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Original Article
care, health and development
doi:10.1111/cch.12262

Outdoor physical activity and its relation with self-

reported health in Japanese children: results from
the Toyama birth cohort study
J. Liu,* M. Sekine, T. Tatsuse, Y. Fujimura, S. Hamanishi, F. Lu and X. Zheng
*Institute of Reproductive and Child Health/Ministry of Health Key Laboratory of Reproductive Health; Department of Epidemiology
and Biostatistics, School of Public Health, Peking University, Beijing, China
Department of Epidemiology and Health Policy, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama,
Toyama, Japan
Research Center for Physical Activity, Diet and Health Promotion, Institute of Sports Science, Department of Physical Education and
Sports Science, Peking University, Beijing, China, and
Institute of Population Research, Peking University, Beijing, China
Accepted for publication 28 April 2015

Abstract
Background Few studies have examined trends in engagement in outdoor physical activity as
children grow and whether changes in physical activity at different ages affect childrens health. This
study determined the preference for and frequency of physical activity among Japanese children
from ages 6 to 12 years and investigated the effect of physical activity and of change in physical
activity on childrens self-reported health.
Methods Data were from the prospective, longitudinal Toyama Birth Cohort Study, a total of 5238
Keywords
outdoor physical activity,
children were followed at their age of 12 years. Preference for and frequency of outdoor physical
quality of life, self- activity were from the self-administered questionnaire. Self-reported health was from the Japanese
reported health, the
version of Dartmouth Primary Care Co-operative project charts.
Toyama study
Results Reporting liking and participating in outdoor physical activity at both ages 6 and 12 years
Correspondence: were associated with higher likelihood of good self-reported health (Odds ratio 1.24 [95% CI: 1.03
Michikazu Sekine, MD, 1.50] for liking activity and OR = 1.27[1.08, 1.50] for participating in activity) compared with those
PhD, MBA, MSc, DLSHTM,
Department of Epide-
who did not like or participate in this at only one or at neither age, after adjustment for lifestyle
miology and Health Policy, factors and body pain. The adjusted OR was 1.23 (95% CI: 0.971.56) for girls whose preference for
Graduate School of Medi-
liking outdoor physical activity was not changed at both ages compared with those whose
cine and Pharmaceutical
Sciences, University of preference changed. The OR was 1.47 (95% CI: 1.141.89) for boys who persisted in participating in
Toyama, 2630 Sugitani, the outdoor physical activity than those who did not persist.
Toyama 930-0194, Japan.
E-mail: sekine@med.u-
Conclusions There is an association between a persistent expression of liking outdoor physical
toyama.ac.jp activity and self- reported health.

vigorous physical activity daily and that most of daily physical

Introduction
Physical activity plays a critical role in childrens well-being.
The World Health Organization recommends that children
aged 517 years engage in at least 60 min of moderate to
activity be aerobic (World Health Organization 2010).
However, studies from the USA (Fakhouri et al. 2013),
Australia (Hinkley et al. 2012) and Belgium (Cardon & De
Bourdeaudhuij 2008) have shown that many children and

920 2015 John Wiley & Sons Ltd


adolescents in developed countries do not achieve this
recommended level. According to the national survey, the
proportion of participating in physical activity less than 60 min
per week in Japanese junior high school students was around
9.3% for boys and 31.1% for girls (Ministry of Education
2010). At the same time, the prevalence of obesity was almost
doubled from late 1980s to 2007 (Yoshinaga et al. 2010), and
the step counts in Japanese elementary school children
decreased in the past decade (Tanaka & Tanaka 2009).
Outdoor physical activity is a powerful and preventative
healthcare tool with low-cost health treatment. Studies con-
firmed that outdoor exercise is particularly useful for supporting
the health of children and adults (Kuo 2010). A higher density of
street trees was associated with 12% lower prevalence of obesity
among preschool children in New York (Lovasi et al. 2013).
Obesity indicators in young Australian children decrease in
relation to time spent outdoors, while vigorous outdoor physical
activity increased (Cleland et al. 2009). A study from Canada
shows that green school grounds would be an important
intervention to encourage moderate outdoor physical activity in
school health promotion initiatives (Dyment & Bell 2008).
It has long been known that being physically active has
positive health effects (U.S.Department of Health and Human
Services 1996). Physical activity may track from childhood to
adolescence until to adulthood; long-term health benefits
depend on a continued engagement in physical activity
(Shephard 1984). Few researches have studied the association
between preference and self-reported health, although several
studies found the correlation between practice of physical
activity and self-reported health. A study from the USA and
Canada showed a positive relationship of physical activity and
self-image and quality of life (Iannotti et al. 2009). A systematic
literature review showed a moderately positive association
between physical activity and physical self-concept (Strong
et al. 2005), and a significant risk of low self-rated health with
physical inactivity was found in boys (Elinder et al. 2011).
However, few studies have examined trends in engagement in
outdoor physical activity as children grow and whether changes
in physical activity at different ages affect childrens health. The
lack of longitudinal data on both physical activity and health
hinders such an exploration.
The aim of the present study therefore was to evaluate the
effects of outdoor physical activity and of change in physical
activity on self-reported health. We hypothesized that the
preference for and frequency of outdoor physical activity can
be maintained from primary school to junior high school and
that persistence in outdoor physical activity would be related to
good self-reported health.
Physical activity and childrens self-reported health 921
Methods
Study design and population
Subjects participated in the Toyama Birth Cohort Study, a
prospective, longitudinal survey of 10 438 children born
between 2 April 1989, and 1 April 1990, in Toyama Prefecture,
Japan (Sekine et al. 2002). Participants of the Toyama study
were all of those who were born in the aforementioned periods
and who lived in Toyama Prefecture at the time of the survey.
The children were followed every 3 years from ages 3 (Phase 1)
to 15 years (Phase 5), and data from ages 6 (Phase 2) to
12 years (Phase 4) were included in the current study. A letter
of invitation and a questionnaire were sent to the subjects
through their schools in the follow-up survey. Participants
answered the questions and returned their responses in a sealed
envelope. Written informed consent was obtained from the
parents of the participants. The study was approved by the
Ethical Committee of the Toyama Medical Pharmaceutical
University.
Preference for and frequency of outdoor physical activity
Contents of the self-administered questionnaire on childrens
outdoor physical activity were examined in phases 2 and 4,
including preference for outdoor physical activity, rated on a 4-
point scale (1 : like very much, 2 : like, 3 : dont like and 4 :
hate) and frequency of participating in outdoor physical
activity during 1 week, rated on 4-point scale (1 : very often,
2 : often, and 3 : occasionally, and 4 : never). In the current
study, preference for physical activity was recoded as like
(combining like very much and like) or dislikes (combining
dont like and hate). Frequency of physical activity was
recoded as frequent (combining very often and often) or
infrequent (combining occasionally and never). In particu-
lar, there is a question on how many hours do the child spend
the whole week in phase 4. We divided the total hours by seven
(whole week) to calculate the general duration of physical
activity every day. We used the frequency of eating breakfast
(measured on a 4-point scale: very often, often, sometimes
and seldom) to describe eating patterns. Average amount of
sleep per day was measured as <7, 78, 89 or >9 h/night. The
validity of the lifestyle questionnaire was examined in a
previous study. In that study, frequent outdoor physical
activity was significantly associated with an increasing trend
in energy expenditure originating from physical activity, mean
steps per day and mean activity counts per day originating
from an Actiwatch (P < 0.05 for a linear trend test) (Chen et al.
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
922 J. Liu et al.
2003). The correlation coefficient between subjective and
objective records was 0.97 (P < 0.001) for assumed amount of
sleep, and the difference between subjective and objective
records was 8.19 min (95% confidence interval [CI]: 4.93
11.45) for assumed amount of sleep (Gaina et al. 2004).
Self-reported health
In phase 4, data on self-reported overall health were collected
using a Japanese version of Dartmouth Primary Care Co-
operative project Charts (Chen et al. 2005a). Children were
asked, During the past 4 weeks, how would you rate your health
in general? The response options were excellent, very good,
good, fair, and poor. The outcome variable was dichoto-
mized: the first three response options (excellent, very good
and good) were combined as good, and the latter two (fair and
poor) were combined as poor (Chen et al. 2005a).
Statistical analysis
To evaluate the association between persisting expressed liking
for outdoor physical activity and participating in outdoor
physical activity and good self-reported health, we performed
chi-square analysis. Adjusted odds ratios (ORs) and their
corresponding 95% CIs for the self-report of good health at age
12 years was calculated from binary logistic regression models,
adjusted for potential confounders found in the single-factor
chi-square analysis. Statistical analyses were conducted using
SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). A two-tailed
P < 0.05 was considered statistically significant.
Results
A total of 5238 children were followed from ages 6 to 12 years;
children had a mean age of 12.25 0.54 years at phase 4.
Demographic characteristics of the subjects are shown Table 1.
There was no significant difference between boys and girls,
except boys were slightly older than girls, took breakfast and
slept more regularly than girls.
The majority of children liked outdoor physical activity and
were physically active and maintained this habit from ages 6 to
12 years. The preference for outdoor physical activity decreased
as children grew: it decreased from 92.1% and 93.9% at age
6 years for boys and girls, respectively, to 87.8% and 75.7% at
age 12 years. The proportion of children who actually engaged
in outdoor physical activity was lower than the proportion who
reported liking outdoor physical activity. A total of 83.1% of
boys and 73.7% of girls expressed persisting liking of outdoor
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
physical activity from ages 6 to 12 years, while 68.9% of boys
and 54.0% of girls could maintain actively participating in
activity from ages 6 to 12 years (Table 2). Boys showed a higher
proportion of liking outdoor physical activity and are more
active than girls at age 12 years (P < 0.05). Only 65.3% of boys
and 46.6% of girls at age 12 years achieved the recommended
level of activity (at least 60 min/day).
Table 3 shows the proportion of good self-reported health by
age and sex. Generally, children who expressed liking outdoor
physical activity and who took part in the activity had higher
proportion of good self-reported health than those without,
irrespective of sex. For example, 85.7% of boys, who liked
outdoor physical activity at age 12 years, reported good health,
while only 77.6% of boys who did not like activity reported good
health. Besides, boys who expressed persisting liking of outdoor
physical activity shared a high proportion of good self-reported
health (85.7%) than those who had no persisting liking of
activity (81.6%). It shows similar trends in the girls.
Reporting liking and participating in outdoor physical
activity at both ages 6 and 12 years was associated with a
higher likelihood of good self-reported health (OR 1.24 [95%
CI: 1.031.50] for liking activity and OR = 1.27[1.08, 1.50] for
participating activity) compared with those who did not like or
participate in this at only one or at neither age, after
adjustment for lifestyle factors and body pain (Table 4). The
adjusted OR was 1.23 (95% CI: 0.971.56) for girls whose
preference for liking outdoor physical activity was not changed
at both ages compared with those whose preference changed.
The OR was 1.47 (95% CI: 1.141.89) for boys who persisted
participating the outdoor physical activity than those who did
not persist.
Discussion
In the present study, we investigated the effect of outdoor
physical activity and of change in physical activity on childrens
self-reported health. Lack of physical activity may be a far
greater public health concern than obesity (Mitchell et al.
2010). Self-reported health is a valid measure of a variety of
physical and emotional dimensions of adolescent well-being
(Fosse & Haas 2009; Elinder et al. 2011). Our study showed
that children who liked and frequently engaged in outdoor
physical activity had better self-reported health than those who
did not, and the persisting liking of and frequent participating
in outdoor physical activity contribute to good self-reported
health. Hence, a preference for outdoor physical activity and
good habits in terms of physical activity are meaningful for
maintaining good health.
 Physical activity and childrens self-reported health 923

Table 1. Descriptive statistics for the subjects at age 12 years (n = 5238)

Males (n = 2526) Females (n = 2712)

Characteristic n % n % P

Age (years) (mean SD) 12.27 0.51 12.23 0.58 0.027

Body mass index (mean SD) 19.27 3.25 19.11 2.82 0.071
Family structure Parents and grandparent(s) 1415 57.5 1557 58.1 0.102
Two parents 973 39.6 1019 38.0
Single parent 71 2.9 104 3.9
Fathers employment Full time 2327 98.7 2478 98.6 0.600
Part time 12 0.5 10 0.4
Not employed 19 0.8 26 1.0
Mothers employment Full time 1218 50.8 1354 52.0 0.612
Part time 795 33.2 830 31.9
Not employed 384 16.0 418 16.1
Siblings Yes 2289 93.0 2494 93.1 0.945
No 172 7.0 186 6.9
Frequency of eating breakfast Every day 2259 90.5 2352 87.2 0.001
Often 151 6.0 244 9.1
Sometimes 68 2.7 75 2.8
Seldom 19 0.8 25 0.9
Amount of sleep <7 h 355 14.3 596 22.2 0.000
78 h 1055 42.5 1260 46.9
89 h 854 34.4 694 25.8
>9 h 216 8.7 135 5.0

Table 2. Preference for and frequency of outdoor physical activity and of change by age and sex

Males Females

Age (years) Characteristic n % n % P

6 Preference Like 2098 92.1 2307 93.9 0.008

Dislike 180 7.9 150 6.1
Frequency Frequent 1918 84.6 2162 88.0 0.000
Infrequent 350 15.4 295 12.0
12 Preference Like 2167 87.8 2014 75.7 0.000
Dislike 300 12.2 645 24.3
Frequency Frequent 1911 76.8 1546 57.8 0.000
Infrequent 577 23.2 1129 42.2
Change from Preference Persisting liking 1862 83.1 1788 73.7 0.000
age 6 to 12 From like to dislike 201 9.0 493 20.3
From dislike to like 113 5.0 57 2.3
Persisting disliking 65 2.9 89 3.7
Frequency Persisting frequent 1537 68.9 1310 54.0 0.000
From frequent to infrequent 348 15.6 822 33.9
From infrequent to frequent 183 8.2 107 4.4
Persisting infrequent 164 7.3 186 7.7

Outdoor physical activity is positively associated with fitness
in children. A study showed that children who reported
spending most of their after-school time outdoors had higher
cardiorespiratory fitness than youth who reported no time
outdoors (Schaefer et al. 2014). As well as the health benefits of
physical activity, outdoor play improves problem solving
ability, aids the development of motor skills, facilitates social
competence and safety skills and allows children to grow
emotionally, which would contribute to health benefits (Smith
et al. 2015). It has also been suggested that children engage in
outdoor play as a form of entertainment, not only to increase
the probability of being physically active in later life, but to
achieve the health benefits (Brockman et al. 2011).
Childhood physical activity yields health benefits; long-term
maintenance may keep benefits in the later life. Most children
liked outdoor physical activity and were physically active and
maintained this habit from ages 6 to 12 years. Our study
showed that 7080% preference for liking outdoor physical

2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
924 J. Liu et al.

Table 3. The association between outdoor physical activity at age 6 to 12 years and of change and good self-reported health at age 12 years by sex
Preference for and frequency of physical activity
Good
Like Dislike Frequent Infrequent
self-reported
health n % n % P n % n % P

Males
At age 6 years 1741 85.3 145 81.5 0.174 1594 85.5 282 81.7 0.076
At age 12 years 1807 85.7 229 77.6 0.000 1608 86.4 447 79.7 0.000
Both ages* 1553 85.7 306 81.6 0.043 1293 86.5 556 81.5 0.003
Females
At age 6 years 1837 80.9 121 81.2 0.924 1724 81.0 235 80.5 0.827
At age 12 years 1637 82.6 484 76.0 0.000 1256 82.5 878 78.7 0.015
Both ages* 1444 82.0 491 77.8 0.020 1063 82.3 871 79.1 0.045

*Children who expressed persisting liking for activity or took part in activities at ages 6 and 12 years.

Table 4. Unadjusted and adjusted* odds ratios (95% confidence intervals) for good self-reported health at age 12 years in relation to change in outdoor
physical activity
Total Males Females

Variable Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

Persisting expressed liking for physical activity

Yes 1.37(1.15,1.63) 1.24(1.03,1.50) 1.35(1.01,1.81) 1.28(0.95,1.74) 1.30(1.04,1.63) 1.23(0.97,1.56)
No
1.00 1.00 1.00
Persisting participate in physical activity
Yes 1.37(1.17,1.60) 1.27(1.08,1.50) 1.45(1.14,1.85) 1.47(1.14,1.89) 1.23(1.00,1.51) 1.14(0.92,1.42)
No
1.00 1.00 1.00

*Adjusted for lifestyle factors (frequency of eating breakfast and amount of sleep), and headache and abdomen pain in the past 6 months.

activity could be maintained during the primary school period,
while 5070% frequency of outdoor physical activity could be
maintained. It is well documented that early life course
experiences shape health outcomes well into adulthood, and
durable exercise patterns take form during childhood
(Umberson et al. 2010). Sports participation in childhood
predicted physical activity in adulthood; it implied that
participating in physical activity at a young age forms a
preference for physical activity participation which is main-
tained throughout life (Smith et al. 2015). The health action
process approach (Schwarzer & Luszczynska 2008) categorizes
health behavioural changes into two stages, the pre-intentional
motivation process and the post-intentional volition process,
with the first process leading to behavioural intention and the
second to actual health behaviours (Duan et al. 2012). To guide
children to like and participate in outdoor physical activities
would be beneficial to build good habits and improve good
health status. Once a person has an intention to act, he or she
needs detailed instructions on how to perform the desired
action and the perceived self-efficacy to initiate and to
maintain the action. Schools, families and society as a whole
should collaborate, for example, through media promotion, to
let children know about the importance of outdoor physical
activity and how to increase their frequency of physical activity.
The proportion of children taking part in physical activity
(actual practice) was lower than the proportion of children
who reported liking physical activity. As it is a common
phenomenon of long school hours and high academic
completion in many Asian countries, the parents in Asian
countries were prone to send their children to study extra time
after school, so cram schools became prevalent. Study showed
that Chinese students cared more about fulfilling academic
expectations than did American students (Chen & Lan 1998),
so did South Korea, Japan and other eastern Asian countries;
they always spent long hours in study to achieve high academic
scores (Byun & Park 2012). Traditional eastern cultural
background, in which Asian children are always told to study
hard and do well in school to secure a bright future, may
account for this phenomenon. While American children are
dividing their time between a thousand different extracurric-
ular activities in addition to household chores, Asian students
are concentrating more on their schoolwork. A growing
number of elementary and junior high school students attend
private extracurricular study schools (juku) after school several

2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927

times a week or even every day (Japan Child and Family
Research Institute 2013). So these students may not have
enough time to participate in physical activity, even if they
enjoy it. About 25% of primary school students (age 9 years)
and 44% of junior high school students (age 12 years) attend
juku; they spend 3 and 5 h per week, respectively, in juku
(Japan Child and Family Research Institute 2013). Increasing
the level of physical activity of children and adolescents will
require strategies that draw on the expertise of school, public
health and medical professionals. Furthermore, health
messages should focus on improving adherence to physical
activity, because the health benefits of physical activity are
maintained only with regular practice (Philipe 2013).
Our study showed significant differences in outdoor physical
activity by gender, which is consistent with other research. Boys
performed better than girls on several motor skills. Total
physical activity and time spent in moderate-vigorous and
vigorous activities during child care were 1225% higher in boys
compared with those in girls in young children (Bonvin et al.
2012). Girls recorded less activity than boys, which may due to
physiological differences or potential gender bias in the
reporting of physical activity (Owen et al. 2009). A recent study
conducted in 2833 elementary and junior high school students
living in Japan also showed that physical activity and leisure
habits scores were lower for girls (Nakano et al. 2013). Hence,
increasing the level of moderate to vigorous physical activity
among girls is a challenge and a public health priority. And of
course, further studies in this field are needed.
This study has several strengths. Firstly, the Toyama Birth
Cohort Study is a longitudinal study which provides
opportunity for analysing trends over time in physical activity.
Secondly, the measurement of self-reported overall health was
originally from Japanese Dartmouth Primary Care Co-operative
project Charts and has been validated (Chen et al. 2005b).
Thirdly, physical activity was validated in our previous study
and could reect the childrens actual lifestyle from the angle of
energy consumption (Chen et al. 2003; Chen et al. 2005b).
Fourthly, we collected data on possible confounders such as
breakfast pattern, amount of sleep, headache and abdomen
pain to exclude the effects from these confounders.
Nevertheless, there are several limitations to the study.
Firstly, we collected information on the amount of physical
activity but not its intensity (moderate or vigorous). Secondly,
because this is a follow-up study, there may be potential
follow-up bias. However, we used validated quality control
measures during the follow-up to minimize the bias, such as
advocating the meaning of the survey to participants, regular
inspection of the survey and post-survey check.
2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 6, 920927
Physical activity and childrens self-reported health 925
In conclusion, using longitudinal data from the Toyama
Birth Cohort Study, we found that only around half of the
children met recommendations for physical activity. Not
only do preferences for and frequency of outdoor physical
activity contribute to good health, but a continued like and
frequency of outdoor physical activity can improve self-
reported health.
Key messages
A preference for and good habits in outdoor physical
activity are meaningful for maintaining good health.
Increasing the level of physical activity of children
and adolescents will require strategies that draw on
the expertise of school, public health, and medical
professionals.
Health messages should focus on improving adher-
ence to physical activity.
Increasing the level of moderate to vigorous physical
activity among females is a challenge and a public
health priority.
Funding
This work was supported in part by Nishiyama Takahito Fund
of the University of Toyama and the National Natural Science
Foundation of China (grant no. 81202265). The Toyama birth
cohort study has been supported by grants from the Ministry
of Health and Welfare (H10-Child-020), the Ministry of
Health, Labour and Welfare (H13-Health-022), Toyama
Medical Association, and the Japan Heart Foundation.
Conflict of interest
We declare there are no competing financial interests in
relation to the work described.
Acknowledgements
We express our great appreciation to all the children and their
parents participating in this study. We are indebted to the
principals and school nurses in the Toyama Prefecture for their
help and co-operation in the study. We also acknowledge the
contribution of Ms Yasuko Yamazaki for data collection and
general management of this study.
926 J. Liu et al.
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