{"paper_id":"092db02e-c970-4411-8db3-ffeca1cbf3b4","body_text":"Prospective acceptability, feasibility and outcomes of a primary school-led outdoor play intervention for young children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prospective acceptability, feasibility and outcomes of a primary school-led outdoor play intervention for young children Amanda Louise Seims, Emily Ranken, Hanan Hauari, Laurence Ewles, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7702361/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background Outdoor play can support children and young people’s mental wellbeing, social and cognitive development and increase physical activity levels. However, many children are not sufficiently active for health. Children’s outdoor play has declined in recent years and barriers exist within the physical and social environment. Forest Schools can encourage outdoor play through familiarisation with local green spaces, but suitable spaces are limited in dense urban areas. Through the Play in Urban Spaces for Health (PUSH) intervention concept, primary school staff support familiarisation of and regular active play in local urban spaces. This could facilitate sustained behaviour change, whereby children use these sites with their families, and have the capability and motivation to create opportunities for outdoor active play within other urban spaces. The aim of this research was to explore the acceptability and feasibility of PUSH. Methods 18 semi-structured interviews were conducted – eight with teachers and headteachers at primary schools near potential urban play spaces in Bradford (Bfd), Yorkshire and Tower Hamlets, London UK to explore attitudes towards, and barriers and facilitators to implementing PUSH - and ten with staff involved in Forest School delivery through primary schools to capture learning and outcomes from taking children to local green spaces for Forest School. Thematic analysis was used to explore acceptability and feasibility of PUSH. Results PUSH was generally found to be acceptable, with perceived benefits aligning with those observed within Forest Schools. Potential barriers to implementing PUSH included curriculum pressures and safety of public spaces. However, the learning from Forest School delivery provided potential solutions to incorporate into the intervention design. The findings informed the intervention theory of change and logic model. Conclusions This study offers preliminary evidence to support the delivery of the PUSH intervention within primary schools, which may support children’s outdoor habitual play. The findings emphasise the need to incorporate activities to ensure parent and staff buy-in prior to a pilot project. Clinical trial number: Not applicable. Child development urban regeneration children’s rights play sufficiency child-friendly cities whole system Figures Figure 1 Figure 2 Background The current generation of children are missing out on the potential physical, social and emotional benefits of outdoor play [ 1 , 2 ], and ’adventurous’ or ‘risky’ play involving situational evaluation and personal development in particular [ 3 ]. Regular outdoor play among children has dramatically declined over the past few generations [ 4 , 5 ], and the average age at which children are allowed to play outside without adult supervision has increased by two years to aged 11 compared to their parents’ generation [ 6 ]. Children are typically more physically active when playing outdoors [ 7 ], and engaged in risky play not constrained by adults [ 8 ]. This decline in outdoor play may therefore partly explain why fewer than 35% and 50% of children and adolescents are sufficiently active for health globally and in the UK respectively [ 9 , 10 ]. Furthermore, it may explain the decrease in mental well-being among children [ 5 , 11 ]. Sufficient levels of physical activity may support bone health, reduce the risk of excessive weight gain in children [ 12 ], and benefit motor skill development, cardiometabolic health [ 13 ], and emotional wellbeing [ 8 , 14 ]. Across Europe, children’s levels of physical activity begin to decline around 6–7 years of age [ 15 ], highlighting the need to intervene early in order to reverse or delay this. Significant play-specific budget cuts for local authorities in the UK have led to children’s play being deprioritised [ 16 ], and opportunities for outdoor play have diminished through the closure of a significant number of public outdoor play spaces [ 17 – 19 ]. Children have unequal access to spaces for play [ 16 , 20 , 21 ], with space and access typically being most limited for children living in the least affluent areas of urban settlements [ 21 ]. Furthermore, this inequality is exacerbated among children from ethnic minority groups (excluding white minority) who are less likely to live close to public green spaces than children of white ethnicity (40% vs. 14% respectively) [ 22 ]. Similarly, the design of public urban spaces limits children’s opportunities for play [ 23 ]. These diminished and compromised opportunities for play contravene the United Nations of the Rights of the Child Art. 31 [ 24 ]. The importance of play provision is increasingly recognised globally, with many cities moving towards low-cost, non-traditional play spaces, embedding and encouraging children’s play through regenerating existing urban spaces [ 25 – 29 ]. Despite this, much work is needed to enable and ‘normalise’ children’s play in urban spaces through changing societal attitudes towards neighbourhood play[ 4 , 29 ] and parents’ perceptions of risky play [ 6 ], and antisocial behaviour and crime [ 30 ]. Parents typically do not consider urban spaces as suitable for play, preferring parks and playgrounds [ 31 ], and have greater safety concerns for using urban spaces for informal play[ 30 , 32 ] in comparison to using traditional play equipment [ 33 ]. Taking a whole systems approach[ 34 , 35 ] through building suitable opportunities for play into urban spaces alongside addressing these societal and parental barriers may help unlock children’s opportunities for outdoor play and physical activity [ 36 ]. With children spending a significant amount of their waking time in school, and schools being a safe and trusted organisation for many families, the setting offers an opportunity to support outdoor play [ 33 , 35 , 37 , 38 ]. School-led interventions remove parental barriers and typically have parent and child support [ 39 , 40 ]. Many schools offer Forest School which provides opportunities for children to engage in active and adventurous play in green spaces [ 41 ]. Forest School initiatives are child-led, where children are free to pursue activities which spark their personal interest [ 41 ], and have been shown to increase children’s physical activity [ 42 , 43 ]. However, there are still many barriers to overcome within the school culture and staff, particularly in relation to safely supporting risky play [ 33 , 37 , 44 ] and accommodating it within the curriculum [ 44 , 45 ]. There is some evidence of acceptability and feasibility of delivering Forest School through primary educational settings [ 44 – 46 ] and limited evidence to suggest Forest School influences families’ independent use of green spaces [ 47 ]. However, for the global majority of children who live in urban areas [ 48 ] increasing urban densification is diminishing children’s access to green space for play [ 49 ]. Acceptability and feasibility of school-led initiatives using other forms of urban spaces should therefore be explored to facilitate child-led neighbourhood play. Using the same Forest School principle of immersive regular visits to local green spaces, the Play in Urban Spaces for Health (PUSH) intervention concept was created to promote the formation of a sustainable habit of physically active outdoor free play and incidental physical activity through familiarisation with local urban spaces. As part of the PUSH intervention, primary schools will regularly take children (aged 4–7 years) in school time to local built-up urban spaces for child-led play to develop their capability and motivation for self-initiating play, and particularly active and risky play. The target age group was chosen to mitigate the decrease in physical activity typically observed around that time of a child’s life [ 15 ]. It is anticipated that routine use of those types of spaces for play becomes familiar and habitual outside of school, leading to increased physical activity and wellbeing among children, and enhanced connection to place. Taking a whole system approach, the PUSH intervention also aims to influence the regeneration of public spaces to design-in play [ 25 – 29 ], and address negative attitudes and behaviours among parents and the wider community. The aim of this research study was to explore the acceptability, feasibility and potential outcomes of the school-led physical activity intervention element of PUSH, considering the experiences and attitudes of primary school teaching staff and Forest School deliverers in Bradford, Yorkshire and Tower Hamlets, London. The research questions were: 1. To what extent is the PUSH school-led intervention acceptable to primary school staff? 2. What factors might influence the implementation of PUSH by primary schools? 3. What benefits might children attain from regularly engaging with the PUSH intervention? Methods Project context and setting The study took place across two neighbourhoods in one council ward within the city of Bradford (Bfd) and two areas within the London Borough of Tower Hamlets (TH), UK. Both TH and the Bfd ward are densely populated, with 16% and 11% of households being overcrowded respectively [ 50 , 51 ]. In the Bfd ward access to green spaces and open spaces for play is a priority for regeneration [ 52 , 53 ]. At the local authority level, Bfd and TH, child poverty, and prevalence of overweight at year 6 is above the national average (Table 1 ). Table 1 Demographic, and child poverty and overweight data for Bradford, Tower Hamlets and England [ 54 , 55 ]. Bradford Tower Hamlets England Total population (N) 546,400 310,300 56,489,800 Children aged under 16 years (% of population) 22.8 18.5 18 Relative child poverty after housing costs (%) 37.7 55.8 30 Ethnicity distribution (% non-white British) 43.3 77.1 25.6 a Predominant non-white British ethnic group Pakistani Bangladeshi Other white Prevalence of overweight (inc. obese) children in reception year (%) 22.3 22 23 Prevalence of overweight (inc. obese) children in year 6 (%) 40.8 41.8 35.2 a England and Wales Through partnership working with the public health and landscape design departments within the local authorities, two urban sites in built-up areas of Bfd and two in TH were identified as having potential or plans to regenerate for play, and these four potential urban play spaces (PUPS) (additional data file 1) were the focus of the research. For each space, a nearby primary school was approached via email to support the research. These primary schools incorporated a very diverse local community, with ethnic groups primarily being non-white British and including Indian, Polish, Russian, Nigerian, Somalian, Bangladeshi, Chinese, with many languages spoken. Study design The study used a qualitative research method involving interviews exploring perceived acceptability, feasibility and potential outcomes among staff at primary schools near the PUPS (and therefore eligible for consideration to implement a pilot of PUSH). Secondly, experiences among teaching staff with experience of delivering Forest School (FS) programmes within public spaces through any primary school were used to support the exploration of potential feasibility and outcomes of the PUSH intervention, given the similarity between the interventions. Ethics approval was granted by University College London’s IOE Research Ethics Committee (REC1787, data protection registration number Z6364106/2023/03/71). Participants Local networks including private Forest School providers and local authority educational leads were used to locate primary schools and Forest School organisations in urban areas of Bfd and TH which met the recruitment criteria - having delivered Forest School programmes as part of the school curriculum and in public green spaces outside of the school grounds. Within the five organisations which responded, head teachers, school staff, and Forest School leaders involved in the setup and delivery of Forest School programmes were approached by email to take part in the research. From these, ten Forest School staff were recruited across one primary school in TH, and four primary schools and one external Forest School organisation in Bfd (Table 2 ). In TH, only one primary school Forest School met the recruitment criteria. At each of the schools recruited near the four PUPS, the headteacher and a member of teaching staff most engaged in supporting children’s physical activity were recruited (Table 2 ). Table 2 Participants recruited for interviews Bradford Tower Hamlets Forest School head teachers 4 1 Forest School teaching staff 4 1 PUPS teaching staff 2 2 PUPS headteachers 2 2 Note: PUPS = Potential urban play spaces All participants received an information sheet (additional data files 2 to 5) and were given the opportunity to ask questions to the researcher via telephone or email before providing written consent to take part (additional data file 6). Data collection - interviews Semi-structured interviews were conducted by AS (female, Senior Research Fellow), ER (female, Research Assistant), HH (female, Lecturer in Social Science Research) and LE (male, Research Assistant) to capture actual and anticipated barriers, facilitators and outcomes of school-led support of children’s play and physical activity in local public spaces. All interviewers were knowledgeable in acceptability and implementation frameworks and children’s health and wellbeing, and had prior training and experience in interviewing. Interviews were completed online or face to face on the school premises in a private room and typically lasted 30–50 minutes. Audio was recorded using a Dictaphone. Organisations participating in the research received £50 per staff member (equivalent to a maximum of £100 per school) for their support with recruitment and use of school time and premises to conduct the interviews. Interview topic guides were created by the researchers for the purpose of this study (topic guides are available through the additional data files listed in the text and accessed via the Harvard dataverse – see ‘availability of data and materials’ statement. To understand the process of setup, delivery, barriers and facilitators, and outcomes of Forest School programmes delivered though primary schools, separate topic guides were used with the headteacher (additional data file 7) who had strategic oversight of FS programmes, and with staff involved in day-to-day delivery (additional data file 8). To explore potential barriers, facilitators and outcomes to establishing and delivering the PUSH intervention, separate topic guides were used with the headteacher at each school near the PUPS (additional data file 9) and member of staff most engaged in supporting children’s physical activity (additional data file 10). Analysis Audio recordings of interviews were transcribed verbatim and anonymised. Transcripts were imported into NVivo (version 14.23.3, Liviero, Denver, USA). Sekhon’s Theoretical Framework of Acceptability (constructs of affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy) [ 56 ] was used to guide deductive coding of data relating to acceptability of the intervention among staff at schools near the PUPS and children, parents and wider community members. Data from Forest Schools was coded inductively by AS, LE and ER with feasibility and outcomes codes used to guide the coding of data from interviews of staff (coded by AS and ER) at schools near the PUPS. All coded data relating to feasibility of implementing PUSH were thematically analysed using a process of: 1) familiarisation with the data by AS and ER, 2) coding by AS and ER, 3) discussion and revision of codes between AS, LE, HH and ER, generation of themes and review and revision of themes by AS, LE, HH and ER. Direct quotes from interviews with staff in Bfd and TH at schools near the PUPS were coded using the PUPS location number (1 or 2), and direct quotes from participants at schools delivering Forest Schools (FS) coded using the FS location number. Results Acceptability of PUSH Affective attitude For those schools located near the PUPS, staff were largely positive about potentially implementing the PUSH intervention, seeing it as ‘ worthwhile ’ and something schools ‘ needed to do ’. They implied a willingness to incorporate it as part of the school day, stating that “ it'd be absolutely something that we timetable ” (Bfd PUPS2 teacher), provided the PUPS was implemented: “ if the resource were there, we would use it ” (TH PUPS1 teacher). One teacher in Bradford (Bfd PUPS1 teacher) agreed that the age group PUSH was targeting (4–7 years) was suitable, as “ [young children] would love things like that…they’ve got a wild imagination, so they can just make things up ” (Bfd PUPS1 teacher). Staff in TH concurred, and recognised that children across the 4–7 age range would have differing needs and interests in a play space, and that the intervention would need to be designed to be suitable for all children. “Just thinking of the younger children, things that are quite sensory... But I think as they get a bit older they do enjoy a bit more challenge... So I think it's trying to get that balance of things that are suitable to the younger ones that are engaging in sensory [play], but then things that are challenging for your older children.” – TH teacher Potential effectiveness of PUSH Discussions with staff suggested that PUSH had the potential to support children’s physical, emotional and social development, and ability to learn, and help develop their connection to place. Bradford Forest School teachers had observed children building ‘ physical skills and stamina ’, through their ability to manage the walk to and from the Forst School site with one parent reporting being “ actually able to go on long walks because of the stamina [child’s name] built up from being out in the woods” ” (Bfd FS4 teacher). Physical improvements were particularly notable among children with previously limited physical abilities: “ they may have mobility issues such as dyspraxia [developmental co-ordination disorder] or things like that. But then being outside and walking on uneven ground, perhaps using things like hammock swings and maintaining that proprioception, that spatial awareness so you'll see the development ”. (Bfd FS3 teacher). “… we also had one that used to be carried to school every day and cry. That was last year. And by the end of Forest School he was running he was loving to run into school ” (Bfd FS4 teacher). Schools near the PUPS felt PUSH could offer the opportunity to ‘ have a go at things ’ and would support children to become more resilient and gain a sense of independence and ‘ belief in themselves ’. This was an important element of Forest School which was embedded in “ understanding where your limits are and that you can push out of your comfort zone and then achieve things and then push a bit further ”. Furthermore, respondents felt that “children would be able to build the skills of “planning things and breaking down problems into sets of steps and all of the communication and social stuff that can be developed through play” (TH PUPS1 headteacher). (Bfd FS3 teacher). Bfd PUPS1 teacher felt this could also enhance self-efficacy among children with additional needs: “ a lot of the [SEN] children…their learning is through play and interaction and finding ways to sort of manage themselves so I think they would get a lot out of it ” (Bfd PUPS1 headteacher) Similar outcomes were reported by staff at a school with Forest School provision, who described “ that focus and that resilience and that that willingness to give it a go without panicking about not achieving a particular outcome ,” (Bfd FS3 teacher), and the “confidence to have a go with something, take a risk with their learning,” (Bfd FS3 co-headteacher 1) that had developed as a result of children’s participation in Forest School. The headteacher of a school with Forest School provision in TH also described the “motivation and resilience” (TH FS headteacher) that they had witnessed develop in children. Staff viewed children’s participation in PUSH as a valuable opportunity for them to spend time with peers outside of the classroom, as a means of “ encouraging them to play with each other rather than be glued to a device” (TH PUPS1 headteacher). It was suggested that this may support social cohesion through “ more interaction, more teamwork, working with each other ” (Bfd PUPS2 teacher) and “ talking to each other and learning how to be with each other ” (TH PUPS1 Headteacher) which may lead to enhanced collaborative working in the classroom: “ …that opportunity would undoubtedly then impact on how they interact with each other in the classroom and how they're able to apply themselves to their work or projects together ” (TH PUPS1 Headteacher) PUSH being part of the school curriculum was perceived as a valuable opportunity to provide children with a mental break from learning through “ getting some fresh air, stepping away from like the four walls of the classroom ”, (Bfd PUPS1 teacher). The Forest School lead in TH described how children felt “relaxed” when they returned to class after having engaged in similar activities. It was also recognised that PUSH could benefit staff-pupil relationships through “ having those discussions with the children outside of the classroom setting and that bonding time ”, (Bfd PUPS2 teacher). This outcome had been achieved through the delivery of Forest schools. One headteacher described how “ [forest school is] an opportunity outside of the classroom to have those talks, that isn't as formal…it's just like a bonding process, really ”, Bfd FS4 headteacher). Staff in PUPS schools predicted that these outcomes, along with the opportunity to be physically active, would improve children’s ability to engage with academic learning, and that children would be “ much more likely when they're back in the classroom to do what you ask them to do and to want to learn ”, (TH FS headteacher). Positive behavioural outcomes were reported by staff involved in Forest Schools, particularly for those children who ‘ might struggle in the classroom’ , as these children “ come back having had no incidents, being a good role model to others ” (Bfd FS3 co-headteacher 2). Another Forest School headteacher described how “ for some of our more challenging children it's calmed them down” , Bfd FS4 headteacher). In TH, the Forest School headteacher described how the positive behavioural outcomes were worth the investment of time into the intervention: “ When I started an intervention in a class, the teachers always used to say, oh, but you know, I'm going to lose 45 minutes every week... And then usually by the end of the intervention, they'd say, do you know what? I'm going to carry on doing this because that 45 minutes that I'm investing there, I'm actually making it up elsewhere because I don't spend so much time dealing with behaviour issues .” (TH FS headteacher) Some Bradford staff felt that PUSH could also support children to build a connection to their neighbourhood, where currently children “ literally know their home and school and that is all ”, (Bfd PUPS2 teacher) to facilitate children and families’ understanding of available opportunities (“ they don't really know what's available. Don't really know what's going on what goes on ” Bfd PUPS1 headteacher), particularly ‘ with 2025 coming out ’, the city’s forthcoming year of culture. Increased connection to and knowledge of their local area was not mentioned by participants in TH. Anticipated burden Despite the expressed confidence in aligning PUSH with existing school practices, there were concerns across both Bfd and TH that delivering PUSH in addition to the existing curriculum could be challenging for staff. Particularly in TH, finding the time in the timetable to take children to the play space was perceived as a potential burden, meaning that the intervention would “struggle” in comparison to other curriculum priorities. TH PUPS1 headteacher reported that “ the timetable is very tightly packed. So we struggle, as it is, to get the actual sort of number of subjects, the amount of time, the content actually taught. It's very, very difficult ”. Similar concerns had initially been raised by senior leadership as to how Forest School delivery might conflict with academic teaching. One teacher in Bfd described a comment from the headteacher: “ I like your rationale, but actually, in real world practicality terms, how would we make sure that it doesn’t impact on our curriculum ?” [Bfd FS1 teacher, referring to a comment from the headteacher]. However, these concerns had been overcome by demonstrating opportunities for learning and linking in with the curriculum: “ …the reason I got [the outdoor enrichment programme] passed by governors and school leaders is because I made that significant link to curriculum ” (Bfd FS1 teacher). “… we do find the gaps…so there's lots of links to PSHE, there's links to science, there's links to PE sometimes. So yeah, we kind of make it ‘legit’ in some ways that way ” (TH FS teacher) Similarly, TH staff at schools near the PUPS felt more favourably towards supporting school trips which linked to the curriculum and focused on learning: “ …where children go out on trips, it's part of the learning of those subjects. It has to be, really. There isn't much space for it to be anything else ” (TH PUPS1 headteacher), “… I know children learn through play, but learning is the bit that we have to do… ” (TH PUPS2 headteacher), “ it's just looking at how we could incorporate it into maybe to tie in with one of the subjects rather than it being something explicit on top ” (TH PUPS2 teacher). The staff capacity needed to implement PUSH was also a concern, with headteachers highlighting the burden of additional staff needed to safely supervise children during off-site visits, noting the need to “send at least three or four adults, so it would have to be carefully planned and it would take a lot of person power to manage ” [Bfd PUPS2 headteacher], which would depend “very much on the class itself and the level of needs that they have ” (TH PUPS1 headteacher). This was something highlighted by some Forest Schools where capacity was addressed by funding external practitioners to support delivery, yet illness among key members of assisting teaching staff and the higher staff to pupil ratios required for nursery children (“ you do need high staff numbers even to get 10 children out” , Bfd FS2 teacher) still had the potential to compromise delivery. Schools near the PUPS sites also noted that any potential increase in staff workload may reduce staff buy-in: “ if the staff see it as something extra that they've got to do or plan because their days are busy as it is, they're not going to buy-in ” (Bfd PUPS2 headteacher). Ethicality Schools in both TH and Bradford considered physical activity to be important, viewing it as both an area for the development of individual strengths and interests (“ we're trying to change a little bit that life isn't all about English and maths…not all children are academically motivated ”, Bfd PUPS2 headteacher). One teacher strongly believed that “ if the children have got good gross motor skills, then they have good fine motor skills ” (Bfd PUPS2 teacher), and provided an example to highlight the importance of this where some nursery children were “ not even confident to walk down steps even holding on to something ” (Bfd PUPS2 teacher). TH staff felt similarly, with one headteacher explaining that she believed that “it’s important for kids to be confident in themselves and to be able to move and express themselves” (TH PUPS2 headteacher). Schools in both areas had an extensive variety of opportunities to support this, including active breaks in class, Forest School, organised games and provision of equipment to support active play time, and outsourcing some PE lessons to specialist cricket and dance providers. Although schools were ‘risk aware’ due to their responsibility for children’s safety, they supported children to take risks through climbing and exploring during play in the playground as this environment was considered ‘safe’. One school demonstrated an existing practice of supporting risky play, where children were supervised from a distance and staff “ don't stop them from exploring [playground equipment] because they're safe and they're built for children ” and believed that “children need to learn to manage their own risk” (Bfd PUPS1 headteacher). However, when discussing the ‘child-led’ element of the PUSH intervention, there was some hesitation for letting children ‘ run loose and do whatever they want ’, and a desire to ensure the time was not just spent ‘ messing around ’ and the importance of having a ‘plan’ and having staff model how to use the space: “… initially until we get used to the equipment ourselves, more of like a PE [physical education] lesson where somebody models and then somebody has a go and it's very much sort of turn taking initially ” (Bfd PUPS2 teacher) Self-efficacy The confidence to implement PUSH (“ We will make it work. If we were to continue to be involved ”, Bfd PUPS2 headteacher) appeared to stem from how it aligned with existing school practices, partly through their experience of taking children on school trips, which was described as “ really not an issue at all ”, (TH PUPS2 teacher). One Bradford headteacher described the approach they would take as part of establishing the intervention: “ [school staff would] go down [to the PUPS] and we'd look at it and talk through some actions and talk through some things we could do, games that can be played and what the children are getting from it…and work together on it .” (Bfd PUPS1 headteacher). For Bradford headteachers, it was felt the PUSH intervention could be implemented ‘ as part of our physical education offer ’ or alongside their existing Forest School programme, suggesting that “ there's no reason if half a class are out doing that. The other half could go down there [the new play space] ”, (Bfd PUPS1 headteacher). One school had a current practice of taking children to a local community centre to use their outside space for play, and considered that the PUPS would “ just become another area that we use, and that we get used to using ”, (Bfd PUPS2 headteacher), using existing staff expertise (“ we'd probably look at [existing Forest school lead] role and how she could be used and timetabled into groups from our from our school to the safe space ”, Bfd PUPS2 teacher). For the TH school near to PUPS1, the site being ‘ just across the road’ deemed it acceptable, and the headteacher suggested that “ there's no reason why we couldn't make use of that during the children's lunchtime ,” (TH PUPS1 headteacher). Intervention coherence Staff near the PUPS demonstrated an understanding of the need for the intervention through recognising the lack of local play opportunities; Bfd PUPS2 teacher stated that “ they just don't go out because there isn't safe spaces for them unfortunately to play” . The role of schools in fulfilling this need was widely acknowledged: “ [The children] don't have gardens, they don't have outdoor space, so the more opportunities we can give them for safe places to play and engage with child-led play, I think would have a massive impact on them… when they get to school and they've got some open space you can see how much they love it ” (TH PUPS1 teacher). Schools also understood PUSH as an opportunity to increase children’s time spent being physically active in addition to current provision of school-based physical education (PE) (“ They're walking to and from the [PUPS]. They're getting that extra time…rather than just sticking to one hour of indoor PE a week ”, Bfd PUPS1 teacher) and allowing a “ less structured ” form of physical activity than PE (Bfd PUPS1 headteacher). Staff at schools near Bfd PUPS2 indicated an understanding of how the school-led intervention might work to change children and families’ behaviours longer-term to facilitate use of the PUPS outside of the school day, recognising the need for parent support. They felt that children would ask their parents to take them to the PUPS, and the headteacher recognised how staff could support this by asking children “ Have you been to the space this weekend? What did you do ?”. The teacher from Bfd PUPS1 provided an example where children had visited destinations with parents after going there on school trips: “ 'Oh, I walked past the cathedral the other day’ after they'd seen it because ‘I wanted to show my mum where we've been' and things like that, so they want to impress you in school ”. This was supported by the Forest School lead teacher in TH, who reported that a key outcome for them was that children had taken their parents to the Forest School site outside of school time: “ it's to do with them knowing that the space is there, that they get back and use it at other times ” (TH FS lead teacher). The key themes within acceptability are summarised in Fig. 1 . Influences on the implementation of the PUSH intervention Motivation and capability of staff Schools near to the PUPS perceived that there were internal staff who would be willing to support the implementation of PUSH as they “ are really really up for things “ (Bfd PUPS1 headteacher), are “ always wanting to learn new things and get out “ (Bfd PUPS2 teacher), and “ like spending time outdoors ” (Bfd PUPS1 teacher) and one headteacher referred to an external sports provider who is “ always looking for opportunities to get involved in more sporting activities within the school ” (Bfd PUPS2 headteacher). A teacher in TH described the staff of the school as “ really dynamic, and we do a lot of trips ” (TH PUPS1 teacher). It was anticipated that this willingness may be dependent on it being ‘sold in the right way’ so staff understand “ why it's so important for young children to be physically active ” (Bfd PUPS2 teacher), and the delivery being consistent through using “ the same rota of staff, so the staff know that they're going to be out [of school] ” (Bfd PUPS1 teacher) and ensuring it is “ led by somebody who can have ownership…accountable to check, measure, lead “ (Bfd PUPS2 headteacher). One headteacher in TH told us that it would be important to “ talk to teachers in respect of what your ideas are… so that it can really be a usable thing ” (TH PUPS1 headteacher) and to get teachers’ buy-in. A Forest School headteacher reported that senior leaders had been more likely to support Forest School programmes if they “ 100% understood the benefits to physical health, mental health, wellbeing ” (Bfd FS4 headteacher) and at another school, support from the headteacher was achieved through visiting a local school delivering Forest Schools and “ having seen what the benefits could be for our school ” (Bfd FS3 teacher). Both Bradford schools reported having access to staff trained in Forest School or play therapy, or were willing to support their staff to access training opportunities using “expertise across the [school academy] trust” (Bfd PUPS1 headteacher). Staff in both TH and Bradford identified training needs relating to familiarisation with the intervention which could be achieved through staff visiting the spaces and “ using these types of equipment ” (Bfd PUPS2 teacher), and “ shown the possibilities ” (TH PUPS2 headteacher). This training need was also recognised by staff within Forest Schools who referred to the importance of understanding of the “ conceptual underpinning, the reasons, the sort of pedagogy or whatever is important ” (TH FS teacher). Existing processes and practices within schools Existing processes within schools could support schools to take children off site for outdoor physical activity. Processes were in place to obtain parent consent for off-site visits at the point of pupil enrolment: “we don't have to ask for permission every time because [parents] signed for it and agreed ” (Bfd headteacher), “ anything done locally, we wouldn't need to get consent for ” (TH PUPS1 teacher). The existing practice of off-site visits meant that risk assessments have already been approved for activities of a similar nature to the PUSH intervention, with Bradford using the online ‘Evolve’ system “if we're going on a local walk, everything tends to go on Project Evolve” (Bfd PUPS2 teacher). As part of the risk assessment for the PUPS sites, schools would still expect staff to do a ‘pre visit’ to “see where any possible dangers might be” (Bfd PUPS1 headteacher). This was also the case in TH. Both Bradford schools highlighted that their learning support staff were first aid trained which was an essential requirement for enabling schools to take children off-site. Procedures to respond to emergency situations were in place across schools in Bradford and TH: “ we always take the first aid kit with us…we'd get a mobile phone for that [specific trip location]…if there was an emergency, they can ring the school and one of us can go and support ” (Bfd PUPS2 headteacher). “ Part of the risk assessment process would be considering all of their medical needs, whether they have allergies, whether they, you know, you need to take medication across there or not” (TH PUPS1 headteacher). Staff were confident of children’s ability to safely walk to PUPS through the provision of high visibility jackets and experience of walking along roads on previous trips “ knowing to stay in partners” and were “… generally good with walking to and from sites ” (Bfd PUPS1 teacher) and their journeys to and from school. A headteacher in TH described how their risk assessments might vary depending on the needs of the class: “You could take a class of 30 older children across there with just two adults. If you, if one thought that that would be safe enough, obviously that would depend very much on the class itself and the level of needs that they have. If you've got a particularly challenging class with a higher level of need, for example, then you may decide as part of that risk assessment process that you need more adults there in order to sort of safeguard the children” (TH PUPS1 headteacher ). Previous support from parents for off-site visits was deemed important for supporting safe staff-pupil ratios and ensuring the safe travel of children with additional needs: “… parents have come with and supported [children with additional needs] and generally the parents have been really on board with that ” (Bfd PUPS1 headteacher). Staff in Bradford referred to encouraging children to be “ outside all the time…regardless of the weather ” (Bfd PUPS1 headteacher) and referred to the provision of wellies and waterproofs, and asking children to “bring a sun hat, sunglasses, suncream, apply it before school. However one school recognised that some parents struggle to provide a basic PE kit and may need schools to provide suitable clothing and equipment: “ just a pair of pumps is just an absolute nightmare…in terms of clothing, that could be a potential barrier if the school weren’t able to fund the children’s clothing ” (Bfd PUPS2 teacher). For Forest Schools, the initial cost of purchasing weatherproof clothing was acknowledged, with some sourcing wellies through donations, but provision was deemed “ a massive facilitator ” where children “ were not interested in the weather, they're not bothered at all ” (Bfd FS1 teacher), and clothing prevented ‘scuffed skin’ from trips and falls. One school in TH already had “wet weather gear for the little ones,” (TH PUPS2 class teacher) but not for the older children, who would be expected to bring their own. Safety and suitability of public spaces for play Keeping children safe outside of school was important, with one headteacher highlighting key design considerations of PUPS to address the “ need to be able to see [the children]. ..” when in public spaces and the importance of seating at the edges where “… you can scan and you can see where everyone is ” (TH PUPS2 headteacher). Despite appropriate risk assessments, it was recognised that some teaching staff may have concerns as to the fluctuating nature of the physical spaces and the people in them, referring to previous experiences of anti-social behaviour and resulting physical hazards: “ even through the day, [Bradford city centre] doesn't feel like the safest place in the world…we can’t stop other people being there…I think some of our staff would be put off ” (Bfd PUPS1 teacher), “gangs are sort of hanging around [on the school premises] and then we often find like needles” (Bfd PUPS2 teacher). Similar experiences were reported by Forest Schools who gave examples of explicit language being used, aggressive dogs off the lead and where “ somebody had gone and smashed glass purposefully and put it down the slide ” (Bfd FS2 teacher). A headteacher in TH expressed concerns that “there is a different level of risk around how one uses a public space, because it can be accessed by anybody at any time, and anything could be left ” (TH PUPS2 headteacher). Suggestions from schools near PUPS to mitigate these concerns included ensuring good links with the local community police “ making sure they are aware of what’s going on ” (Bfd PUPS2 teacher) and having an “ extra pair of eyes ” from parents or wardens (Bfd PUPS1 teacher). Bfd FS2 and FS3 referred to the use of ‘safety rules’ discussed with children at the start of each session to ensure children returned to the teacher when called (particularly if a teacher identifies a safety risk from another person): “ some kind of call and response so when you say ‘stop’ they come back to me…you have to talk about the issues with dogs and what they do if a dog comes up to them ” (Bfd FS2 teacher), “ a few kind of recall Hide and Seek games to make sure they're maintaining the boundaries we've set out and they understand when to come back and things like that ” (Bfd FS3 teacher). Bfd FS3 also saw these risks to children’s safety as an opportunity for staff to educate them through being exposed to “ the [potential dangers] they're going to encounter when they're out anyway if they are out playing…there's somebody there that can kind of support them to deal with it in the safest way, whether it's, you know, antisocial dog, bikes, syringes on the floors… ” (Bfd FS3 headteacher). Asides from safety concerns, some staff stressed the importance of ensuring the physical space accommodates children with sensory and physical needs, and some considered how facilities within or near the PUPS could support children’s ability to play: “ So things like toilets, a place to put their shoes or their coats if they wanted to, you know, take layers off, for example, and play a bit more freely…a tap to refill their water bottles or to have access to ” (TH PUPS2 teacher) “ A lot of children maybe they're like scoot to school, or they'll bike to school. So maybe somebody that can like take a bike tour or take a scooter Yeah. So it's got that apparatus for them to use like, skating area or scooting area just so they've got something to like, do ” (Bfd PUPS1 teacher). Concern among parents Schools had generally not faced many issues with parents permitting children to go on school trips, but one school gave an example where some parents doubted their child’s physical ability to walk to the local swimming baths (\" You expect them to walk? \", “… they can’t walk that fast ”, “ her legs hurt ”, Bfd PUPS1 headteacher referring to parent comments). Similarly, some parents at this school had been “ funny about children taking risks… ”, finding it “ quite hard to understand that you're not following them behind all the time to catch them ” and asking “ why didn’t anyone stop them? ” when children have fallen off climbing structures in the playground (Bfd PUPS1 headteacher). Another school referred to some parents’ beliefs that “[their children] were going to get ill ” (Bfd PUPS2 headteacher) playing outside, and with some parents “ very, very protective of their children, don't want their children to get wet ” (TH PUPS1 headteacher) or dirty. This had been the experience among some Forest School programmes from parents of nursery age children (“ we get told they're not allowed to go out today because they might get cold, they might get ill ”, Bfd FS4 headteacher), but one school had taken the approach that “ if they're well enough to be in school, they're well enough to go ” (Bfd FS3 co-headteacher 2). When considering the PUSH intervention, some schools were aware that some parents “ think playing is a pastime…[children are] not really learning from it ” (TH PUPS 2 headteacher) and may have concerns about children giving up time they could be spending on academic subjects “ ‘ why are not doing math, why are they not doing English?...they’re not doing any writing’ “ highlighting the importance of educating parents on the potential benefits of play on children’s ability to engage in academic learning, as reported by Forest Schools. The importance of addressing parent concerns was demonstrated by some Bradford Forest Schools, where parents typically viewed Forest School provision as an important enrichment experience for their children: “The majority of the parents see the benefits that the children get out of it ” (Bfd FS3 teacher), and “ some parents have chosen us because we've got forest schools ” (Bfd FS4 headteacher). This positive support from parents was also experienced in TH where “ parents are really aware [Forest School is] part of the success, and that's why the children do so well here” (TH FS headteacher). This success for Bfd FS4 may have been due to their efforts to address various potential concerns among parents, for example sharing photos of activities, addressing parents’ concerns around children being taken out of school (e.g. wanting specific details of where they are going and how they are travelling) and addressing concerns relating to exposure to cold weather through focused communication with parents: “ we have got a letter or a leaflet, from the school nursing team, which basically says being cold doesn't mean you get a cold… staff from the community…talk to parents and say, ‘what are you actually worried about?’ ” (Bfd FS4 headteacher) This Forest School had also invited parents to experience Forest School which “ changed their perspective on what it is because they think they're just going out and getting muddy and not really seeing the benefit the whole benefit of it ” (Bfd FS4 teacher) and through a focus on promoting the benefits for wellbeing: “ Lots of our parents are much more aware of mental health and its importance ” (Bfd FS4 headteacher). The key themes relating to potential barriers and facilitators to implementing PUSH are summarised in Fig. 2 . These findings, along with findings from the wider project and existing literature, were used to develop an initial theory of change (additional data file 11) and logic model (additional data file 12) that can be used to support a pilot of the PUSH intervention. Discussion This study demonstrates the use of primary schools as suitable settings to facilitate outdoor physically active play interventions like the PUSH intervention in urban public realm spaces due to existing school cultures and practices, and highlights key challenges to mitigate and practical additions to the intervention design which could strengthen its implementation. The findings suggest general acceptability and coherence of the PUSH concept, with school staff anticipating many potential benefits for children, some of which had been observed by staff delivering Forest Schools. Furthermore, the intervention generally aligned with the school ethos of supporting children to have a wide range of opportunities for physical play and activity. There were some concerns for the additional burden on staff and curriculum time needed to implement it, which aligns with perceptions of other school-delivered play interventions [ 38 , 41 , 44 , 45 ]. However, acceptability of PUSH was potentially conditional on there being opportunities to link activities into the curriculum. Furthermore, experience of delivering such interventions and of benefits for children can enhance acceptability among staff and willingness to adopt this practice [ 38 ]. PUSH was perceived as feasible to implement within existing school processes for off-site trips and staff capability, provided that early buy-in and suitable training is ensured. School-based delivery of adventurous play-based activities can be compromised due to some staff attitudes and beliefs about adventurous play and concerns around health and safety [ 33 , 46 ]; our research suggested staff were primarily concerned for their liability if children experienced any injuries. PUSH therefore needs to ensure school staff understand the benefits of adventurous play and how to safely manage risk, and school staff have shown a willingness to undertake training to support the safe delivery of outdoor play interventions [ 46 ]. Staff perceived many benefits of PUSH on children’s physical and emotional wellbeing, and anticipated it could encourage prosocial behaviour and educational engagement which was supported by insight from Forest School leaders and in line with previous research [ 47 , 57 – 59 ]. Despite a generally positive attitude towards supporting risky play among those staff interviewed, there was apprehension of the presence of the general public in urban spaces, and Forest School staff reported experiences of antisocial behaviour in green spaces. Furthermore, school staff highlighted the potential of parental concerns for their child’s ability to manage risk during play, their perceived risk to health from playing in cold weather conditions, and play displacing academic activities. Insight from Forest Schools highlighted potential strategies to mitigate many of these challenges which, along with findings from other outdoor play initiatives, should be considered within future revisions and the piloting of PUSH. Parent concerns of risk can be a barrier for some schools supporting children’s risky play, however the use of educational workshops with teachers and parents to ‘reframe’ risk can overcome this [ 33 ]. Parent support for risky play in schools can be enhanced through communicating the benefits in advance and having appropriate resources in place to ensure child safety [ 39 ]. Parent concerns about children getting wet and cold is consistent with Forest School research [ 46 ], demonstrating the importance of schools ensuring children have access to clothing suitable for weather conditions, and of providing credible information from trusted sources dispelling myths relating to cold exposure causing viral illnesses. Strengths and limitations A strength of this research is the use of the Theoretical Framework of Acceptability [ 56 ] which allowed us to understand how PUSH was acceptable among educational stakeholders. Furthermore, understanding potential barriers and facilitators to implementation may enhance the success of a future pilot through further revision of the delivery protocol. The recruitment strategy successfully enabled the completion of the targeted number of interviews in Bfd; whilst the number of interviews with Forest School staff in TH was less than intended, this was due to the lack of schools meeting the recruitment criteria. Furthermore, both schools near the Bfd PUPS were had experience of delivering Forest School programmes and could therefore draw on their experiences of supporting children’s play within the school day at an external location. Limitations of this study include the potential of positive bias due to the need for a purposeful sampling process to recruit schools near to the PUPS or which delivered off-site Forest Schools, and restricted the sample size. Those schools who agreed to participate already recognised the value of physical activity on behaviour and academic engagement. Furthermore, interviews with more strategic decision-makers at the school governance level may have revealed different attitudes towards implementation. The research was conducted in some of the most built-up and deprived areas of Bradford and Tower Hamlets, and was focused on potential implementation at specific local sites which may restrict its generalisability to other urban areas within these wards and in other cities. Evaluation of future implementation of PUSH will provide valuable insight as to the key characteristics needed to support successful delivery and outcomes. Comparisons with previous studies was limited due to school-delivered outdoor play interventions typically being delivered within school grounds, or in green spaces which are typically considered suitable and appropriate for outdoor play. the delivery of PUSH adds complexity through the need for staff to walk children to local sites, and using sites which are not typically considered suitable or acceptable for play. However, the attitudes and concerns among staff to risky outdoor play within the school curriculum, and potential parent concerns were consistent with previous studies. Implications of findings for further development PUSH is an evidence-based intervention with the potential to increase children’s physical activity and wellbeing through regular outdoor play in urban spaces. The findings demonstrate the need to adapt PUSH to include activities to ensure staff and parent buy-in prior to implementation. This could be achieved by communication strategies and parent involvement in delivery, and staff training to include experience of Forest Schools, as used by Forest School participating in this research. There is also a need to explore the potential for PUSH to be delivered via community groups, initiatives and organisations which support children but are not bound to deliver an academic curriculum. Since the research was conducted, there has been increased cross-party support to ensure children’s rights to play are enforced through play sufficiency legislation within planning, and national support for a new play strategy for England [ 60 ], demonstrating the relevance and importance of PUSH. Implementation and evaluation of evidence-based interventions such as PUSH could support the need for this strategy. Conclusions Overall, our findings support the future of PUSH, and highlight useful revisions to feed into its design and delivery. PUSH aligns with a whole school approach to supporting children’s physical activity, and could provide an opportunity to create behaviour change in relation to outdoor play for children living in urban areas. This could form part of the wider solution to the current problem of low levels of physical activity and wellbeing among children and young people, and aligns with the current drive to enhance children’s rights to play. Abbreviations Bfd Bradford TH Tower Hamlets FS Forest School PUSH Play in Urban Spaces for Health PUPS potential urban play spaces Declarations Ethics approval The research was conducted in accordance with the Declaration of Helsinki. Ethics approval was granted by University College London’s IOE Research Ethics Committee (REC1787, data protection registration number Z6364106/2023/03/71). Consent for publication Not applicable – data were anonymised and consent was obtained from all participants to use their anonymised quotes within research publications. Availability of data and materials The materials used to conduct this research (participant information sheets, consent forms and interview topic guides) and the theory of change and logic model produced as an output are available online through the Harvard dataverse here The datasets generated during the current study are not publicly available due to sensitivity of individual data but redacted anonymised transcripts are available from the corresponding author on reasonable request. To request access to anonymised interview transcripts, please email the Born in Bradford research team ( [email protected] ). If your request is approved, we will ask you to sign a data sharing contract and a data sharing agreement. Additional data file 1: overview of potential urban play spaces Additional data file 2 – participant information sheet for Bradford schools near the PUPS Additional data file 3 - participant information sheet for Tower Hamlets schools near the PUPS Additional data file 4 – participant information sheet for staff delivering Forest Schools in Bradford Additional data file 5 – participant information sheet for staff delivering Forest Schools in Tower Hamlets Additional data file 6 – consent form Additional data file 7 – interview topic guide for headteachers of schools delivering Forest School programmes Additional data file 8 – interview topic guide for staff delivering Forest School programmes Additional data file 9 – interview topic guide for headteachers of schools located near the PUPS Additional data file 10 – interview topic guide for staff supporting children’s play or physical activity at schools located near the PUPS Additional data file 11 – theory of change Additional data file 12 – logic model Competing interests The authors declare that they have no competing interests Funding This research was primarily funded through an NIHR programme development grant (NIHR204232), and the authors’ involvement was supported by funding from the Yorkshire and Humber Applied Research Collaboration (ARC), Bristol Biomedical Research Centre (BRC), Sport England Local Delivery Pilot Bradford, and Act Early UK Prevention Research Partnership (MR/S037527/1). Author’s contributions AS led the draft of the manuscript, made substantial contributions to the design of the work, and led elements of the data acquisition, and had significant involvement in the analysis and interpretation of the data. ER made a substantial contribution to the design of the work, led elements of the data acquisition, had significant involvement in the analysis and interpretation of data and had substantial involvement in drafting the manuscript. HH made a substantial contribution to the design of the work, led elements of the data acquisition, had significant involvement in the analysis and interpretation of data, and supported the revision of the manuscript. CC and SB jointly led the conception of the project, and made substantial contributions to the design and interpretation of data, and the revision of the manuscript. LE contributed to the draft of the manuscript, supported data acquisition and had significant involvement in the analysis and interpretation of data. EM contributed to the draft of the manuscript and made substantial contributions to the conception of the project and design of the work. NC contributed to the draft of the manuscript and made substantial contributions to the conception of the project and design of the work. TR contributed to the draft of the manuscript and made substantial contributions to the interpretation of the data. All authors read and approved the final manuscript and have agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. 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Educ 3–13. 2015;43:722–30. Cronin de Chavez A, Seims AL, Dharni N, McEachan RRC, Dickerson J. Unlocking the forest: An ethnographic evaluation of Forest Schools on developmental outcomes for 3-year-olds unaccustomed to woodland spaces. Wellcome Open Res. 2024;9:519. UNICEF. Growing cities: Child friendly cities initiative in the urban agenda. 2023. https://www.childfriendlycities.org/growing-cities . Accessed 25 May 2025. van den Haaland C. Challenges and strategies for urban green-space planning in cities undergoing densification: A review. Urban Urban Green. 2015;14:760–71. City of Bradford Metropolitan District Council. Ward profile - City. Bradford. 2024. https://ubd.bradford.gov.uk/media/1818/city-2024.pdf . Accessed 9 Mar 2025. Corporate Strategy and Improvement Team. Tower Hamlets borough profile. 2024. https://www.towerhamlets.gov.uk/Documents/Borough_statistics/Tower-Hamlets-Borough-Profile-2024.pdf . Accessed 5 Apr 2025. City of Bradford Metropolitan District Council. Open space audit. 2021. https://www.bradford.gov.uk/Documents/EvidenceBase/Environment/Open Space Studies/1. Open Space Audit Report 2021.pdf. Accessed 20 Sept 2025. Fields. in Trust. Greenspace Index 2024: interactive maps. No date. https://experience.arcgis.com/experience/405187bb87f041c9a4d70c6b346c5bc4 . Accessed 28 Aug 2024. Vafai Y, Benson R, Albert A, Cameron C, Pickett K. Child and family health and wellbeing in Bradford and Tower Hamlets: an ActEarly report. 2023. https://actearly.org.uk/wp-content/uploads/2023/05/55843_HL_Act-Early-Report_v10-1-3.pdf . Accessed 7 July 2025. Office for National Statistics. Ethnic group, England and Wales: Census 2021. 2022. https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/bulletins/ethnicgroupenglandandwales/census2021 . Accessed 15 Sept 2025. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: An overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17:1–13. McCree M, Cutting R, Sherwin D. The hare and the tortoise go to Forest School: Taking the scenic route to academic attainment via emotional wellbeing outdoors. Early Child Dev Care. 2018;188:980–96. Dabaja ZF. The Forest School impact on children: reviewing two decades of research. Educ 3–13. 2022;50:640–53. Coates JK, Pimlott-Wilson H. Learning while playing: Children’s Forest School experiences in the UK. Br Educ Res J. 2019;45:21–40. Play England. It All Starts with Play. 2025. https://www.playengland.org.uk/s/It-All-Starts-with-Play-Full-Version-FINAL.pdf . Accessed 17 Aug 2025. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 05 Nov, 2025 Reviews received at journal 25 Oct, 2025 Reviews received at journal 16 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers agreed at journal 30 Sep, 2025 Reviewers invited by journal 30 Sep, 2025 Editor assigned by journal 30 Sep, 2025 Editor invited by journal 29 Sep, 2025 Submission checks completed at journal 29 Sep, 2025 First submitted to journal 29 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7702361\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":527656611,\"identity\":\"4beff191-96d3-47f7-a61e-369f56361561\",\"order_by\":0,\"name\":\"Amanda Louise 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feasibility and outcomes of a primary school-led outdoor play intervention for young children\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eThe current generation of children are missing out on the potential physical, social and emotional benefits of outdoor play [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e], and \\u0026rsquo;adventurous\\u0026rsquo; or \\u0026lsquo;risky\\u0026rsquo; play involving situational evaluation and personal development in particular [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Regular outdoor play among children has dramatically declined over the past few generations [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e], and the average age at which children are allowed to play outside without adult supervision has increased by two years to aged 11 compared to their parents\\u0026rsquo; generation [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eChildren are typically more physically active when playing outdoors [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e], and engaged in risky play not constrained by adults [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. This decline in outdoor play may therefore partly explain why fewer than 35% and 50% of children and adolescents are sufficiently active for health globally and in the UK respectively [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. Furthermore, it may explain the decrease in mental well-being among children [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eSufficient levels of physical activity may support bone health, reduce the risk of excessive weight gain in children [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e], and benefit motor skill development, cardiometabolic health [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e], and emotional wellbeing [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. Across Europe, children\\u0026rsquo;s levels of physical activity begin to decline around 6\\u0026ndash;7 years of age [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], highlighting the need to intervene early in order to reverse or delay this.\\u003c/p\\u003e\\u003cp\\u003eSignificant play-specific budget cuts for local authorities in the UK have led to children\\u0026rsquo;s play being deprioritised [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e], and opportunities for outdoor play have diminished through the closure of a significant number of public outdoor play spaces [\\u003cspan additionalcitationids=\\\"CR18\\\" citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. Children have unequal access to spaces for play [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e], with space and access typically being most limited for children living in the least affluent areas of urban settlements [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. Furthermore, this inequality is exacerbated among children from ethnic minority groups (excluding white minority) who are less likely to live close to public green spaces than children of white ethnicity (40% vs. 14% respectively) [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. Similarly, the design of public urban spaces limits children\\u0026rsquo;s opportunities for play [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. These diminished and compromised opportunities for play contravene the United Nations of the Rights of the Child Art. 31 [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe importance of play provision is increasingly recognised globally, with many cities moving towards low-cost, non-traditional play spaces, embedding and encouraging children\\u0026rsquo;s play through regenerating existing urban spaces [\\u003cspan additionalcitationids=\\\"CR26 CR27 CR28\\\" citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. Despite this, much work is needed to enable and \\u0026lsquo;normalise\\u0026rsquo; children\\u0026rsquo;s play in urban spaces through changing societal attitudes towards neighbourhood play[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e] and parents\\u0026rsquo; perceptions of risky play [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e], and antisocial behaviour and crime [\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. Parents typically do not consider urban spaces as suitable for play, preferring parks and playgrounds [\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e], and have greater safety concerns for using urban spaces for informal play[\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e] in comparison to using traditional play equipment [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. Taking a whole systems approach[\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e] through building suitable opportunities for play into urban spaces alongside addressing these societal and parental barriers may help unlock children\\u0026rsquo;s opportunities for outdoor play and physical activity [\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eWith children spending a significant amount of their waking time in school, and schools being a safe and trusted organisation for many families, the setting offers an opportunity to support outdoor play [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. School-led interventions remove parental barriers and typically have parent and child support [\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e]. Many schools offer Forest School which provides opportunities for children to engage in active and adventurous play in green spaces [\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e]. Forest School initiatives are child-led, where children are free to pursue activities which spark their personal interest [\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e], and have been shown to increase children\\u0026rsquo;s physical activity [\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e]. However, there are still many barriers to overcome within the school culture and staff, particularly in relation to safely supporting risky play [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e] and accommodating it within the curriculum [\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e]. There is some evidence of acceptability and feasibility of delivering Forest School through primary educational settings [\\u003cspan additionalcitationids=\\\"CR45\\\" citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e] and limited evidence to suggest Forest School influences families\\u0026rsquo; independent use of green spaces [\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e]. However, for the global majority of children who live in urban areas [\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e] increasing urban densification is diminishing children\\u0026rsquo;s access to green space for play [\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e]. Acceptability and feasibility of school-led initiatives using other forms of urban spaces should therefore be explored to facilitate child-led neighbourhood play.\\u003c/p\\u003e\\u003cp\\u003eUsing the same Forest School principle of immersive regular visits to local green spaces, the Play in Urban Spaces for Health (PUSH) intervention concept was created to promote the formation of a sustainable habit of physically active outdoor free play and incidental physical activity through familiarisation with local urban spaces. As part of the PUSH intervention, primary schools will regularly take children (aged 4\\u0026ndash;7 years) in school time to local built-up urban spaces for child-led play to develop their capability and motivation for self-initiating play, and particularly active and risky play. The target age group was chosen to mitigate the decrease in physical activity typically observed around that time of a child\\u0026rsquo;s life [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. It is anticipated that routine use of those types of spaces for play becomes familiar and habitual outside of school, leading to increased physical activity and wellbeing among children, and enhanced connection to place. Taking a whole system approach, the PUSH intervention also aims to influence the regeneration of public spaces to design-in play [\\u003cspan additionalcitationids=\\\"CR26 CR27 CR28\\\" citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e], and address negative attitudes and behaviours among parents and the wider community.\\u003c/p\\u003e\\u003cp\\u003eThe aim of this research study was to explore the acceptability, feasibility and potential outcomes of the school-led physical activity intervention element of PUSH, considering the experiences and attitudes of primary school teaching staff and Forest School deliverers in Bradford, Yorkshire and Tower Hamlets, London. The research questions were:\\u003c/p\\u003e\\u003cp\\u003e1. To what extent is the PUSH school-led intervention acceptable to primary school staff?\\u003c/p\\u003e\\u003cp\\u003e2. What factors might influence the implementation of PUSH by primary schools?\\u003c/p\\u003e\\u003cp\\u003e3. What benefits might children attain from regularly engaging with the PUSH intervention?\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eProject context and setting\\u003c/h2\\u003e\\u003cp\\u003eThe study took place across two neighbourhoods in one council ward within the city of Bradford (Bfd) and two areas within the London Borough of Tower Hamlets (TH), UK. Both TH and the Bfd ward are densely populated, with 16% and 11% of households being overcrowded respectively [\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e]. In the Bfd ward access to green spaces and open spaces for play is a priority for regeneration [\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eAt the local authority level, Bfd and TH, child poverty, and prevalence of overweight at year 6 is above the national average (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eDemographic, and child poverty and overweight data for Bradford, Tower Hamlets and England [\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e].\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eBradford\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eTower Hamlets\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eEngland\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal population (N)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e546,400\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e310,300\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e56,489,800\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChildren aged under 16 years (% of population)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e22.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e18.5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e18\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRelative child poverty after housing costs (%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e37.7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e55.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e30\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEthnicity distribution (% non-white British)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e43.3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e77.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e25.6\\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePredominant non-white British ethnic group\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePakistani\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eBangladeshi\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eOther white\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePrevalence of overweight (inc. obese) children in reception year (%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e22.3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e22\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e23\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePrevalence of overweight (inc. obese) children in year 6 (%)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e40.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e41.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e35.2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e\\u003csup\\u003ea\\u003c/sup\\u003e England and Wales\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eThrough partnership working with the public health and landscape design departments within the local authorities, two urban sites in built-up areas of Bfd and two in TH were identified as having potential or plans to regenerate for play, and these four potential urban play spaces (PUPS) (additional data file 1) were the focus of the research. For each space, a nearby primary school was approached via email to support the research. These primary schools incorporated a very diverse local community, with ethnic groups primarily being non-white British and including Indian, Polish, Russian, Nigerian, Somalian, Bangladeshi, Chinese, with many languages spoken.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eStudy design\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study used a qualitative research method involving interviews exploring perceived acceptability, feasibility and potential outcomes among staff at primary schools near the PUPS (and therefore eligible for consideration to implement a pilot of PUSH). Secondly, experiences among teaching staff with experience of delivering Forest School (FS) programmes within public spaces through any primary school were used to support the exploration of potential feasibility and outcomes of the PUSH intervention, given the similarity between the interventions. Ethics approval was granted by University College London\\u0026rsquo;s IOE Research Ethics Committee (REC1787, data protection registration number Z6364106/2023/03/71).\\u003c/p\\u003e\\n\\u003ch3\\u003eParticipants\\u003c/h3\\u003e\\n\\u003cp\\u003eLocal networks including private Forest School providers and local authority educational leads were used to locate primary schools and Forest School organisations in urban areas of Bfd and TH which met the recruitment criteria - having delivered Forest School programmes as part of the school curriculum and in public green spaces outside of the school grounds. Within the five organisations which responded, head teachers, school staff, and Forest School leaders involved in the setup and delivery of Forest School programmes were approached by email to take part in the research. From these, ten Forest School staff were recruited across one primary school in TH, and four primary schools and one external Forest School organisation in Bfd (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). In TH, only one primary school Forest School met the recruitment criteria. At each of the schools recruited near the four PUPS, the headteacher and a member of teaching staff most engaged in supporting children\\u0026rsquo;s physical activity were recruited (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eParticipants recruited for interviews\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eBradford\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eTower Hamlets\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eForest School head teachers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eForest School teaching staff\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePUPS teaching staff\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePUPS headteachers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"3\\\"\\u003eNote: PUPS\\u0026thinsp;=\\u0026thinsp;Potential urban play spaces\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eAll participants received an information sheet (additional data files 2 to 5) and were given the opportunity to ask questions to the researcher via telephone or email before providing written consent to take part (additional data file 6).\\u003c/p\\u003e\\n\\u003ch3\\u003eData collection - interviews\\u003c/h3\\u003e\\n\\u003cp\\u003eSemi-structured interviews were conducted by AS (female, Senior Research Fellow), ER (female, Research Assistant), HH (female, Lecturer in Social Science Research) and LE (male, Research Assistant) to capture actual and anticipated barriers, facilitators and outcomes of school-led support of children\\u0026rsquo;s play and physical activity in local public spaces. All interviewers were knowledgeable in acceptability and implementation frameworks and children\\u0026rsquo;s health and wellbeing, and had prior training and experience in interviewing.\\u003c/p\\u003e\\u003cp\\u003eInterviews were completed online or face to face on the school premises in a private room and typically lasted 30\\u0026ndash;50 minutes. Audio was recorded using a Dictaphone. Organisations participating in the research received \\u0026pound;50 per staff member (equivalent to a maximum of \\u0026pound;100 per school) for their support with recruitment and use of school time and premises to conduct the interviews.\\u003c/p\\u003e\\u003cp\\u003eInterview topic guides were created by the researchers for the purpose of this study (topic guides are available through the additional data files listed in the text and accessed via the Harvard dataverse \\u0026ndash; see \\u0026lsquo;availability of data and materials\\u0026rsquo; statement. To understand the process of setup, delivery, barriers and facilitators, and outcomes of Forest School programmes delivered though primary schools, separate topic guides were used with the headteacher (additional data file 7) who had strategic oversight of FS programmes, and with staff involved in day-to-day delivery (additional data file 8).\\u003c/p\\u003e\\u003cp\\u003eTo explore potential barriers, facilitators and outcomes to establishing and delivering the PUSH intervention, separate topic guides were used with the headteacher at each school near the PUPS (additional data file 9) and member of staff most engaged in supporting children\\u0026rsquo;s physical activity (additional data file 10).\\u003c/p\\u003e\\n\\u003ch3\\u003eAnalysis\\u003c/h3\\u003e\\n\\u003cp\\u003eAudio recordings of interviews were transcribed verbatim and anonymised. Transcripts were imported into NVivo (version 14.23.3, Liviero, Denver, USA).\\u003c/p\\u003e\\u003cp\\u003eSekhon\\u0026rsquo;s Theoretical Framework of Acceptability (constructs of affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy) [\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e] was used to guide deductive coding of data relating to acceptability of the intervention among staff at schools near the PUPS and children, parents and wider community members. Data from Forest Schools was coded inductively by AS, LE and ER with feasibility and outcomes codes used to guide the coding of data from interviews of staff (coded by AS and ER) at schools near the PUPS.\\u003c/p\\u003e\\u003cp\\u003eAll coded data relating to feasibility of implementing PUSH were thematically analysed using a process of: 1) familiarisation with the data by AS and ER, 2) coding by AS and ER, 3) discussion and revision of codes between AS, LE, HH and ER, generation of themes and review and revision of themes by AS, LE, HH and ER.\\u003c/p\\u003e\\u003cp\\u003eDirect quotes from interviews with staff in Bfd and TH at schools near the PUPS were coded using the PUPS location number (1 or 2), and direct quotes from participants at schools delivering Forest Schools (FS) coded using the FS location number.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eAcceptability of PUSH\\u003c/h2\\u003e\\u003cp\\u003eAffective attitude\\u003c/p\\u003e\\u003cp\\u003eFor those schools located near the PUPS, staff were largely positive about potentially implementing the PUSH intervention, seeing it as \\u0026lsquo;\\u003cem\\u003eworthwhile\\u003c/em\\u003e\\u0026rsquo; and something schools \\u0026lsquo;\\u003cem\\u003eneeded to do\\u003c/em\\u003e\\u0026rsquo;. They implied a willingness to incorporate it as part of the school day, stating that \\u0026ldquo;\\u003cem\\u003eit'd be absolutely something that we timetable\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher), provided the PUPS was implemented: \\u0026ldquo;\\u003cem\\u003eif the resource were there, we would use it\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 teacher).\\u003c/p\\u003e\\u003cp\\u003eOne teacher in Bradford (Bfd PUPS1 teacher) agreed that the age group PUSH was targeting (4\\u0026ndash;7 years) was suitable, as \\u0026ldquo;\\u003cem\\u003e[young children] would love things like that\\u0026hellip;they\\u0026rsquo;ve got a wild imagination, so they can just make things up\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 teacher). Staff in TH concurred, and recognised that children across the 4\\u0026ndash;7 age range would have differing needs and interests in a play space, and that the intervention would need to be designed to be suitable for all children.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;Just thinking of the younger children, things that are quite sensory... But I think as they get a bit older they do enjoy a bit more challenge... So I think it's trying to get that balance of things that are suitable to the younger ones that are engaging in sensory [play], but then things that are challenging for your older children.\\u0026rdquo;\\u003c/em\\u003e \\u0026ndash; TH teacher\\u003c/p\\u003e\\u003cp\\u003ePotential effectiveness of PUSH\\u003c/p\\u003e\\u003cp\\u003eDiscussions with staff suggested that PUSH had the potential to support children\\u0026rsquo;s physical, emotional and social development, and ability to learn, and help develop their connection to place.\\u003c/p\\u003e\\u003cp\\u003eBradford Forest School teachers had observed children building \\u0026lsquo;\\u003cem\\u003ephysical skills and stamina\\u003c/em\\u003e\\u0026rsquo;, through their ability to manage the walk to and from the Forst School site with one parent reporting being \\u0026ldquo;\\u003cem\\u003eactually able to go on long walks because of the stamina [child\\u0026rsquo;s name] built up from being out in the woods\\u0026rdquo;\\u003c/em\\u003e\\u0026rdquo; (Bfd FS4 teacher). Physical improvements were particularly notable among children with previously limited physical abilities:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003ethey may have mobility issues such as dyspraxia [developmental co-ordination disorder] or things like that. But then being outside and walking on uneven ground, perhaps using things like hammock swings and maintaining that proprioception, that spatial awareness so you'll see the development\\u003c/em\\u003e\\u0026rdquo;. (Bfd FS3 teacher).\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u0026hellip;\\u003cem\\u003ewe also had one that used to be carried to school every day and cry. That was last year. And by the end of Forest School he was running he was loving to run into school\\u003c/em\\u003e\\u0026rdquo; (Bfd FS4 teacher).\\u003c/p\\u003e\\u003cp\\u003eSchools near the PUPS felt PUSH could offer the opportunity to \\u0026lsquo;\\u003cem\\u003ehave a go at things\\u003c/em\\u003e\\u0026rsquo; and would support children to become more resilient and gain a sense of independence and \\u0026lsquo;\\u003cem\\u003ebelief in themselves\\u003c/em\\u003e\\u0026rsquo;. This was an important element of Forest School which was embedded in \\u0026ldquo;\\u003cem\\u003eunderstanding where your limits are and that you can push out of your comfort zone and then achieve things and then push a bit further\\u003c/em\\u003e\\u0026rdquo;. Furthermore, respondents felt that \\u0026ldquo;children would be able to build the skills of \\u003cem\\u003e\\u0026ldquo;planning things and breaking down problems into sets of steps and all of the communication and social stuff that can be developed through play\\u0026rdquo;\\u003c/em\\u003e (TH PUPS1 headteacher). (Bfd FS3 teacher). Bfd PUPS1 teacher felt this could also enhance self-efficacy among children with additional needs:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003ea lot of the [SEN] children\\u0026hellip;their learning is through play and interaction and finding ways to sort of manage themselves so I think they would get a lot out of it\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 headteacher)\\u003c/p\\u003e\\u003cp\\u003eSimilar outcomes were reported by staff at a school with Forest School provision, who described \\u0026ldquo;\\u003cem\\u003ethat focus and that resilience and that that willingness to give it a go without panicking about not achieving a particular outcome\\u003c/em\\u003e,\\u0026rdquo; (Bfd FS3 teacher), and the \\u0026ldquo;confidence to have a go with something, take a risk with their learning,\\u0026rdquo; (Bfd FS3 co-headteacher 1) that had developed as a result of children\\u0026rsquo;s participation in Forest School. The headteacher of a school with Forest School provision in TH also described the \\u003cem\\u003e\\u0026ldquo;motivation and resilience\\u0026rdquo;\\u003c/em\\u003e (TH FS headteacher) that they had witnessed develop in children.\\u003c/p\\u003e\\u003cp\\u003eStaff viewed children\\u0026rsquo;s participation in PUSH as a valuable opportunity for them to spend time with peers outside of the classroom, as a means of \\u0026ldquo;\\u003cem\\u003eencouraging them to play with each other rather than be glued to a device\\u0026rdquo;\\u003c/em\\u003e (TH PUPS1 headteacher). It was suggested that this may support social cohesion through \\u0026ldquo;\\u003cem\\u003emore interaction, more teamwork, working with each other\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher) and \\u0026ldquo;\\u003cem\\u003etalking to each other and learning how to be with each other\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 Headteacher) which may lead to enhanced collaborative working in the classroom:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003e\\u0026hellip;that opportunity would undoubtedly then impact on how they interact with each other in the classroom and how they're able to apply themselves to their work or projects together\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 Headteacher)\\u003c/p\\u003e\\u003cp\\u003ePUSH being part of the school curriculum was perceived as a valuable opportunity to provide children with a mental break from learning through \\u0026ldquo;\\u003cem\\u003egetting some fresh air, stepping away from like the four walls of the classroom\\u003c/em\\u003e\\u0026rdquo;, (Bfd PUPS1 teacher). The Forest School lead in TH described how children felt \\u0026ldquo;relaxed\\u0026rdquo; when they returned to class after having engaged in similar activities.\\u003c/p\\u003e\\u003cp\\u003eIt was also recognised that PUSH could benefit staff-pupil relationships through \\u0026ldquo;\\u003cem\\u003ehaving those discussions with the children outside of the classroom setting and that bonding time\\u003c/em\\u003e\\u0026rdquo;, (Bfd PUPS2 teacher). This outcome had been achieved through the delivery of Forest schools. One headteacher described how \\u0026ldquo;\\u003cem\\u003e[forest school is] an opportunity outside of the classroom to have those talks, that isn't as formal\\u0026hellip;it's just like a bonding process, really\\u003c/em\\u003e\\u0026rdquo;, Bfd FS4 headteacher).\\u003c/p\\u003e\\u003cp\\u003eStaff in PUPS schools predicted that these outcomes, along with the opportunity to be physically active, would improve children\\u0026rsquo;s ability to engage with academic learning, and that children would be \\u0026ldquo;\\u003cem\\u003emuch more likely when they're back in the classroom to do what you ask them to do and to want to learn\\u003c/em\\u003e\\u0026rdquo;, (TH FS headteacher).\\u003c/p\\u003e\\u003cp\\u003ePositive behavioural outcomes were reported by staff involved in Forest Schools, particularly for those children who \\u0026lsquo;\\u003cem\\u003emight struggle in the classroom\\u0026rsquo;\\u003c/em\\u003e, as these children \\u0026ldquo;\\u003cem\\u003ecome back having had no incidents, being a good role model to others\\u003c/em\\u003e\\u0026rdquo; (Bfd FS3 co-headteacher 2). Another Forest School headteacher described how \\u0026ldquo;\\u003cem\\u003efor some of our more challenging children it's calmed them down\\u0026rdquo;\\u003c/em\\u003e, Bfd FS4 headteacher). In TH, the Forest School headteacher described how the positive behavioural outcomes were worth the investment of time into the intervention:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eWhen I started an intervention in a class, the teachers always used to say, oh, but you know, I'm going to lose 45 minutes every week... And then usually by the end of the intervention, they'd say, do you know what? I'm going to carry on doing this because that 45 minutes that I'm investing there, I'm actually making it up elsewhere because I don't spend so much time dealing with behaviour issues\\u003c/em\\u003e.\\u0026rdquo; (TH FS headteacher)\\u003c/p\\u003e\\u003cp\\u003eSome Bradford staff felt that PUSH could also support children to build a connection to their neighbourhood, where currently children \\u0026ldquo;\\u003cem\\u003eliterally know their home and school and that is all\\u003c/em\\u003e\\u0026rdquo;, (Bfd PUPS2 teacher) to facilitate children and families\\u0026rsquo; understanding of available opportunities (\\u0026ldquo;\\u003cem\\u003ethey don't really know what's available. Don't really know what's going on what goes on\\u003c/em\\u003e\\u0026rdquo; Bfd PUPS1 headteacher), particularly \\u0026lsquo;\\u003cem\\u003ewith 2025 coming out\\u003c/em\\u003e\\u0026rsquo;, the city\\u0026rsquo;s forthcoming year of culture. Increased connection to and knowledge of their local area was not mentioned by participants in TH.\\u003c/p\\u003e\\u003cp\\u003eAnticipated burden\\u003c/p\\u003e\\u003cp\\u003eDespite the expressed confidence in aligning PUSH with existing school practices, there were concerns across both Bfd and TH that delivering PUSH in addition to the existing curriculum could be challenging for staff. Particularly in TH, finding the time in the timetable to take children to the play space was perceived as a potential burden, meaning that the intervention would \\u0026ldquo;struggle\\u0026rdquo; in comparison to other curriculum priorities. TH PUPS1 headteacher reported that \\u0026ldquo;\\u003cem\\u003ethe timetable is very tightly packed. So we struggle, as it is, to get the actual sort of number of subjects, the amount of time, the content actually taught. It's very, very difficult\\u003c/em\\u003e\\u0026rdquo;.\\u003c/p\\u003e\\u003cp\\u003eSimilar concerns had initially been raised by senior leadership as to how Forest School delivery might conflict with academic teaching. One teacher in Bfd described a comment from the headteacher: \\u0026ldquo;\\u003cem\\u003eI like your rationale, but actually, in real world practicality terms, how would we make sure that it doesn\\u0026rsquo;t impact on our curriculum\\u003c/em\\u003e?\\u0026rdquo; [Bfd FS1 teacher, referring to a comment from the headteacher]. However, these concerns had been overcome by demonstrating opportunities for learning and linking in with the curriculum:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003e\\u0026hellip;the reason I got [the outdoor enrichment programme] passed by governors and school leaders is because I made that significant link to curriculum\\u003c/em\\u003e\\u0026rdquo; (Bfd FS1 teacher).\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u0026hellip;\\u003cem\\u003ewe do find the gaps\\u0026hellip;so there's lots of links to PSHE, there's links to science, there's links to PE sometimes. So yeah, we kind of make it \\u0026lsquo;legit\\u0026rsquo; in some ways that way\\u003c/em\\u003e\\u0026rdquo; (TH FS teacher)\\u003c/p\\u003e\\u003cp\\u003eSimilarly, TH staff at schools near the PUPS felt more favourably towards supporting school trips which linked to the curriculum and focused on learning: \\u0026ldquo;\\u003cem\\u003e\\u0026hellip;where children go out on trips, it's part of the learning of those subjects. It has to be, really. There isn't much space for it to be anything else\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 headteacher), \\u0026ldquo;\\u0026hellip;\\u003cem\\u003eI know children learn through play, but learning is the bit that we have to do\\u0026hellip;\\u003c/em\\u003e\\u0026rdquo; (TH PUPS2 headteacher), \\u0026ldquo;\\u003cem\\u003eit's just looking at how we could incorporate it into maybe to tie in with one of the subjects rather than it being something explicit on top\\u003c/em\\u003e\\u0026rdquo; (TH PUPS2 teacher).\\u003c/p\\u003e\\u003cp\\u003eThe staff capacity needed to implement PUSH was also a concern, with headteachers highlighting the burden of additional staff needed to safely supervise children during off-site visits, noting the need to \\u0026ldquo;send at least three or four adults, so \\u003cem\\u003eit would have to be carefully planned and it would take a lot of person power to manage\\u003c/em\\u003e\\u0026rdquo; [Bfd PUPS2 headteacher], which would depend \\u003cem\\u003e\\u0026ldquo;very much on the class itself and the level of needs that they have\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 headteacher). This was something highlighted by some Forest Schools where capacity was addressed by funding external practitioners to support delivery, yet illness among key members of assisting teaching staff and the higher staff to pupil ratios required for nursery children (\\u0026ldquo;\\u003cem\\u003eyou do need high staff numbers even to get 10 children out\\u0026rdquo;\\u003c/em\\u003e, Bfd FS2 teacher) still had the potential to compromise delivery. Schools near the PUPS sites also noted that any potential increase in staff workload may reduce staff buy-in: \\u0026ldquo;\\u003cem\\u003eif the staff see it as something extra that they've got to do or plan because their days are busy as it is, they're not going to buy-in\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 headteacher).\\u003c/p\\u003e\\u003cp\\u003eEthicality\\u003c/p\\u003e\\u003cp\\u003eSchools in both TH and Bradford considered physical activity to be important, viewing it as both an area for the development of individual strengths and interests (\\u0026ldquo;\\u003cem\\u003ewe're trying to change a little bit that life isn't all about English and maths\\u0026hellip;not all children are academically motivated\\u003c/em\\u003e\\u0026rdquo;, Bfd PUPS2 headteacher). One teacher strongly believed that \\u0026ldquo;\\u003cem\\u003eif the children have got good gross motor skills, then they have good fine motor skills\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher), and provided an example to highlight the importance of this where some nursery children were \\u0026ldquo;\\u003cem\\u003enot even confident to walk down steps even holding on to something\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher). TH staff felt similarly, with one headteacher explaining that she believed that \\u003cem\\u003e\\u0026ldquo;it\\u0026rsquo;s important for kids to be confident in themselves and to be able to move and express themselves\\u0026rdquo;\\u003c/em\\u003e (TH PUPS2 headteacher). Schools in both areas had an extensive variety of opportunities to support this, including active breaks in class, Forest School, organised games and provision of equipment to support active play time, and outsourcing some PE lessons to specialist cricket and dance providers.\\u003c/p\\u003e\\u003cp\\u003eAlthough schools were \\u0026lsquo;risk aware\\u0026rsquo; due to their responsibility for children\\u0026rsquo;s safety, they supported children to take risks through climbing and exploring during play in the playground as this environment was considered \\u0026lsquo;safe\\u0026rsquo;. One school demonstrated an existing practice of supporting risky play, where children were supervised from a distance and staff \\u0026ldquo;\\u003cem\\u003edon't stop them from exploring [playground equipment] because they're safe and they're built for children\\u003c/em\\u003e\\u0026rdquo; and believed that \\u0026ldquo;children need to learn to manage their own risk\\u0026rdquo; (Bfd PUPS1 headteacher).\\u003c/p\\u003e\\u003cp\\u003eHowever, when discussing the \\u0026lsquo;child-led\\u0026rsquo; element of the PUSH intervention, there was some hesitation for letting children \\u0026lsquo;\\u003cem\\u003erun loose and do whatever they want\\u003c/em\\u003e\\u0026rsquo;, and a desire to ensure the time was not just spent \\u0026lsquo;\\u003cem\\u003emessing around\\u003c/em\\u003e\\u0026rsquo; and the importance of having a \\u0026lsquo;plan\\u0026rsquo; and having staff model how to use the space:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u0026hellip;\\u003cem\\u003einitially until we get used to the equipment ourselves, more of like a PE [physical education] lesson where somebody models and then somebody has a go and it's very much sort of turn taking initially\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher)\\u003c/p\\u003e\\u003cp\\u003eSelf-efficacy\\u003c/p\\u003e\\u003cp\\u003eThe confidence to implement PUSH (\\u0026ldquo;\\u003cem\\u003eWe will make it work. If we were to continue to be involved\\u003c/em\\u003e\\u0026rdquo;, Bfd PUPS2 headteacher) appeared to stem from how it aligned with existing school practices, partly through their experience of taking children on school trips, which was described as \\u0026ldquo;\\u003cem\\u003ereally not an issue at all\\u003c/em\\u003e\\u0026rdquo;, (TH PUPS2 teacher). One Bradford headteacher described the approach they would take as part of establishing the intervention:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003e[school staff would] go down [to the PUPS] and we'd look at it and talk through some actions and talk through some things we could do, games that can be played and what the children are getting from it\\u0026hellip;and work together on it\\u003c/em\\u003e.\\u0026rdquo; (Bfd PUPS1 headteacher).\\u003c/p\\u003e\\u003cp\\u003eFor Bradford headteachers, it was felt the PUSH intervention could be implemented \\u0026lsquo;\\u003cem\\u003eas part of our physical education offer\\u003c/em\\u003e\\u0026rsquo; or alongside their existing Forest School programme, suggesting that \\u0026ldquo;\\u003cem\\u003ethere's no reason if half a class are out doing that. The other half could go down there [the new play space]\\u003c/em\\u003e\\u0026rdquo;, (Bfd PUPS1 headteacher). One school had a current practice of taking children to a local community centre to use their outside space for play, and considered that the PUPS would \\u0026ldquo;\\u003cem\\u003ejust become another area that we use, and that we get used to using\\u003c/em\\u003e\\u0026rdquo;, (Bfd PUPS2 headteacher), using existing staff expertise (\\u0026ldquo;\\u003cem\\u003ewe'd probably look at [existing Forest school lead] role and how she could be used and timetabled into groups from our from our school to the safe space\\u003c/em\\u003e\\u0026rdquo;, Bfd PUPS2 teacher). For the TH school near to PUPS1, the site being \\u0026lsquo;\\u003cem\\u003ejust across the road\\u0026rsquo;\\u003c/em\\u003e deemed it acceptable, and the headteacher suggested that \\u0026ldquo;\\u003cem\\u003ethere's no reason why we couldn't make use of that during the children's lunchtime\\u003c/em\\u003e,\\u0026rdquo; (TH PUPS1 headteacher).\\u003c/p\\u003e\\u003cp\\u003eIntervention coherence\\u003c/p\\u003e\\u003cp\\u003eStaff near the PUPS demonstrated an understanding of the need for the intervention through recognising the lack of local play opportunities; Bfd PUPS2 teacher stated that \\u0026ldquo;\\u003cem\\u003ethey just don't go out because there isn't safe spaces for them unfortunately to play\\u0026rdquo;\\u003c/em\\u003e. The role of schools in fulfilling this need was widely acknowledged:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003e[The children] don't have gardens, they don't have outdoor space, so the more opportunities we can give them for safe places to play and engage with child-led play, I think would have a massive impact on them\\u0026hellip; when they get to school and they've got some open space you can see how much they love it\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 teacher).\\u003c/p\\u003e\\u003cp\\u003eSchools also understood PUSH as an opportunity to increase children\\u0026rsquo;s time spent being physically active in addition to current provision of school-based physical education (PE) (\\u0026ldquo;\\u003cem\\u003eThey're walking to and from the [PUPS]. They're getting that extra time\\u0026hellip;rather than just sticking to one hour of indoor PE a week\\u003c/em\\u003e\\u0026rdquo;, Bfd PUPS1 teacher) and allowing a \\u0026ldquo;\\u003cem\\u003eless structured\\u003c/em\\u003e\\u0026rdquo; form of physical activity than PE (Bfd PUPS1 headteacher).\\u003c/p\\u003e\\u003cp\\u003eStaff at schools near Bfd PUPS2 indicated an understanding of how the school-led intervention might work to change children and families\\u0026rsquo; behaviours longer-term to facilitate use of the PUPS outside of the school day, recognising the need for parent support. They felt that children would ask their parents to take them to the PUPS, and the headteacher recognised how staff could support this by asking children \\u0026ldquo;\\u003cem\\u003eHave you been to the space this weekend? What did you do\\u003c/em\\u003e?\\u0026rdquo;. The teacher from Bfd PUPS1 provided an example where children had visited destinations with parents after going there on school trips: \\u0026ldquo;\\u003cem\\u003e'Oh, I walked past the cathedral the other day\\u0026rsquo; after they'd seen it because \\u0026lsquo;I wanted to show my mum where we've been' and things like that, so they want to impress you in school\\u003c/em\\u003e\\u0026rdquo;. This was supported by the Forest School lead teacher in TH, who reported that a key outcome for them was that children had taken their parents to the Forest School site outside of school time: \\u0026ldquo;\\u003cem\\u003eit's to do with them knowing that the space is there, that they get back and use it at other times\\u003c/em\\u003e\\u0026rdquo; (TH FS lead teacher).\\u003c/p\\u003e\\u003cp\\u003eThe key themes within acceptability are summarised in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eInfluences on the implementation of the PUSH intervention\\u003c/h3\\u003e\\n\\u003cp\\u003eMotivation and capability of staff\\u003c/p\\u003e\\u003cp\\u003eSchools near to the PUPS perceived that there were internal staff who would be willing to support the implementation of PUSH as they \\u0026ldquo;\\u003cem\\u003eare really really up for things\\u003c/em\\u003e\\u0026ldquo; (Bfd PUPS1 headteacher), are \\u0026ldquo;\\u003cem\\u003ealways wanting to learn new things and get out\\u003c/em\\u003e\\u0026ldquo; (Bfd PUPS2 teacher), and \\u0026ldquo;\\u003cem\\u003elike spending time outdoors\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 teacher) and one headteacher referred to an external sports provider who is \\u0026ldquo;\\u003cem\\u003ealways looking for opportunities to get involved in more sporting activities within the school\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 headteacher). A teacher in TH described the staff of the school as \\u0026ldquo;\\u003cem\\u003ereally dynamic, and we do a lot of trips\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 teacher).\\u003c/p\\u003e\\u003cp\\u003eIt was anticipated that this willingness may be dependent on it being \\u0026lsquo;sold in the right way\\u0026rsquo; so staff understand \\u0026ldquo;\\u003cem\\u003ewhy it's so important for young children to be physically active\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher), and the delivery being consistent through using \\u0026ldquo;\\u003cem\\u003ethe same rota of staff, so the staff know that they're going to be out [of school]\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 teacher) and ensuring it is \\u0026ldquo;\\u003cem\\u003eled by somebody who can have ownership\\u0026hellip;accountable to check, measure, lead\\u003c/em\\u003e\\u0026ldquo; (Bfd PUPS2 headteacher). One headteacher in TH told us that it would be important to \\u0026ldquo;\\u003cem\\u003etalk to teachers in respect of what your ideas are\\u0026hellip; so that it can really be a usable thing\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 headteacher) and to get teachers\\u0026rsquo; buy-in.\\u003c/p\\u003e\\u003cp\\u003eA Forest School headteacher reported that senior leaders had been more likely to support Forest School programmes if they \\u0026ldquo;\\u003cem\\u003e100% understood the benefits to physical health, mental health, wellbeing\\u003c/em\\u003e\\u0026rdquo; (Bfd FS4 headteacher) and at another school, support from the headteacher was achieved through visiting a local school delivering Forest Schools and \\u0026ldquo;\\u003cem\\u003ehaving seen what the benefits could be for our school\\u003c/em\\u003e\\u0026rdquo; (Bfd FS3 teacher).\\u003c/p\\u003e\\u003cp\\u003eBoth Bradford schools reported having access to staff trained in Forest School or play therapy, or were willing to support their staff to access training opportunities using \\u0026ldquo;expertise across the [school academy] trust\\u0026rdquo; (Bfd PUPS1 headteacher). Staff in both TH and Bradford identified training needs relating to familiarisation with the intervention which could be achieved through staff visiting the spaces and \\u0026ldquo;\\u003cem\\u003eusing these types of equipment\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher), and \\u0026ldquo;\\u003cem\\u003eshown the possibilities\\u003c/em\\u003e\\u0026rdquo; (TH PUPS2 headteacher). This training need was also recognised by staff within Forest Schools who referred to the importance of understanding of the \\u0026ldquo;\\u003cem\\u003econceptual underpinning, the reasons, the sort of pedagogy or whatever is important\\u003c/em\\u003e\\u0026rdquo; (TH FS teacher).\\u003c/p\\u003e\\u003cp\\u003eExisting processes and practices within schools\\u003c/p\\u003e\\u003cp\\u003eExisting processes within schools could support schools to take children off site for outdoor physical activity. Processes were in place to obtain parent consent for off-site visits at the point of pupil enrolment: \\u0026ldquo;we \\u003cem\\u003edon't have to ask for permission every time because [parents] signed for it and agreed\\u003c/em\\u003e\\u0026rdquo; (Bfd headteacher), \\u0026ldquo;\\u003cem\\u003eanything done locally, we wouldn't need to get consent for\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 teacher).\\u003c/p\\u003e\\u003cp\\u003eThe existing practice of off-site visits meant that risk assessments have already been approved for activities of a similar nature to the PUSH intervention, with Bradford using the online \\u0026lsquo;Evolve\\u0026rsquo; system \\u0026ldquo;if we're going on a local walk, everything tends to go on Project Evolve\\u0026rdquo; (Bfd PUPS2 teacher). As part of the risk assessment for the PUPS sites, schools would still expect staff to do a \\u0026lsquo;pre visit\\u0026rsquo; to \\u0026ldquo;see where any possible dangers might be\\u0026rdquo; (Bfd PUPS1 headteacher). This was also the case in TH. Both Bradford schools highlighted that their learning support staff were first aid trained which was an essential requirement for enabling schools to take children off-site. Procedures to respond to emergency situations were in place across schools in Bradford and TH: \\u0026ldquo;\\u003cem\\u003ewe always take the first aid kit with us\\u0026hellip;we'd get a mobile phone for that [specific trip location]\\u0026hellip;if there was an emergency, they can ring the school and one of us can go and support\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 headteacher). \\u0026ldquo;\\u003cem\\u003ePart of the risk assessment process would be considering all of their medical needs, whether they have allergies, whether they, you know, you need to take medication across there or not\\u0026rdquo;\\u003c/em\\u003e (TH PUPS1 headteacher).\\u003c/p\\u003e\\u003cp\\u003eStaff were confident of children\\u0026rsquo;s ability to safely walk to PUPS through the provision of high visibility jackets and experience of walking along roads on previous trips \\u0026ldquo;\\u003cem\\u003eknowing to stay in partners\\u0026rdquo;\\u003c/em\\u003e and were \\u0026ldquo;\\u0026hellip;\\u003cem\\u003egenerally good with walking to and from sites\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 teacher) and their journeys to and from school. A headteacher in TH described how their risk assessments might vary depending on the needs of the class:\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;You could take a class of 30 older children across there with just two adults. If you, if one thought that that would be safe enough, obviously that would depend very much on the class itself and the level of needs that they have. If you've got a particularly challenging class with a higher level of need, for example, then you may decide as part of that risk assessment process that you need more adults there in order to sort of safeguard the children\\u0026rdquo;\\u003c/em\\u003e (TH PUPS1 headteacher\\u003cem\\u003e).\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003ePrevious support from parents for off-site visits was deemed important for supporting safe staff-pupil ratios and ensuring the safe travel of children with additional needs: \\u0026ldquo;\\u0026hellip;\\u003cem\\u003eparents have come with and supported [children with additional needs] and generally the parents have been really on board with that\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 headteacher).\\u003c/p\\u003e\\u003cp\\u003eStaff in Bradford referred to encouraging children to be \\u0026ldquo;\\u003cem\\u003eoutside all the time\\u0026hellip;regardless of the weather\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 headteacher) and referred to the provision of wellies and waterproofs, and asking children to \\u0026ldquo;bring a sun hat, sunglasses, suncream, apply it before school. However one school recognised that some parents struggle to provide a basic PE kit and may need schools to provide suitable clothing and equipment: \\u0026ldquo;\\u003cem\\u003ejust a pair of pumps is just an absolute nightmare\\u0026hellip;in terms of clothing, that could be a potential barrier if the school weren\\u0026rsquo;t able to fund the children\\u0026rsquo;s clothing\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher). For Forest Schools, the initial cost of purchasing weatherproof clothing was acknowledged, with some sourcing wellies through donations, but provision was deemed \\u0026ldquo;\\u003cem\\u003ea massive facilitator\\u003c/em\\u003e\\u0026rdquo; where children \\u0026ldquo;\\u003cem\\u003ewere not interested in the weather, they're not bothered at all\\u003c/em\\u003e\\u0026rdquo; (Bfd FS1 teacher), and clothing prevented \\u0026lsquo;scuffed skin\\u0026rsquo; from trips and falls. One school in TH already had \\u003cem\\u003e\\u0026ldquo;wet weather gear for the little ones,\\u0026rdquo;\\u003c/em\\u003e (TH PUPS2 class teacher) but not for the older children, who would be expected to bring their own.\\u003c/p\\u003e\\u003cp\\u003eSafety and suitability of public spaces for play\\u003c/p\\u003e\\u003cp\\u003eKeeping children safe outside of school was important, with one headteacher highlighting key design considerations of PUPS to address the \\u0026ldquo;\\u003cem\\u003eneed to be able to see [the children].\\u003c/em\\u003e..\\u0026rdquo; when in public spaces and the importance of seating at the edges where \\u0026ldquo;\\u0026hellip;\\u003cem\\u003eyou can scan and you can see where everyone is\\u003c/em\\u003e\\u0026rdquo; (TH PUPS2 headteacher).\\u003c/p\\u003e\\u003cp\\u003eDespite appropriate risk assessments, it was recognised that some teaching staff may have concerns as to the fluctuating nature of the physical spaces and the people in them, referring to previous experiences of anti-social behaviour and resulting physical hazards: \\u0026ldquo;\\u003cem\\u003eeven through the day, [Bradford city centre] doesn't feel like the safest place in the world\\u0026hellip;we can\\u0026rsquo;t stop other people being there\\u0026hellip;I think some of our staff would be put off\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 teacher), \\u0026ldquo;gangs are sort of hanging around [on the school premises] and then we often find like needles\\u0026rdquo; (Bfd PUPS2 teacher). Similar experiences were reported by Forest Schools who gave examples of explicit language being used, aggressive dogs off the lead and where \\u0026ldquo;\\u003cem\\u003esomebody had gone and smashed glass purposefully and put it down the slide\\u003c/em\\u003e\\u0026rdquo; (Bfd FS2 teacher). A headteacher in TH expressed concerns that \\u003cem\\u003e\\u0026ldquo;there is a different level of risk around how one uses a public space, because it can be accessed by anybody at any time, and anything could be left\\u003c/em\\u003e\\u0026rdquo; (TH PUPS2 headteacher).\\u003c/p\\u003e\\u003cp\\u003eSuggestions from schools near PUPS to mitigate these concerns included ensuring good links with the local community police \\u0026ldquo;\\u003cem\\u003emaking sure they are aware of what\\u0026rsquo;s going on\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 teacher) and having an \\u0026ldquo;\\u003cem\\u003eextra pair of eyes\\u003c/em\\u003e\\u0026rdquo; from parents or wardens (Bfd PUPS1 teacher).\\u003c/p\\u003e\\u003cp\\u003eBfd FS2 and FS3 referred to the use of \\u0026lsquo;safety rules\\u0026rsquo; discussed with children at the start of each session to ensure children returned to the teacher when called (particularly if a teacher identifies a safety risk from another person): \\u0026ldquo;\\u003cem\\u003esome kind of call and response so when you say \\u0026lsquo;stop\\u0026rsquo; they come back to me\\u0026hellip;you have to talk about the issues with dogs and what they do if a dog comes up to them\\u003c/em\\u003e\\u0026rdquo; (Bfd FS2 teacher), \\u0026ldquo;\\u003cem\\u003ea few kind of recall Hide and Seek games to make sure they're maintaining the boundaries we've set out and they understand when to come back and things like that\\u003c/em\\u003e\\u0026rdquo; (Bfd FS3 teacher).\\u003c/p\\u003e\\u003cp\\u003eBfd FS3 also saw these risks to children\\u0026rsquo;s safety as an opportunity for staff to educate them through being exposed to \\u0026ldquo;\\u003cem\\u003ethe [potential dangers] they're going to encounter when they're out anyway if they are out playing\\u0026hellip;there's somebody there that can kind of support them to deal with it in the safest way, whether it's, you know, antisocial dog, bikes, syringes on the floors\\u0026hellip;\\u003c/em\\u003e\\u0026rdquo; (Bfd FS3 headteacher).\\u003c/p\\u003e\\u003cp\\u003eAsides from safety concerns, some staff stressed the importance of ensuring the physical space accommodates children with sensory and physical needs, and some considered how facilities within or near the PUPS could support children\\u0026rsquo;s ability to play:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eSo things like toilets, a place to put their shoes or their coats if they wanted to, you know, take layers off, for example, and play a bit more freely\\u0026hellip;a tap to refill their water bottles or to have access to\\u003c/em\\u003e\\u0026rdquo; (TH PUPS2 teacher)\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eA lot of children maybe they're like scoot to school, or they'll bike to school. So maybe somebody that can like take a bike tour or take a scooter Yeah. So it's got that apparatus for them to use like, skating area or scooting area just so they've got something to like, do\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS1 teacher).\\u003c/p\\u003e\\u003cp\\u003eConcern among parents\\u003c/p\\u003e\\u003cp\\u003eSchools had generally not faced many issues with parents permitting children to go on school trips, but one school gave an example where some parents doubted their child\\u0026rsquo;s physical ability to walk to the local swimming baths (\\\"\\u003cem\\u003eYou expect them to walk?\\u003c/em\\u003e\\\", \\u0026ldquo;\\u0026hellip;\\u003cem\\u003ethey can\\u0026rsquo;t walk that fast\\u003c/em\\u003e\\u0026rdquo;, \\u0026ldquo;\\u003cem\\u003eher legs hurt\\u003c/em\\u003e\\u0026rdquo;, Bfd PUPS1 headteacher referring to parent comments). Similarly, some parents at this school had been \\u0026ldquo;\\u003cem\\u003efunny about children taking risks\\u0026hellip;\\u003c/em\\u003e\\u0026rdquo;, finding it \\u0026ldquo;\\u003cem\\u003equite hard to understand that you're not following them behind all the time to catch them\\u003c/em\\u003e\\u0026rdquo; and asking \\u0026ldquo;\\u003cem\\u003ewhy didn\\u0026rsquo;t anyone stop them?\\u003c/em\\u003e\\u0026rdquo; when children have fallen off climbing structures in the playground (Bfd PUPS1 headteacher).\\u003c/p\\u003e\\u003cp\\u003eAnother school referred to some parents\\u0026rsquo; beliefs that \\u003cem\\u003e\\u0026ldquo;[their children] were going to get ill\\u003c/em\\u003e\\u0026rdquo; (Bfd PUPS2 headteacher) playing outside, and with some parents \\u0026ldquo;\\u003cem\\u003every, very protective of their children, don't want their children to get wet\\u003c/em\\u003e\\u0026rdquo; (TH PUPS1 headteacher) or dirty. This had been the experience among some Forest School programmes from parents of nursery age children (\\u0026ldquo;\\u003cem\\u003ewe get told they're not allowed to go out today because they might get cold, they might get ill\\u003c/em\\u003e\\u0026rdquo;, Bfd FS4 headteacher), but one school had taken the approach that \\u0026ldquo;\\u003cem\\u003eif they're well enough to be in school, they're well enough to go\\u003c/em\\u003e\\u0026rdquo; (Bfd FS3 co-headteacher 2).\\u003c/p\\u003e\\u003cp\\u003eWhen considering the PUSH intervention, some schools were aware that some parents \\u0026ldquo;\\u003cem\\u003ethink playing is a pastime\\u0026hellip;[children are] not really learning from it\\u003c/em\\u003e\\u0026rdquo; (TH PUPS 2 headteacher) and may have concerns about children giving up time they could be spending on academic subjects \\u0026ldquo;\\u003cem\\u003e\\u0026lsquo; why are not doing math, why are they not doing English?...they\\u0026rsquo;re not doing any writing\\u0026rsquo;\\u003c/em\\u003e\\u0026ldquo; highlighting the importance of educating parents on the potential benefits of play on children\\u0026rsquo;s ability to engage in academic learning, as reported by Forest Schools.\\u003c/p\\u003e\\u003cp\\u003eThe importance of addressing parent concerns was demonstrated by some Bradford Forest Schools, where parents typically viewed Forest School provision as an important enrichment experience for their children: \\u003cem\\u003e\\u0026ldquo;The majority of the parents see the benefits that the children get out of it\\u003c/em\\u003e\\u0026rdquo; (Bfd FS3 teacher), and \\u0026ldquo;\\u003cem\\u003esome parents have chosen us because we've got forest schools\\u003c/em\\u003e\\u0026rdquo; (Bfd FS4 headteacher). This positive support from parents was also experienced in TH where \\u0026ldquo;\\u003cem\\u003eparents are really aware [Forest School is] part of the success, and that's why the children do so well here\\u0026rdquo;\\u003c/em\\u003e (TH FS headteacher).\\u003c/p\\u003e\\u003cp\\u003eThis success for Bfd FS4 may have been due to their efforts to address various potential concerns among parents, for example sharing photos of activities, addressing parents\\u0026rsquo; concerns around children being taken out of school (e.g. wanting specific details of where they are going and how they are travelling) and addressing concerns relating to exposure to cold weather through focused communication with parents:\\u003c/p\\u003e\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003ewe have got a letter or a leaflet, from the school nursing team, which basically says being cold doesn't mean you get a cold\\u0026hellip; staff from the community\\u0026hellip;talk to parents and say, \\u0026lsquo;what are you actually worried about?\\u0026rsquo;\\u003c/em\\u003e \\u0026rdquo; (Bfd FS4 headteacher)\\u003c/p\\u003e\\u003cp\\u003eThis Forest School had also invited parents to experience Forest School which \\u0026ldquo;\\u003cem\\u003echanged their perspective on what it is because they think they're just going out and getting muddy and not really seeing the benefit the whole benefit of it\\u003c/em\\u003e\\u0026rdquo; (Bfd FS4 teacher) and through a focus on promoting the benefits for wellbeing: \\u0026ldquo;\\u003cem\\u003eLots of our parents are much more aware of mental health and its importance\\u003c/em\\u003e\\u0026rdquo; (Bfd FS4 headteacher).\\u003c/p\\u003e\\u003cp\\u003eThe key themes relating to potential barriers and facilitators to implementing PUSH are summarised in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eThese findings, along with findings from the wider project and existing literature, were used to develop an initial theory of change (additional data file 11) and logic model (additional data file 12) that can be used to support a pilot of the PUSH intervention.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study demonstrates the use of primary schools as suitable settings to facilitate outdoor physically active play interventions like the PUSH intervention in urban public realm spaces due to existing school cultures and practices, and highlights key challenges to mitigate and practical additions to the intervention design which could strengthen its implementation.\\u003c/p\\u003e\\u003cp\\u003eThe findings suggest general acceptability and coherence of the PUSH concept, with school staff anticipating many potential benefits for children, some of which had been observed by staff delivering Forest Schools. Furthermore, the intervention generally aligned with the school ethos of supporting children to have a wide range of opportunities for physical play and activity. There were some concerns for the additional burden on staff and curriculum time needed to implement it, which aligns with perceptions of other school-delivered play interventions [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e]. However, acceptability of PUSH was potentially conditional on there being opportunities to link activities into the curriculum. Furthermore, experience of delivering such interventions and of benefits for children can enhance acceptability among staff and willingness to adopt this practice [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003ePUSH was perceived as feasible to implement within existing school processes for off-site trips and staff capability, provided that early buy-in and suitable training is ensured. School-based delivery of adventurous play-based activities can be compromised due to some staff attitudes and beliefs about adventurous play and concerns around health and safety [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e]; our research suggested staff were primarily concerned for their liability if children experienced any injuries. PUSH therefore needs to ensure school staff understand the benefits of adventurous play and how to safely manage risk, and school staff have shown a willingness to undertake training to support the safe delivery of outdoor play interventions [\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e]. Staff perceived many benefits of PUSH on children\\u0026rsquo;s physical and emotional wellbeing, and anticipated it could encourage prosocial behaviour and educational engagement which was supported by insight from Forest School leaders and in line with previous research [\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR58\\\" citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eDespite a generally positive attitude towards supporting risky play among those staff interviewed, there was apprehension of the presence of the general public in urban spaces, and Forest School staff reported experiences of antisocial behaviour in green spaces. Furthermore, school staff highlighted the potential of parental concerns for their child\\u0026rsquo;s ability to manage risk during play, their perceived risk to health from playing in cold weather conditions, and play displacing academic activities.\\u003c/p\\u003e\\u003cp\\u003eInsight from Forest Schools highlighted potential strategies to mitigate many of these challenges which, along with findings from other outdoor play initiatives, should be considered within future revisions and the piloting of PUSH. Parent concerns of risk can be a barrier for some schools supporting children\\u0026rsquo;s risky play, however the use of educational workshops with teachers and parents to \\u0026lsquo;reframe\\u0026rsquo; risk can overcome this [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. Parent support for risky play in schools can be enhanced through communicating the benefits in advance and having appropriate resources in place to ensure child safety [\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e]. Parent concerns about children getting wet and cold is consistent with Forest School research [\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e], demonstrating the importance of schools ensuring children have access to clothing suitable for weather conditions, and of providing credible information from trusted sources dispelling myths relating to cold exposure causing viral illnesses.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStrengths and limitations\\u003c/h2\\u003e\\u003cp\\u003eA strength of this research is the use of the Theoretical Framework of Acceptability [\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e] which allowed us to understand how PUSH was acceptable among educational stakeholders. Furthermore, understanding potential barriers and facilitators to implementation may enhance the success of a future pilot through further revision of the delivery protocol. The recruitment strategy successfully enabled the completion of the targeted number of interviews in Bfd; whilst the number of interviews with Forest School staff in TH was less than intended, this was due to the lack of schools meeting the recruitment criteria. Furthermore, both schools near the Bfd PUPS were had experience of delivering Forest School programmes and could therefore draw on their experiences of supporting children\\u0026rsquo;s play within the school day at an external location.\\u003c/p\\u003e\\u003cp\\u003eLimitations of this study include the potential of positive bias due to the need for a purposeful sampling process to recruit schools near to the PUPS or which delivered off-site Forest Schools, and restricted the sample size. Those schools who agreed to participate already recognised the value of physical activity on behaviour and academic engagement. Furthermore, interviews with more strategic decision-makers at the school governance level may have revealed different attitudes towards implementation.\\u003c/p\\u003e\\u003cp\\u003e The research was conducted in some of the most built-up and deprived areas of Bradford and Tower Hamlets, and was focused on potential implementation at specific local sites which may restrict its generalisability to other urban areas within these wards and in other cities. Evaluation of future implementation of PUSH will provide valuable insight as to the key characteristics needed to support successful delivery and outcomes.\\u003c/p\\u003e\\u003cp\\u003eComparisons with previous studies was limited due to school-delivered outdoor play interventions typically being delivered within school grounds, or in green spaces which are typically considered suitable and appropriate for outdoor play. the delivery of PUSH adds complexity through the need for staff to walk children to local sites, and using sites which are not typically considered suitable or acceptable for play. However, the attitudes and concerns among staff to risky outdoor play within the school curriculum, and potential parent concerns were consistent with previous studies.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eImplications of findings for further development\\u003c/h2\\u003e\\u003cp\\u003ePUSH is an evidence-based intervention with the potential to increase children\\u0026rsquo;s physical activity and wellbeing through regular outdoor play in urban spaces. The findings demonstrate the need to adapt PUSH to include activities to ensure staff and parent buy-in prior to implementation. This could be achieved by communication strategies and parent involvement in delivery, and staff training to include experience of Forest Schools, as used by Forest School participating in this research. There is also a need to explore the potential for PUSH to be delivered via community groups, initiatives and organisations which support children but are not bound to deliver an academic curriculum.\\u003c/p\\u003e\\u003cp\\u003eSince the research was conducted, there has been increased cross-party support to ensure children\\u0026rsquo;s rights to play are enforced through play sufficiency legislation within planning, and national support for a new play strategy for England [\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e], demonstrating the relevance and importance of PUSH. Implementation and evaluation of evidence-based interventions such as PUSH could support the need for this strategy.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eOverall, our findings support the future of PUSH, and highlight useful revisions to feed into its design and delivery. PUSH aligns with a whole school approach to supporting children\\u0026rsquo;s physical activity, and could provide an opportunity to create behaviour change in relation to outdoor play for children living in urban areas. This could form part of the wider solution to the current problem of low levels of physical activity and wellbeing among children and young people, and aligns with the current drive to enhance children\\u0026rsquo;s rights to play.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eBfd\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eBradford\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eTH\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eTower Hamlets\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eFS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eForest School\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003ePUSH\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ePlay in Urban Spaces for Health\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003ePUPS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003epotential urban play spaces\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch3\\u003eEthics approval\\u003c/h3\\u003e\\n\\u003cp\\u003eThe research was conducted in accordance with the Declaration of Helsinki. Ethics approval was granted by University College London\\u0026rsquo;s IOE Research Ethics Committee (REC1787, data protection registration number Z6364106/2023/03/71).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3\\u003eConsent for publication\\u003c/h3\\u003e\\n\\u003cp\\u003eNot applicable \\u0026ndash; data were anonymised and consent was obtained from all participants to use their anonymised quotes within research publications.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3\\u003eAvailability of data and materials\\u003c/h3\\u003e\\n\\u003cp\\u003eThe materials used to conduct this research (participant information sheets, consent forms and interview topic guides) and the theory of change and logic model produced as an output are available online through the Harvard dataverse \\u003ca href=\\\"https://dataverse.harvard.edu/dataset.xhtml;jsessionid=8986a44ce48db92ebd84629b3af9?persistentId=doi%3A10.7910%2FDVN%2FLI5GBK\\u0026version=DRAFT\\\"\\u003ehere \\u003c/a\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated during the current study are not publicly available due to sensitivity of individual data but redacted anonymised transcripts are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003eTo request access to anonymised interview transcripts, please email the Born in Bradford research team (borninbradford@bthft.nhs.uk). If your request is approved, we will ask you to sign a data sharing contract and a data sharing agreement.\\u003c/p\\u003e\\u003cul\\u003e\\n \\u003cli\\u003eAdditional data file 1: overview of potential urban play spaces\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 2 \\u0026ndash; participant information sheet for Bradford schools near the PUPS\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 3 - participant information sheet for Tower Hamlets schools near the PUPS\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 4 \\u0026ndash; participant information sheet for staff delivering Forest Schools in Bradford\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 5 \\u0026ndash; participant information sheet for staff delivering Forest Schools in Tower Hamlets\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 6 \\u0026ndash; consent form\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 7 \\u0026ndash; interview topic guide for headteachers of schools delivering Forest School programmes\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 8 \\u0026ndash; interview topic guide for staff delivering Forest School programmes\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 9 \\u0026ndash; interview topic guide for headteachers of schools located near the PUPS\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 10 \\u0026ndash; interview topic guide for staff supporting children\\u0026rsquo;s play or physical activity at schools located near the PUPS\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 11 \\u0026ndash; theory of change\\u003c/li\\u003e\\n \\u003cli\\u003eAdditional data file 12 \\u0026ndash; logic model\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003ch3\\u003eCompeting interests\\u003c/h3\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests\\u003c/p\\u003e\\n\\u003ch3\\u003eFunding\\u003c/h3\\u003e\\n\\u003cp\\u003eThis research was primarily funded through an NIHR programme development grant (NIHR204232), and the authors\\u0026rsquo; involvement was supported by funding from the Yorkshire and Humber Applied Research Collaboration (ARC), Bristol Biomedical Research Centre (BRC), Sport England Local Delivery Pilot Bradford, and Act Early UK Prevention Research Partnership (MR/S037527/1).\\u003c/p\\u003e\\n\\u003ch3\\u003eAuthor\\u0026rsquo;s contributions\\u003c/h3\\u003e\\n\\u003cp\\u003eAS led the draft of the manuscript, made substantial contributions to the design of the work, and led elements of the data acquisition, and had significant involvement in the analysis and interpretation of the data.\\u003c/p\\u003e\\n\\u003cp\\u003eER made a substantial contribution to the design of the work, led elements of the data acquisition, had significant involvement in the analysis and interpretation of data and had substantial involvement in drafting the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eHH made a substantial contribution to the design of the work, led elements of the data acquisition, had significant involvement in the analysis and interpretation of data, and supported the revision of the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eCC and SB jointly led the conception of the project, and made substantial contributions to the design and interpretation of data, and the revision of the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eLE contributed to the draft of the manuscript, supported data acquisition and had significant involvement in the analysis and interpretation of data.\\u003c/p\\u003e\\n\\u003cp\\u003eEM contributed to the draft of the manuscript and made substantial contributions to the conception of the project and design of the work.\\u003c/p\\u003e\\n\\u003cp\\u003eNC contributed to the draft of the manuscript and made substantial contributions to the conception of the project and design of the work.\\u003c/p\\u003e\\n\\u003cp\\u003eTR contributed to the draft of the manuscript and made substantial contributions to the interpretation of the data.\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors read and approved the final manuscript and have agreed to be personally accountable for the author\\u0026apos;s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\\u003c/p\\u003e\\n\\u003ch3\\u003eAcknowledgements\\u003c/h3\\u003e\\n\\u003cp\\u003eWe would like to thank all of the participants who gave up their time to take part in this research, and those schools in Bradford and Tower Hamlets which supported the recruitment and data collection process. We would also like to thank Professor Jo Van Herwegen for her contribution as an advisory board member, and Dave Turner, Mevagh Harris, Elliot Lever, and Lauren Charlesworth who helped transcribe the interviews.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eBento G, Dias G. The importance of outdoor play for young children\\u0026rsquo;s healthy development. Porto Biomed J. 2017;2:157\\u0026ndash;60.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eBrussoni M, Olsen LL, Pike I, Sleet DA. Risky play and children\\u0026rsquo;s safety: balancing priorities for optimal child development. Int J Environ Res Public Health. 2012;9:3134\\u0026ndash;48.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eBeaulieu E, Beno S. Healthy childhood development through outdoor risky play: Navigating the balance with injury prevention. 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Educ 3\\u0026ndash;13. 2023;51:1\\u0026ndash;12.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eDabaja ZF. The strands of the Forest School implementation challenges: A literature review. PRISM J PRISM Early View. 2023;6:63\\u0026ndash;77.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eElliott H. Forest School in an inner city? Making the impossible possible. Educ 3\\u0026ndash;13. 2015;43:722\\u0026ndash;30.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eCronin de Chavez A, Seims AL, Dharni N, McEachan RRC, Dickerson J. Unlocking the forest: An ethnographic evaluation of Forest Schools on developmental outcomes for 3-year-olds unaccustomed to woodland spaces. Wellcome Open Res. 2024;9:519.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eUNICEF. 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Tower Hamlets borough profile. 2024. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.towerhamlets.gov.uk/Documents/Borough_statistics/Tower-Hamlets-Borough-Profile-2024.pdf\\u003c/span\\u003e\\u003c/span\\u003e. Accessed 5 Apr 2025.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eCity of Bradford Metropolitan District Council. Open space audit. 2021. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.bradford.gov.uk/Documents/EvidenceBase/Environment/Open\\u003c/span\\u003e\\u003c/span\\u003e Space Studies/1. Open Space Audit Report 2021.pdf. Accessed 20 Sept 2025.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eFields. in Trust. Greenspace Index 2024: interactive maps. No date. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://experience.arcgis.com/experience/405187bb87f041c9a4d70c6b346c5bc4\\u003c/span\\u003e\\u003c/span\\u003e. Accessed 28 Aug 2024.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eVafai Y, Benson R, Albert A, Cameron C, Pickett K. Child and family health and wellbeing in Bradford and Tower Hamlets: an ActEarly report. 2023. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://actearly.org.uk/wp-content/uploads/2023/05/55843_HL_Act-Early-Report_v10-1-3.pdf\\u003c/span\\u003e\\u003c/span\\u003e. Accessed 7 July 2025.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eOffice for National Statistics. Ethnic group, England and Wales: Census 2021. 2022. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/bulletins/ethnicgroupenglandandwales/census2021\\u003c/span\\u003e\\u003c/span\\u003e. Accessed 15 Sept 2025.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eSekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: An overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17:1\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eMcCree M, Cutting R, Sherwin D. The hare and the tortoise go to Forest School: Taking the scenic route to academic attainment via emotional wellbeing outdoors. Early Child Dev Care. 2018;188:980\\u0026ndash;96.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eDabaja ZF. The Forest School impact on children: reviewing two decades of research. Educ 3\\u0026ndash;13. 2022;50:640\\u0026ndash;53.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003eCoates JK, Pimlott-Wilson H. Learning while playing: Children\\u0026rsquo;s Forest School experiences in the UK. Br Educ Res J. 2019;45:21\\u0026ndash;40.\\u003c/span\\u003e\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cspan\\u003ePlay England. It All Starts with Play. 2025. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.playengland.org.uk/s/It-All-Starts-with-Play-Full-Version-FINAL.pdf\\u003c/span\\u003e\\u003c/span\\u003e. Accessed 17 Aug 2025.\\u003c/span\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pubh\",\"sideBox\":\"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pubh/default.aspx\",\"title\":\"BMC Public Health\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Child development, urban regeneration, children’s rights, play sufficiency, child-friendly cities, whole system\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7702361/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7702361/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eOutdoor play can support children and young people’s mental wellbeing, social and cognitive development and increase physical activity levels. However, many children are not sufficiently active for health. Children’s outdoor play has declined in recent years and barriers exist within the physical and social environment. Forest Schools can encourage outdoor play through familiarisation with local green spaces, but suitable spaces are limited in dense urban areas. Through the Play in Urban Spaces for Health (PUSH) intervention concept, primary school staff support familiarisation of and regular active play in local urban spaces. This could facilitate sustained behaviour change, whereby children use these sites with their families, and have the capability and motivation to create opportunities for outdoor active play within other urban spaces. The aim of this research was to explore the acceptability and feasibility of PUSH.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e18 semi-structured interviews were conducted – eight with teachers and headteachers at primary schools near potential urban play spaces in Bradford (Bfd), Yorkshire and Tower Hamlets, London UK to explore attitudes towards, and barriers and facilitators to implementing PUSH - and ten with staff involved in Forest School delivery through primary schools to capture learning and outcomes from taking children to local green spaces for Forest School. Thematic analysis was used to explore acceptability and feasibility of PUSH.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePUSH was generally found to be acceptable, with perceived benefits aligning with those observed within Forest Schools. Potential barriers to implementing PUSH included curriculum pressures and safety of public spaces. However, the learning from Forest School delivery provided potential solutions to incorporate into the intervention design. The findings informed the intervention theory of change and logic model.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study offers preliminary evidence to support the delivery of the PUSH intervention within primary schools, which may support children’s outdoor habitual play. The findings emphasise the need to incorporate activities to ensure parent and staff buy-in prior to a pilot project.\\u003c/p\\u003e\\n\\u003cp\\u003eClinical trial number: Not applicable.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Prospective acceptability, feasibility and outcomes of a primary school-led outdoor play intervention for young children\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-10-14 20:36:44\",\"doi\":\"10.21203/rs.3.rs-7702361/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-11-06T04:37:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-10-25T21:11:23+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-10-16T10:32:37+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"306613139247332116236123406681118948839\",\"date\":\"2025-10-06T17:26:07+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"40232146764707786361850181078741347612\",\"date\":\"2025-09-30T16:09:32+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-09-30T12:01:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-09-30T11:59:17+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-09-29T11:45:25+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-09-29T11:40:30+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Public Health\",\"date\":\"2025-09-29T11:29:07+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pubh\",\"sideBox\":\"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pubh/default.aspx\",\"title\":\"BMC Public Health\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"d3fe9a45-118c-47b2-8630-837ab5a7b217\",\"owner\":[],\"postedDate\":\"October 14th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-16T16:09:08+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-7702361\",\"link\":\"https://doi.org/10.1186/s12889-026-26846-y\",\"journal\":{\"identity\":\"bmc-public-health\",\"isVorOnly\":false,\"title\":\"BMC Public Health\"},\"publishedOn\":\"2026-03-12 16:00:32\",\"publishedOnDateReadable\":\"March 12th, 2026\"},\"versionCreatedAt\":\"2025-10-14 20:36:44\",\"video\":\"\",\"vorDoi\":\"10.1186/s12889-026-26846-y\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12889-026-26846-y\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7702361\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7702361\",\"identity\":\"rs-7702361\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}