Physical Activity and Screen-Time Regulations in Childcare Centers: Influence on Young Children's Health Behaviors (Pause & Play) - Aim 1
Conditions: Childhood Obesity
Sponsor: Pennington Biomedical Research Center

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Protocol Title: Painting Preschool Playgrounds: a scalable approach to increasing physical activity and 
motor skills in Louisiana preschool aged children. Aim 1: Observation
PI: Amanda Staiano, PhD, MPP 
Co-Investigators: Maura Kepper, PhD; Stephanie Broyles, PhD; Elizabeth (“Kip”) Webster, PhD
Sponsor: Blue Cross Blue Shield of Louisiana, New Horizons Grant
Protocol Version Date:  TBD
Objectives
A. Specific Aims
Preschool is a critical period during which children develop fundamental motor skills, build 
confidence in their movement, and start a physical activity trajectory that follows through adolescence 
and beyond. Unfortunately, few sustainable interventions have succeeded in increasing preschool 
children’s physical activity, and subsequently children are developing obesity at alarming rates. 1 A 
simple, low-cost strategy is the addition of colorful markings (i.e. hopscotch, foursquare, fun trails) to 
existing playgrounds or open spaces. These “painted playgrounds” have been shown to be effective to 
increase physical activity in older school-aged children but remain understudied in preschool 
children.1,2,3 The proposed project will implement and test the effectiveness of a scalable playground 
stenciling intervention to increase physical activity and fundamental motor skills and decrease sedentary 
behaviors among preschool aged children attending childcare centers. 
The aim of this pilot project is:
Aim 1: To examine the physical activity environment of licensed childcare centers before and 
after the implementation of a promising (cost-effective, easily scalable) playground stenciling 
intervention.  
The aim will be achieved through a prospective observational epidemiological approach before and 
after a stenciling intervention is implemented. Among 4 childcare centers licensed in East Baton Rouge 
Parish (EBR), we will first observe the playground environment to assess the equipment, space, ground 
material, etc. to provide a baseline measure of the physical activity environment prior to stenciling and 
ensure that intervention and control centers have similar playground environments. We will use a 
modified behavioral observation method, the System for Observing Play and Leisure Activity in Youth 
(SOPLAY), during recess to identify changes in physical activity after the stencils are added and which 
stencils are generating the biggest changes in physical activity. We will also administer surveys to center 
directors to further understand the physical activity environment (i.e. policies, additional PA support, 
etc.) in each center. 
This project will test the effectiveness of a promising (cost-effective, easily scalable) playground 
stenciling intervention in order to validate the need for dissemination to numerous childcare centers 
across Louisiana. Ultimately, this pilot may launch an innovative strategy that has the potential to 
disrupt negative trends in obesity and sedentary behavior among Louisiana preschoolers.
B.
Background
The significance of this project stems from Louisiana’s prevalence of preschool obesity which is 60% 
higher than the national average: 13.8% of preschoolers in the state are obese compared to 8.4% 
nationally.4,5  Physical activity during early childhood is known to reduce the risk of being overweight or 
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obese and therefore protect against the development of comorbidities, such as heart disease, diabetes, 
etc. later in life.6 Furthermore, at this young age the development of fundamental motor skills is highly 
related to physical activity and is therefore an important correlate to obesity.7 Despite assumptions that 
young children are active throughout the day, studies indicate that almost half of preschool play time is 
spent in sedentary activities.1 Over 80% of children spend some time in childcare settings by the age of 3 
years, making childcare facilities an important venue for the promotion of fundamental motor skills and 
physical activity.8 As playground stenciling has been shown to increase moderate to vigorous physical 
activity (MVPA) during recess among older children, it is necessary to determine whether it has the 
same benefit for preschool aged children. Therefore, we propose to use a scientifically rigorous design 
(intervention vs. wait-list control) to determine the effectiveness of playground stenciling in Louisiana 
preschool aged children, a population burdened with an urgent, established obesity epidemic.
Inclusion/Exclusion Criteria
Four licensed (two intervention and two wait-list control centers) DOE Class A or B childcare centers will 
be selected from a list of all DOE licensed childcare centers in EBR.
Inclusion Criteria:

Licensed by DOE as a Class A or Class B childcare center

Current childcare enrollment of at least 20 children between the ages of 3-6 years 

Has a playground/play area with adequate space for stenciling
Exclusion Criteria:

Childcare center and/or childcare center director are unwilling to participate.
Number of Subjects and Subject Timeline
We plan to evaluate 4 EBR licensed DOE Class A or B childcare centers over a 6 month period. 
Each childcare center will participate in the study for approximately 2-3 months, including prospective 
observational evaluations of the childcare center playground environment. We plan to conduct all 
center evaluations between September 2017 and December 2017.
Study Timeline
This project will occur from July 1, 2017, to July 1, 2018. We will recruit, implement and evaluate 
playground stenciling in 4 East Baton Rouge licensed childcare centers from July 1, 2017, to December 1, 
2017. The data analysis, manuscript and toolkit development, and application for additional funding to 
facilitate expansion to numerous childcare centers across Louisiana will occur from December 1, 2017, 
to July 1, 2018. Furthermore, during December 2017 we will provide stenciling on the playground to the 
wait-list control childcare centers so that children who attend the control centers will receive the same 
benefits from participating in this pilot study as those children at the intervention centers. A detailed 
timeline of the implementation procedures for the stenciling intervention and evaluation is displayed in 
a table below. The recruitment of the four childcare centers will take approximately 9 weeks. During this 
time project staff will assess the playgrounds at childcare centers to ensure that our intervention and 
wait-list control schools have similar playground environments and that it is feasible to provide 
playground stenciling at all centers. Project staff will obtain consent from the childcare center directors 
in the form of a permission letter signed by the director. The playground at the intervention centers will 
then be painted using the stencils. 
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Table 1: Study Timeline
Weeks
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Recruitment/ 
Planning
Playground 
assessment
Pre-Testing
Stenciling
Novel-effect 
Wait Period
Post-Testing
Recruitment Methods
Childcare Centers:
Four childcare centers will be invited to participate. Childcare centers may be contacted via 
phone, mail, email, and/or in-person. Once interest is expressed by the childcare center’s 
director/administration, PBRC staff will travel to the childcare center to examine their 
playground/outdoor space. Once the playground/outdoor space is deemed valid for the study, written 
documentation will be obtained from the childcare center’s director/administrator to allow the conduct 
of study procedures at that site. If a center is not interested in participating or their playground does not 
meet study criteria, another childcare center will be randomly selected. This process will continue until 4 
childcare centers have been successfully enrolled. There are currently 192 licensed childcare centers 
totaling an approximate capacity of 16,500 students and 13 Head Start centers in EBR, so we do not 
envision problems recruiting 4 childcare centers for evaluation. We aim to recruit all 4 childcare centers 
between July 2017 and September 2017.
Consent Process
Written approval from the childcare center’s director/administrator to allow the conduct of 
playground observations, the implementation of the intervention (playground stenciling), behavioral 
observation pre and post intervention and director-completed surveys will serve as one formal consent 
document. 
Parents will be notified about the study prior to data collection, including information about the 
study purpose, procedures, and timeline. Parents will be notified about the study in at least 2 of the 
following ways: informational handout/flyer, phone call, email, mail, or in-person, and will be given 
adequate time to refuse for their child to be observed. All children in the selected classroom will be 
included in the recess observations except for children whose parents explicitly request for their child to 
be excluded from the observations. These children will be relocated to another play area or otherwise 
excluded from observational counts during the observation period. Children and teachers will be 
notified that researchers will be present during recess but the full purpose of the study will not be 
disclosed to children or teachers at the childcare center until after the completion of all recess 
observations, so as not to alter the children’s behaviors or teachers’ behaviors.  
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Procedures
Below are the procedures that will be completed during study participation (Table 2).
Table 2: Procedures and Timeframes
Baseline 
Intervention 
Center
Baseline 
Control Center
Follow-up 
Intervention 
Center
Follow-up 
Control 
Center
Childcare Center 
Director’s Survey
X
X
X
X
SOPLAY (Observation)
X
X
Childcare center policies and practices surveys.  Surveys will be administered to the director of each 
childcare center to determine the following: amount of time allowed for free play and amount of time 
spent outside (including exact outdoor play times for the week of evaluation); staff support for physical 
activity, structured programs and/or field trips that allow children to be physically active (including 
number of times per day or week); if one or more community organizations support or provide physical 
activity programs at the center; and whether or not the childcare center has policies regarding television 
viewing and computer use. 
SOPLAY. We will use an adapted version of the System for Observing Play and Leisure Activity in Youth 
(SOPLAY) tool, which was created to objectively evaluate physical activity and energy expenditure in a 
targeted area.12 The physical activity coding scheme used in SOPLAY has been found to be valid in 
relation to heart rate monitor measurements. SOPLAY also displays adequate inter-observer reliability 
(IOA=80%; R=.75). A research assistant will be trained to implement SOPLAY and will attend two trial 
observations prior to observing recess for this pilot study. A research assistant will conduct two 
observations during recess hours of the outdoor physical activity environment of both childcare centers 
after the stenciling intervention has been implemented. During the observation recesses, a trained data 
collector will observe all activities of the playground at the intervention childcare center, including 
activity intensity, environment characteristics, equipment availability/ accessibility, organized activities, 
supervision, and child characteristics. 
Primary Endpoints and Data Analysis Plan
Primary endpoints include change in overall SOPLAY score and change in all SOPLAY subscales.  
Statistical analyses will be performed with the latest version of SAS. Means, standard deviations, and 
Pearson correlations will be calculated to describe the sample and examine differences between the 
intervention and control group. Differences in center characteristics (i.e. racial distribution) will be 
tested using t-tests and chi-square tests. 
Data Management and Confidentiality 
The Pediatric Obesity and Health Behavior Laboratory, supervised by Dr. Staiano, will have primary 
responsibility for data collection, data management, manual data entry, and data analysis. All electronic 
data will be stored in the secure Pennington database, with access given to only necessary, HIPAA-
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certified staff. All hard copies of data will be stored in a secure, locked cabinet at Pennington Biomedical 
Research Center. Data collected at the childcare centers will be securely transported to PBRC by trained 
staff. Access to data files can be made only with permission of the Principal Investigator. Data will be 
stored for 5 years following study completion.
Provisions to Protect the Privacy Interests of Subjects and Monitor the Data to Ensure the Safety of 
Subjects 
This study does not involve more than minimal risk to participants. All data will be collected 
through non-invasive measurements, observations or surveys. All observations will take place during 
normal recess time and will be done as unobtrusively as possible. Observations will take place at the 
center level and thus will not include any personal identifying information of the children being 
observed. Survey items do not contain sensitive items to ensure childcare directors are comfortable 
responding. The parent and/or pertinent childcare personnel will be notified of any significant health 
problems that are brought to our attention and participants will be referred to the participant’s usual 
source of medical care. 
Withdrawal of Subjects 
Participation is voluntary, so childcare centers or the child may withdraw from the study at any 
time. Data that have already been collected during the course of study participation from a withdrawn 
childcare center will be used, unless a specific request is otherwise received. Childcare centers may be 
withdrawn from the study for the following reasons: 
• Unwillingness on behalf of the childcare center to participate in the study or cooperate with 
study staff 
Risks/Benefits to Subjects
There are no foreseeable risks to participants in this study. We cannot promise any direct 
benefits to the participant, although the stencils may provide additional opportunities for physical 
activity and fundamental motor skill development. 
Vulnerable Populations 
This study will involve young children as participants (3-6 year olds). As such the children’s 
parents/legal guardians will provide written informed consent. Furthermore, the childcare director will 
provide written permission for recess observations and the implementation of playground stencils.
Sharing of Results with Subjects
Study results will not be shared with participants unless requested. If requested, only group 
summary data will be available.
Setting
All childcare evaluations and study procedures involving children will be conducted in the East 
Baton Rouge community, at selected DOE licensed Class A or B childcare centers. Each childcare center 
will be required to provide written documentation to allow the conduct of study procedures at that site.
Resources Available 
Amanda E. Staiano, Ph.D., M.P.P., Principal Investigator, is Assistant Professor and Director of the 
Pediatric Obesity and Health Behavior Laboratory at Pennington Biomedical. Dr. Staiano is a 
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developmental psychologist with expertise in epidemiological surveys of children’s physical activity and 
screen-time and interventions to improve children’s physical health.
Maura Kepper, Ph.D, Co-Investigator, is a postdoctoral researcher at Pennington Biomedical. Dr. Kepper 
is a trained behavioral scientist with expertise in physical activity assessments, surveys and 
observational assessments of children’s behaviors and environments related to children’s health. 
Prior Approvals 
The director/administrator of each childcare center will be required to provide written approval 
to allow the conduct of study procedures at their site. 
Compensation for Research-Related Injury 
No form of compensation for medical treatment or for other damages (i.e., lost wages, time lost 
from work, etc.) will be available for this research study. In the event of injury or medical illness resulting 
from the research procedures, participants will be referred to a treatment facility. 
Economic Burden to Subjects and Compensation 
All visits will take place at the childcare center during normal hours and will not add any 
economic burden on the children being observed or childcare directors. Thus, no additional 
compensation will be provided to childcare centers, childcare directors, parents, or children 
participating in the childcare center evaluations.
References
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pre-school playground: The effects of providing markings and play equipment.Preventive 
Medicine,48(4), 335-340. doi:10.1016/j.ypmed.2009.02.013
2. Ridgers, N. D., Stratton, G., Fairclough, S. J., & Twisk, J. W. (2007). Children's physical activity levels 
during school recess: a quasi-experimental intervention study.International Journal of Behavioral 
Nutrition and Physical Activity,4(1), 19. doi:10.1186/1479-5868-4-19
3. Stratton, G., & Mullan, E. (2005). The effect of multicolor playground markings on children's physical 
activity level during recess.Preventive Medicine,41(5-6), 828-833. doi:10.1016/j.ypmed.2005.07.009
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preschools. Pediatrics. 2004;114(5):1258-1263.
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(2008). Motor Skill Performance and Physical Activity in Preschool Children.Obesity,16(6), 1421-1426. 
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8. Tandon PS, Zhou C, Lozano P, Christakis DA. Preschoolers’ total daily screen time at home and by type 
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http://aspe.hhs.gov/poverty/08Poverty.shtml. Accessed March 10, 2017.
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2011; http://www.cdc.gov/nccdphp/dnpao/growthcharts/resources/sas.htm. Accessed February
20, 2015.
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