566273 research-article2014
HPPXXX10.1177/1524839914566273Health Promotion PracticeAltin et al. / Upgrading Preschool Environment in Sweden
Upgrading Preschool Environment in a Swedish Municipality: Evaluation of an Implementation Process Carolina Altin, MPH1 Sofia Kvist Lindholm, MPH2,3 Mats Wejdmark, MSc4 Robert Lättman-Masch, MSc4 Cecilia Boldemann, PhD1,3 Redesigning outdoor preschool environment may favorably affect multiple factors relevant to health and reach many children. Cross-sectional studies in various landscapes at different latitudes have explored the characteristics of preschool outdoor environment considering the play potential triggering combined physical activity and sun-protective behavior due to space, vegetation, and topography. Criteria were pinpointed to upgrade preschool outdoor environment for multiple health outcomes to be applied in local government in charge of public preschools. Purposeful land use policies and administrative management of outdoor land use may serve to monitor the quality of preschool outdoor environments (upgrading and planning). This study evaluates the process of implementing routines for upgrading outdoor preschool environments in a medium-sized municipality, Sweden, 2008-2011, using qualitative and quantitative analysis. Recorded written material (logs and protocols) related to the project was processed using thematic analysis. Quantitative data (m2 flat/multileveled, overgrown/naked surface, and fraction of free visible sky) were analyzed to assess the impact of implementation (surface, topography, greenery integrated in play). The preschool outdoor environments were upgraded accordingly. The quality of implementation was assessed using the theory of policy streams approach. Though long-term impact remains to be confirmed the process seems to have changed work routines in the interior management for
Health Promotion Practice Month XXXX Vol. XX , No. (X) 1–9 DOI: 10.1177/1524839914566273 © 2015 Society for Public Health Education
purposeful upgrading of preschool outdoor environments. The aptitude and applicability of inexpensive methods for assessing, selecting, and upgrading preschool land at various latitudes, climates, and outdoor play policies (including gender aspects and staff policies) should be further discussed, as well as the compilation of data for monitoring and evaluation. Keywords: process evaluation; program planning and evaluation; strategic planning; physical activity/exercise; cancer prevention and control
Introduction >> In Sweden, one child out of five is overweight/obese (Kelly et al., 2008; Sjöberg et al., 2011), and an impact on the cardiovascular system has been observed in children (Andersen et al., 2006). In a long-term perspective, this may lead to type 2 diabetes, cardiovascular disease, 1
Karolinska Institutet, Stockholm, Sweden University of Linköping, Linköping, Sweden 3 Centre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden 4 Nature School, Municipality of Nynäshamn, Stockholm, Sweden 2
Authors’ Note: The evaluation of this project took place within the framework of the studies for a master’s degree in public health sciences at Karolinska Institutet, Stockholm. Address correspondence to Sofia Kvist Lindholm, MPH, Department of Thematic Studies-Child Studies, University of Linköping, 581 83, Sweden; e-mail: [email protected].
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and cancer (Andersen et al., 2006; Kelly et al., 2008; Tanha et al., 2011). Also skin cancer increases rapidly in Sweden (Jaresand, 2013). Approximately 80% to 90% of all skin cancers are caused by overexposure to ultraviolet (UV) radiation from the sun (Boldemann et al., 2006). Among Swedish toddlers, 20% have experienced sunburn (Bränström, Kristjansson, Dal, & Rodvall, 2006). Lifestyles and habits that are formed at an early age will often prevail and affect the entire life span (Janz et al, 2010). Redesigning outdoor preschool environment may favorably affect these multiple factors relevant to health and reach many children as an increasing number of them spend most of their waking hours at preschool (in Sweden 95% of all 3- to 5-year-old children attend preschool; The Swedish National Agency for Education, 2013). Several studies have shown a relationship between physical environment and health. Outdoor environment at preschool has been found to affect children’s physical activity, sun exposure (avoidance of sunburn and yet sufficient exposure whenever possible to form vitamin D except in winter), attention abilities, body frame, night sleep, and general health by virtue of their free play (Boldemann et al., 2006; Boldemann et al., 2011; Mårtensson et al., 2009; Söderström et al., 2013). The potential of physical activity further promotes and maintains energy balance, well-being, bone health, and mobility (Pitukcheewanont, Punyasavatsut, & Feuille, 2006). All these advantages may be obtained by environment that affords creative and active play and recreation that in turn serves to improve motor skills and academic performance, which has been observed to be of particular benefit for children from disadvantaged areas (Mårtensson et al., 2009). Thus, such an intervention contributes to leveling out differences in the conditions that children grow up in (Mårtensson et al., 2009). The findings have resulted in a set of criteria for high-quality environment considering surface, levels, and vegetation used in play. This set of criteria was developed as a result of research exploring the combined impact of the physical properties of preschool outdoor environment on physical activity and sun exposure in terms of erythemally effective solar UV radiation. Fulfilment of these criteria increases physical activity by >20%. The amount of daily physical activity required for children’s optimal chances of maintaining a healthy body weight has been defined (Tudor-Locke et al., 2004). A high-score environment thus functions as proxy (with sufficient amounts of physical activity as intermediate endpoint) for decreasing the risk of obesity. Further such environment decreases relative UV exposure (fraction of available UV when outdoors) by 40% by attracting children to play in shaded areas, which enables prolonged outdoor
stay without a risk of sunburn (Boldemann et al., 2006, Boldemann et al., 2011). Based on this, the preschool environment was to be upgraded accordingly. A project for health-promoting preschool outdoor environment (hereafter the Project) was initiated in a medium-sized municipality south of Stockholm, Sweden. Five preschool outdoor environments whose environments did not fulfill the requirements for health-promoting properties were eligible for upgrading. The Project ran from 2008 to 2011. This article presents its implementation process and impact in terms of quantitative criteria for health-promoting outdoor environment. The quality of implementation was assessed using Kingdon’s (2011) theory of policy streams approach. It explains why certain issues are taken up on the political agenda and others are not. It describes the way separate “streams” (the “problem,” “policy,” and “political,” streams, respectively) may open up a “window of opportunity” into the politics of making macro policy and hence bring about changes at a certain time and in a certain context (Figure 1; Guldbrandsson & Fossum, 2009; Kingdon, 2011). To open up “a window of opportunity” a problem needs to be identified and clearly formulated (problem stream), practicable suggestions for change need to be at hand (policy stream), and the suggestions for change need to be supported by a political wish expressed via proposition-related processes (political stream; Guldbrandsson & Fossum, 2009; Kingdon, 2011). This in turn demands policy entrepreneurs defined by Kingdon as key persons who advocate specific solutions to a problem. Policy entrepreneurs possess certain qualities, such as an ability to talk for others, a decision-making position or expert knowledge of the issue, and as such represent someone who people “listen to” (“claim to a hearing”). They have political contacts and negotiation abilities, enabling a combination of political and technical skills for implementation. The most important quality of a policy entrepreneur according to Kingdon is persistence to advocate and disseminate a concept to several fora, investing time and other resources to anchor the suggested change. The three streams evolve independently of each other. When they connect, that is, a problem is recognized, a solution is at hand, and the political climate is in favor of change, a policy window may open up that facilitates political change (Kingdon, 2011). In the present study, the quantitative criteria for health-promoting outdoor environment and the policy streams approach elaborated on above have been used as a basis for evaluating the Project. More specifically, the
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Problem stream: A problem needs to be identified and clearly formulated, e.g. preschool outdoor environment of poor quality Policy stream: Practicable suggestions for change need to be at hand, e.g. criteria for good outdoor environment.
Policy window to bring about policy change
Political stream: The suggestions for change need to be supported by a political wish expressed via proposition-related processes, e.g. earmarked money for action to upgrade preschool environment.
Figure 1 Kingdon’s Theory of the Policy Streams Approach: When the “Streams” Connect, a Policy Window Opens That Facilitates Policy Change
purpose of the study was to evaluate the implementation of a health-promoting preschool outdoor environment by considering the following questions: 1. Which factors hampered or facilitated the implementation as seen from the Policy Streams Approach? 2. Did the implementation impact preschool outdoor environment considering the criteria for high-quality outdoor environment in terms of space, topography, vegetation, and shade?
Method >> Qualitative method was applied for the investigation of what happened when, how, and why during the process, and quantitative method to assess the impact of implementation considering the criteria for highquality preschool outdoor environment. Additionally, an assessment of the sky views from favored play locations was made using a simplified method (Kawanishi, 2007, 2013). The intersectoral steering group for the Project was made up of representatives from the municipal executive committee of various competencies, responsibilities, and authorizations. The members (all pseudonyms) were managers Adam and Bill from the Nature School in the municipality, both positioned under the committee for child care and education, and commissioned to advocate and stimulate learning for sustainable development in the municipality. Further members of the steering group were Gordon, head of park attendance at the technical board, Cynthia, chief development officer for public health issues, Fred, head of the real estate board, Erin, Project coordinator jointly with researcher
Dana and Lorna, planning architect from the board of environmental and societal planning (Table 1). Qualitative data were made up of process documentation, in total 152 pages, more specifically of protocols, municipal documents, minutes, and a process log kept by Adam and Bill. The process log, encompassing a rich material of the “black box,” specified the different steps of the Project progression. The log contained mail correspondence, reflections on meetings, documented action, and reflections about the process and its implementation. Furthermore, it contained detailed descriptions of problems encountered during the project and of circumstances identified as crucial for facilitating the implementation process. The text material was analyzed based on theorydriven thematic analysis (Braun & Clarke, 2006). Initially, the material was read through several times, coded, and arranged along a time axis based on the questions: What happened when, where, how, and why during the Project process? To incorporate Kingdon’s (2011) policy streams approach, the next step was to reread the material to identify policy entrepreneurs with “claim to a hearing,” political contacts, negotiation capacity, and endurance, and at the same time consider the following criteria: •• •• ••
Was the design of preschool outdoor environments expressed as a specific problem? (problem stream) Was there a solution to the problem? (policy stream) How did the political wishes make themselves heard during the project process? (political stream)
Based on these preceding steps of analysis the final step was to form broader themes of factors that seemed
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Table 1 Pseudonyms and Titles of the Persons Involved in the Project Adam and Bill Cynthia Dana Erin Fred Gordon Hugh Irene Jane Lorna Morgan
Managing Directors of the Project (Under the Child Care and Education Committee) Chief development officer for public health issues Researcher Project coordinator Head of the real estate board Head of park attendance at the technical board (succeeded by Hugh) Head of park attendance at the technical board Landscape architect Real estate technician Planning architect from the board of environmental and societal planning Facility manager of the Child Care and Education Committee
to promote or hamper the implementation of a healthpromoting preschool outdoor environment (Figure 2). As the project managers, Adam and Bill, disposed of the log semistructured interviews were carried out with two other key persons to validate the data. The interviews focused on what had hampered or promoted the project. Examples of questions posed were “What do you believe were the reasons that the Project was raised on the agenda?” and “Did you experience any obstacles (/ success) in the execution of the Project? If so, please describe.” Different follow-up questions were posed depending on their answers. Furthermore, questions specifically related to the Policy Streams Approach were asked. Since their descriptions corresponded with the results generated by the thematic analysis (further described in the Result section), and as no new information was added the material was considered as saturated. For quantitative analysis data were collected of the respective outdoor environments considering sky view factors and surfaces: Sky view factors (SVFs), that is, the fractions of visible free sky from fixed play structures and/or favored play locations as determined by observation of the preschool staff were photographed. For the computation of the SVF a method was applied that considers season and latitude and thus the solar intensity from various parts of the sky (Kawanishi, 2007), a handy method that enables assessment of the SVF by viewing the sky on the site. The Outdoor Play Environment Categories (OPEC) tool was applied for inspection of the preschool environmental designs and to assess the surfaces along 3 dimensions (A, B, C), each scored 1-3: A. Total outdoor area (1 = 6,000 m2).
B. Trees, shrubbery, and hilly terrain: 1 = little/nonexistent, 2 = half of area. C. Integration between vegetation, open areas, and play structures: 1 = none, all in separate parts of environment, 2 = either (a) trees or shrubbery adjacent to play areas or play areas with the character of wild nature or (b) open spaces in between play areas, 3 = 2a and 2b.
Size (m2, surface of property excluded), multileveled ground, vegetation, and sky view from favored positions of play were assessed at the start of the Project in 2007 and on implementation in 2011 (Mårtensson et al, 2009). The amount of multileveled and overgrown surface was determined by inspection on the site, and its relative part of the whole area computed. The integration of areas with open spaces and vegetation used for play, and “play integrated” greenery was assessed by identifying worn patches on the ground. The observations were verified by the preschool staff. Five out of the 18 preschools of the municipality were selected for participation, and received oral and written information about the requirements for participation, which formed the base for informed consent to participate. The outdoor environments of these sites did not fulfill any of the criteria required for health-promoting outdoor environment. For data analysis the SPSS statistical software package (Version 21) has been applied. The chisquare test was applied to compute the significance of change in SVF and OPEC between the years 2007 and 2011.
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SUCCESS
Project start
Anchoring PROJECT
New preschool mo vated PROJECT D introduced research.PROJECT anchored key access persons Info mee ng on preschools with D
E examines who should write the maer
CEC approve PROJECT E, A
F:PROJECT criteria control how administra ve funds are used PROJECT spreads in media
PROJECT approved in MB. MA owns PROJECT. E
I performes detailed dra plans
2 and 3: Incorporate land, J execute
3: sun protecon.
530,000 SEK granted for 2010
C applying for funds for 2009
I’s suggesons: stairs, plantaon on 3 & 2 Incorporated land on 1. A invesgate
4: sun protecon 1: climbing frame and sandbox that is shaded and integrated with greenery (A, J, H execute)
All implemented. A, J, H (except database)
Granted money for monitoring
Plantaon and Incorporated land at 5. J, H
A mee ng with 3 to raise the aim and background of PROJECT
1, 2, 3, 4 and 5 take part. A Intersectoral steering group with mandate: A, B, C, D, E, F, G, L
500,000 SEK for 2010. C
I’s suggesons 4: sun protecon, plantaon, willow hut, playhouse, (A J H execute)
C applying for funds for 2010
A budget manager aer C
Core group formed: A, B, J, H. A applying for funds for 2011
F & E quit, J and K replaces
TIME Issue adjourne
G deceased. H replace Rejec on SCC’s public health effort
OBSTACLE
Authoriza on requires inves ga on
C quit
No funds for opera ons
Bad info upsets staff on 3 Adders’ nest on one preschool
= Working group meeting Steer group meeting = Log-book =
1, 2, 3, 4, 5 = Preschools A=Adam, B=Bill, C=Cynthia, D=Dana, E=Erin, F=Fred, G=Gordon, H=Hugh, I=Irene, J=Jane, L=Lorna, M=Morgan
Plan and system maintenance is lacking (G had the knowledge)
4 do not want to move the fence 1 want a fence to stop the youngest children, non-compliance with criteria. Staff frustrated.
J starng computerizaon of the database, but sll split responsibilies
Uncertaines in the budget
CEC = Child care and Education Committee MB = Municipal Board MA = Municipal Administration SCC = Stockholm’s County Council
A database is s ll missing
Thick arrow = Necessary or sufficient conditions for the process (promoting factors)
Figure 2 The Process of Implementation, Considering Success Factors, and Obstacles
Results >>
Qualitative Analysis A policy window was opened as (1) a problem was identified and formulated (problem stream), namely the need for upgrading sun-exposed and cramped outdoor environment; (2) necessary and feasible suggestions, and hence political options, for change were at hand–to anchor the Project (policy stream), combined with solid scientific evidence, and experience invested with the managers of the project, combined with wellfunctioning networks with good coverage in the municipality, and several policy entrepreneurs appearing on the scene; and (3) policy-related processes that implicitly indicated political intention, for example, in the form of earmarked money (political stream). Obstacles and success factors are shown in Figure 2. Initially, the local community was invited to an open lecture with Dana on the importance of the outdoor environment for children’s health (October 2006,
arranged by Nynäshamn Nature school). Following the formal Project start (first meeting with the intersectoral steering group) the concept was anchored with key access persons (heads of involved boards, parents, politicians, etc.) who on the second meeting with the steering group were briefed by Dana about the research data forming the base for implementation. As an immediate impact, the draft design for a new preschool was rotated by 180° by initiative of Fred to incorporate a stretch of adjacent woodland. The result was a model outdoor environment in line with the health promotion criteria, which motivated the municipality to invest in the project (Figure 2, Table 2). The project rapidly branched off by the involvement of parents and preschool staff who were invited to submit suggestions for upgrading. However, cost estimates that needed to be specified prior to decision-making hampered flexibility. This became obvious later on when discontent was expressed (Figure 2, 2010, staff frustrated) as wishes were not
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Table 2 Sky View Factors (SVFs) and Components of the Outdoor Play Environment Categories (OPEC) 2007 and 2011, and Quality of Incorporated Land SVF a (%)
OPEC 2
Site 1 2 3 4 5
2
Children (n)
Children(n)
2007
2011
m 2007b
m 2011b
OPEC Score of Incorporated Land 2011
Score 2007
Score 2011
2007
2011
82 67 90 97 95
20 21 27 46 37
2,389 1,804 4,482 1,300 6,500
2,896 2,531 7,548 1,300 8,900
2 (surface not fulfilled) 2 (surface not fulfilled) 3 (all criteria fulfilled) 2 (surface not fulfilled) 2 (surface previously fulfilled)
1.3 1.3 1,7 1.3 1.7
2.7 2.7 3.0 2.0 2.7
44 40 36 31 40
42 41 46 23 40
a. Mean value of three measurements. b. Surface occupied by building(s) excluded.
fulfilled, partly due to noncompliance with the criteria set up in the project. Initially, policy entrepreneurs Hugh, Morgan, and Fred, commissioned to implement the Project, were important key persons jointly with Erin. They were all prominent policy entrepreneurs who posessed the required qualities as advocated by Kingdon (2011), among others, “claim to a hearing” and negotiation capacities. On the second steering group meeting Fred earmarked maintenance money, attached to the healthpromoting criteria (part of the political stream), and set aside staff with high awareness of the issue from his unit to the steering group. The endurance displayed by Adam (the most important quality as by Kingdon) was evident. The intersectoral steering group was authorized to handle issues of, among others, economy and staffing, which was vital as all involved authorities engaged from the start in the Project (Figure 2). Approval from the child care and education committee (seat of the Project) was delayed (issue adjourned) due to external causes. Being the seat of the Project, they expressed a wish to form a steering group of their own. A conflict of interests arose, jeoparizing the existing steering group that disposed of authorization. However, it was transferred intact to the municipal executive committee. Fiscal responsibility was then transferred to Adam after a period of fiscal fuzziness, which began as Cynthia, in charge of invoices, quit and payments had been made in spite of uncertainties whether the money was adequatly marked or not. The staff at preschool Site 4 was opposed to the incorporation of woodland by moving the fence (Figure 2, obstacle 2010). The area was felt as steep and brushy
and hence unsafe. At another site the incorporated land was a hibernation ground for adders (causing parents’ and staff’s worries) who however “emigrated” at springtime. During 2010, Adam, Bill, Jane, and Hugh formed an executive team to implement the upgrading of the preschool outdoor environments, that is, incorporation of land, sun protection, and plantations for the preschool outdoors. City architect Hugh (Gordon deceased) was new and inexperienced and assisted by landscape architect Irene who performed detailed draft plans with markings for species and positions for new plantation. Its documentation now forms the base of a 3-year investment plan (a stage in follow-up). Quantitative Analysis Measurements of the dependent key outcome variables to define the quality of the preschool outdoor environment in terms of the criteria for their health-promoting potential, demonstrated a significant increase of OPEC scores and a reduction of SVFs (relative sky view), that is, the correlation tests (n = 181) were significant. OPEC scores increased and SVFs decreased significantly between 2007 and 2011. The correlation between OPEC and SVF was moderate in 2007 and high in 2011 (chisquare test), that is, there was a significant increase of the criteria of the health-promoting potential in terms of quantitative outcome measures (p < .01; Table 2). The correlation between SVF 2011 and OPEC 2011 was negative, that is, high-score OPEC correlated with low SVF. At Sites 1 and 2 no extension could be made to achieve >6,000 m2. However, the space that was incorporated was multileveled or made multileveled, with vegetation (self-grown and/or planted) the children used
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in their play. At Site 1 surface owned by a tenant–owner’s society was sold to the municipality to be incorporated in the preschool ground. At Site 4 no extension of the ground could be made, however, the existing ground was made hilly, passages were created through brushwood, and all fences inside the area removed. Site 3 became a full-score environment by the incorporation of high-quality woodland (Table 3, top bar). Site 5 did not lack space, but it was meagre and sun-exposed before upgrading (Table 3, bars 2 and 3). It needs to be pointed out that the new sky views were not the same at baseline and afterward as locations favored for play did move after upgrading of the outdoor environment. The results were reformulated into a practical tool for the upgrading of preschool environment (Table 3).
Discussion >> Theory-driven thematic analysis identified all the three streams (policy streams approach) required to open a policy window. Several policy entrepreneurs were identified who jointly had all the required qualities as specified by Kingdon (Guldbrandsson & Fossum, 2009, Kingdon, 2011). It is impossible to predict for how long a policy window stays open, but the analysis indicates that the time for the Project to start was right. A prerequisite to keep up the new routine is the buildup of a database for maintenance that has been started. The design of a new preschool in line with the health promotion criteria showed to be an important facilitating factor to motivate the municipality to invest in the project. The implementation process encountered several obstacles related to delayed decisions, conflicts of interests, and key persons quitting and being replaced. However, a wide anchoring of the project with an intersectoral steering group that disposed of authorization to integrate the project within ordinary working structures and the enduring work by involved key persons helped facilitate its implementation. Furthermore, the involvement of preschools and parents in the upgrading of outdoor environments showed to be important factors to make the Project branch off. There are still some uncertainties whether the job descriptions of the involved personal have been upgraded to maintain the new routines. However, the documentation of the outdoor environments today form the base for a 3-year investment plan that forms a link of maintenance of health-promoting criteria. It has started functioning, as a new preschool is planned for which the health-promoting criteria are discussed. The changes indicate that the quality and size of the preschool outdoors have increased by incorporated land,
but that a limitation in its use may be discerned due to the fears of staff and parents to let the children play in newly incorporated woodland. Consequently, the gates to these areas are often closed, and worries that these areas may be less safe need to be addressed with respectful reflection for optimal solutions. Other reasons not to use incorporated land as frequently as intended could be that moving around in multileveled and steep land is experienced as cumbersome. This, however, is considered an obstacle for the children’s motor development. So far the implementation resulted in improved OPEC scores and reduced SVFs and was obtained in accordance with the research that the Project was based on (Boldemann et al., 2006; Boldemann et al., 2011; Mårtensson et al., 2009; Söderström et al. 2013). Long-term impact on the children cannot be confirmed, but increasing physical activity and suberythemal sun exposure due to this implementation may in a long-term perspective lead to decreasing prevalence of overweight and sunburn experience. A limitation of this study was the absence of objective measurements of physical activity and UV exposure to confirm relationships at each one of the preschools. However, the proxy variables can be expected to represent objective measurement by virtue of their stability and generalizability, irrespective of climate or latitude (Boldemann et al., 2006; Boldemann et al., 2011; Mårtensson et al., 2009). Constructed sunshades are costly but a handy solution until planted trees have grown up to provide optimal shade, provided that they are maintained. The analysis was done by an external evaluator. This underpins impartiality, which is crucial when conducting an evaluation. The downside may be the evaluator’s lack of inside knowledge concerning the organization and the involved persons. This was counterbalanced by talks with the persons acting in the Project, which delivered an all-round perspective of the process. As previously stated the qualitative data consisted of a process log and of official documents such as protocols, municipal documents, and minutes. A disadvantage of using official documents is the obligation to use “correct” language with ensuing risk of omitting what could have been identified by interviews (e.g., obstacles). Systematic interviews could thus have yielded a deeper understanding of the process. The downside of interviews, on the other hand, is the dependence of the result on the interviewees’ memories and on how they want to appear in front of the interviewer. With these things in mind, the choice was made to base the study on the official documents and combine it with the nonofficial, informal process
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Table 3 Criteria for Preschool Environment to Promote Physical Activity and Sun-Protective Behavior: Suggestions for Action Incorporation of adjacent nature/woodland to increase size of area (preferably to >6,000 m2)
Space to “pick up speed” (good for bone growth) and for romping and running. Removal of high fences segmenting the outdoor environment, combined with variation: 1/2 to 2/3 of the area be hilly and vegetated (trees, free-growing brushwood and saplings, for play “underneath and between”). Flat ground may be broken up with big piles of earth (e.g., excavated material), and large objects of natural materials. Segmentation, by barriers of natural materials Open sky view > The presence of policy entrepreneurs and factors within the policy stream, the problem stream and the political stream departing from the policy streams approach were success factors for the implementation that resulted in changes of the outcome variables based on the criteria for health-promoting outdoor environment at preschool (ample surface, multileveled ground, vegetation used in play, and small sky views). However, more research is warranted to state long-term impact of the implementation, not least when it comes to handling obstacles to this type of structural implementation. References Andersen, L. B., Harro, M., Sardinha, L. B., Froberg, K., Ekelund, U., Brage, S., & Anderssen, S. A. (2006). Physical activity and clustered cardiovascular risk in children: A cross-sectional study (The European Heart Study). Lancet, 368, 299-304. doi:10.1016/ S0140-6736(06)69075-2 Boldemann, C., Blennow, M., Dal, H., Mårtensson, F., Raustorp, A., Yuen, K., & Wester, U. (2006). Impact of preschool environment upon children’s physical activity and sun exposure. Preventive Medicine, 42, 301-308. doi:10.1016/j.ypmed.2005. 12.006 Boldemann, C., Dal, H., Mårtensson, F., Cosco, N., Moore, R., Bieber, B., . . . Wester, U. (2011). Preschool outdoor play environment may combine promotion of children’s physical activity and sun protection. Further evidence from Southern Sweden and North Carolina. Science & Sports, 26, 72-82. doi:10.1016/j. scispo.2011.01.007 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.1191/ 1478088706qp063oa Bränström, R., Kristjansson, S., Dal, H., & Rodvall, Y. (2006). Sun exposure and sunburn among Swedish toddlers. European Journal of Cancer, 42, 1441-1447. doi:10.1016/j.ejca.2006.02.008
Guldbrandsson, K., & Fossum, B. (2009). An exploration of the theoretical concepts policy windows and policy entrepreneurs at the Swedish public health arena. Health Promotion International, 24, 434-44. doi:10.1093/heapro/dap033 Janz, K. F., Letuchy, E. M., Eichenberger Gilmore, J. M., Burns, T. L., Torner, J. C., Willing, M. C., & Levy, S. M. (2010). Early physical activity provide sustained bone health benefits later in childhood. Medicine and Science in Sports and Exercise, 42, 1072-1078. doi:10.1249/MSS.0b013e3181c619b2 Jaresand, M. (Ed.). (2013). Report from the Swedish Cancer Society, 2013. Stockholm, Sweden: Cancerfonden. Retrieved from http://www.cancerfonden.se/sv/Om-Cancerfonden/Press/ Pressmappar/Cancerfondsrapporten-2013/ Kawanishi, T. (2007, September). UV shade chart (pp. 157-158). Presentation at A UV Conference celebrating one century of UV Radiation Research (Physikalisch-Meteorologisches Observatorium), Davos, Switzerland. Retrieved from http://www.pmodwrc.ch/uvconf 2007/presentations/speeches/session6/6_6%20UV%20shade%20 chart%20SWISS0709.pdf Kawanishi, T. (2013). Sky erythema ultraviolet radiance and UV shade charts. AIP Conference Proceedings, 1531, 876-878. doi:10.1063/1.4804910 Kingdon, W. J. (Ed.). (2011). Agendas, alternatives and public policies (2nd ed.). Boston, MA: Longman. Kelly, T., Yang, W., Chen, C. S., Reynolds, K., & He, J. (2008). Global burden of obesity in 2005 and projections to 2030. International Journal of Obesity, 32, 1431-1437. doi:10.1038/ ijo.2008.102 Mårtensson, F., Boldemann, C., Söderström, M., Blennow, M., Englund, J. E., & Grahn, P. (2009). Outdoor environmental assessment of attention promoting settings for preschool children. Health & Place, 15, 1149-1157. doi:10.1016/j.healthplace. 2009.07.002 Pitukcheewanont, P., Punyasavatsut, N., & Feuille, M. (2010). Physical activity and bone health in children and adolescents. Pediatric Endocrinology Reviews, 7, 275-282. Sjöberg, A., Moraeus, L., Yngve, A., Poortvliet, E., Al-Ansari, U., & Lissner, L. (2011). Overweight and obesity in a representative sample of schoolchildren: Exploring the urban-rural gradient in Sweden. Obesity Reviews, 12, 305-314. doi:10.1111/j.1467-789X. 2010.00838.x Söderström, M., Boldemann, C., Sahlin, U., Mårtensson, F., Raustorp, A., & Blennow, M. (2013). The quality of the outdoor environment influences children’s health: A cross-sectional study of preschools. Acta Paediatrica, 102, 83-91. doi:10.1111/apa. 12047. Tanha, T., Wollmer, P., Thorsson, O., Karlsson, M. K., Lindén, C., Andersen, L. B., & Dencker, M. (2011). Lack of physical activity in young children is related to higher composite risk factor score for cardiovascular disease. Acta Paediatrica, 100, 717-721. doi:10.1111/j.1651-2227.2011.02226.x The Swedish National Agency for Education. (2013). Statistics (in Swedish). Stockholm, Sweden: Author. Tudor-Locke, C., Pangrazi, R. P., Corbin, C. B., Rutherford, W. J., Vincent, S. D., Raustorp, A., . . . Cuddihy, T. E. (2004). BMIreferenced standards for recommended pedometer-determined steps/day in children. Preventive Medicine, 38, 857-864.
Altin et al. / Upgrading Preschool Environment in Sweden 9
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HPPXXX10.1177/1524839914566273Health Promotion PracticeAltin et al. / Upgrading Preschool Environment in Sweden
Upgrading Preschool Environment in a Swedish Municipality: Evaluation of an Implementation Process Carolina Altin, MPH1 Sofia Kvist Lindholm, MPH2,3 Mats Wejdmark, MSc4 Robert Lättman-Masch, MSc4 Cecilia Boldemann, PhD1,3 Redesigning outdoor preschool environment may favorably affect multiple factors relevant to health and reach many children. Cross-sectional studies in various landscapes at different latitudes have explored the characteristics of preschool outdoor environment considering the play potential triggering combined physical activity and sun-protective behavior due to space, vegetation, and topography. Criteria were pinpointed to upgrade preschool outdoor environment for multiple health outcomes to be applied in local government in charge of public preschools. Purposeful land use policies and administrative management of outdoor land use may serve to monitor the quality of preschool outdoor environments (upgrading and planning). This study evaluates the process of implementing routines for upgrading outdoor preschool environments in a medium-sized municipality, Sweden, 2008-2011, using qualitative and quantitative analysis. Recorded written material (logs and protocols) related to the project was processed using thematic analysis. Quantitative data (m2 flat/multileveled, overgrown/naked surface, and fraction of free visible sky) were analyzed to assess the impact of implementation (surface, topography, greenery integrated in play). The preschool outdoor environments were upgraded accordingly. The quality of implementation was assessed using the theory of policy streams approach. Though long-term impact remains to be confirmed the process seems to have changed work routines in the interior management for
Health Promotion Practice Month XXXX Vol. XX , No. (X) 1–9 DOI: 10.1177/1524839914566273 © 2015 Society for Public Health Education
purposeful upgrading of preschool outdoor environments. The aptitude and applicability of inexpensive methods for assessing, selecting, and upgrading preschool land at various latitudes, climates, and outdoor play policies (including gender aspects and staff policies) should be further discussed, as well as the compilation of data for monitoring and evaluation. Keywords: process evaluation; program planning and evaluation; strategic planning; physical activity/exercise; cancer prevention and control
Introduction >> In Sweden, one child out of five is overweight/obese (Kelly et al., 2008; Sjöberg et al., 2011), and an impact on the cardiovascular system has been observed in children (Andersen et al., 2006). In a long-term perspective, this may lead to type 2 diabetes, cardiovascular disease, 1
Karolinska Institutet, Stockholm, Sweden University of Linköping, Linköping, Sweden 3 Centre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden 4 Nature School, Municipality of Nynäshamn, Stockholm, Sweden 2
Authors’ Note: The evaluation of this project took place within the framework of the studies for a master’s degree in public health sciences at Karolinska Institutet, Stockholm. Address correspondence to Sofia Kvist Lindholm, MPH, Department of Thematic Studies-Child Studies, University of Linköping, 581 83, Sweden; e-mail: [email protected].
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and cancer (Andersen et al., 2006; Kelly et al., 2008; Tanha et al., 2011). Also skin cancer increases rapidly in Sweden (Jaresand, 2013). Approximately 80% to 90% of all skin cancers are caused by overexposure to ultraviolet (UV) radiation from the sun (Boldemann et al., 2006). Among Swedish toddlers, 20% have experienced sunburn (Bränström, Kristjansson, Dal, & Rodvall, 2006). Lifestyles and habits that are formed at an early age will often prevail and affect the entire life span (Janz et al, 2010). Redesigning outdoor preschool environment may favorably affect these multiple factors relevant to health and reach many children as an increasing number of them spend most of their waking hours at preschool (in Sweden 95% of all 3- to 5-year-old children attend preschool; The Swedish National Agency for Education, 2013). Several studies have shown a relationship between physical environment and health. Outdoor environment at preschool has been found to affect children’s physical activity, sun exposure (avoidance of sunburn and yet sufficient exposure whenever possible to form vitamin D except in winter), attention abilities, body frame, night sleep, and general health by virtue of their free play (Boldemann et al., 2006; Boldemann et al., 2011; Mårtensson et al., 2009; Söderström et al., 2013). The potential of physical activity further promotes and maintains energy balance, well-being, bone health, and mobility (Pitukcheewanont, Punyasavatsut, & Feuille, 2006). All these advantages may be obtained by environment that affords creative and active play and recreation that in turn serves to improve motor skills and academic performance, which has been observed to be of particular benefit for children from disadvantaged areas (Mårtensson et al., 2009). Thus, such an intervention contributes to leveling out differences in the conditions that children grow up in (Mårtensson et al., 2009). The findings have resulted in a set of criteria for high-quality environment considering surface, levels, and vegetation used in play. This set of criteria was developed as a result of research exploring the combined impact of the physical properties of preschool outdoor environment on physical activity and sun exposure in terms of erythemally effective solar UV radiation. Fulfilment of these criteria increases physical activity by >20%. The amount of daily physical activity required for children’s optimal chances of maintaining a healthy body weight has been defined (Tudor-Locke et al., 2004). A high-score environment thus functions as proxy (with sufficient amounts of physical activity as intermediate endpoint) for decreasing the risk of obesity. Further such environment decreases relative UV exposure (fraction of available UV when outdoors) by 40% by attracting children to play in shaded areas, which enables prolonged outdoor
stay without a risk of sunburn (Boldemann et al., 2006, Boldemann et al., 2011). Based on this, the preschool environment was to be upgraded accordingly. A project for health-promoting preschool outdoor environment (hereafter the Project) was initiated in a medium-sized municipality south of Stockholm, Sweden. Five preschool outdoor environments whose environments did not fulfill the requirements for health-promoting properties were eligible for upgrading. The Project ran from 2008 to 2011. This article presents its implementation process and impact in terms of quantitative criteria for health-promoting outdoor environment. The quality of implementation was assessed using Kingdon’s (2011) theory of policy streams approach. It explains why certain issues are taken up on the political agenda and others are not. It describes the way separate “streams” (the “problem,” “policy,” and “political,” streams, respectively) may open up a “window of opportunity” into the politics of making macro policy and hence bring about changes at a certain time and in a certain context (Figure 1; Guldbrandsson & Fossum, 2009; Kingdon, 2011). To open up “a window of opportunity” a problem needs to be identified and clearly formulated (problem stream), practicable suggestions for change need to be at hand (policy stream), and the suggestions for change need to be supported by a political wish expressed via proposition-related processes (political stream; Guldbrandsson & Fossum, 2009; Kingdon, 2011). This in turn demands policy entrepreneurs defined by Kingdon as key persons who advocate specific solutions to a problem. Policy entrepreneurs possess certain qualities, such as an ability to talk for others, a decision-making position or expert knowledge of the issue, and as such represent someone who people “listen to” (“claim to a hearing”). They have political contacts and negotiation abilities, enabling a combination of political and technical skills for implementation. The most important quality of a policy entrepreneur according to Kingdon is persistence to advocate and disseminate a concept to several fora, investing time and other resources to anchor the suggested change. The three streams evolve independently of each other. When they connect, that is, a problem is recognized, a solution is at hand, and the political climate is in favor of change, a policy window may open up that facilitates political change (Kingdon, 2011). In the present study, the quantitative criteria for health-promoting outdoor environment and the policy streams approach elaborated on above have been used as a basis for evaluating the Project. More specifically, the
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Problem stream: A problem needs to be identified and clearly formulated, e.g. preschool outdoor environment of poor quality Policy stream: Practicable suggestions for change need to be at hand, e.g. criteria for good outdoor environment.
Policy window to bring about policy change
Political stream: The suggestions for change need to be supported by a political wish expressed via proposition-related processes, e.g. earmarked money for action to upgrade preschool environment.
Figure 1 Kingdon’s Theory of the Policy Streams Approach: When the “Streams” Connect, a Policy Window Opens That Facilitates Policy Change
purpose of the study was to evaluate the implementation of a health-promoting preschool outdoor environment by considering the following questions: 1. Which factors hampered or facilitated the implementation as seen from the Policy Streams Approach? 2. Did the implementation impact preschool outdoor environment considering the criteria for high-quality outdoor environment in terms of space, topography, vegetation, and shade?
Method >> Qualitative method was applied for the investigation of what happened when, how, and why during the process, and quantitative method to assess the impact of implementation considering the criteria for highquality preschool outdoor environment. Additionally, an assessment of the sky views from favored play locations was made using a simplified method (Kawanishi, 2007, 2013). The intersectoral steering group for the Project was made up of representatives from the municipal executive committee of various competencies, responsibilities, and authorizations. The members (all pseudonyms) were managers Adam and Bill from the Nature School in the municipality, both positioned under the committee for child care and education, and commissioned to advocate and stimulate learning for sustainable development in the municipality. Further members of the steering group were Gordon, head of park attendance at the technical board, Cynthia, chief development officer for public health issues, Fred, head of the real estate board, Erin, Project coordinator jointly with researcher
Dana and Lorna, planning architect from the board of environmental and societal planning (Table 1). Qualitative data were made up of process documentation, in total 152 pages, more specifically of protocols, municipal documents, minutes, and a process log kept by Adam and Bill. The process log, encompassing a rich material of the “black box,” specified the different steps of the Project progression. The log contained mail correspondence, reflections on meetings, documented action, and reflections about the process and its implementation. Furthermore, it contained detailed descriptions of problems encountered during the project and of circumstances identified as crucial for facilitating the implementation process. The text material was analyzed based on theorydriven thematic analysis (Braun & Clarke, 2006). Initially, the material was read through several times, coded, and arranged along a time axis based on the questions: What happened when, where, how, and why during the Project process? To incorporate Kingdon’s (2011) policy streams approach, the next step was to reread the material to identify policy entrepreneurs with “claim to a hearing,” political contacts, negotiation capacity, and endurance, and at the same time consider the following criteria: •• •• ••
Was the design of preschool outdoor environments expressed as a specific problem? (problem stream) Was there a solution to the problem? (policy stream) How did the political wishes make themselves heard during the project process? (political stream)
Based on these preceding steps of analysis the final step was to form broader themes of factors that seemed
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Table 1 Pseudonyms and Titles of the Persons Involved in the Project Adam and Bill Cynthia Dana Erin Fred Gordon Hugh Irene Jane Lorna Morgan
Managing Directors of the Project (Under the Child Care and Education Committee) Chief development officer for public health issues Researcher Project coordinator Head of the real estate board Head of park attendance at the technical board (succeeded by Hugh) Head of park attendance at the technical board Landscape architect Real estate technician Planning architect from the board of environmental and societal planning Facility manager of the Child Care and Education Committee
to promote or hamper the implementation of a healthpromoting preschool outdoor environment (Figure 2). As the project managers, Adam and Bill, disposed of the log semistructured interviews were carried out with two other key persons to validate the data. The interviews focused on what had hampered or promoted the project. Examples of questions posed were “What do you believe were the reasons that the Project was raised on the agenda?” and “Did you experience any obstacles (/ success) in the execution of the Project? If so, please describe.” Different follow-up questions were posed depending on their answers. Furthermore, questions specifically related to the Policy Streams Approach were asked. Since their descriptions corresponded with the results generated by the thematic analysis (further described in the Result section), and as no new information was added the material was considered as saturated. For quantitative analysis data were collected of the respective outdoor environments considering sky view factors and surfaces: Sky view factors (SVFs), that is, the fractions of visible free sky from fixed play structures and/or favored play locations as determined by observation of the preschool staff were photographed. For the computation of the SVF a method was applied that considers season and latitude and thus the solar intensity from various parts of the sky (Kawanishi, 2007), a handy method that enables assessment of the SVF by viewing the sky on the site. The Outdoor Play Environment Categories (OPEC) tool was applied for inspection of the preschool environmental designs and to assess the surfaces along 3 dimensions (A, B, C), each scored 1-3: A. Total outdoor area (1 = 6,000 m2).
B. Trees, shrubbery, and hilly terrain: 1 = little/nonexistent, 2 = half of area. C. Integration between vegetation, open areas, and play structures: 1 = none, all in separate parts of environment, 2 = either (a) trees or shrubbery adjacent to play areas or play areas with the character of wild nature or (b) open spaces in between play areas, 3 = 2a and 2b.
Size (m2, surface of property excluded), multileveled ground, vegetation, and sky view from favored positions of play were assessed at the start of the Project in 2007 and on implementation in 2011 (Mårtensson et al, 2009). The amount of multileveled and overgrown surface was determined by inspection on the site, and its relative part of the whole area computed. The integration of areas with open spaces and vegetation used for play, and “play integrated” greenery was assessed by identifying worn patches on the ground. The observations were verified by the preschool staff. Five out of the 18 preschools of the municipality were selected for participation, and received oral and written information about the requirements for participation, which formed the base for informed consent to participate. The outdoor environments of these sites did not fulfill any of the criteria required for health-promoting outdoor environment. For data analysis the SPSS statistical software package (Version 21) has been applied. The chisquare test was applied to compute the significance of change in SVF and OPEC between the years 2007 and 2011.
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SUCCESS
Project start
Anchoring PROJECT
New preschool mo vated PROJECT D introduced research.PROJECT anchored key access persons Info mee ng on preschools with D
E examines who should write the maer
CEC approve PROJECT E, A
F:PROJECT criteria control how administra ve funds are used PROJECT spreads in media
PROJECT approved in MB. MA owns PROJECT. E
I performes detailed dra plans
2 and 3: Incorporate land, J execute
3: sun protecon.
530,000 SEK granted for 2010
C applying for funds for 2009
I’s suggesons: stairs, plantaon on 3 & 2 Incorporated land on 1. A invesgate
4: sun protecon 1: climbing frame and sandbox that is shaded and integrated with greenery (A, J, H execute)
All implemented. A, J, H (except database)
Granted money for monitoring
Plantaon and Incorporated land at 5. J, H
A mee ng with 3 to raise the aim and background of PROJECT
1, 2, 3, 4 and 5 take part. A Intersectoral steering group with mandate: A, B, C, D, E, F, G, L
500,000 SEK for 2010. C
I’s suggesons 4: sun protecon, plantaon, willow hut, playhouse, (A J H execute)
C applying for funds for 2010
A budget manager aer C
Core group formed: A, B, J, H. A applying for funds for 2011
F & E quit, J and K replaces
TIME Issue adjourne
G deceased. H replace Rejec on SCC’s public health effort
OBSTACLE
Authoriza on requires inves ga on
C quit
No funds for opera ons
Bad info upsets staff on 3 Adders’ nest on one preschool
= Working group meeting Steer group meeting = Log-book =
1, 2, 3, 4, 5 = Preschools A=Adam, B=Bill, C=Cynthia, D=Dana, E=Erin, F=Fred, G=Gordon, H=Hugh, I=Irene, J=Jane, L=Lorna, M=Morgan
Plan and system maintenance is lacking (G had the knowledge)
4 do not want to move the fence 1 want a fence to stop the youngest children, non-compliance with criteria. Staff frustrated.
J starng computerizaon of the database, but sll split responsibilies
Uncertaines in the budget
CEC = Child care and Education Committee MB = Municipal Board MA = Municipal Administration SCC = Stockholm’s County Council
A database is s ll missing
Thick arrow = Necessary or sufficient conditions for the process (promoting factors)
Figure 2 The Process of Implementation, Considering Success Factors, and Obstacles
Results >>
Qualitative Analysis A policy window was opened as (1) a problem was identified and formulated (problem stream), namely the need for upgrading sun-exposed and cramped outdoor environment; (2) necessary and feasible suggestions, and hence political options, for change were at hand–to anchor the Project (policy stream), combined with solid scientific evidence, and experience invested with the managers of the project, combined with wellfunctioning networks with good coverage in the municipality, and several policy entrepreneurs appearing on the scene; and (3) policy-related processes that implicitly indicated political intention, for example, in the form of earmarked money (political stream). Obstacles and success factors are shown in Figure 2. Initially, the local community was invited to an open lecture with Dana on the importance of the outdoor environment for children’s health (October 2006,
arranged by Nynäshamn Nature school). Following the formal Project start (first meeting with the intersectoral steering group) the concept was anchored with key access persons (heads of involved boards, parents, politicians, etc.) who on the second meeting with the steering group were briefed by Dana about the research data forming the base for implementation. As an immediate impact, the draft design for a new preschool was rotated by 180° by initiative of Fred to incorporate a stretch of adjacent woodland. The result was a model outdoor environment in line with the health promotion criteria, which motivated the municipality to invest in the project (Figure 2, Table 2). The project rapidly branched off by the involvement of parents and preschool staff who were invited to submit suggestions for upgrading. However, cost estimates that needed to be specified prior to decision-making hampered flexibility. This became obvious later on when discontent was expressed (Figure 2, 2010, staff frustrated) as wishes were not
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Table 2 Sky View Factors (SVFs) and Components of the Outdoor Play Environment Categories (OPEC) 2007 and 2011, and Quality of Incorporated Land SVF a (%)
OPEC 2
Site 1 2 3 4 5
2
Children (n)
Children(n)
2007
2011
m 2007b
m 2011b
OPEC Score of Incorporated Land 2011
Score 2007
Score 2011
2007
2011
82 67 90 97 95
20 21 27 46 37
2,389 1,804 4,482 1,300 6,500
2,896 2,531 7,548 1,300 8,900
2 (surface not fulfilled) 2 (surface not fulfilled) 3 (all criteria fulfilled) 2 (surface not fulfilled) 2 (surface previously fulfilled)
1.3 1.3 1,7 1.3 1.7
2.7 2.7 3.0 2.0 2.7
44 40 36 31 40
42 41 46 23 40
a. Mean value of three measurements. b. Surface occupied by building(s) excluded.
fulfilled, partly due to noncompliance with the criteria set up in the project. Initially, policy entrepreneurs Hugh, Morgan, and Fred, commissioned to implement the Project, were important key persons jointly with Erin. They were all prominent policy entrepreneurs who posessed the required qualities as advocated by Kingdon (2011), among others, “claim to a hearing” and negotiation capacities. On the second steering group meeting Fred earmarked maintenance money, attached to the healthpromoting criteria (part of the political stream), and set aside staff with high awareness of the issue from his unit to the steering group. The endurance displayed by Adam (the most important quality as by Kingdon) was evident. The intersectoral steering group was authorized to handle issues of, among others, economy and staffing, which was vital as all involved authorities engaged from the start in the Project (Figure 2). Approval from the child care and education committee (seat of the Project) was delayed (issue adjourned) due to external causes. Being the seat of the Project, they expressed a wish to form a steering group of their own. A conflict of interests arose, jeoparizing the existing steering group that disposed of authorization. However, it was transferred intact to the municipal executive committee. Fiscal responsibility was then transferred to Adam after a period of fiscal fuzziness, which began as Cynthia, in charge of invoices, quit and payments had been made in spite of uncertainties whether the money was adequatly marked or not. The staff at preschool Site 4 was opposed to the incorporation of woodland by moving the fence (Figure 2, obstacle 2010). The area was felt as steep and brushy
and hence unsafe. At another site the incorporated land was a hibernation ground for adders (causing parents’ and staff’s worries) who however “emigrated” at springtime. During 2010, Adam, Bill, Jane, and Hugh formed an executive team to implement the upgrading of the preschool outdoor environments, that is, incorporation of land, sun protection, and plantations for the preschool outdoors. City architect Hugh (Gordon deceased) was new and inexperienced and assisted by landscape architect Irene who performed detailed draft plans with markings for species and positions for new plantation. Its documentation now forms the base of a 3-year investment plan (a stage in follow-up). Quantitative Analysis Measurements of the dependent key outcome variables to define the quality of the preschool outdoor environment in terms of the criteria for their health-promoting potential, demonstrated a significant increase of OPEC scores and a reduction of SVFs (relative sky view), that is, the correlation tests (n = 181) were significant. OPEC scores increased and SVFs decreased significantly between 2007 and 2011. The correlation between OPEC and SVF was moderate in 2007 and high in 2011 (chisquare test), that is, there was a significant increase of the criteria of the health-promoting potential in terms of quantitative outcome measures (p < .01; Table 2). The correlation between SVF 2011 and OPEC 2011 was negative, that is, high-score OPEC correlated with low SVF. At Sites 1 and 2 no extension could be made to achieve >6,000 m2. However, the space that was incorporated was multileveled or made multileveled, with vegetation (self-grown and/or planted) the children used
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in their play. At Site 1 surface owned by a tenant–owner’s society was sold to the municipality to be incorporated in the preschool ground. At Site 4 no extension of the ground could be made, however, the existing ground was made hilly, passages were created through brushwood, and all fences inside the area removed. Site 3 became a full-score environment by the incorporation of high-quality woodland (Table 3, top bar). Site 5 did not lack space, but it was meagre and sun-exposed before upgrading (Table 3, bars 2 and 3). It needs to be pointed out that the new sky views were not the same at baseline and afterward as locations favored for play did move after upgrading of the outdoor environment. The results were reformulated into a practical tool for the upgrading of preschool environment (Table 3).
Discussion >> Theory-driven thematic analysis identified all the three streams (policy streams approach) required to open a policy window. Several policy entrepreneurs were identified who jointly had all the required qualities as specified by Kingdon (Guldbrandsson & Fossum, 2009, Kingdon, 2011). It is impossible to predict for how long a policy window stays open, but the analysis indicates that the time for the Project to start was right. A prerequisite to keep up the new routine is the buildup of a database for maintenance that has been started. The design of a new preschool in line with the health promotion criteria showed to be an important facilitating factor to motivate the municipality to invest in the project. The implementation process encountered several obstacles related to delayed decisions, conflicts of interests, and key persons quitting and being replaced. However, a wide anchoring of the project with an intersectoral steering group that disposed of authorization to integrate the project within ordinary working structures and the enduring work by involved key persons helped facilitate its implementation. Furthermore, the involvement of preschools and parents in the upgrading of outdoor environments showed to be important factors to make the Project branch off. There are still some uncertainties whether the job descriptions of the involved personal have been upgraded to maintain the new routines. However, the documentation of the outdoor environments today form the base for a 3-year investment plan that forms a link of maintenance of health-promoting criteria. It has started functioning, as a new preschool is planned for which the health-promoting criteria are discussed. The changes indicate that the quality and size of the preschool outdoors have increased by incorporated land,
but that a limitation in its use may be discerned due to the fears of staff and parents to let the children play in newly incorporated woodland. Consequently, the gates to these areas are often closed, and worries that these areas may be less safe need to be addressed with respectful reflection for optimal solutions. Other reasons not to use incorporated land as frequently as intended could be that moving around in multileveled and steep land is experienced as cumbersome. This, however, is considered an obstacle for the children’s motor development. So far the implementation resulted in improved OPEC scores and reduced SVFs and was obtained in accordance with the research that the Project was based on (Boldemann et al., 2006; Boldemann et al., 2011; Mårtensson et al., 2009; Söderström et al. 2013). Long-term impact on the children cannot be confirmed, but increasing physical activity and suberythemal sun exposure due to this implementation may in a long-term perspective lead to decreasing prevalence of overweight and sunburn experience. A limitation of this study was the absence of objective measurements of physical activity and UV exposure to confirm relationships at each one of the preschools. However, the proxy variables can be expected to represent objective measurement by virtue of their stability and generalizability, irrespective of climate or latitude (Boldemann et al., 2006; Boldemann et al., 2011; Mårtensson et al., 2009). Constructed sunshades are costly but a handy solution until planted trees have grown up to provide optimal shade, provided that they are maintained. The analysis was done by an external evaluator. This underpins impartiality, which is crucial when conducting an evaluation. The downside may be the evaluator’s lack of inside knowledge concerning the organization and the involved persons. This was counterbalanced by talks with the persons acting in the Project, which delivered an all-round perspective of the process. As previously stated the qualitative data consisted of a process log and of official documents such as protocols, municipal documents, and minutes. A disadvantage of using official documents is the obligation to use “correct” language with ensuing risk of omitting what could have been identified by interviews (e.g., obstacles). Systematic interviews could thus have yielded a deeper understanding of the process. The downside of interviews, on the other hand, is the dependence of the result on the interviewees’ memories and on how they want to appear in front of the interviewer. With these things in mind, the choice was made to base the study on the official documents and combine it with the nonofficial, informal process
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Table 3 Criteria for Preschool Environment to Promote Physical Activity and Sun-Protective Behavior: Suggestions for Action Incorporation of adjacent nature/woodland to increase size of area (preferably to >6,000 m2)
Space to “pick up speed” (good for bone growth) and for romping and running. Removal of high fences segmenting the outdoor environment, combined with variation: 1/2 to 2/3 of the area be hilly and vegetated (trees, free-growing brushwood and saplings, for play “underneath and between”). Flat ground may be broken up with big piles of earth (e.g., excavated material), and large objects of natural materials. Segmentation, by barriers of natural materials Open sky view > The presence of policy entrepreneurs and factors within the policy stream, the problem stream and the political stream departing from the policy streams approach were success factors for the implementation that resulted in changes of the outcome variables based on the criteria for health-promoting outdoor environment at preschool (ample surface, multileveled ground, vegetation used in play, and small sky views). However, more research is warranted to state long-term impact of the implementation, not least when it comes to handling obstacles to this type of structural implementation. References Andersen, L. B., Harro, M., Sardinha, L. B., Froberg, K., Ekelund, U., Brage, S., & Anderssen, S. A. (2006). Physical activity and clustered cardiovascular risk in children: A cross-sectional study (The European Heart Study). Lancet, 368, 299-304. doi:10.1016/ S0140-6736(06)69075-2 Boldemann, C., Blennow, M., Dal, H., Mårtensson, F., Raustorp, A., Yuen, K., & Wester, U. (2006). Impact of preschool environment upon children’s physical activity and sun exposure. Preventive Medicine, 42, 301-308. doi:10.1016/j.ypmed.2005. 12.006 Boldemann, C., Dal, H., Mårtensson, F., Cosco, N., Moore, R., Bieber, B., . . . Wester, U. (2011). Preschool outdoor play environment may combine promotion of children’s physical activity and sun protection. Further evidence from Southern Sweden and North Carolina. Science & Sports, 26, 72-82. doi:10.1016/j. scispo.2011.01.007 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.1191/ 1478088706qp063oa Bränström, R., Kristjansson, S., Dal, H., & Rodvall, Y. (2006). Sun exposure and sunburn among Swedish toddlers. European Journal of Cancer, 42, 1441-1447. doi:10.1016/j.ejca.2006.02.008
Guldbrandsson, K., & Fossum, B. (2009). An exploration of the theoretical concepts policy windows and policy entrepreneurs at the Swedish public health arena. Health Promotion International, 24, 434-44. doi:10.1093/heapro/dap033 Janz, K. F., Letuchy, E. M., Eichenberger Gilmore, J. M., Burns, T. L., Torner, J. C., Willing, M. C., & Levy, S. M. (2010). Early physical activity provide sustained bone health benefits later in childhood. Medicine and Science in Sports and Exercise, 42, 1072-1078. doi:10.1249/MSS.0b013e3181c619b2 Jaresand, M. (Ed.). (2013). Report from the Swedish Cancer Society, 2013. Stockholm, Sweden: Cancerfonden. Retrieved from http://www.cancerfonden.se/sv/Om-Cancerfonden/Press/ Pressmappar/Cancerfondsrapporten-2013/ Kawanishi, T. (2007, September). UV shade chart (pp. 157-158). Presentation at A UV Conference celebrating one century of UV Radiation Research (Physikalisch-Meteorologisches Observatorium), Davos, Switzerland. Retrieved from http://www.pmodwrc.ch/uvconf 2007/presentations/speeches/session6/6_6%20UV%20shade%20 chart%20SWISS0709.pdf Kawanishi, T. (2013). Sky erythema ultraviolet radiance and UV shade charts. AIP Conference Proceedings, 1531, 876-878. doi:10.1063/1.4804910 Kingdon, W. J. (Ed.). (2011). Agendas, alternatives and public policies (2nd ed.). Boston, MA: Longman. Kelly, T., Yang, W., Chen, C. S., Reynolds, K., & He, J. (2008). Global burden of obesity in 2005 and projections to 2030. International Journal of Obesity, 32, 1431-1437. doi:10.1038/ ijo.2008.102 Mårtensson, F., Boldemann, C., Söderström, M., Blennow, M., Englund, J. E., & Grahn, P. (2009). Outdoor environmental assessment of attention promoting settings for preschool children. Health & Place, 15, 1149-1157. doi:10.1016/j.healthplace. 2009.07.002 Pitukcheewanont, P., Punyasavatsut, N., & Feuille, M. (2010). Physical activity and bone health in children and adolescents. Pediatric Endocrinology Reviews, 7, 275-282. Sjöberg, A., Moraeus, L., Yngve, A., Poortvliet, E., Al-Ansari, U., & Lissner, L. (2011). Overweight and obesity in a representative sample of schoolchildren: Exploring the urban-rural gradient in Sweden. Obesity Reviews, 12, 305-314. doi:10.1111/j.1467-789X. 2010.00838.x Söderström, M., Boldemann, C., Sahlin, U., Mårtensson, F., Raustorp, A., & Blennow, M. (2013). The quality of the outdoor environment influences children’s health: A cross-sectional study of preschools. Acta Paediatrica, 102, 83-91. doi:10.1111/apa. 12047. Tanha, T., Wollmer, P., Thorsson, O., Karlsson, M. K., Lindén, C., Andersen, L. B., & Dencker, M. (2011). Lack of physical activity in young children is related to higher composite risk factor score for cardiovascular disease. Acta Paediatrica, 100, 717-721. doi:10.1111/j.1651-2227.2011.02226.x The Swedish National Agency for Education. (2013). Statistics (in Swedish). Stockholm, Sweden: Author. Tudor-Locke, C., Pangrazi, R. P., Corbin, C. B., Rutherford, W. J., Vincent, S. D., Raustorp, A., . . . Cuddihy, T. E. (2004). BMIreferenced standards for recommended pedometer-determined steps/day in children. Preventive Medicine, 38, 857-864.
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