Open access

Designing Landscapes for Child Health

Written By

Aydın Özdemir

Submitted: 26 July 2012 Published: 01 July 2013

DOI: 10.5772/55762

From the Edited Volume

Advances in Landscape Architecture

Edited by Murat Özyavuz

Chapter metrics overview

3,480 Chapter Downloads

View Full Metrics

1. Introduction

Childhood obesity has reached epidemic proportions and is a major public health problem globally (Ebbeling et al., 2002; Pate et al., 2008), which causes many serious health-related problems (van Emmerik et al., 2012; Daniels et al., 2005; Din-Dzietham et al., 2007; Lorch and Sharkey, 2007) such as coronary heart disease, diabetes, osteoporosis (Sallis and Owen 1999; Pate et al. 1995; Hume et al. 2005; Raitakari et al., 1997; Teixeira et al., 2001; Bailey, 1995; Berenson, 1986; Van Mechelen et al., 2000), sleep apnea syndrome (Wabitsch, 2000) and psychological problems (Dietz, 1998; Daniels, 2006). Obesity is caused by a higher energy intake than energy expenditure, resulting in excessive weight gain (Koezuka et al., 2006). Theory implies that energy balance is maintained by energy expenditure, and physical activity helps to improve energy expenditure resulting weight loss (Weinsier et al., 1998; Lambert and Goedecke, 2004; Chaput et al., 2011). Physical activity helps to improve metabolic profile, muscular and bone health (Anderson and Butcher, 2006; Ekelund et al., 2008; Hind and Burrows, 2007; Biddle et al., 1998), mental health and academic performance (Singh et al., 2012; Strong et al., 2005). For a healthy living, it is recommended that children should participate to at least 60 min/day of physical activity and include vigorous physical activity at least 3 days/week (Strong et al., 2008). Daily walking is a useful activity for healthy living (Shultz et al., 2011) and children should accumulate at least 12.000 steps per day to maintain a healthy weight (Tudor-Locke et al., 2011).

Environmental factors, which discourage energy expenditure and thus limit the availability of facilities for physical activity, have potential to influence body weight and healthy behavior (Lachowycz and Jones, 2011; Feng et al., 2010; Papas et al., 2007; Sallis et al., 2000). Studies reported a positive relationship between access to greenspaces and physical activity (Lachowycz and Jones, 2011; Kaczynski and Henderson, 2007; Kaczynski et al., 2008). Increased vegetation was associated with reduced weight among children (Liu et al., 2007) and neighborhood greenness influenced less weight gain in children (Bell et al., 2008). Promoting physical activity among children, therefore, should be a public health priority, and studies should focus on the determinants of the environmental variables of physical activity.

Previous reviews found associations between aesthetic attributes of the physical environment with physical activity (Sallis and Owen, 1999; Sallis et al., 1998; Owen et al., 2000; Humpel et al., 2002). Models developed from such research help to explain environment-behavior relationships that can play a key role in linking research, policy and practice. In this context, there is a need for high-quality empirical evidence supporting environmental influences on health (Humpel et al., 2002) and an understanding of how these environmental attributes are related to promoting more physical activity.

Within the extant literature there are many models and theories which help to conceptualize a potential way of mapping ecological, social and biological frameworks. Ecological model implies that behavior is influenced by the environmental factors, and changes in the environment—positive or negative—will have effects on health (McLeroy et al., 1988). The evidence shows that the built environment—the office environments (Chao et al., 2003), healing environments such as hospitals and day care centers (Whitehouse et al., 2001; Cooper-Marcus and Barnes, 1999), school buildings (Cradock, et al., 2007; Everett Jones et al., 2003), outdoor school environments (Rivkin, 1997; Dyment et al., 2009; Dyment and Bell, 2007; Tranter and Malone, 2004; Brink et al., 2010; Özdemir and Yılmaz, 2008), housing and home environments (Shaw, 2004; Wigle, 2003; Evans et al., 2003; Saegert, 1982), recreation facilities and access to green spaces (Wells and Evans, 2003; Maller et al., 2006; Stigsdotter et al., 2010; Sugiyama et al., 2008), greening vacant urban space (Branas et al., 2011), the design of neighborhoods (Wells and Yang, 2008) and store locations (Holsten, 2009)—will affect health and well-being of users.

Figure 1.

Model of environment health relation (Adapted from Pikora et al., 2003).

Established links between health and environment suggest that individual, social and physical environmental factors are related to behavioral intention, thus, shape our way of activities (Figure 1). As a result, improvements in the physical environment might lead to a number of long-term health outcomes: decrease in obesity, increase in physical activity, and decrease in serious health problems. Several studies have linked urban green space to fewer health complaints (Maas et al., 2009; Takano et al., 2002; Mitchell and Popham, 2008; Richardson and Mitchell, 2010; Mitchell et al., 2011). Based on these numerous health outcomes, planning and design decisions should take into consideration these public health impacts.

1.1. Environmental characteristics and health outcomes

Research on the determinants of potential environmental variables of physical activity is a growing trend (Carnegie et al., 2002; Sallis et al., 1990; Brug et al., 2005; Humpel et al., 2002; Owen et al., 2004; Trost et al., 2002; Saelens et al., 2003; Cunningham and Michael 2004; Wendel-Vos et al., 2007). Despite extensive research, the determinants of physical activity are not fully understood (Dishman and Sallis, 1994; Sallis and Owen, 1997; Vita and Owen, 1995). In order to promote planned and systematic physical activity among children, the key issue should be to gain insight into environmental factors that facilitate or obstruct physical activity among children (Baranowski and Jago, 2005; Wendel-Vos et al., 2004).

The social model of health conceptualizes health in environmental and social rather than just physical or individual terms (Figure 2). Research on the determinants of healthy child development showed that studies should include a mix of social and environmental factors—income, education, health and everyday environments—and all levels of society (Bonnefoy, et al., 2007). Healthy children will be those who are enabled to satisfy their needs and change, and cope with the urban environment (Davis and Jones, 1996; Black and Krishnakumar, 1998). However there is no systematic analysis of health effects of environments (Davis and Jones, 1996). Physical activity researchers, on the other hand, have not seriously addressed how the wider social and physical environment influences children’s play and mobility.

Figure 2.

Factors influencing physical activity in communities (Adapted from Dahlgren and Whitehead, 1991).

1.2. Outdoor school environments and health outcomes

Despite the fact that most physical activity by children is undertaken outside of the school building (Sallis et al., 1993; Vicent and Pangrazi, 2002), schools have not been recognized as key settings both to promote and to contribute to physical activity guidelines (Zimring et al., 2005; Zask et al., 2001; Iverson et al., 1985; Biddle et al., 1998) because children spend a large proportion of their time there (Biddle et al., 1998; Iverson et al., 1985).

School environments and policies have been studied for their effects on healthy behavior and obesity prevention (Trudeau and Shepherd, 2005; Story et al., 2006; Wechsler et al., 2000). Additionally, school building and campus characteristics have been associated with objective measures of physical activity (Cradock et al., 2007). Effects of school recess time (Ridgers et al., 2006), type and size of space and fixed outdoor equipments (Sallis et al., 2001), school size and available number of balls (Zask et al., 2001), size of schoolyards (Özdemir and Yılmaz, 2008), the provision of extra equipment (Sallis et al., 2003; Verstraete et al., 2006), school ground paintings (Stratton and Mullan, 2005; Ridgers et al., 2007) and school environment improvements (Haug et al., 2010) have been found to be associated with physical activity. Past studies concentrated on environmental influences on health outcomes, however, found limited and ambiguous results (Ferreira et al., 2007; Davison and Lawson, 2006). Children were found to be healthier in large schoolyards (Özdemir and Yılmaz, 2008); however, children were more active in small schoolyards (Özdemir and Çorakçı, 2010). Additionally, limited outdoor play time and short recess were associated with a higher body mass index levels in young children (Ernst and Pangrazi, 1999; Alhassan et al., 2007; Ridgers et al., 2006).

Access to urban parks and recreational facilities, schoolyard renovations, type and quality of play spaces have been studied for their effects on increased physical activity in children (Sallis et al., 2009; Stucky-Ropp and DiLorenzo, 1993; Sallis et al., 1993). Some studies reported a significant association between active commuting to school and weight status (Faulkner et al., 2009; Lee et al., 2008; Lee and Tudor-Locke, 2005; Heelan et al., 2005; Pabayo et al., 2011; Rosenberg, et al., 2006; Mendoza et al., 2011), and children who actively commute to school are healthier than passive commuters (Heelan et al., 2005; Özdemir and Yılmaz, 2008; Lee and Tudor-Locke, 2005). In a comparison between cycling and non-cycling children, after 6 years of observations, children who cycle to school were found healthier (Cooper et al., 2008).

In order to develop school-based interventions, it is crucial to better understand the ways by which the school environment may promote or inhibit children’s physical activity (van Sluijs et al., 2012). For a sustainable and a successful transition of school grounds from a conventional asphalt surface to a natural educational setting, outdoor school environments need to be conducive to health promotion with an integrated and a participatory approach.

1.3. Neighborhood characteristics and health outcomes

Active behaviors should be promoted with city planning and infrastructure by creating safe and accessible urban environments (Lopez and Hynes, 2006; Frank et al., 2005; Badland and Schofield, 2005; Handy et al., 2002), which in turn enhance energy expenditure. Environmental factors are influential in type and frequency of activity, such as climate of the region, terrains, neighborhood and traffic safety, and parents’ perceptions of their children’s activities outdoors (Saelens et al., 2003; Leslie et al., 2005). Sociocultural background (Flavia et al., 2010; Fredriks, 2005) and neighborhood characteristics are effective in obesity prevention; children in deprived neighborhoods are more likely to be overweight (deJong et al., 2011; Janssen et al., 2006; Lackshman et al., 2010; Veugelers and Fitzgerald, 2005). Several reviews indicate that people with low income are more likely to live in poor quality built environments, and this contributes to poor health (Lavin et al., 2006; Sallis et al., 2009). Parents in lower income neighborhoods reported the highest rates of unpleasant walking environments (van Lenthe et al., 2005). Neighborhood violent crime may be a significant environmental barrier to outdoor physical activity for urban dwelling (Bennett et al., 2007; Gomez, 2004).

Studies reported a positive relationship between access to greenspaces and physical activity (Kaczynski and Henderson, 2007; Lachowycz and Jones, 2011; Lee and Maheswaran, 2010). Children living in neighborhoods with playgrounds, parks and other recreational facilities engage in more physical activities and are less likely to be obese (Veugelers et al., 2008; Gordon-Larsen et al., 2006). Increased vegetation was associated with reduced weight among children (Liu et al., 2007) and neighborhood greenness influenced less weight gain in children (Kaczynski and Henderson, 2007; Roemmich et al., 2006; Bell et al., 2008). Park playgrounds were influential in reduced BMI values in children (Potwarka et al., 2008). A cross-sectional survey of adults in 8 European cities found that people in the greenest areas are less likely to be obese (Ellaway et al., 2005). Parents complained about the heavy traffic streets and the absence of a park nearby, which limited their children’s play outside. Additionally, some parents indicated that their children never play outside of their home, even during the weekend due to the lack of nearby park (Aarts et al., 2012).

1.4. Measurement techniques of physical activity

The assessment techniques of physical activity can be grouped into two categories: subjective and objective. Subjective techniques include observations, questionnaires, interviews, physical activity logs and activity diaries. Objective techniques include physiological indices such as heart rate monitoring and electronic motion sensors (accelerometry, pedometer measurements), and tracking movement with Global Positioning Systems (GPS).

1.4.1. Subjective assessments

Assessment of children’s physical activity levels is a research-priority (Trost et al., 2000) and several tools have been developed for this assessment (Welk, 2002; Ekelund et al., 2001). The most common technique is the subjectively measurement of child physical activity by survey techniques with self-reports (Loprinzi and Cardinal, 2011). Sallis et al. (2002) discussed self-report techniques that are defined as inexpensive and easy to administer. However, accuracy and reliability of self-report data are discussed, since young children may have difficulties in recalling their activity behaviors (Pate et al., 1995; Welk et al., 2000; Affuso et al., 2011), which calls for a response bias that affect the quality of data (Klesges et al., 2004).

Some studies included parental reports of their children’s height and weight (Hinkley et al., 2008; Oliver et al., 2007; Eiser and Morse, 2001), which are often inaccurate (Rowland, 1990). Indirect subjective measures such as parent and teacher questionnaires were also administered to assess child physical activity (Oliver et al., 2007) and health related quality of life (Eiser et al., 2000).

The evaluation of the children’s perception of the environment and its effect on behavior should be provided by multi-method approach. Focus groups are useful techniques in research with children (Hoppe et al., 1995; Morgan et al., 2002; O’Dea, 2003; Vaughn et al., 1996), and discussing topics in groups in schools is an appropriate method to gain insight into child views on several topics. Focus group method has been used for providing data which are deeper, more qualified and appropriate to the purpose of the research. Focus group is one of the rapid scanning methods which provide qualitative information in a short time. It is generally realized with 10-12 participants. The moderator provides the different/same opinion, comment or information to occur via questions which help to discuss. It is one of the most frequently used information gathering methods, because it provides convenience to reach different information in a short time, enables the flexible, unexpected and unknown findings to occur, catches extreme points and is cost-effective (Babbie, 2006; Debus, 1990; Engelbrektsson, 2002; Krueger and King, 1998; Krueger and Casey, 2000).

1.4.2. Objective measurements

Direct measures with objective tools such as accelerometers, pedometers, heart-rate monitoring (Oliver et al., 2007; Sirard and Pate, 2001; Trost et al., 2000) and GPS techniques can be used to monitor, measure and assess childhood physical activity. The use of these tools reduces the bias commonly associated with self-report measures. The objective assessment with measurement tools has high practical utility, high reliability and high validity relative to subjective measurements (King et al., 2011; Corder et al., 2008).

Pedometers and accelerometers

Accelerometer-based devices provide valid and objective information on physical activity with several outputs such as calories and fat burnt during a period of time, time spent in moderate and vigorous activity, distance walked and total step counts (Bassett and John, 2010). They are battery-operated devices that are attached to the wrists or ankles of the subjects to measure the number of steps during activities. Pedometers enable translating physical activity recommendations into pedometer-based step goals and commonly used in research with children (Pate et al., 2010; Mitre et al., 2009; Marshall et al., 2009; Tudor-Locke et al., 2011; Tudor-Locke and Bassett, 2004). They are widely used in medical research to compare descriptive data (steps per day) for specific age groups, cultures and environmental contexts (Whitt et al., 2004). However, they fail to capture data of seated activity (Berlin et al., 2006) and they only measure horizontal activities such as walking and running.

Accelerometers are also useful, reliable and valid tools with motion sensors to assess the intensity, frequency, pattern and duration of activity, which is an advantage over the pedometers (Berlin et al., 2006). Data collected by these devices should be processed on a computer. Research that included pedometer measurements found that obese children have lower pedometer counts than non-obese children (Tudor-Locke and Bassett, 2004; Eisenmann et al., 2007; Al-Hazzaa, 2007). Tudor-Locke and Bassett (2004) proposed a system used to classify healthy adults based on their activity levels: <5,000 steps a day for sedentary lifestyle, 5,000 to 7,499 steps a day for low activity, 7,500 to 9,999 steps a day for somewhat active, 10,000 to 12,499 steps a day for active, and >12,500 steps a day for highly active.

Heart rate monitoring

Heart rate (HR) monitoring is an objective, inexpensive and unobtrusive assessment tool providing indirect, intensity and duration data of physical activity among children (Loprinzi and Cardinal, 2011). HR monitoring provides information about total energy expenditure and about the amount of time spent in high-intensity activity (Ainslie et al., 2003). This tool has provided a valid and reliable objective estimate of physical activity (Rowlands and Eston, 2007) however, the link between heart rate measurements and energy expenditure is not as strong as other objective techniques (Trost et al., 2001). Heart rate can be measured easily with monitors attached to the wrists and the beltline. The resting and maximal heart rate is compared to gauge exercise and activity intensity. According to the American College of Sports Medicine Position Stand (1998), physical activity intensity according to frequency of heart rate is calculated for practical purposes as shown in Table 1 below:

Intensity descriptorRelative Intensity
% Heart rate reserveRating of perceived exertion
Very light< 20< 10
Light20-3910-11
Moderate40-5912-13
Vigorous60-8414-16
Very vigorous"/> 8517-19

Table 1

Physical activity intensity according to frequency of heart rate*Adapted from American College of Sports Medicine Position Stand (1998).

Heart rate also has a significant relationship with energy expenditure and has been widely used in studies of physical activity in children (Eston et al., 1998; Spurr et al., 1988; Ceesay et al., 1989; Livingstone et al., 1992). HR monitoring reports much lower levels of physical activity and is based on small sample groups (Livingstone et al., 2003). However there are a number of limitations to the use of this technique (Armstrong and Welsman, 2006; Rowlands et al., 1997). Since HR is influenced not only by physical activity, reliability of this measurement is questionable. A child with low levels of physical activity may have high heart rates due to the influence of other parameters such as emotional stress, anxiety, hydration and environment (Armstrong and Welsman, 2006; Rowlands et al., 1997). In this respect, heart rate monitoring should be considered to measure moderate to vigorous physical activity, and heart rates below 120bpm would be considered to be valid measures of physical activity.

GIS/GPS Tools

Transportation, urban design and planning studies include Geographic Information Systems (GIS) to support the hypothesis that neighborhood environment is associated with physical activity in the form of walking and biking for transport (Frumkin, 2002; Saelens et al., 2003). GIS tools have been used to describe the associations between objective measures of the built environment and walking and transportation activity (McGinn et al., 2007). In the public health literature, the relationship between the built environment and physical activity was assessed by measuring the frequency, intensity and duration of activity. In such studies, objective measures of the environment were collected and mapped using GIS tools (McGinn et al., 2007). Global positioning system (GPS) is also used to track areas in a settlement or a space in a district where physical activity is promoted (Wheeler et al., 2010; Fjörtoft et al., 2009; Fjörtoft et al., 2010). GPS system was used to record children’s movement patterns, which was transferred to GIS systems for further analysis (Fjörtoft et al., 2009; Fjörtoft et al., 2010). The purpose of the studies using GPS tools is to describe the interaction between environment and physical activity; based on the GPS data, designers explore and determine how space may interact with physical activity in children. However, GPS devices fail to record position indoors, under heavy tree canopy and in dense urban areas (Maddison and Ni Mhurchu, 2009) and they have limited accuracy in sensing stationary device location (Chen et al., 2012).

Photography

Studies of children’s geography and social behavior concluded that children’s physical activity and use of public spaces have been constricted and controlled (Blades et al., 1998; Matthews et al., 1998). In order to include views of children as key informants of research for their health and well-being, qualitative approaches have been employed (Darbyshire et al., 2005). It is important to offer children the opportunity to portray their own environments and one of the methods used for this purpose is photography, which is commonly accepted and validated by many researchers (Booth and Booth, 2003; Sharples et al., 2003; Wang and Burris, 1997) aiming to generate different and complementary visual information (Darbyshire et al, 2005). In a current study, children were asked to take pictures with disposable cameras (Özdemir, 2010). This visual data production strategy enabled children to relate their everyday life with their activities and environmental perceptions. There is extensive research with children using photography (Aitken and Wingate, 1993; Dodman, 2003; Morrow, 2001; Young and Barrett, 2001). However, there limits of this technique; the method of photography did not include children’s talk about their taken pictures and the reasons of taking those pictures. Children took pictures and we defined and discussed them as adults.

Advertisement

2. Schoolyard design to promote physical activity: An exploratory study

2.1. Methodology

This study aims to assess outdoor school environments for their possible association with healthy behavior of children. For this purpose, children’s total step counts were associated with the schoolyard size and 1115 students in 4 primary schools were surveyed. The aim of the project is to examine whether size and design of the outdoor school environments affect child physical activity. In addition, gender and age were selected to be variables to determine their relation to physical activity.

A random stratified sampling of primary schools from various districts of the city was used to represent a cross-section of the population. The schools, which have the adequate open space for the renewal projects, are located in different districts in terms of socio-culture and economy, have different numbers of students and need their schoolyards to be renewed, have been selected from a list of elementary schools provided from the Provincial Directorate for National Education (Table 2).

DistrictSchool
ÇankayaKavaklıdere Primary School
MamakÇocuk Sevenler Primary School
KeçiörenKamil Ocak Primary School
AkyurtTOKİ Primary School

Table 2

The primary schools subject to the research and their districts

2.1.1. Defining landscape characteristics of schoolyards

For each schoolyard, ordinal categories were used as being applied for the classification of landscape quality. Aerial images and photo surveys were used to assess outdoor school environments; total area, usable area, landscaped-vegetated areas and hard surfaces were measured. The reliability tests of these measurements showed that both measurements on aerial images and hand measurements of a selected schoolyard gave specific and similar results. The photographs describe a variety of outdoor settings suggesting the need for a more spacious space per student after the calculation of the open space standards for school population for each case. Outdoor environments and the adjacent areas were assessed with respect to physical and landscape qualities (i.e. vegetation, material, size). A group of reviewers, which includes landscape architects and architects, reviewed the photographs and scored the schoolyards based on the features such as size, material, vegetation cover, vegetation quality, maintenance and spaciousness. Environments with low physical qualities scored 1. Environments with advanced features scored 2.

2.1.2. Focus groups

The study also included 30 minutes meetings that were held with the students in each school. These focus groups, targeting children, included discussions on the current problems and future developments of the schoolyards; children’s attitudes towards the school settings and the parents’ views on their children’s use of the schoolyards were discussed. Teachers did not attend the meetings; students had the chance to express their opinions freely.

2.1.3. Pedometer measurements and BMI value assessments

Intensity of children’s school time activities was measured with electronic pedometers (Omron HJ-12). Pedometers were attached to randomly selected students. Average step counts of 10 children in each school were determined. Measurements also included distance covered, the amount of calorie (kcal) and body oil (gram) burnt during activities. It was assumed that the measurements would be distributed according to age groups, gender and schoolyard size.

Students were asked to indicate their weight and height on the questionnaire sheets to assess their nutritional status. In order to ensure reliability of self-reports, we weighed a group of students using a standard electronic scale, and their heights were measured with a wooden measuring board. Self-reported and objectively measured height and weight status were compared and it was found that self-reports were reliable. The height and weight information obtained in the surveys were used to calculate the BMI, which was computed as weight in kilograms divided by height in meters squared (kg/m2).

BMI values according to age groups are shown below (Table 3) (Uluocak et al., 2006; Şimşek et al., 2005; Öner et al., 2004; Altunkaynak and Özbek, 2007; Uğuz ve Bodur, 2007).

GradeAgeUnderweightNormalOverweight
Primary School3 and 49-10<14.014.0-20.0"/>20
5 and 611-12<14.614.6-23.1"/>23.1

Table 3

BMI values according to age groups

2.1.4. Photography

Children’s perception of environment was evaluated with photography technique. In this scope, students, selected randomly from each school, were given disposable cameras and were asked to take pictures of places they visit during weekend. It was assumed that children would take pictures of a number of scenes such as greenery, plants, open views, pets, buildings and structures, traffic, indoors and their daily activities. Children’s environmental perception would differ according to places they visit such as an urban park or an indoor environment. Based on the picture characteristics, potential perceptual variables were listed after expert ratings of scenes; experts included landscape architects and graduate students.

2.1.5. Workshops

Researchers offered a variety of workshops for school-aged children, teachers and parents. These workshops were oriented towards the respective target audience and based on participatory methods, providing insight into the design process. The aim was to increase environmental awareness among children and to inspire creative thinking. In these workshops, children were introduced to landscape design through presentation, design drawings, sketches and 3D models.

In this case study, after the presentations to the school community, workshops were organized with the voluntary students. Firstly, borders of the schoolyards on the layout plans and draft drawings, entrances, current uses (parking, playfield, etc.) and green fields were shown to the students and they became familiar with the plan. Alternative uses, requested by the students in the schoolyard, were listed. Group of students prepared their own designs. In this process, the researchers assisted the children regarding the drawing techniques. Each project was developed in line with different concepts such as “adventure” or “blossom.” First group made an adventure road strolling along the schoolyard. Each member of the second group named her/himself after a flower name and requested these flowers to be planted to the different parts of the schoolyard. The authentic design examples provided at the end of nearly half-hour study were displayed and presented by the group representatives (Figure 3).

Each group prepared a draft plan with sketches and colored markings. The final version of these projects, including before and after images, was displayed on the school boards in order to get feedback from students and teachers (Figure 4 and 5).

Figure 3.

Views from the workshops

Figure 4.

Current status of the schoolyards and the views after the arrangement

Figure 5.

One of the alternative projects include sport facilities, fruit and vegetable gardens, rose garden, parking lot, open-air class, play field and walking trail, as proposed by the children

2.2. Results

Physical and landscape characteristics of schoolyards were defined according to total yard size, total school size, and available space per students as shown in Table 4.

DistrictSchoolNumber of studentsTotal school areaTotal yard areaUsable yard space per student
ÇankayaKavaklıdere PS650*2050 m21350 m22.08 m2
MamakÇocuk Sevenler PS580*5500 m24750 m28.19 m2
KeçiörenKamil Ocak PS1300*9300 m26800 m25.23 m2
AkyurtTOKİ PS7206100 m24525 m26.28 m2

Table 4

Physical assessment of schoolyards*The number shows only the morning shift students

Kamil Ocak Primary School has the largest yard; however, the available area per student is not adequate. According to zoning standards in Turkey, child play spaces should have at least 10m2 usable area per child. This standard is also applicable to schoolyards; however, none of the schools provide sufficient space for child activities in this study (Table 4). Çocuk Sevenler Primary School, which has the largest usable space per student, received the best expert rating score. On the other hand, Kavaklıdere Primary School, which has the smallest and inadequate space per student, received the lowest expert rating score. It is assumed that spatial conditions such as spaciousness influence expert ratings. Kamil Ocak Primary School yard received one of the lowest scores due to the confined feeling and the existence of a high retaining wall that divides the yard into separate lots. This wall was defined as dangerous and useless. Green spaces that have the potential for recreational purposes are out of reach of children and they are not accessible. There is the scarcity of shaded seating spaces and most of the ground is covered with hard material such as asphalt.

2.2.1. Questionnaires

Almost half of the respondents were boys (49,4%) and 4th and 5th graders (55,6%). Most of the students have spent at least two years in their school. We may conclude that these students are familiar with the school settings. More than half of the students (54,8%) reside in the same neighborhood where the school is located, and most of the students prefer to walk to their schools. Only 22,3% of respondents commute to school with a vehicle.

There is variability in type of activities during recess. A considerable amount of children spend their recess time inside the school (13,5%). More than half of students spend their recess time both indoors and outdoors (59%). Most of the students prefer to walk in the schoolyard (43,5%) and 21,2% of them behave active during recess. On the other hand, only 13,3% of children in these four schools prefer passive behaviors such as eating and sitting during recess (Figure 6).

Figure 6.

Scatter-plot diagram showing the distribution of type of activities across schools

More than half of respondents define their schoolyards as inadequate for any of the activities (59%). Regardless of the size of schoolyards, this relationship was found statistically significant (F=113.05, df=3, p<0.005, R=0.48) (Figure 7).

Figure 7.

Adequacy of schoolyards

There is a statistical significance among number of students who liked yards; most of the students preferred the larger yards (F=226.6, df=3, p<0.005, R=0.60). Similar results were identified between the expert ratings and students’ responses; children liked the yards which were also highly rated by the experts (F=226.6, df=3, p<0.005, R=0.60) (Figure 8).

Most of the students (65%) were not satisfied with the yards. Responses indicated that the size of the yards was a major contributor of this result; most of the children (34,2%) did not enjoy the small yards (F=16.1, p<0.05). Other reasons included inadequacy of sport facilities and limited green spaces.

Figure 8.

Students’ satisfaction of schoolyards among scored yards (Quality scores - 1: High quality; 4: Low quality)

2.2.2. BMI distribution among schools

As a result of BMI distribution among schools, 16,2% of children were defined as overweight (N=181). Most of the students were in the normal range of BMI values (78,6%, N=876). Boys had higher BMI values than girls, and as expected, BMI values raised according to age groups, except 3rd grade students, which had lower BMI values than 2nd grade students (Table 5).

DomainNPercentageMeansd
GenderFemale56450.617.892.88
Male55149.418.642.96
Grade2706.317.862.71
321519.217.302.79
430327.218.152.86
531728.418.622.98
621018.818.992.93
BMIUnderweight585.2
Normal87678.6
Overweight18116.2
Type of commuteWalk86677.718.202.95
Vehicle24922.318.472.87
Yard sizeKamil Ocak (Largest yard)29318.172.75
Çocuk Sevenler29317.582.88
TOKİ Akyurt5518.132.73
Kavaklıdere (Smallest yard)47418.753.02

Table 5

Subject characteristics and BMI values

Results showed that there is a statistical significance between type of activities and BMI values (F=2.67, P=0.032). Students who were active during recess had lower BMI values than passive students. This was similar with the active school commuters; children who actively commute to school have lower BMI values, and this result is statistically significant (F=3.78, df=1, p=0.013). Interestingly, large schoolyards have limited influence on decreased BMI values. Children in smaller schoolyards were more active and had lower BMI values. This finding is assessed by the relationship between total step counts and yard sizes, which is presented in the next section.

2.2.3. Pedometer measurements

A total of 120 measurements were made to indicate the variations in daily step counts, distance covered, burnt calories and fat among children at ages between 9 and 11 (Table 6).

N%Step countsdDistance (km)sdBurnt calorie (Kcal)sdBurnt fat (gr)sd
GenderFemale65554201.719712.431.1966.633.93.752.01
Male55454609.520682.751.2584.141.84.712.48
Grade310856052970.83.321.9182.551.14.853.2
4403448392041.72.811.3274.634.34.171.95
5705839571734.42.340.9673.439.34.12.32
Yard sizeKamil Ocak (Largest yard)40333645.82171.62.231.3461.1836.93.462.24
Çocuk Sevenler40334173.71585.72.491.0261.127.33.61.54
Kavaklıdere (Smallest yard)40335346.41914.73.011.7697.540.15.52.4

Table 6

Step counts, distance, burnt fat and calorie across gender, grades, and yard sizes

Average step counts were 5346 in Kavaklıdere, 4174 in Çocuk sevenler, 3646 in Kamil Ocak primay schools. Boys were more active than girls, and small children were more active than older ones. Similar results were found for values of energy expenditure; boys and small children burnt more calorie and fat than girls and older students. The most interesting outcome of the study was the statistical significant and inverse relationship between schoolyard size and pedometer counts. Children in small schoolyards walked more (F=4.47, df=2, p=0.013), and burnt more calories (F=12.83, df=2, p<0.05) and fat (F=11.78, df=2, p<0.05).

2.2.4. Assessment of student pictures

Total of 472 pictures taken by students were assessed as shown in Table 7. Experts defined type of images and visible elements in the pictures. As a control group, researcher took pictures with a disposable camera and included these images within other groups of images for a random presentation. Both control group images and student images were similarly assessed, which conclude that assessments are reliable and valid.

SchoolGenderTotalBuiltPlantingEnclosedOpen sceneScene- plantsAnimals
Kamil OcakF194528
F1527123
F203818
F27531135
F203818
M2217185
M25116341
KavaklıdereF252194
F2216555
F2513120
F237493
F183843
F251142143
F1544511
M2010136
M2116275
Çocuk SevenlerF2321128
F1618412
F203674
F171583
F27110943
M2728512

Table 7

Number of pictures according to the picture character across schools

Most of the students took pictures of plants and plant groups (35%). A considerable number of students took landscape images (27%). Only 12% of children captured interior spaces such as their home environments and school interiors. The most frequent type of images was captured from a vantage point—balcony or a terrace—looking toward the green spaces and plant groups. Although most of the images were captured during weekend, most of the pictures included home environments and local parks. We may conclude that children spend their weekend time at home and in the neighborhood.

Distribution of image properties are associated with regional locations (Figure 9). Kavaklıdere Primary School is located in a highly dense region with dense traffic and limited green spaces. Local parks in the district are scarce and limited front yards of apartments are used for parking cars. Kamil Ocak Primary School, on the other hand, is located in a district with lower dense housing distribution. This neighborhood with lower income families has more open spaces and green lots. Students’ perceptions of environment, therefore, may vary according to the neighborhood characteristics. Most of the students in Kavaklıdere Primary School took pictures of plants in their homes. On the other hand, Kamil Ocak and Çocuk Sevenler students took pictures of open spaces and open vistas. These results can be associated with neighborhood characteristics. However, these assumptions should be based on valid and systematic research that should include significant comparisons of children’s environmental perceptions and spatial characteristics of neighborhoods.

Figure 9.

Distribution of picture properties across schools

2.3. Discussion

The results of this study contribute to both health and design professionals; environmental variables are effective in health promotion. In terms of design outcomes, this study provides evidence indicating the spatial effects of school environments on child health. Although most schools lack spacious schoolyards that were defined as mostly crowded and congested during recess, children were more active in small yards. Students generally complain about limited outdoor space for both play and physical activities; most students requested more spacious and green space for attraction and comfort. On the contrary of the expectations, pedometer measurements provided support that space distribution rather than the size is effective in health promotion. As many children attend to public schools, improvement the quality of the schoolyards to promote more physical activities is recommended.

It was expected that larger yards would improve health of students with lower BMI values, which was found in the study of Özdemir and Yılmaz (2008). However, this study found a statistical significant and inverse relationship between schoolyard size and pedometer counts. Children in smaller schoolyards were more active with more step counts. The findings from the questionnaires, which included assessment of BMI values showed similar results; children in schools with smaller yards are more active and have lower BMI values.

The schools are considered for the purpose of this study in the small to medium size bracket. The current study questionnaire sample would appear to be representative in terms of school size and regional distribution. Data in the present study indicate that small schools reported more positive physical activity promoting practices than larger schools. Small schools experienced fewer barriers than larger schools specifically with respect to restricted areas, accessibility, supervision, security and availability of play equipments. Small schoolyards may provide more opportunities for mixed and group plays and the limited availability of space may promote children to be more active. Children in small schoolyards all play together, rather than being in separate groups in larger yards. However, these factors were not included in this study, which requires further investigation.

On the other hand, larger schoolyards were more likely to permit children to play on the green areas, which are generally allocated for cars. These schools also permit the free-play of children during recess for security and health reasons; teachers are generally worried about the possible injury of children on vast and vacant yards. Meanwhile in larger schoolyards, children were more likely to engage in group activities. Since these schools lack fixed equipments and playground markings, children stroll around during recess. Barriers in the large yards such as walls, fences and parked cars limit the active behavior of children.

The findings of this study are relevant to Zask et al. (2001)’s results that as schools got larger children became less active. On the other hand, the pedometer measurements of Cardon et al. (2008) and Louie and Chan (2003) indicated that more space per child was found to be associated with more PA during recess; children in schools with large outdoor space were significantly more active than children at schools with smaller outdoor space. The present study would indicate that the comparison of yard sizes exhibit different challenges in relation to play habits, yard organization, and availability of play equipments, crowding, landscaping, maintenance and most importantly effects on physical activity and child health. More research is needed to investigate possible relations between these factors in order to overcome these challenges and to decide whether yard size is influential on child health.

Children who were active during recess had lower BMI values than passive students. This finding is similar with the active school commuters; children who actively commute to school have lower BMI values. The study also found gender and age differences; boys have higher BMI values than girls, and as expected, BMI values rise according to age groups, except 3rd grade students, which have lower BMI values than 2nd grade students. Boys and small children burnt more calorie and fat than girls and older students. More boys were engaged in active behavior than girls and similar findings were consistently reported in other studies (Myers et al., 1996; Sallis et al., 2000; Mota et al., 2005; Tudor-Locke et al., 2006; Özdemir and Yılmaz, 2008).

2.4. Conclusions

Given the increasing rates of childhood obesity, energy expenditure is a research priority to improve settings promoting more activity. The effect of the built environment on health is a current research agenda and research has found associations between environmental features and physical activity and body mass. However, the examination of physical environments to explain and promote physical activity is an important yet under-investigated area of research inquiry, and research on health outcomes of the physical environment has been limited by insufficient data regarding the role of the environment.

Many factors contribute to obesity, and the physical environment in particular can have a strong influence on children’s opportunities for regular physical activity. Decisions made at the local level regarding planning and design of school environments can have a significant impact on child health. By recognizing these links, communities can help reverse obesity trends and build healthy environments. Young children appear to engage in low levels of physical activity at school. With more than 25 millions of children attending schools in Turkey, it is important to better understand factors inherent in school environment that influence physical activity behaviors of young children.

Major critical factor emerged from this investigation was the spaciousness is not a critical measure for an active behavior as well as for play and learning. Almost all students had complaints about the lack of adequate space for play due to the crowded schoolyard in all recess time. However small spaces may promote more active behavior and public schools with limited space inside the city centers can better develop design guidelines to improve the physical qualities of these yards.

Previous studies have shown the impact of outdoor environments on physical activity and prevention from obesity in various nations, and the recognition of such approach may lead to the advancement of the outdoor school environments. Encouraging students to be active in safe and attractive outdoor environments may be accomplished by careful and systematic landscape designs, but the major concerns are the finance and the maintenance.

The urban environment is not built to suit child needs and to accommodate child play behaviors in a safe environment. The most natural way to be active and to develop healthy attitudes in PA among children is to play outside in a safe and open environment (Caroli et al., 2011), and the school environment is one of the settings to provide safe and healthy environment for children. School setting is a valuable resource contributing improved PA and this type of environment should be studied to find ways of reducing obesity by improving active behavior. Research should include identification of environmental variables of schools contributing to high levels of obesity in children. Schools in neighborhoods with high risks of obesity should be the focus of future studies; those school settings should be re-developed and re-designed to encourage PA in children.

It is assumed that findings would reinforce the need to provide and support school physical environments related to physical activity. The results of exploratory studies indicate support for the contention that child spaces should be thought of as a part of a viable strategy for health promotion. The hypothesis is that outdoor environments with more natural landscape characteristics are a viable context for health promotion activities such as physical activity.

A conceptual framework should be outlined that addresses the complexity of the relationship between spatial characteristics of outdoor environments and students’ physical activity behavior, which should be structured to guide future policy and research.

Active behaviors should be promoted with city planning and infrastructure by creating safe and accessible urban environments. Changes in neighborhood characteristics, adding more parks, safe walking routes and playgrounds and recreational facilities will have positive effects on health of children and adults.

2.5. Future directions

Research is needed to develop effective interventions to increase daily physical activity via active commute to school, monitoring daily physical activity behaviors, promoting school activity programs and promoting healthy curriculum and dietary habits. Studies should include more objective measurements of physical activity among different age groups and the specific roles of environmental factors should be defined that are related to preventing childhood obesity (Lobstein et al., 2004). School environment represents a fundamental opportunity for children to gain active lifestyle through the use of spaces that promote active behavior (Pate et al., 2006; Wagner and Kirch, 2006). Schools are ideal places for health promotion by including healthy school programs, curriculums and making availability of daily exercise (Stice et al., 2006; Doak et al., 2006; Brown et al., 2009). Research should include identification of environmental variables of schools contributing to high levels of obesity in children. Schools in neighborhoods with high risks of obesity should be the focus of future studies; those school settings should be re-developed and re-designed to encourage physical activity focusing on minority and disadvantaged groups and communities.

Research should include longitudinal approach to track changes in children’s activities, and include sample from rural and remote areas with disadvantaged neighborhoods. Changes in neighborhood characteristics, adding more parks, safe walking routes and playgrounds and recreational facilities will have positive effects on health of children. Promoting physical activity in urban neighborhoods, especially lower income ones, must address concerns about the physical and social environment.

2.6. Strengths and limitations

The key strengths of this study are the use of measured height and weight for the calculation of BMI, the objective measurement of the PA by pedometers and the adoption of BMI cut-off points for children. This use of objective measurement of PA reduces the bias commonly associated with self-report measures. The sample selected is a good representative of the population; schools were randomly selected according to regions and a considerable number of students were included in the study in each school.

This study was conducted during spring season only, and children were more likely to be outside with active behaviors which resulted with limited variability in the outcomes. Another limitation of our study is the presentation of results from a single time point, which limits the casual directions in the relationships between overweight and well-being. In our study, there may be too many other external factors in the setting—the schoolyards—which are difficult to measure and available to include as independent factors affecting health of children.

As with all questionnaire-based surveys, social desirability bias in the responses is a problem; children may have difficulties in recalling types of behavior they participated in the last two weeks.

Studies that define the casual relationships between environmental interventions and health behaviors with empirical associations usually lack definitions on how and why these variables influence health behaviors, which is one of the limitations of this study.

Based on these limitations, more systematic research is needed on developing strategies to prevent childhood obesity, to find ways in promoting more active behavior and to better design environments for improving child health.

Acknowledgement

This study; “Schoolyard Design to Promote Physical Activity: An Exploratory Study” was supported by a grant from the Scientific Research Projects Coordination Unit, Ankara University, Turkey (BAP-09Ö4347001). The author is grateful for the help and support of Mehmet Çorakçı, Gizem Kılınç, Merve Heper and Filiz Uncu who worked with the author in the development and design of this case study.

References

  1. 1. AartsM. J.De VriesS. I.Van OersH. A.and SchuitA. J.2012Outdoor play among children in relation to neighborhood characteristics: a cross-sectional neighborhood observation studyInternational Journal of Behavioral Nutrition and Physical Activity
  2. 2. AffusoO.StevensJ.CatellierD.McmurrayR. G.WardD. S.LytleL.et al2 EOF2011Validity of self-reported leisure-time sedentary behavior in adolescents.Journal of Negative Results in Biomedicine
  3. 3. AinslieP. N.ReillyT.and WesterterpK. R.2003Estimating human energy expenditure: a review of techniques with particular reference to doubly labelled waterSports Medicine683 EOF698 EOF
  4. 4. AitkenS. C.and WingateJ.1993A.Preliminary-studyof the self-directed photography of middle-class, homeless, and mobility-impaired children. Professional Geographer, 45(1), 65-72.
  5. 5. AlhassanS.SirardJ. R.and RobinsonT. N.2007The effects of increasing outdoor play time on physical activity in Latino preschool children.International Journal of Pediatric Obesity, 2153158
  6. 6. Al-hazzaaH.2007Pedometer-determined physical activity in obese and non-obese boys 8-12 years. Journal of Physiological Anthropology, 26459465
  7. 7. AltunkaynakB. Z.and ÖzbekE.2007Obezite: nedenleri ve tedavi seçenekleri. Dicle Tip Dergisi, 34(2), 144-149.
  8. 8. American College of Sports Medicine Position Stand1998The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Medicine and Science in Sports and Exercise, 30(6), 975-991.
  9. 9. AndersonP. M.and ButcherK. E.2006Childhood obesity: trends and potential causesThe Future of Children, 16(1), 19-45.
  10. 10. ArmstrongN.and WelsmanJ. R.2006The physical activity patterns of European youth with reference to methods of assessment.Sports Medicine, 36(12), 1067 EOF86 EOF
  11. 11. BabbieE.2006The Practice of Social ResearchNew York: Wadsworth Publishing.
  12. 12. BadlandH.and SchofieldG.2005Transport, urban design, and physical activity: an evidence-based update. Transportation Research Part D: Transport and Environment, 10(3), 177-196.
  13. 13. BaileyD. A.1995The role of mechanical loading in the regulation of skeletal development during growth. In: C.J.R. Blimkie and O. Bar-Or (Eds.), New Horizons in Pediatric Exercise Science (97108Champaign, IL: Human Kinetics.
  14. 14. BaranowskiT.and JagoR.2005Understanding the mechanisms of change in children’s physical activity programs.Exercise and Sport Sciences Reviews163 EOF8 EOF
  15. 15. BassettD. R.and JohnD.2010Use of pedometers and accelerometers in clinical populations: validity and reliability issuesPhysical Therapy Reviews135 EOF142 EOF
  16. 16. BellJ. F.WilsonJ. S.and LiuG. C.2008Neighborhood greenness and 2year changes in body mass index of children and youth.American Journal of Preventive Medicine
  17. 17. BennettG. G.McneillL. H.WolinK. Y.DuncanD. T.PuleoE.and EmmonsK. M.2007Safe to walk? Neighborhood safety and physical activity among public housing residentsPLoS Medicine, 4(10), e306.
  18. 18. BerensonG. S.1986Evolution of cardiovascular risk factors in early life: perspectives on causation. In: G.S. Berenson (ed.), Causation of Cardiovascular Risk Factors in Children, New York: Raven Press, 126
  19. 19. BerlinJ. E.StortiK. L.and BrachJ. S.2006Using activity monitors to measure physical activity in free-living conditions.Physical Therapy1137 EOF45 EOF
  20. 20. BiddleS.SallisJ. F.and CavillN. A.1998Young and active? Young People and Health Enhancing Physical Activity: Evidence and Implications. London: Health Education Authority.
  21. 21. BlackM. M.and KrishnakumarA.1998Children in low-income, urban settings: interventions to promote mental health and well-being. American Psychologists, 53(6), 635-646.
  22. 22. BladesM.BlautJ. M.DarvizehZ.ElgueaS.SowdenS.SoniD.SpencerC.SteaD.SurajpaulR.and UttalD.1998A.Cross-culturalstudy of young children’s mapping abilities. Transactions of the Institute of British Geographer, 23(2), 269 EOF277 EOF
  23. 23. Bonnefoy, J., Morgan, A., Kelly, M.P., Butt, J. and Bergman, V. (2007). Constructing the evidence base on the social determinants of health: a guide. National Institute for Health and Clinical Excellence. Retrieved on December, 18, 2012. http://www.who.int/social_determinants/knowledge_networks/add_documents/mekn_final_guide_112007.pdf
  24. 24. BoothT.and BoothW.2003In the frame: photovoice and mothers with learning difficultiesDisability and Society, 18(4), 431 EOF442 EOF
  25. 25. BranasC. C.CheneyR. A.MacDonald, J.M., Tam, V.W., Jackson, T.D. and Ten Have, T.R. (2011A difference-in-difference analysis of health, safety, and greening vacant urban space.American Journal of Epidemiology, 174(11), 1296-1306.
  26. 26. BrinkL. A.NiggC. R.LampeS. M.KingstonB. A.MootzA. L.and Van VlietW.2010Influence of schoolyard renovations on children’s physical activity: the Learning Landscapes ProgramAmerican Journal of Public Health, 100(9), 1672-1678.
  27. 27. BrownW. J.BaumanA. E.and OwenN.2009Stand upsit down, keep moving: turning circles in physical activity research? British Medical Journal, 43(2), 86.
  28. 28. BrugJ.OenemaA.and FerreiraI.2005Theory, evidence and Intervention Mapping to improve behavior nutrition and physical activity interventions. International Journal of Behavioral Nutrition and Physical Activity, 2(1), 2.
  29. 29. CardonG.Van CauwenbergheE.LabarqueV.HaerensL.and De BourdeaudhuijI.2008The contribution of preschool playground factors in explaining children’s physical activity during recessInternational Journal of Behavioral Nutrition and Physical Activity11 EOF
  30. 30. CarnegieM. A.BaumanA.MarshallA. L.MohsinM.Westley-wiseV.and BoothM. L.2002Perceptions of the physical environment, stage of change for physical activity, and walking among Australian adults.Research Quarterly for Exercise and Sport146 EOF55 EOF
  31. 31. CeesayS. M.PrenticeA. M.DayK. C.MurgatroydP. R.GoldbergG. R.ScottW.and SpurrG. B.1989The use of heart rate monitoring in the estimation of energy expenditure: a validation study using indirect whole-body calorimetry.British Journal of Nutrition, 61(2), 175 EOF86 EOF
  32. 32. ChaoH. J.SchwartzJ.MiltonD. K.and BurgeH. A.2003The work environment and workers’ health in four large office buildings.Environmental Health Perspectives, 111(9), 1242.
  33. 33. ChaputJ. P.KlingenbergL.AstrupA.and SjodinA. M.2011Modern sedentary activities promote overconsumption of food in our current obesogenic environmentObesity Reviews, 12(5), 12-20.
  34. 34. ChenK. Y.JanzK. F.ZhuW.and BrychtaR. J.2012Re-defining the roles of sensors in objective physical activity monitoring. Medicine and Science in Sports and Exercise, 44(1), 13-23.
  35. 35. CooperA. R.WedderkoppN.JagoR.KristensenP. L.MollerN. C.FrobergK.PageA. S.and AndersenL. B.2008Longitudinal associations of cycling to school with adolescent fitness.Preventive Medicine324 EOF8 EOF
  36. 36. Cooper-marcusC.and BarnesM.1999Healing Gardens: Therapeutic Benefits and Design Recommendations.New York: John Wiley and Sons.
  37. 37. CorderK.EkelundU.SteeleR. M.WarehamN. J.and Søren Brage, S. (2008Assessment of physical activity in youth.Journal of Applied Physiology, 105(3), 977 EOF87 EOF
  38. 38. CradockA. L.MellyS. J.AllenJ. G.MorrisJ. S.and GortmakerS. L.2007Characteristics of school campuses and physical activity among youth.American Journal of Preventive Medicine106 EOF113 EOF
  39. 39. CunninghamG. O.and MichaelY. L.2004Concepts guiding the study of the impact of the built environment on physical activity for older adults: a review of the literature.American Journal of Health Promotion, 18(6), 435 EOF43 EOF
  40. 40. DahlgrenG.and WhiteheadM.1991Policies and Strategies to Promote Equity in HealthStockholm : Institute for Future Studies.
  41. 41. DanielsS. R.2006The consequences of childhood overweight and obesityFuture Child, 16(1), 47-67.
  42. 42. DanielsS. R.ArnettD. K.EckelR. H.GiddingS. S.HaymanL. L.KumanyikaS.and WilliamsC. L.2005Overweight in children and adolescents pathophysiology, consequences, prevention, and treatment.irculation1999 EOF2012 EOF
  43. 43. DarbyshireP.MacDougall, C. and Schiller, W. (2005Multiple methods in qualitative research with children: more insight or just more?Qualitative research, 5(4), 417-436.
  44. 44. DavisA.and JonesL. J.1996Children in the urban environment: an issue for the new public agenda. Health and Place, 2(2), 107 EOF113 EOF
  45. 45. DavisonK. K.and LawsonC. T.2006Do attributes in the physical environment in?uence children’s physical activity? A review of the literature.International Journal of Behavioral Nutrition and Physical Activity, 3(1), 19.
  46. 46. DebusM.1990Handbook for Excellence in Focus Group Research. Washington, DC: Academy for Educational Development.
  47. 47. De JongK.AlbinM.SkärbäckE.GrahnP.WadbroJ.MerloJ.and BjörkJ.2011Area-aggregated assessments of perceived environmental attributes may overcome single-source bias in studies of green environments and health: results from a cross-sectional survey in southern Sweden.Environmental Health, 10(1), 4 EOF
  48. 48. DietzW. H.1998Health consequences of obesity in youth: childhood predictors of adult disease.PediatricsPt 2), 518 EOF25 EOF
  49. 49. Din-dziethamR.LiuY.BieloM. V.and ShamsaF.2007High blood pressure trends in children and adolescents in national surveys, 1963 to 2002.Circulation1488 EOF96 EOF
  50. 50. DishmanR. K.and SallisJ. F.1994Determinants and interventions for physical activity and exercise. In: C. Bouchard, R.J. Shephard and T. Stephens (Eds.), Physical Activity, Fitness and Health: International Proceedings and Consensus Statement (214238Champaign, IL: Human Kinetics.
  51. 51. DoakC. M.VisscherT. L. S.RendersC. M.and SeidellJ. C.2006The prevention of overweight and obesity in children and adolescents: a review of interventions and programs. Obesity Reviews, 7(1), 111-136.
  52. 52. DodmanD. R.2003Shooting in the city: an autophotographic exploration of the urban environment in Kingston, JamaicaArea293 EOF304 EOF
  53. 53. DymentJ. E.and BellA. C.2007Active by design: promoting physical activity through school ground greeningChildren’s Geographies463 EOF477 EOF
  54. 54. DymentJ. E.BellA. C.and LucasA. J.2009The relationship between school ground design and intensity of physical activityChildren’s Geographies261 EOF276 EOF
  55. 55. EbbelingC. B.PawlakD. B.and LudwigD. S.2002Childhood obesity: public-health crisis, common sense cure.Lancet473 EOF82 EOF
  56. 56. EisenmannJ. C.LaursonK. R.WickelE. E.GentileD.and WalshD.2007Utility of pedometer step recommendations for predicting overweight in children.International Journal of Obesity, 31(7), 1179 EOF82 EOF
  57. 57. EiserC.and MorseR.2001Can parents rate their child’s health related quality of life? Results of a systematic review.Quality of Life, 10(4), 347 EOF57 EOF
  58. 58. EiserC.MohayH.and MorseR.2000The measurement of quality of life in young children.Child: CareHealth and Development, 26(5), 401 EOF14 EOF
  59. 59. EkelundU.SjostromM.YngveA.PoortvlietE.NilssonA.FrobergK.WedderkoppN.and WesterterpK.2001Physical activity assessed by activity monitor and doubly labelled water in childrenMedicine and Science in Sports and Exercise275 EOF81 EOF
  60. 60. EllawayA.MacintyreS.and BonnefoyX.2005Graffiti, greenery, and obesity in adults: secondary analysis of European cross-sectional surveyBritish Medical Journal, 331(7517), 611-612.
  61. 61. EngelbrektssonP.2002Effects of product experience and product presentations in focus group interviews. Journal of Engineering Design, 13(3), 215-221
  62. 62. ErnstM. P.and PangraziR. P.1999Effects of a physical activity program on children’s activity levels and attraction to physical activityPediatric Exercise Science11393405
  63. 63. EstonR. G.RowlandsA. V.and IngledewD. K.1998Validity of heart rate, pedometry, and accelerometry for predicting the energy cost of children’s activities.International Journal of Applied Physiology, 84 (1), 362 EOF71 EOF
  64. 64. EvansG. W.WellsN. M.and MochA.2003Housing and mental health: A review of the evidence and a methodological and conceptual critiqueJournal of Social59475 EOF500 EOF
  65. 65. Everett JonesS., Brener, N.D. and McManus, T. (2003Prevalence of school policies, programs, and facilities that promote a healthy physical school environmentAmerican Journal of Public Health, 93(9), 1570-1575.
  66. 66. FaulknerG. E. J.BuliungR. N.FloraP. K.and FuscoC.2009Active school transport, physical activity levels and body weight of children and youth: a systematic review. Preventive Medicine, 48(1), 3-8.
  67. 67. FengJ.GlassT. A.CurrieroF. C.StewartW. F.and SchwartzB. S.2010The built environment and obesity: a systematic review of the epidemiologic evidence.Health Place, 16(2), 175 EOF90 EOF
  68. 68. FerreiraI.Van Der HorstK.Wendel-vosW.KremersS.Van LentheF. J.and BrugJ.2007Environmental correlates of physical activity in youth: a review and update.Obesity Reviews129 EOF154 EOF
  69. 69. FjörtoftI.KristoffersenB.and SageieJ.2009Children in schoolyards: tracking movement patterns and physical activity using global positioning system and heart rate monitoring. Landscape Urban Planning, 93(3-4), 210 EOF217 EOF
  70. 70. FjörtoftI.LofmanO.and Halvorsen Thoren, K. (2010Schoolyard physical activity in 14year-old adolescents assessed by mobile GPS and heart rate monitoring analyzed by GIS. Scandinavian Journal of Public Health, 38(5), 28-37.
  71. 71. FlaviaB.MeyerU.NiedererI.EbeneggerV.Marques-vidalP.GranacherU.and KoebnickC.2010Socio-cultural determinants of adiposity and physical activity in preschool children: A cross-sectional studyBMC Public Health
  72. 72. FrankL.SchmidT.SallisJ.ChapmanJ.and SaelensB.2005Linking objectively measured physical activity with objectively measured urban form: findings from SMARTRAQ.American Journal of Preventive MedicineS2), 117 EOF25 EOF
  73. 73. FredriksA. M.BuurenS.Van HirasingR. A.WitJ. M.and Verloove-vanhorickS. P.2005Alarming prevalences of overweight and obesity for children of Turkish, Moroccan and Dutch origin in The Netherlands according to international standardsActa Paediatrica496 EOF498 EOF
  74. 74. Frumkin, H. (2002). Urban sprawl and public health. Public Health Reports, 117(3), 201-217.
  75. 75. GomezJ. E.2004Violent crime and outdoor physical activity among inner-city youth.Preventive Medicine39876881
  76. 76. Gordon-larsenP.NelsonM. C.PageP.and PopkinB. M.2006Inequality in the built environment underlies key health disparities in physical activity and obesityPediatrics, 117(2), 417-424.
  77. 77. HandyS. L.BoarnetM. G.EwingR.and KillingsworthR. E.2002How the built environment affects physical activityAmerican Journal of Preventive Medicine64 EOF73 EOF
  78. 78. HaugE.TorsheimT.SallisJ. F.and SamdalO.2010The characteristics of the outdoor school environment associated with physical activityHealth Education Research, 25(2), 248-256.
  79. 79. HeelanK. A.DonnellyJ. E.JacobsenD. J.MayoM. S.WashburnR.and GreeneL.2005Active commuting to and from school and BMI in elementary school children-preliminary data.Child: CareHealth and Development, 31(3), 341-349.
  80. 80. HindK.and BurrowsM.2007Weight-bearing exercise and bone mineral accrual in children and adolescents: a review of controlled trialsBone14 EOF27 EOF
  81. 81. HinkleyT.CrawfordD.SalmonJ.OkelyA. D.and HeskethK.2008Preschool children and physical activity: a review of correlates.American Journal of Preventive Medicine, 34(5), 435-441.
  82. 82. HolstenJ. E.2009Obesity and the community food environment: a systematic review.Public Health Nutrition397 EOF405 EOF
  83. 83. HoppeM. J.WellsE. A.MorrisonD. M.GillmoreM. R.and WilsdonA.1995Using focus groups to discuss sensitive topics with children.Evaluation Review102 EOF14 EOF
  84. 84. HumeC.SalmonJ.and BallK.2005Children’s perceptions of their home and neighborhood environments, and their association with objectively measured physical activity: a qualitative and quantitative study. Health Education Research, 20 (1), 1-13.
  85. 85. HumpelN.OwenN.and LeslieE.2002Environmental factors associated with adults’ participation in physical activity: a reviewAmerican Journal of Preventive Medicine, 22(3), 188-199.
  86. 86. IversonD. C.FieldingJ. E.CrowR. S.and ChristensonG. M.1985The promotion of physical activity in the United States population: the status of programs in medical, worksite, community, and school settings.Public Health Reports, 100(2), 212- 214.
  87. 87. JanssenI.BoyceW. F.SimpsonK.and PickettW.2006Influence of individual- and area-level measures of socio-economic status on obesity, unhealthy eating, and physical inactivity in Canadian adolescents. American Journal of Clinical Nutrition, 83(1), 139-145.
  88. 88. JanzK. F.LetuchyE. M.GilmoreJ. M. E.BurnsT. L.TornerJ. C.WillingM. C.and LevyS. M.2010Early physical activity provides sustained bone health benefits later in childhood.Medicine and Science in Sports and Exercise1072 EOF8 EOF
  89. 89. KaczynskiA. T.and HendersonK. A.2007Environmental correlates of physical activity: A review of evidence about parks and recreationLeisure Sciences315 EOF354 EOF
  90. 90. KaczynskiA. T.PotwarkaL. R.and SaelensB. E.2008Association of park size, distance, and features with physical activity in neighborhood parksAmerican Journal of Public Health, 98(8), 1451-1456.
  91. 91. KingA. C.ParkinsonK. N.AdamsonA. J.MurrayL.BessonH.ReillyJ. J.and BasterfieldL.2011Correlates of objectively measured physical activity and sedentary behavior in English children. European Journal of Public Health, 21(4), 424-431.
  92. 92. KlesgesL.BaranowskiT.BeechB.CullenK.MurrayD.RochonJ.and PrattC.2004Social desirability bias in self-reported dietary, physical activity and weight concerns measures in 8 to 10year old African-American girls: results from the Girls Health Enrichment Multisite Studies (GEMS).Preventive MedicineSupp), 78-87.
  93. 93. KoezukaN.KooM.AllisonK. R.AdlafE. M.DwyerJ. J.FaulknerG.and GoodmanJ.2006The relationship between sedentary activities and physical inactivity among adolescents: results from the Canadian Community Health SurveyJournal of Adolescent Health515 EOF522 EOF
  94. 94. KruegerR. A.and KingJ. A.1998Involving Community Members in Focus GroupsSAGE: Thousand Oaks, CA.
  95. 95. KruegerR. A.and CaseyM.2000Focus Groups: A Practical Guide for Applied Research.SAGE: Thousand Oaks, CA.
  96. 96. LachowyczK.and JonesA. P.2011Greenspace and obesity: a systematic review of the evidenceObesity Reviews
  97. 97. LackshmanR.McconvilleA.HowS.FlowersJ.WarehamN.and CosfordP.2010Association between area-level socioeconomic deprivation and a cluster of behavioral risk factors: cross-sectional, population-based study. Journal of Public Health, 33(2), 234-245.
  98. 98. LambertE. V.and GoedeckeJ. H.2004Energy balance and energy expenditure in obesity-is obesity a disease of inactivity? South African Journal of Sports Medicine, 15(1), 21-25.
  99. 99. Lavin, T., Higgins, C., Metcalfe, O. and Jordan, A. (2006). Health effects of the built environment. Dublin, Institute of Public Health. Retrieved on December, 18, 2012. http://www.publichealth.ie/publications/healthimpactsofthebuiltenvironmentareview
  100. 100. LeeA. C.and MaheswaranR.2010The health benefits of urban green spaces: a review of the evidence.Journal of Public Health, 33(2), 212 EOF22 EOF
  101. 101. LeeM. C.OrensteinM. R.and RichardsonM. J.2008Systematic review of active commuting to school and children’s physical activity and weightJournal of Physical Activity and Health, 5(6), 930 EOF49 EOF
  102. 102. LeeS. M.and Tudor-lockeC.2005Active versus passive commuting to school: what children sayAmerican Journal of Health Studies212 EOF218 EOF
  103. 103. LeslieA.SaelensB.FrankL.OwenN.BaumandA.CoffeeN.and HugoG.2005Residents’ perceptions of walkability attributes in objectively different neighbourhoods: a pilot study. Health and Place, 11227236
  104. 104. LiuG. G.WilsonJ. S.QiR.and YingR.2007Green neighborhoods, food retail and childhood overweight: differences by population density. American Journal of Health Promotion, 21(4), 317-25.
  105. 105. LivingstoneM. B. E.RobsonP. J.BlackA. E.CowardW. A.WallaceJ. M. W.MckinleyM. C.and MckennaP. G.2003An evaluation of the sensitivity and specificity of energy expenditure measured by heart rate and the Goldberg cut-off for energy intake: basal metabolic rate for identifying mis-reporting of energy intake by adults and children: a retrospective analysisEuropean Journal of Clinical Nutrition455 EOF463 EOF
  106. 106. LivingstoneM. B.CowardW. A.PrenticeA. M.DaviesP. S.StrainJ. J.MckennaP. G.and KerrM. J.1992Daily energy expenditure in free-living children: comparison of heart-rate monitoring with the doubly-labelled water (2H2 (18) O) method. The American Journal of Clinical Nutrition, 56(2), 343-352.
  107. 107. LopezR. P.and HynesH. P.2006Obesity, physical activity and the urban environment: public health research needs. Environmental Health, 5(1), 25-35.
  108. 108. LoprinziP. D.and CardinalB. J.2011Measuring children’s physical activity and sedentary behaviorsJournal of Exercise Science and Fitness, 9(1), 15 EOF23 EOF
  109. 109. LorchS. M.and SharkeyA.2007Myocardial velocity, strain, and strain rate abnormalities in healthy obese children.Journal of Cardiometabolic Syndrome, 2(1),30 EOF4 EOF
  110. 110. LouieL.and ChanL.2003The use of pedometry to evaluate the physical activity levels among preschool children in Hong KongEarly Child Development and Care97 EOF107 EOF
  111. 111. MaasJ.VerheijR. A.De VriesS.SpreeuwenbergP.SchellevisF. G.and GroenewegenP. P.2009Morbidity is related to a green living environment.Journal of Epidemiology and Community Health, 63(12), 967-973.
  112. 112. MaddisonR.and Ni Mhurchu, C. (2009Global positioning system: a new opportunity in physical activity measurementInternational Journal of Behavioral Nutrition and Physical Activity, 6(1), 73.
  113. 113. MallerC.TownsendM.PryorA.BrownP.and St Leger, L. (2006Healthy nature healthy people: ‘contact with nature’ as an upstream health promotion intervention for populationsHealth Promotion International, 21(1), 45-54
  114. 114. MarshallS. J.LevyS. S.Tudor-lockeC. E.KolkhorstF. W.WootenK. M.JiM.MaceraC. A.and AinsworthB. E.2009Translating physical activity recommendations into a pedometer-based step goal: 3000 steps in 30 minutes.American Journal of Preventive Medicine410 EOF5 EOF
  115. 115. MatthewsH.LimbM.and TaylorM.1998The geography of children: some ethical and methodological considerations for project and dissertation work.Journal of Geography in Higher Education, 22(3), 311-324.
  116. 116. McginnA. P.EvensonK. R.HerringA. H.HustonS. L.and RodriguezD. A.2007Exploring associations between physical activity and perceived and objective measures of the built environmentJournal of Urban Health, 84(2), 162-184.
  117. 117. McleroyK. R.BibeauD.StecklerA.and GlanzK.1988An ecological perspective on health promotion programs.Health Education Quarterly, 15(4), 351 EOF377 EOF
  118. 118. MendozaJ. A.WatsonK.NguyenN.CerinE.BaranowskiT.and NicklasT. A.2011Active commuting to school and association with physical activity and adiposity among US youth.Journal of Physical Activity and Health, 8(4), 488 EOF95 EOF
  119. 119. MitchellR.and PophamF.2008Effect of exposure to natural environment on health inequalities: an observational population study.Lancet1655 EOF60 EOF
  120. 120. MitchellR.Astell-burtT.and RichardsonE. A.2011A comparison of green space indicators for epidemiological research.Journal of Epidemiology and Community Health1016
  121. 121. MitreN.Lanningham-fosterL.FosterR.and LevineJ. A.2009Pedometer accuracy for children: can we recommend them for our obese population? Pediatrics, 123(1), 127-131.
  122. 122. MorganM.GibbsS.MaxwellK.and BrittenN.2002Hearing children’s voices: methodological issues in conducting focus groups with children aged 711yearsQualitative Research
  123. 123. MorrowV.2001Using qualitative methods to elicit young people’s perspectives on their environments: some ideas for community health initiativesHealth Education Research, 16(3), 255-268.
  124. 124. MotaJ.SilvaP.SantosM. P.RibeiroJ. C.OliveiraJ.and DuarteJ. A.2005Physical activity and school recess time: differences between the sexes and the relationship between children’s playground physical activity and habitual physical activityJournal of Sports Sciences269 EOF275 EOF
  125. 125. O.DeaJ.A. (2003Why do kids eat healthful food? Perceived benefits of and barriers to healthful eating and physical activity among children and adolescents.Journal of the American Dietetic Association497 EOF501 EOF
  126. 126. OliverM.SchofieldG. M.GrantM.and GregoryS.2007Physical activity in preschoolers: understanding prevalence and measurement issuesSports Medicine1045 EOF1070 EOF
  127. 127. OwenN.HumpelN.LeslieE.BaumanA.and SallisJ. F.2004Understanding environmental influences on walking: review and research agenda.American Journal of Preventive Medicine, 276776
  128. 128. OwenN.LeslieE.SalmonJ.and FotheringhamM. J.2000Environmental determinants of physical activity and sedentary behavior.Exercise and Sport Sciences Reviews153 EOF8 EOF
  129. 129. ÖnerN.VatanseverÜ.and SariA.2004Prevalence of underweight, overweight and obesity in Turkish adolescents.Swiss Medical Weekly134529533
  130. 130. ÖzdemirA.2010The Authentic Landscape Design of Primary School’s Yards. Ankara University Scientific Research Projects Unit, Final Report for the Project 09Ö4347001
  131. 131. ÖzdemirA.and YilmazO.2008Assessment of outdoor school environments and physical activity in Ankara’s primary schoolsJournal of Environmental Psychology287 EOF300 EOF
  132. 132. ÖzdemirA.and ÇorakçiM.2010Participation in the greening of schoolyards in the Ankara public school systemScientific Research and Essays2065 EOF2077 EOF
  133. 133. PabayoR.GauvinL.and BarnettT. A.2011Longitudinal changes in active transportation to school in Canadian youth aged 6 through 16 years.Pediatrics
  134. 134. PapasM. A.AlbergA. J.EwingR.HelzlsouerK. J.GaryT. L.and KlassenA. C.2007The built environment and obesityEpidemiologic Reviews129 EOF143 EOF
  135. 135. PateR. R.PrattM.BlairS. N.HaskellW. L.MaceraC. A.BouchardC.et al1995Physical activity and public healthA recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Journal of the American Medical Association, 273(5), 402-407.
  136. 136. PateR. R.O.NeillJ. R.and LobeloF. (2008The evolving definition of ‘sedentary’.Exercises and Sport Sciences Reviews, 36(4), 173 EOF8 EOF
  137. 137. PateR. R.O.NeillJ. R.and MitchellJ. (2010Measurement of physical activity in preschool children.Medicine and Science in Sports and Exercise508 EOF12 EOF
  138. 138. PikoraT.Giles-cortiB.BullF.JamrozikK.and DonovanR.2003Developing a framework for assessment of the environmental determinants of walking and cycling.Social Science and Medicine, 56(8), 1693 EOF703 EOF
  139. 139. PotwarkaL. R.KaczynskiA. T.and FlackA. L.2008Places to play: association of park space and facilities with healthy weight status among children.Journal of Community Health344 EOF50 EOF
  140. 140. RaitakariO. T.TaimelaS.PorkkaK. V.TelamaR.ValimakiI.AkerblomH. K.and ViikariJ. S.1997Association between physical activity and risk factors for coronary heart disease: The Cardiovascular Risk in Young Finns Study. Medicine and Science in Sports and Exercise1055 EOF61 EOF
  141. 141. RichardsonE. A.and MitchellR.2010Gender differences in relationships between urban green space and health in the United KingdomSocial Science and Medicine, 71(3), 568 EOF575 EOF
  142. 142. RidgersN. D.StrattonG.FaircloughS. J.and TwiskT. W.2007Long-term effects of playground markings and physical structures on children’s recess physical activity levels.Preventive Medicine, 44(5), 393-397.
  143. 143. RidgersN. D.StrattonG.ClarkE.FaircloughS. J.and RichardsonD. J.2006Day-to-day and seasonal variability of physical activity during school recessPreventive Medicine, 42(5), 372-374.
  144. 144. RidgersN. D.StrattonG.and FaircloughS. J.2006Physical activity levels of children during school playtimeSports Medicine, 36(4), 359-371.
  145. 145. RivkinM.1997The schoolyard habitat movement: What it is and why children need it.Early Childhood Education, 25(1), 61 EOF66 EOF
  146. 146. RoemmichJ. N.EpsteinL. H.RajaS.YinL.RobinsonJ.and WiniewiczD.2006Association of access to parks and recreational facilities with the physical activity of young childrenPreventive Medicine437 EOF441 EOF
  147. 147. RosenbergD. E.SallisJ. F.ConwayT. L.CainK. L.and MckenzieT. L.2006Active transportation to school over 2 years in relation to weight status and physical activity.Obesity, 14(10), 1771 EOF6 EOF
  148. 148. RowlandT. W.1990Exercise and Children’s HealthChampaign, IL: Human Kinetics.
  149. 149. RowlandsA. V.and EstonR. G.2007The measurement and interpretation of children’s physical activity. Journal of Sports Science and Exercise, 6270276
  150. 150. RowlandsA. V.EstonR. G.and IngledewD. K.1997Measurement of physical activity in children with particular reference to the use of heart rate and pedometry.Sports Medicine, 24258272
  151. 151. SaegertS.1982Environments and children’s mental health: residential density and low income children. In: A. Baum and J.E. Singer (Eds.), Handbook of Psychology and Health (247271Hillsdale, NJ: Erlbaum.
  152. 152. SaelensB. E.SallisJ. F.BlackJ. B.and ChenD.2003Neighborhood-based differences in physical activity: an environment scale evaluation.American Journal of Public Health1552 EOF8 EOF
  153. 153. SaelensB. E.SallisJ. F.and FrankL. D.2003Environmental correlates of walking and cycling: findings from the transportation, urban design, and planning literatures.Annals of Behavioral Medicine, 25(2), 80 EOF91 EOF
  154. 154. SallisJ. F.HovellM. F.HofstetterC. R.ElderJ. P.HackleyM.CaspersenC. J.and PowellK. E.1990Distance between homes and exercise facilities related to the frequency of exercise among San Diego residents. Public Health Reports, 105(2), 179-185.
  155. 155. SallisJ. F.NaderP.BroylesS.BerryC.ElderJ.MckenzieT.and NelsonJ.1993Correlates of physical activity at home in Mexican-American and Anglo-American preschool children.Health Psychology, 12(5), 390 EOF8 EOF
  156. 156. SallisJ. F.and OwenN.1997Ecological models. In: K. Glanz, F.MLewis and B.K. Rimer (Eds.), Health Behavior and Health Education: Theory, Research and Practice (403424San Francisco: Jossey-Bass.
  157. 157. Sallis, J.F., Bauman, A. and Pratt, M. (1998). Environmental and policy interventions to promote physical activity. American Journal of Preventive Medicine, 15(4), 379 EOF397 EOF .
  158. 158. SallisJ. F.and OwenN.1999Physical Activity and Behavioral MedicineThousand Oaks, CA: Sage Publications.
  159. 159. SallisJ. F.JudithP.and WendellT.2000A review of correlates of physical activity of children and adolescents.Medicine and Science in Sports and Exercise963 EOF75 EOF
  160. 160. SallisJ. F.ConwayT. L.ProchaskaJ. J.MckenzieT. L.MarshallS. J.and BrownM.2001The association of school environments with youth physical activity.American Journal of Public Health, 91(4), 618.
  161. 161. SallisJ. F.MckenzieT. L.ConwayT. L.ElderJ. P.ProchaskaJ. J.BrownM.et al2003Environmental interventions for eating and physical activity- a randomized controlled trial in middle schools. American Journal of Preventive Medicine, 24(3), 209-217.
  162. 162. SallisJ. F.SaelensB. E.FrankL. D.ConwayT. L.SlymenD. J.CainK. L.et al2009Neighborhood built environment and income: examining multiple health outcomes.Social Science and Medicine, 68(7), 1285 EOF93 EOF
  163. 163. SallisJ. F.TaylorW. C.DowdaM.FreedsonP. S.and PateR. R.2002Correlates of vigorous physical activity for children in grades 1 through 12: comparing parent-reported and objectively measured physical activityPediatric Exercise Science30 EOF44 EOF
  164. 164. SallisJ. F.KraftK.CutterC. L.KerrJ.WeitzelJ.and WilsonA.2009The active living research programAmerican Journal of Preventive Medicine1 EOF
  165. 165. SharplesM.DavisonL.ThomasG.and RudmanP.2003Children as photographers: an analysis of children’s photographic behavior and intentions at three age levels. Visual Communication, 2(3), 303-30.
  166. 166. ShawM.2004Housing and public health. Annual Review of Public Health, 25397418
  167. 167. ShultzS. P.BrowningR. C.SchutzY.MaffeisC.and HillsA. P.2011Childhood obesity and walking: guidelines and challengesInternational Journal of Pediatric Obesity, 6(5-6), 332-341.
  168. 168. SinghA.UijtdewilligenL.TwiskJ. W.Van MechelenW.and ChinapawM. J.2012Physical activity and performance at school: a systematic review of the literature including a methodological quality assessment.Archives of Pediatrics and Adolescent Medicine, 166(1), 49 EOF55 EOF
  169. 169. SirardJ.and PateR.2001Physical activity assessment in children and adolescents.Sports Medicine, 31(6), 439 EOF54 EOF
  170. 170. SpurrG. B.PrenticeA. M.MurgatroydP. R.GoldbergG. R.ReinaJ. C.and ChristmanN. T.1988Energy expenditure from minute-by-minute heart-rate recording: comparison with indirect calorimetry.American Journal of Clinical Nutrition, 48(3), 552 EOF9 EOF
  171. 171. SticeE.ShawH.and MartiC. N.2006A.Meta-analyticreview of obesity prevention programs for children and adolescents: the skinny on interventions that work. Psychological Bulletin667 EOF691 EOF
  172. 172. StigsdotterU. K.EkholmO.SchipperijnJ.ToftagerM.Kamper-jørgensenF.and RandrupT. B.2010Health promoting outdoor environments: associations between green space, and health, health-related quality of life and stress based on a Danish national representative survey.Scandinavian Journal of Public Health411 EOF7 EOF
  173. 173. StoryM.KaphingstK. M.and FrenchS.2006The role of schools in obesity preventionFuture of Children, 16(1), 109-142.
  174. 174. StrattonG.and MullanE.2005The effect of multicolor playground markings on children’s physical activity level during recess.Preventive Medicine41828833
  175. 175. StrongW. B.MalinaR. M.BlimkieC. J.DanielsS. R.DishmanR. K.GutinB.HergenroederA. C.MustA.NixonP. A.PivarnikJ. M.et al2005Evidence based physical activity for school-age youth.Journal of Pediatrics, 146(6), 732 EOF7 EOF
  176. 176. StrongK. A.ParksS. L.AndersonE.WinettR.and DavyB. M.2008Weight gain prevention: identifying theory-based targets for health behavior change in young adults.Journal of the American Dietetic Association1708 EOF1715 EOF
  177. 177. Stucky-roppR.and DiLorenzo, T.M. (1993Determinants of exercise in children.Preventive Medicine880 EOF9 EOF
  178. 178. SugiyamaT.LeslieE.Giles-cortiB.and OwenN.2008Associations of neighborhood greenness with physical and mental health: do walking, social coherence and local social interaction explain the relationships? Journal of Epidemiology and Community Health, 62(5), e9.
  179. 179. SimsekF.UlukolB.BerberogluM.and GülnarS. B.2005Ankara’da bir ilkögretim okulu ve lisede obezite sikligi. Ankara Üniversitesi Tip Fakültesi Dergisi, 58163166
  180. 180. TakanoT.NakamuraK.and WatanabeM.2002Urban residential environments and senior citizens’ longevity in megacity areas: the importance of walkable green spacesJournal of Epidemiology and Community Health, 56(12), 913-918.
  181. 181. TeixeiraP. J.SardinhaL. B.GoingS. B.and LohmanT. G.2001Total and regional fat and serum cardiovascular disease risk factors in lean and obese children and adolescents.Obesity Research432 EOF42 EOF
  182. 182. TranterP. J.and MaloneK.2004Geographies of environmental learning: an exploration of children’s use of school groundsChildren’s Geographies, 2(1), 131 EOF155 EOF
  183. 183. TrudeauF.and ShepherdR. J.2005Contribution of school programs to physical activity levels and attitudes in children and adults. Sports Medicine, 35(2), 89-105.
  184. 184. TrostS. G.PateR. R.FreedsonP. S.SallisJ. F.and TaylorW. C.2000Using objective physical activity measures with youth: how many days of monitoring are needed? Medicine and Science in Sports and Exercise, 32(2), 426-431.
  185. 185. TrostS. G.KerrL. M.WardD. S.and PateR. R.2001Physical activity and determinates of physical activity in obese and non-obese children. International Journal of Obesity, 25(6), 822-829.
  186. 186. TrostS. G.OwenN.BaumanA. E.SallisJ. F.and BrownW.2002Correlates of adults’ participation in physical activity: review and updateMedicine and Science in Sports and Exercise, 34(12), 1996-2001.
  187. 187. Tudor-lockeC. E.and BassettD. R.2004How many steps are enough? Pedometer-determined physical activity indices. Sports Medicine, 34(1), 1-8.
  188. 188. Tudor-lockeC.CraigC. L.BeetsM. W.BeltonS.CardonG. M.DuncanS.HatanoY.LubansD. R.OldsT. S.RaustorpA.et al2011How many steps/day are enough? for children and adolescentsInternational Journal of Behavioral Nutrition and Physical Activity, 8(1), 78.
  189. 189. UguzM.and BodurS.2007Konya il merkezindeki ergenlik öncesi ve ergen çocuklarda asiri agirlik ve sismanlik durumunun demografik özelliklerle iliskisi. Genel Tip Dergisi, 17(1), 1-7.
  190. 190. UluocakN.ParlaktasB. S.ErdemirF.and ÇaglarM. N.2006Saglikli okul çagi çocukalrinda böbrek boyutlarinin vücut kitle indeksi ve cinsiyet ile olan iliskisi. Çocuk Ürolojisi, 32(3), 370-374.
  191. 191. Van EmmerikN. M.RendersC. M.van deVeer, M., van Buuren, S., van der Baan-Slootweg, O.H., Kist-van Holthe, J.E. and Hirasing, R.A. (2012High cardiovascular risk in severely obese young children and adolescentsArchives of Disease in Childhood, 97(9), 818-821.
  192. 192. Van LentheF.BrugJ.and MackenbachJ.2005Neighborhood inequalities in physical inactivity: the role of neighborhood attractiveness, proximity to local facilities and safety in the Netherlands. Social Science and Medicine, 60(4), 763-775.
  193. 193. Van MechelenW.TwiskJ. W.PostG. B.SnelJ. A. N.and KemperH. C.2000Physical activity of young people: The Amsterdam Longitudinal Growth and Health Study.Medicine and Science in Sports and Exercise1610 EOF6 EOF
  194. 194. Van SluijsE. M.JonesN. R.JonesA. P.SharpS. J.HarrisonF.and GriffinS. J.2012School-level correlates of physical activity intensity in 10year-old children.International Journal of Pediatric Obesity, 6(2Part2), 574-581.
  195. 195. VaughnS.SchummJ. S.and SinagubJ.1996Use of focus groups with children and adolescents. In: J.M. Sinagub, S. Vaughn and J.S. Schumm (Eds.), Focus Group Interviews in Education and Psychology (128142Thousand Oaks, CA: Sage.
  196. 196. VerstraeteS. J.CardonG. M.De ClercqD. L. R.and De BourdeaudhuijI. M. M.2006Increasing children’s physical activity levels during recess periods in elementary schools: the effects of providing game equipmentEuropean Journal of Public Health, 16(4), 415-419.
  197. 197. VeugelersP. J.SitholeF.ZhangS.and MuhajarineN.2008Neighborhood characteristics in relation to diet, physical activity and overweight of Canadian children.International Journal of Pediatric Obesity, 3(3), 152 EOF9 EOF
  198. 198. VeugelersP. J.and FitzgeraldA. L.2005Prevalence of and risk factors for childhood overweight and obesityCanadian Medical Association Journal, 173(6), 607-613.
  199. 199. VincentS. D.and PangraziR. P.2002An examination of the activity patterns of elementary school childrenPediatric Exercise Science432 EOF441 EOF
  200. 200. VitaP.and OwenN.1995A perspective on the behavioral epidemiology: the determinants and the stages of exercise involvement. Australian Psychologist, 30(2), 135-140.
  201. 201. WabitschM.2000Overweight and obesity in European children and adolescents: causes and consequences, treatment and preventionan introduction. European Journal of Pediatrics
  202. 202. WangC.and BurrisM. A.1997Photovoice: concept, methodology, and use for participatory needs assessment.Health Education and Behavior, 24(3), 369 EOF87 EOF
  203. 203. WeickK. E.and QuinnR. E.1999Organizational change and development. Annual Review of Psychology, 50(1), 361-386.
  204. 204. WeinsierR. L.HunterG. R.HeiniA. F.GoranM. I.and SellS. M.1998The etiology of obesity: relative contribution of metabolic factors, diet, and physical activity.American Journal of Medicine, 105(2), 145 EOF50 EOF
  205. 205. WechslerH.DevereauxA. B.DavisM.and CollinsJ.2000Using the school environment to promote physical activity and healthy eatingPreventive Medicine
  206. 206. WelkG. J.2002Physical Activity Assessments for Health-Related ResearchChampaign, IL: Human Kinetics Publishers.
  207. 207. WelkG. J.CorbinC. B.and DaleD.2000Measurement issues in the assessment of-physical activity in children. Research Quarterly for Exercise and Sport, 715973
  208. 208. WellsN. M.and EvansG. W.2003Nearby Nature: A Buffer of Life Stress among Rural ChildrenEnvironment and Behavior, 35(3), 311 EOF330 EOF
  209. 209. WellsN. M.and YangY.2008Neighborhood design and walking: a quasi-experimental longitudinal study,American Journal of Preventive Medicine313 EOF9 EOF
  210. 210. Wendel-vosW.DroomersM.KremersS.BrugJ.and Van LentheF.2007Potential environmental determinants of physical activity in adults: a systematic reviewObesity reviews425 EOF440 EOF
  211. 211. Wendel-vosG. C.SchuitA. J.De NietR.BoshuizenH. C.SarisW. H.and KromhoutD.2004Factors of the physical environment associated with walking and bicycling.Medicine and Science in Sports and Exercise36725730
  212. 212. WheelerB. W.CooperA. R.PageA. S.and JagoR.2010Greenspace and children’s physical activity: A GPS/GIS analysis of the PEACH projectPreventive Medicine148 EOF152 EOF
  213. 213. WhitehouseS.VarniJ. W.SeidM.Cooper-marcusC.EnsbergM. J.JacobsJ. R.and MehlenbeckR. S.2001Evaluating a children’s hospital garden environment: utilisation and consumer satisfaction. Journal of Environmental Psychology, 21301314
  214. 214. WhittM. C.DuBose, K.D., Ainsworth, B.E. and Tudor-Locke, C. (2004Walking patterns in a sample of African American, Native American, and Caucasian women: the cross-cultural activity participation studyHealth Education and Behavior, 31(Suppl 4), 45-56.
  215. 215. WigleD. T.2003Child Health and the EnvironmentNew York: Oxford University Press.
  216. 216. YoungL.and BarrettH.2001Adapting visual methods: action research with Kampala street childrenArea141 EOF152 EOF
  217. 217. ZaskA.Van BeurdenE.BarnettL. M.BrooksL. O.and DietrichU. C.2001Active school playgrounds-myth or reality? Results of the’Move It Groove It’ project. Preventive Medicine, 33(5), 402-408.
  218. 218. ZimringC.JosephA.NicollG. L.and TsepasS.2005Influences of building design and site design on physical activity: research and intervention opportunities.American Journal of Preventive Medicine186 EOF93 EOF

Written By

Aydın Özdemir

Submitted: 26 July 2012 Published: 01 July 2013