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Original Article
care, health and development
doi:10.1111/cch.12262
Abstract
Background Few studies have examined trends in engagement in outdoor physical activity as
children grow and whether changes in physical activity at different ages affect childrens health. This
study determined the preference for and frequency of physical activity among Japanese children
from ages 6 to 12 years and investigated the effect of physical activity and of change in physical
activity on childrens self-reported health.
Methods Data were from the prospective, longitudinal Toyama Birth Cohort Study, a total of 5238
Keywords
outdoor physical activity,
children were followed at their age of 12 years. Preference for and frequency of outdoor physical
quality of life, self- activity were from the self-administered questionnaire. Self-reported health was from the Japanese
reported health, the
version of Dartmouth Primary Care Co-operative project charts.
Toyama study
Results Reporting liking and participating in outdoor physical activity at both ages 6 and 12 years
Correspondence: were associated with higher likelihood of good self-reported health (Odds ratio 1.24 [95% CI: 1.03
Michikazu Sekine, MD, 1.50] for liking activity and OR = 1.27[1.08, 1.50] for participating in activity) compared with those
PhD, MBA, MSc, DLSHTM,
Department of Epide-
who did not like or participate in this at only one or at neither age, after adjustment for lifestyle
miology and Health Policy, factors and body pain. The adjusted OR was 1.23 (95% CI: 0.971.56) for girls whose preference for
Graduate School of Medi-
liking outdoor physical activity was not changed at both ages compared with those whose
cine and Pharmaceutical
Sciences, University of preference changed. The OR was 1.47 (95% CI: 1.141.89) for boys who persisted in participating in
Toyama, 2630 Sugitani, the outdoor physical activity than those who did not persist.
Toyama 930-0194, Japan.
E-mail: sekine@med.u-
Conclusions There is an association between a persistent expression of liking outdoor physical
toyama.ac.jp activity and self- reported health.
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
922 J. Liu et al.
2003). The correlation coefficient between subjective and physical activity from ages 6 to 12 years, while 68.9% of boys
objective records was 0.97 (P < 0.001) for assumed amount of and 54.0% of girls could maintain actively participating in
sleep, and the difference between subjective and objective activity from ages 6 to 12 years (Table 2). Boys showed a higher
records was 8.19 min (95% confidence interval [CI]: 4.93 proportion of liking outdoor physical activity and are more
11.45) for assumed amount of sleep (Gaina et al. 2004). active than girls at age 12 years (P < 0.05). Only 65.3% of boys
and 46.6% of girls at age 12 years achieved the recommended
level of activity (at least 60 min/day).
Self-reported health
Table 3 shows the proportion of good self-reported health by
In phase 4, data on self-reported overall health were collected age and sex. Generally, children who expressed liking outdoor
using a Japanese version of Dartmouth Primary Care Co- physical activity and who took part in the activity had higher
operative project Charts (Chen et al. 2005a). Children were proportion of good self-reported health than those without,
asked, During the past 4 weeks, how would you rate your health irrespective of sex. For example, 85.7% of boys, who liked
in general? The response options were excellent, very good, outdoor physical activity at age 12 years, reported good health,
good, fair, and poor. The outcome variable was dichoto- while only 77.6% of boys who did not like activity reported good
mized: the first three response options (excellent, very good health. Besides, boys who expressed persisting liking of outdoor
and good) were combined as good, and the latter two (fair and physical activity shared a high proportion of good self-reported
poor) were combined as poor (Chen et al. 2005a). health (85.7%) than those who had no persisting liking of
activity (81.6%). It shows similar trends in the girls.
Reporting liking and participating in outdoor physical
Statistical analysis
activity at both ages 6 and 12 years was associated with a
To evaluate the association between persisting expressed liking higher likelihood of good self-reported health (OR 1.24 [95%
for outdoor physical activity and participating in outdoor CI: 1.031.50] for liking activity and OR = 1.27[1.08, 1.50] for
physical activity and good self-reported health, we performed participating activity) compared with those who did not like or
chi-square analysis. Adjusted odds ratios (ORs) and their participate in this at only one or at neither age, after
corresponding 95% CIs for the self-report of good health at age adjustment for lifestyle factors and body pain (Table 4). The
12 years was calculated from binary logistic regression models, adjusted OR was 1.23 (95% CI: 0.971.56) for girls whose
adjusted for potential confounders found in the single-factor preference for liking outdoor physical activity was not changed
chi-square analysis. Statistical analyses were conducted using at both ages compared with those whose preference changed.
SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). A two-tailed The OR was 1.47 (95% CI: 1.141.89) for boys who persisted
P < 0.05 was considered statistically significant. participating the outdoor physical activity than those who did
not persist.
Results
Discussion
A total of 5238 children were followed from ages 6 to 12 years;
children had a mean age of 12.25 0.54 years at phase 4. In the present study, we investigated the effect of outdoor
Demographic characteristics of the subjects are shown Table 1. physical activity and of change in physical activity on childrens
There was no significant difference between boys and girls, self-reported health. Lack of physical activity may be a far
except boys were slightly older than girls, took breakfast and greater public health concern than obesity (Mitchell et al.
slept more regularly than girls. 2010). Self-reported health is a valid measure of a variety of
The majority of children liked outdoor physical activity and physical and emotional dimensions of adolescent well-being
were physically active and maintained this habit from ages 6 to (Fosse & Haas 2009; Elinder et al. 2011). Our study showed
12 years. The preference for outdoor physical activity decreased that children who liked and frequently engaged in outdoor
as children grew: it decreased from 92.1% and 93.9% at age physical activity had better self-reported health than those who
6 years for boys and girls, respectively, to 87.8% and 75.7% at did not, and the persisting liking of and frequent participating
age 12 years. The proportion of children who actually engaged in outdoor physical activity contribute to good self-reported
in outdoor physical activity was lower than the proportion who health. Hence, a preference for outdoor physical activity and
reported liking outdoor physical activity. A total of 83.1% of good habits in terms of physical activity are meaningful for
boys and 73.7% of girls expressed persisting liking of outdoor maintaining good health.
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
Physical activity and childrens self-reported health 923
Characteristic n % n % P
Table 2. Preference for and frequency of outdoor physical activity and of change by age and sex
Males Females
Outdoor physical activity is positively associated with fitness et al. 2015). It has also been suggested that children engage in
in children. A study showed that children who reported outdoor play as a form of entertainment, not only to increase
spending most of their after-school time outdoors had higher the probability of being physically active in later life, but to
cardiorespiratory fitness than youth who reported no time achieve the health benefits (Brockman et al. 2011).
outdoors (Schaefer et al. 2014). As well as the health benefits of Childhood physical activity yields health benefits; long-term
physical activity, outdoor play improves problem solving maintenance may keep benefits in the later life. Most children
ability, aids the development of motor skills, facilitates social liked outdoor physical activity and were physically active and
competence and safety skills and allows children to grow maintained this habit from ages 6 to 12 years. Our study
emotionally, which would contribute to health benefits (Smith showed that 7080% preference for liking outdoor physical
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
924 J. Liu et al.
Table 3. The association between outdoor physical activity at age 6 to 12 years and of change and good self-reported health at age 12 years by sex
Preference for and frequency of physical activity
Good
Like Dislike Frequent Infrequent
self-reported
health n % n % P n % n % P
Males
At age 6 years 1741 85.3 145 81.5 0.174 1594 85.5 282 81.7 0.076
At age 12 years 1807 85.7 229 77.6 0.000 1608 86.4 447 79.7 0.000
Both ages* 1553 85.7 306 81.6 0.043 1293 86.5 556 81.5 0.003
Females
At age 6 years 1837 80.9 121 81.2 0.924 1724 81.0 235 80.5 0.827
At age 12 years 1637 82.6 484 76.0 0.000 1256 82.5 878 78.7 0.015
Both ages* 1444 82.0 491 77.8 0.020 1063 82.3 871 79.1 0.045
*Children who expressed persisting liking for activity or took part in activities at ages 6 and 12 years.
Table 4. Unadjusted and adjusted* odds ratios (95% confidence intervals) for good self-reported health at age 12 years in relation to change in outdoor
physical activity
Total Males Females
*Adjusted for lifestyle factors (frequency of eating breakfast and amount of sleep), and headache and abdomen pain in the past 6 months.
activity could be maintained during the primary school period, let children know about the importance of outdoor physical
while 5070% frequency of outdoor physical activity could be activity and how to increase their frequency of physical activity.
maintained. It is well documented that early life course The proportion of children taking part in physical activity
experiences shape health outcomes well into adulthood, and (actual practice) was lower than the proportion of children
durable exercise patterns take form during childhood who reported liking physical activity. As it is a common
(Umberson et al. 2010). Sports participation in childhood phenomenon of long school hours and high academic
predicted physical activity in adulthood; it implied that completion in many Asian countries, the parents in Asian
participating in physical activity at a young age forms a countries were prone to send their children to study extra time
preference for physical activity participation which is main- after school, so cram schools became prevalent. Study showed
tained throughout life (Smith et al. 2015). The health action that Chinese students cared more about fulfilling academic
process approach (Schwarzer & Luszczynska 2008) categorizes expectations than did American students (Chen & Lan 1998),
health behavioural changes into two stages, the pre-intentional so did South Korea, Japan and other eastern Asian countries;
motivation process and the post-intentional volition process, they always spent long hours in study to achieve high academic
with the first process leading to behavioural intention and the scores (Byun & Park 2012). Traditional eastern cultural
second to actual health behaviours (Duan et al. 2012). To guide background, in which Asian children are always told to study
children to like and participate in outdoor physical activities hard and do well in school to secure a bright future, may
would be beneficial to build good habits and improve good account for this phenomenon. While American children are
health status. Once a person has an intention to act, he or she dividing their time between a thousand different extracurric-
needs detailed instructions on how to perform the desired ular activities in addition to household chores, Asian students
action and the perceived self-efficacy to initiate and to are concentrating more on their schoolwork. A growing
maintain the action. Schools, families and society as a whole number of elementary and junior high school students attend
should collaborate, for example, through media promotion, to private extracurricular study schools (juku) after school several
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
Physical activity and childrens self-reported health 925
times a week or even every day (Japan Child and Family In conclusion, using longitudinal data from the Toyama
Research Institute 2013). So these students may not have Birth Cohort Study, we found that only around half of the
enough time to participate in physical activity, even if they children met recommendations for physical activity. Not
enjoy it. About 25% of primary school students (age 9 years) only do preferences for and frequency of outdoor physical
and 44% of junior high school students (age 12 years) attend activity contribute to good health, but a continued like and
juku; they spend 3 and 5 h per week, respectively, in juku frequency of outdoor physical activity can improve self-
(Japan Child and Family Research Institute 2013). Increasing reported health.
the level of physical activity of children and adolescents will
require strategies that draw on the expertise of school, public
health and medical professionals. Furthermore, health Key messages
messages should focus on improving adherence to physical
activity, because the health benefits of physical activity are A preference for and good habits in outdoor physical
maintained only with regular practice (Philipe 2013). activity are meaningful for maintaining good health.
Our study showed significant differences in outdoor physical
Increasing the level of physical activity of children
activity by gender, which is consistent with other research. Boys and adolescents will require strategies that draw on
performed better than girls on several motor skills. Total the expertise of school, public health, and medical
physical activity and time spent in moderate-vigorous and professionals.
vigorous activities during child care were 1225% higher in boys Health messages should focus on improving adher-
compared with those in girls in young children (Bonvin et al. ence to physical activity.
2012). Girls recorded less activity than boys, which may due to Increasing the level of moderate to vigorous physical
physiological differences or potential gender bias in the activity among females is a challenge and a public
reporting of physical activity (Owen et al. 2009). A recent study health priority.
conducted in 2833 elementary and junior high school students
living in Japan also showed that physical activity and leisure
habits scores were lower for girls (Nakano et al. 2013). Hence,
increasing the level of moderate to vigorous physical activity
among girls is a challenge and a public health priority. And of Funding
course, further studies in this field are needed. This work was supported in part by Nishiyama Takahito Fund
This study has several strengths. Firstly, the Toyama Birth of the University of Toyama and the National Natural Science
Cohort Study is a longitudinal study which provides Foundation of China (grant no. 81202265). The Toyama birth
opportunity for analysing trends over time in physical activity. cohort study has been supported by grants from the Ministry
Secondly, the measurement of self-reported overall health was of Health and Welfare (H10-Child-020), the Ministry of
originally from Japanese Dartmouth Primary Care Co-operative Health, Labour and Welfare (H13-Health-022), Toyama
project Charts and has been validated (Chen et al. 2005b). Medical Association, and the Japan Heart Foundation.
Thirdly, physical activity was validated in our previous study
and could reect the childrens actual lifestyle from the angle of
Conflict of interest
energy consumption (Chen et al. 2003; Chen et al. 2005b).
Fourthly, we collected data on possible confounders such as We declare there are no competing financial interests in
breakfast pattern, amount of sleep, headache and abdomen relation to the work described.
pain to exclude the effects from these confounders.
Nevertheless, there are several limitations to the study.
Acknowledgements
Firstly, we collected information on the amount of physical
activity but not its intensity (moderate or vigorous). Secondly, We express our great appreciation to all the children and their
because this is a follow-up study, there may be potential parents participating in this study. We are indebted to the
follow-up bias. However, we used validated quality control principals and school nurses in the Toyama Prefecture for their
measures during the follow-up to minimize the bias, such as help and co-operation in the study. We also acknowledge the
advocating the meaning of the survey to participants, regular contribution of Ms Yasuko Yamazaki for data collection and
inspection of the survey and post-survey check. general management of this study.
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
926 J. Liu et al.
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