International Society for Physical Activity and Health’s Eight Investments for Physical Activity (Milton et al., 2021) and the WHO’s Global Action Plan for Physical Activity (Organization, 2019) may provide a starting point for policies as referenced in Parrish et al., 2021. Though these initiatives are an exciting starting point, there is limited research on the effectiveness of these policies on the home and specifically to increase child physical activity. State licensing regulations and policies within childcare settings have been effective at improving preschooler physical activity (O’Neill et al., 2017, Kracht et al., 2020), but these same approaches of requiring certain outdoor play equipment and limiting screen-time may not translate to the home environment. There was a clear missed opportunity amongst the COVID-19 pandemic to assess state, county, and local level guidance or policies pertaining to social distancing (e.g., park usage, outdoor area usage, and transport restrictions) on the home environment and preschooler physical activity. Many assessed prevalence (Kracht et al., 2021) and changes before and after initial COVID-19 lockdown in existing cohorts (Kuhn et al., 2021), but it is unclear if these results are reflective of policies, parents, or other influences. Variable guidance and enforcement of restrictions across municipalities may have made this opportunity difficult in the circumstances. Therefore, our first recommendation for future research is to examine the role of municipal policies on the home environment and ability for preschoolers to be active while they are at home. As of this publication, the COVID-19 pandemic is ongoing thus this opportunity may still be available. Working with communities to create tailored and pragmatic options, along with rigorous assessment of the uptake and effectiveness of these options, may build our understanding of how policy changes can result in physical activity for all, including preschoolers.

As for community, the Parrish study was conducted within a northwestern state of the U.S. and may not be generalizable to other states within that country or across the globe. There is little work amongst the larger influence of community, social beliefs, culture, or media on child physical activity within the home. Considering culture, the home environment and role of formal childcare in a child’s day differ across countries, including space and equipment for physical activity, cultural preferences, or expectations for physical activity, financial or resource support received from the municipality (Jackson et al., 2021). Further, results of studies conducted in high-income countries (e.g., U.S. and Canada) may not be generalizable to middle- or low-income countries. Recent efforts led by the SUNRISE International Study of Movement Behaviours in the Early Years group to measure adherence to the 24-Hour Movement Guidelines in preschoolers across low-, middle-, and high-income countries (Okely et al., 2021), provide some additional assessment of home factors (e.g. bed sharing and use of outdoor space at home) but are primarily centered on the childcare setting. This multi-country assessment using universal measurements presents opportunity to explore differences in culture, societal beliefs, community, and their influence on the home environments and child physical activity. Therefore, our second recommendation in this macrosystem level is to conduct similar assessments across countries to better understand and identify how these high-level factors may influence the home environment and preschooler physical activity. As described by Riazi et al. in an exploration amongst stakeholders and end users of the Canadian 24-hour movement guidelines for the early years, societal norms of high screen-time or focusing on academic achievement over play may hinder preschooler physical activity in home environments across Canada (Riazi et al., 2017). Similar research efforts may help describe the role these larger influences play on the home environment and preschooler physical activity in different areas.

2. Reimagination of the family environment

The Parrish study presents the home environment through the materialities of care framework, whereby evaluating the interrelationships of the physical environment and objects with the family’s care-taking behaviors (Buse et al., 2018). This framework included interview questions on space and materials available in the indoor home environment, along with the yard, and larger outdoor spaces near the home such as parks or green spaces. This approach is similar to the framework proposed by Hesketh et al.(Hesketh et al., 2017a), but quantitative evidence within the family and home microsystem is limited. Existing quantitative evidence focuses on defining the home physical environment, including home inventories (Vaughn et al., 2019, Patience et al., 2021, Cheng et al., 2016), which mainly focus on the availability and accessibility of physical activity and screen-time space in and near homes in preschoolers. What remains to be assessed include the family components within the home that may influence physical activity. As proposed by Hesketh et al. (Hesketh et al., 2017a) and expanded upon by Rhodes et al. (Rhodes et al., 2020), crowding and other noise may prevent preschoolers from being active or deter caregivers from encouraging physical activity within the home environment as found in Parrish study. Crowding, noise, and disorganization, collectively termed household chaos, has become an emerging risk factor for additional screen-time and less sleep (Emond et al., 2018). A recent report amongst the COVID-19 pandemic found that household chaos was also negatively related to preschooler physical activity (Kracht et al., 2021), suggesting opportunities for routine within the home may help facilitate child physical activity. Combining assessment of household chaos, the physical environment, and other caregiver preferences (e.g., parental support for physical activity and physical activity knowledge) to create a comprehensive assessment of the family and home environment is a promising next step to understanding and characterizing this system, and to identify potential modifiable targets for interventions to promote children’s physical activity.

Still, these efforts speak to how research and policymakers see the interplay of physical activity within the home as mainly an interaction of the physical environment. As proposed by Rhodes et al. (Rhodes et al., 2020), adoption of family systems theory in the design and conduct of physical activity interventions may be the larger step needed to achieve sustained physical activity behavior change but is rarely adopted in interventions. Further, addressing these components of the family environment as an intervention target is important. One opportunity to address household chaos is to propose routine within the home, which may in turn lead to regular, structured opportunities for physical activity. As stated in the Parrish article, routines were an important component to consider in child movement behavior. Family planning for physical activity can result in changes to family physical activity in older children, but has not been applied to this younger age range (Rhodes et al., 2019). A recent routine-based intervention pilot study over 6-weeks in preschoolers did result in lower household chaos scores and improvements in sleep outcomes (Marsh et al., 2020). Taken together, contemporary and comprehensive design of home-based interventions to address the family and home microsystem may improve on past interventions and our understanding of how changes in this area can influence preschooler physical activity.

3. Measurement of physical activity and movement behaviors

The final area we must revisit is at the individual level regarding how we measure and track physical activity in this age range. The Parrish study utilized qualitative data and did not measure preschooler physical activity, so it is unclear the level of activity in the sample. However, the authors did note a theme of “mundane movement”, where the parents and grandparents described how children’s activity transitioned through the wide range of physical activity, from sedentary to vigorous activity within the home environment (Parrish et al., 2021). In childcare settings, measures such as direct observation are used to document and classify child physical activity patterns, such as the Environmental and Policy Assessment and Observation tool (Ward et al., 2008, Bower et al., 2008) and the System for Observing Play and Leisure Activities in Youth tool (Saint-Maurice et al., 2011), including observing outdoor play and classroom practices. These opportunities may not be afforded in the home environment where space and observation logistics may be limited. Physical activity in the home is commonly viewed as movement within the vertical plane on a waist-worn accelerometer (Leeger-Aschmann et al., 2019). Protocols for waist-worn accelerometry provide insight into time children spend at home and away from childcare settings. At a childcare setting, trained staff can properly place the device on the child when they arrive, monitor wear throughout the day, and then remove the device when the child leaves. Parents may not be able to always monitor accelerometer wear at home. Further, other sites on the body to wear the device may be more tolerable (e.g., the wrist) for long periods away from school. As with changes to the U.S. National Health and Nutrition Examination Survey (Troiano et al., 2014), we propose that a wrist-based accelerometer protocol may be better suited to measure activity within the home setting and increase compliance. Commercially available activity-tracking devices (e.g. Garmin vívofit jr.® (Muller et al., 2018) have already evolved for this age range though have not been as thoroughly validated as accelerometry and also use proprietary algorithms inaccessible to researchers. Wrist-based accelerometry may also better capture other preschooler behavior, such as sleep patterns, compared to waist-worn protocols (Tudor-Locke et al., 2014, Galland et al., 2012).

To address gaps in physical activity measurement, we recommend future research explore wrist-based accelerometry protocols to aid in capturing physical activity and movement in the home environment. To overcome the limitations of direct observation in the home, we encourage researchers to pair these devices with other technology that can assess multiple facets of the home environment in real-time (e.g., ecological momentary assessment [EMA]). These additional measures of contextual factors may provide the most in-depth assessment of child physical activity within the home environment. These in-depth assessments of person (e.g., who they are with), place (e.g., inside the home, outside the home), context (e.g., active play, sports, parent co-participation), and parental mood (e.g., stress and chaos) may extend our knowledge of physical activity and other movement behaviors in the home. Previous research has already harnessed pairing EMA with dietary records in preschoolers, but this has not extended to physical activity devices and context yet (Loth et al., 2020). These technological methods may also be further supplemented with qualitative interviews in a mixed-methods design, which may extend findings of the Parrish study (as it was solely based on interviews). These advanced measurements may allow researchers and public health professionals to achieve more accurate prevalence estimates, describe the context of home physical activity, and better identify opportunities to increase physical activity at home.

Conclusions

The Parrish study illuminates an important gap within the preschooler physical activity literature, the home environment. Through their assessment of qualitative interviews, we are introduced to the home environment through the eyes of parents and grandparents and presented opportunities for public policy to evolve to meet recent physical activity guidance. By revisiting our own fundamental thinking of preschooler physical activity and the home environment, and by creating active home and community spaces for all, the field may begin to fill these cracks in knowledge. Merging these new opportunities with recent public health efforts may help design activity-promoting home environments that facilitate healthier movement patterns for preschoolers now and into the future.

Highlights.

1. Parrish et al. addresses the home environment and preschooler physical activity

2. The COVID-19 pandemic and 24-hour movement guidelines renewed interest in the home

3. Social, family, and physical home components are important for physical activity

4. Assessing the role of policy and society on child physical activity is important

5. Adopting modern technology for real-time assessment can improve current research