An Applied Learning Activity for Health and Fitness Students to Advocate for School Playground and Gymnasium Safety

Playground accidents are a leading cause of injury to children at school and home. Health and physical education faculty and students from a university school of education and college of nursing collaborated with wellness team members in a public school system to complete a systematic planning process. The aim was to enhance the school health program and reduce risk of injuries. University faculty mentored health and physical education students as they developed professional competencies related to program planning and advocacy. Students identified safety hazards in 52 school/community playgrounds and 45 gymnasiums, and reported maintenance issues to reduce the risk of injuries. Teachers, parents, students and community residents can learn to assess playground and gymnasium safety, identify hazards, and plan improvements to the school health environment. © 2009 Californian Journal of Health Promotion. All rights reserved.


Introduction
Structured and unstructured play is essential to children's healthy growth and development.Play provides opportunities to learn and to practice social, physical and relationship skills (National Program for Playground Safety [NPPS], 2006a;Vygotsky, 2002).Secondary benefits of play include increased attention to cognitive tasks and decreased restlessness in the classroom (Azar, 2002;Del Busto, 2005;KaBoom!, n.d.).
School personnel and taxpayers must provide safe facilities for supervised recess and physical education classes.State curriculum frameworks for health and physical education provide the impetus to teach safety and risk reduction at school and at home.Unfortunately, injury and death to children occur due to faulty construction, poor maintenance, and unsupervised use of playgrounds.Why should we be concerned about playground and gymnasium safety?
Children need to play in safe environments.Children residing in low-income areas face additional playground hazards due to unsafe equipment and inadequate maintenance (Cradock, Kawachi, Colditz, Hannon, Melly, Weicha, et al., 2005;Suecoff, Avner, Chou, & Crain, 1999).It is difficult to obtain accurate estimates of annual playground injuries as there is no mandatory reporting requirement or single database.Estimates of annual emergency room visits to treat children's playground injuries range between 50,000 (U.S. Consumer Product & Safety Commission [CPSC], 2005) and 200,000 (Frost & Drescher, 2000).Approximately 45% are severe injuries including fractures, internal injuries, concussions, dislocations, and amputations.Of these injuries, 148,000 occur on public playgrounds in schools and community parks, most often falls from swings, climbers and slides.Fewer than 10% of playgrounds where injuries occurred clearly indicated appropriate ages for safe use (Frost & Drescher, 2000).One study of 66 Atlanta child care centers found safety hazards at 84% of sites (Sacks, Holt, Holmgreen, Colwell, Jr., & Brown, Jr., 1990).Similarly, Suecoff and colleagues (1999) identified inadequate fall zones in 81% of 186 New York City playgrounds.
Fifty-one thousand injuries occur on home playgrounds, most often on swings.Sixty percent of injuries are due to falls onto hard surfaces not in compliance with United States Product and Safety Commission (CPSC, 2005).An average of 15 children per year dies due to strangulation and falls onto hard surfaces or onto other equipment.The estimated cost to treat playground injuries in 2003 was $6.8 billion (CDC, 2007;CPSC, n.d., a-e;Frost & Drescher, 2000).
Faculty and students at a university school of education and a rural nursing program in a southeastern state in the U.S. collaborated with faculty, staff and parents in a public school between the years of 2004-2007.The aim of the collaboration was to enhance the school health program to reduce risk of chronic disease and injuries (Geiger, Sims, Evans, Roy, Werner, Prier, et al., 2009).The collaboration was a catalyst to enhance health and physical activity opportunities in at least two ways: develop and field test two practical instruments for students, teachers and caregivers to assess playground and gymnasium safety, and publish a Civil Rights and fitness walking trail through historic sites (Geiger & Werner, 2009).
The focus of this manuscript is a report of a practical application of knowledge to enhance professional practice in health and physical education.Our intent was to teach undergraduate students to advocate for high-quality health promotion programs and related policies.

Learning Project Development
Before developing the applied student learning activity, wellness teams prepared digital images of playgrounds and gymnasiums in all 11 public schools.High school students and their teacher desired to provoke group discussion about correcting safety hazards in schools.As a result, wellness team members requested assistance from university health education faculty and students to systematically record safety hazards in need of correction.This was an ideal opportunity to engage health and physical education students enrolled in two courses (Health Promotion Program Planning and Evaluation, Planning and Management of Fitness Facilities) and nursing students from a local community college in an applied learning project.
The next step was to search for a low-cost and simple tool suitable for use by secondary students, teachers and caregivers.None was found after a preliminary literature review and queries made of health and physical education colleagues.Note that the activity described in this paper preceded publication of "America's Playground: Safety Report Card" by the National Program for Playground Safety (NPPS, 2006b).It is encouraging to note that identification of safety hazards by more than one group of researchers led to the development of checklists to improve playground safety.
Collaborators reviewed available documents about installation, use, and monitoring of playground equipment, and safe use of indoor athletic facilities to inform development of simple assessments (Frost & Drescher, 2000;National Association for Sport and Physical Education, 2006 revised;NPPS, 2006cNPPS, & 2002;;Texas State Department of Health, n.d.;CPSC, 2005CPSC, , 2001, & n.d., a-e;, & n.d., a-e;Suecoff, et al., 1999).One student's father is an architect employed by a municipality who suggested several reference documents reviewed by the class.
Wellness teams developed two new tools during an academic term, "Assessment of an Outdoor Elementary School Playground" containing 32 dichotomous items, and "Assessment of a School Gymnasium" containing 29 dichotomous items (Geiger, 2005a(Geiger, , 2005b)).Draft tools were developed for public school audiences, reviewed by wellness team members, and then sent to a volunteer panel of eight experts.Experts represented the disciplines of physical education, health, early childhood education, exercise physiology, and school leadership and worked in K-12 and higher education.Students formed small groups and individually completed a minimum of five different assessments and then discussed ratings until reaching consensus.In some cases, students revisited a setting to repeat the assessment.
Faculty mentors accompanied the entire group of student raters to a community playground for a guided practice session.Numerous maintenance issues were identified across settings including tall grass, protruding tree stumps, eroded asphalt, broken concrete, trash, metal, and glass hazards, uncovered sand in play areas unprotected from animals and insects, and vehicles parked on play surfaces.None of the playgrounds featured posted safety rules or emergency contact information; however, a few had signs prohibiting use during non-school hours.
Unintentional injuries are likely due to inadequate width and depth of fall zones around and beneath playground structures, limited space for movement between different structures (climbers, swings, seesaws, etc.), and lack of guardrails and protective barriers to prevent falls.Few play areas featured secure fencing to prevent young children from wandering and entrance of uninvited visitors and animals.
Students observed that electrical appliances were not securely covered.
Equipment hazards included unsafe surfacing below play equipment (earth, grass or loose fill material of gravel and stone), and entanglement hazards (uncovered hardware connectors).
Students identified trip and fall hazards such as exposed anchors, loose ropes, frayed cables, warped and cracked wood, and rusted and unmoving parts.
Unfortunately, few playgrounds in 12 cities and 1 county received high ratings that reflect compliance with recommended guidelines for equipment, installation, and maintenance.Desirable features included: • at least one accessible route from the perimeter to all equipment and play areas

Lessons Learned and Recommendations
The collaboration between a university school of education, college of nursing, and public school system in the southeastern U.S. yielded several outcomes including development of two instruments, "Assessment of an Outdoor Elementary School Playground" and "Assessment of a School Gymnasium."Developers believe these brief instruments are a viable option for school, park and recreation professionals and community advocates with limited funds to purchase safety checklists and consultation for staff training.Data were used to recommend improvements to school, city, and park administrators.The town mayor where the project was conducted formed a partnership with a regional medical center to renovate a city park, which now features a paved walking trail and fitness stations accessible to children and those with mobility impairments.The school board scheduled overdue maintenance for playgrounds in one community.
Plans include continued work to estimate instrument reliability and validity before use in a research study.Authors learned that neither instrument universally applies to all settings (public schools and parks, as well as commercial playgrounds).Differences in resources to purchase, install, and maintain facilities for physical activity may exist across urban and rural communities.Construction and safety standards need to be widely communicated among professional and governmental organizations.
Teachers, parents, students, and community residents can learn to assess local playgrounds and gymnasiums and use data to plan improvements.It is necessary to provide free or low-cost assessment tools.Shared events, such as community build or clean-up days, are opportunities to increase collective responsibility for youth health and fitness.Parent-teacher organizations may plan fundraisers to acquire new park property and purchase equipment.Community business and industry partners may contribute expertise and funding.
School wellness teams may use data to establish a need, and then contact local community foundations to apply for funding.National initiatives, such as Project FIT America (http://projectfitamerica.org/), KaBOOM!(http: //www.kaboom.org/), the Shade Foundation of America (http://www.shadefoundation.org/structures.php),and Lowe's Toolbox for Education (http://www.toolboxforeducation .com/)provide small grants to promote active, fit and healthy youth.Funds may be used for teacher and parent training, site preparation, purchasing equipment, and program evaluation.

Acknowledgement
Authors gratefully acknowledge support for Selma NEWS received from the University of Alabama at Birmingham School of Education, Alabama State Department of Education, Child Caring Foundation, and Alabama Department of Agriculture and Industries in the United States.
Each panelist independently responded to a series of questions about draft items, including: 1) which items would you change; 2) what items should be added; & 3) what items should be deleted?Panelists were asked to write an explanation of recommended changes.Collaborators added new items, revised items for clarity after expert review, and then planned pilot testing.The first instrument, "Assessment of an Outdoor Elementary School Playground," contains 32 items presented with dichotomous response options (1=Yes, 0=No), plus a section to add comments.Sample items include:• Playground equipment is appropriate for age of children.Look for safety signs identifying ages and body size for safe use.Watch children at play to ensure they are able to use the equipment without signs of fear or falling.• There is a minimum of 6 feet between playground equipment to reduce accidents and injuries.•Stairways or stepladders shall have handrailsor alternate means of hand support as shown in Figure1.The second, "Assessment of a School Gymnasium," contains 29 dichotomous items, plus a section to add comments.Sample items include:• The space for physical activity is large enough to accommodate all students of a class moving at the same time.• Electrical appliances (air conditioners, power outlets, switch boxes, transformers) are inaccessible to children.• Emergency lighting system and exit signs in working order.• General appearance is clean without trash, debris, spills, vermin, and graffiti.• Smoke detectors and fire alarms visible and in working order.

Figure 1 .
Figure 1.Illustration of a City Park with Safe Playground Features

Table 1 .
Sample Data Sheet from a Student Pair Using Playground Assessment.