CONTEXT Daily outdoor play is encouraged by the American Academy of Pediatrics. Existing evidence is unclear on the independent effect of nature exposures on child health. OBJECTIVE We systematically evaluated evidence regarding the relationship between nature contact and children’s health. DATA SOURCES The database search was conducted by using PubMed, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, ERIC, Scopus, and Web of Science in February 2021. STUDY SELECTION We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In all searches, the first element included nature terms; the second included child health outcome terms. DATA EXTRACTION Of the 10 940 studies identified, 296 were included. Study quality and risk of bias were assessed. RESULTS The strongest evidence for type of nature exposure was residential green space studies (n = 147, 50%). The strongest evidence for the beneficial health effects of nature was for physical activity (n = 108, 32%) and cognitive, behavioral, or mental health (n = 85, 25%). Physical activity was objectively measured in 55% of studies, and 41% of the cognitive, behavioral, or mental health studies were experimental in design. LIMITATIONS Types of nature exposures and health outcomes and behaviors were heterogenous. Risk of selection bias was moderate to high for all studies. Most studies were cross-sectional (n = 204, 69%), limiting our ability to assess causality. CONCLUSIONS Current literature supports a positive relationship between nature contact and children’s health, especially for physical activity and mental health, both public health priorities. The evidence supports pediatricians in advocating for equitable nature contact for children in places where they live, play, and learn.

Background: Participation in outdoor play has been extensively documented as beneficial for the health, well-being, and development of children. Canadian early childhood education centers (ECECs) are important settings in young children’s lives and provide opportunities to participate in outdoor play. However, there are barriers to the provision of outdoor play opportunities at ECECs, such as adverse weather conditions, poorly designed outdoor spaces, outdoor time policies, and early childhood educator comfort levels. Objective: The PROmoting Early Childhood Outside (PRO-ECO) study is a wait-list control cluster randomized trial that evaluates the impact of the PRO-ECO intervention, an innovative outdoor play intervention, on children’s outdoor play behavior. The purpose of this paper was to provide a detailed overview of the pilot study protocol and the methods that will be used to develop, implement, and evaluate the PRO-ECO intervention. Methods: A total of 8 ECECs delivering licensed care to children aged 2.5 to 6 years in the Greater Vancouver region of British Columbia, Canada, and operated by the YMCA of Greater Vancouver (YMCA GV) are included in this study. Using a wait-list control cluster randomized trial design, we randomly allocated ECECs to either the PRO-ECO intervention arm (n=4) or the wait-list control arm (n=4). The primary outcome measures include changes in the proportion and diversity of observed outdoor play behavior during dedicated outdoor times at the ECECs as measured through observational behavior mapping. Secondary outcome measures include changes in educator attitudes; quality of ECECs’ outdoor play space; and children’s psychosocial strengths, physical activity levels, and social behaviors. A process evaluation of the acceptability of the PRO-ECO intervention in the 8 YMCA GV ECECs will also be assessed. Outcome data will be collected at baseline, 6-month follow-up, and 12-month follow-up. Mixed effect models will test the effect of the PRO-ECO intervention on quantitative outcomes. Baseline and postintervention data will be included in the analysis, controlling for the cluster design. Qualitative data will support quantitative findings and provide evidence for the acceptability of implementation. Results: Participant recruitment for this study began in August 2021, and baseline data collection was completed at all 8 ECECs in November 2021. As of April 2022, a total of 130 children have been recruited to participate in this study. Conclusions: The PRO-ECO pilot study will develop, implement, and evaluate the PRO-ECO intervention within 8 YMCA GV ECECs in the Vancouver region of British Columbia, Canada. The findings of this study will be useful for early childhood educators, ECEC providers, and policy makers to consider means for enhancing outdoor play provision and assessing the sustainability of the intervention in ECEC settings. Trial Registration: ClinicalTrials.gov NCT05075580; https://clinicaltrials.gov/ct2/show/NCT05073380 International Registered Report Identifier (IRRID): DERR1-10.2196/38365

Objective: To examine the associations between social determinants of health (SDOH) and prevalent overweight/obesity status and change in adiposity status among American Indian and Alaska Native (AI/AN) children. Methods: The study sample includes 23,950 AI/AN children 2–11 years of age, who used Indian Health Service (IHS) from 2010 to 2014. Multivariate generalized linear mixed models were used to examine the following: (1) cross-sectional associations between SDOH and prevalent overweight/obesity status and (2) longitudinal associations between SDOH and change in adiposity status over time. Results: Approximately 49% of children had prevalent overweight/obesity status; 18% had overweight status and 31% had obesity status. Prevalent severe obesity status was 20% in 6–11-year olds. In adjusted cross-sectional models, children living in counties with higher levels of poverty had 28% higher odds of prevalent overweight/obesity status. In adjusted longitudinal models, children 2–5 years old living in counties with more children eligible for free or reduced-priced lunch had 15% lower odds for transitioning from normal-weight status to overweight/obesity status. Conclusions: This work contributes to accumulating knowledge that economic instability, especially poverty, appears to play a large role in overweight/obesity status in AI/AN children. Research, clinical practice, and policy decisions should aim to address and eliminate economic instability in childhood.

A growing body of literature suggests that outdoor time is beneficial for physical and mental health in childhood. Profound disparities exist in access to outdoor spaces (and the health benefits thereof) for children in communities of color. The objectives of this research were to: (1) identify challenges and solutions to outdoor time for children; (2) assess the importance of outdoor time for children; and (3) evaluate results stratified by race/ethnicity. Using a convergent mixed methods approach, we conducted a thematic analysis from 14 focus groups (n = 50) with outdoor educators, parents with children attending outdoor preschools, and community members with children. In addition, 49 participants completed a survey to identify challenges and solutions, perceived importance, and culturally relevant perspectives of outdoor time. The main challenges identified for outdoor time were safety concerns, inclement weather, lack of access to outdoor spaces, and parent work schedules. The primary proposed solution was integrating outdoor time into the school day. Nearly all participants, independent of racial identity, reported that outdoor time improved physical and mental health. Overall outdoor time was lower in participants from communities of color (~8 h/week) compared to their White counterparts (~10 h/week). While 50% of people of color (POC) reported that outdoor time was an important cultural value, only 18% reported that people in their respective culture spent time outside. This work contributes to accumulating knowledge that unique barriers to outdoor time exist for communities of color, and the children that live, learn, and play in these communities. Increasing outdoor time in school settings offers a potential solution to reduce identified barriers and to promote health equity in childhood.

The current literature supports the positive relationship between time in nature and the improvement in children’s health and identifies early childhood education (ECE) settings as an avenue for intervention. Unfortunately, access to both outdoor time and ECE opportunities is lower in communities facing economic adversity. Efforts are needed to identify the best approaches to incorporate outdoor time in ECE settings, especially in communities facing socioeconomic adversity. The objectives of this research were to use a mixed methods approach to identify (1) barriers and solutions to the integration of outdoor time in ECE settings, (2) if outdoor time is a priority in ECE settings compared to other ECE priorities, and (3) how socioeconomic status influences ECE priorities and barriers for outdoor time, and health outcomes. Fourteen focus groups were conducted (n = 50) in the United States (US) with participants from three stakeholder groups: outdoor educators, parents of children attending outdoor preschool, and community members with children. Participants completed a survey (n = 49) to evaluate demographics, views on ECE and outdoor time, and health characteristics. Exploratory analyses of F as an effect modifier were conducted. The survey results showed that parents prioritized social and emotional learning and outdoor time when selecting an ECE setting for their child. The barriers identified include financial challenges and the limited availability of ECE programs. The solutions discussed included increased availability and financial support. Low income was correlated with higher rates of anxiety and increased outdoor time was a potential protective factor. These insights inform interventions to enhance outdoor time in ECE settings, with the goal of reducing disparities and promoting children’s overall health.

Outdoor time is positively associated with improved physical and mental health in adults. Little is known about the specific effects of outdoor time on health outcomes for parents and educators of preschool-aged children. Early childhood is a critical window for growth and development, as parental and educator stress negatively impacts young children; thus, it is of paramount importance to systematically support parents and educators during these developmental years. The objectives of this research were to use a cross-sectional natural experiment to (1) evaluate the association between outdoor time and physical and mental health in caregivers and educators who engage with preschool-aged children; (2) evaluate the association between income and physical and mental health in caregivers and educators who engage with preschool-aged children; and (3) identify benefits and barriers of outdoor time and the importance, availability, and accessibility of community resources for outdoor time. Participants were recruited from three stakeholder groups: preschool educators, parents of children attending an outdoor preschool, and parents of preschool-aged children in the local community. Participants completed a health needs assessment (n = 46) to assess demographics, mental and physical health outcomes, and benefits, barriers, and resources for outdoor time. Caregivers and educators in the higher income group (≥USD 70,000) were 41% (95% CI: 12%, 70%) more likely to report very good or excellent self-reported health. Mean anxiety, depression, and perceived stress were lower in the higher-income group. Caregivers and educators in the higher outdoor time group had lower body mass index (−5.5 kg/m²; 95% CI: −11.6, 0.7), and outdoor time appeared to be protective for general health independent of income. Thus, outdoor time may be a critical protective factor to enhance biological resilience for caregivers and educators, especially for those facing financial adversity.