The aim of the study was to investigate nurses’ and care workers’ experiences of spiritual needs among residents with dementia in nursing homes. Nurses claim to practice holistic nursing. Nevertheless, there is little knowledge about how to recognise spiritual needs in residents with dementia.The study was conducted using a qualitative method with an exploratory design. Eight focus- group interviews in four Norwegian nursing homes were performed from June 2011 – Jan 2012. Using open-ended research questions, a total of 31 participants were asked to share their understanding and experiences regarding residents’ spiritual needs. The interviews were analysed using a phenomenological – hermeneutical method.contemplative and restful moments” and “calmness due to familiarity”, ii) The need for confirmation, described as “love and proximity” and iii) The need to express faith and beliefs, described as “participate in worship and prayers” and “approaching death”.The nurses’ and care workers’ experiences of residents’ spiritual needs were related to three main themes; i) The need for serenity and inner peace, described as “The comprehensive analyses revealed that the nurses believe the residents’ spiritual needs were linked to the residents’ previous sources of finding meaning, in relation to inter-personal, intra-personal and trans-personal dimensions in residents’ lives.Nurses' and care workers’ experiences of spiritual needs in people with dementia are very similar to the findings for the general population regardless of the severity of the dementia. The study’s relevance to clinical practice indicates the importance of developing more knowledge about how people with dementia in nursing homes express spiritual needs and how to observe and interpret such needs. Holistic nursing targets the physical, mental, social and spiritual needs in people’s lives ,2. SpiriResearch regarding care workers’ experience of residents’ spiritual needs in nursing homes is scarce. A search of the CINAHL, AgeLine, Medline and PsychInfo databases was performed initially in October 2012. We used the following search terms: dementia AND spiritual needs AND nursing homes. We limited to the search to articles that were peer-reviewed, in the English language, published 2007 – 2012 and included participants’ age 65 and older. The search resulted in 168 articles in which only one empirical article focused on nurses’ experiences of residents’ spiritual needs in nursing homes . In BursThe aim of this study was therefore to investigate nurses’ and care workers’ experience of spiritual needs in residents with dementia in nursing homes.However, there were a few studies that described spiritual needs from the residents’ perspective. The findings revealed that residents identified spiritual needs as experiences of meaning in different ways. The sense of meaning could be provided by relationships with family members, friends or through communication ,19. ResiSpiritual needs have traditionally been understood in terms of trust, forgiveness, love, peace, hope and purpose ,21-26. S“Spirituality refers to the propensity to make meaning through a sense of relatedness to dimensions that transcend them self in such a way that empowers and does not devalue the individual. This relatedness may be experienced intra-personally (as a connectedness within self), inter-personally  and trans-personally .Reed  emphasisSelf- transcendence, (1a) Vertical self-transcendence: orientating towards an immaterial, supernatural power such as faith in God, and (1b) Horizontal self- transcendence: taking responsibility for (worldly) affairs beyond one’s immediate concerns, such as self-knowledge or unison with nature.(1) Self- actualisation, employing, challenging and fostering one’s capacities, such as experiences of freedom, creativity, power.(2) Order, holding on to values, practicality, decency, and the tried and tested, which can be linked to moral and traditions.(3) Well-being and relatedness, cultivating and enjoying life’s pleasures in privacy and company, such as experiences of harmony, comfort, love, fun, community.(4) Despite the different descriptions, we regarded Reed’s  definitiTo investigate professionals’ experiences in a scarcely studied field, using a qualitative method with an exploratory design was appropriate. The advantage of focus groups is that the group is jointly creating data through the participants’ sharing of similar experiences -38.Four nursing homes participated in the study. All four nursing homes had special expertise in caring for residents with dementia by employing competence-raising measures for nurses and care workers for several years. Studies conducted in a Nordic context reveal that 81% of residents in Norwegian nursing homes have dementia and are in need of extensive help throughout the day . The nurPurposive sampling was used to select participants, and information was given orally and in written form to the head nurses, who chose and requested two participants from their department to interview. Participants had to be permanent employees in the nursing home and have worked more than one year in dementia care. Because there were more care workers than nurses, we invited both professions to participate in the study. A total of 30 women and 1 man were included, fifteen nurses and sixteen care workers, and four of them were educated in palliative care, mental health and geriatric nursing. Four of the participants were under 30 years of age, one between 30 – 50 years, and sixteen of the participants were older than 50 years. The participants’ working experience included the following: <5 years (n = 4), between 5–10 years (n = 10) or more than 10 years (n = 17). Twenty six nurses and care workers from the four institutions participated in the first interview. In the follow-up interview, twenty participated. We preferred that the same professionals participated in both interviews, but because of different shifts, five new participants were included in two of the follow-up interviews.Is spiritual care a familiar term in care for people with dementia?” "In what ways do residents express spiritual needs"? “What knowledge among nurses is of importance in the provision of spiritual care in practice”? The moderator asked follow-up questions, and the observer asked supplementary questions [Data were collected from June 2011 to January 2012. At least one interview was performed at each of the four institutions, and a follow-up interview was conducted. Research shows that recurrent knowledge dialogue in a particular group may increase the understanding of a theme ,41. Throuestions . All intWe applied Lindseth and Nordberg’s  phenomenThe text was read several times to grasp the meaning as a whole. During the reading, we tried to focus on the nurses’ lived experiences as they reflected on the residents spiritual and existential expressions. Naïve reading was discussed between the researchers and further guided the thematic structural analysis.All four researchers conducted data coding. First, the text was divided into meaning units. We reflected on the meaning units based on the background of the naïve understanding and then condensed the units to reflect the essential meaning. We read through all of the condensed meaning units and reflected on their similarities and differences. Sub-themes were then created, which were assembled to themes and main themes. We further reflected on the themes in relation to the naïve understanding, and if we discovered a discrepancy between the naïve understanding and themes, the structural analysis process was repeated until there was compliance.We reflected on the themes and sub-themes in relation to our pre-understanding, research question, and the context of the study, in which we sought a comprehensive understanding. The credibility of the findings was assessed in the process of coding, in that we selected significant sections from the participants’ statements and identified explicit themes. We sought to safeguard transparency and trustworthiness through quotations from different participations in the presentation of the findings. During the entire process, we attempted to assess consistency between the data presented and the study findings, including both major and minor themes. By comparing themes to the naive reading, we strengthened the validity of the analysis.Consistent with Norwegian legislation, collecting data about professional healthcare workers job experiences has to be assessed ethically by Data Protection Official for Research at the Norwegian Social Science Data Services (NSD). This was done in the current study in April 2011 (with reference number 26783). NSD confirmed that the study met the requirements for ethical soundness in relation to standards and codes of ethics. The study was also performed according to the Declaration of Helsinki. The licenses of leaders from the municipalities and the nursing institutions were obtained, and participation was voluntary. To ensure the participants' well-being, integrity and dignity throughout the interview process, the importance of safeguarding the confidentiality of each participant was emphasised. Written informed consent was obtained from all participants, and all attendees were informed that they could withdraw from the study at any time.In the results, we use the term “nurses” to simplify the presentation, and the care workers are therefore included in the term. The quotes are presented indicating the specific interview , which of the informants that spoke in the group (indicated by numbers) and the page number in the transcribed text.Nurses understood the residents’ restlessness and expressions of negative feelings, including anxiety, fear, despair, loneliness, and confusion, which they interpreted as uncovered spiritual needs. They also noticed that some residents could verbally express demands for religious activities, such as prayer and singing hymns. Furthermore, they observed that residents wanted to connect to them on a personal level. The nurses described residents’ previous interests, such as nature experiences, culture and traditions as spiritual needs, as they saw they gave a sense of meaning to the residents.The need for serenity and inner peace, ii) The need for confirmation, and iii) The need to express faith and beliefs. Sub-themes are presented under each main theme with detailed descriptions.The nurses’ and care workers’ experiences of spiritual needs in residents with dementia in nursing homes embodied three themes in the structural analysis: i) In spiritual experiences, the nurses realised something transgressed in the form of a peaceful moment. These experiences focused nurses’ attention on important values in residents’ lives.Nurses observed that the dementia caused confusion and uncertainty for the residents.They also experienced that the residents’ changed between a state of passivity or apathy and a state of inappropriate restlessness. Restlessness was interpreted as an expression of discomfort or lack of inner peace, and the nurses wanted to help the resident into a state of rest.The nurses believed that music could be a tool to reach residents’ spiritual needs and also to those residents who were apathetic. The music created a good atmosphere, and the residents’ reactions were generally seen as positive. In some cases, music affected residents’ emotions and evoked reactions in the form of tears, frustration or anger. One of the participants regarded such reactions as valuable expressions of spiritual needs that should not be prevented. One nurse said:2 H: “Somebody sang Evert Taube, - and the tears started streaming, - and they said “look how distressed she is”. But I didn’t think it was distressing. It showed that she is a whole person. The music touched some of her memories, and maybe they were painful, - but I think that's OK. It makes you feel like a whole person, because that’s what we are”. (p 19)Music was also used in addition to physical massage of residents’ feet, arms or shoulders. Nurses observed that the impact of such contact resulted in what the nurses interpreted as inner harmony of the resident. They saw that the resident was able to relax in a moment and feel a form of serenity. One nurse articulated about her experience:3 J: “I found one CD with religious music way back in the patient’s drawer. So I put on the CD and gave her a gentle massage. As she sat there, the tears started rolling. She talks a lot, but struggles to communicate, so it’s difficult to know what she wants. But obviously, this music must have struck a chord in her, -it seemed very important to her. And she became very calm and balanced for a little while. So this was a good moment”. (p 1)The residents sometimes expressed fear as to whether they could trust the nurses or not. Trust between nurses and residents’ were seen as essential and was created through an atmosphere that the nurses regarded as safe and kind.Many restless residents became tired during the day. Nevertheless, the nurses found that the residents could not manage to sit still, and the nurses believed they should not force them to be still. A better way to meet the residents’ needs was to engage them in familiar activities as a way to deflect the non-focussed wandering in the department. The nurses' observed that residents benefited from activities that were adapted to them individually. The nurses believed that when the residents were introduced to familiar activities, they most often responded positively by a sense of relief and calmness. One nurse exemplified this reaction in the following:A 6: “A very restless resident couldn’t sit still during group gatherings, no matter what we did. He used to work outdoors a lot. So we took him for a walk and let him push a wheelbarrow. And in some way or another, I think this activity made sense to him”. (p 13)Appropriate activities included walking in the garden, singing songs, talking about old objects and/or pictures, and listening to familiar poems or stories. The purpose of the activities was the residents’ experience of coping with their restlessness and to become settled. The resident’s altered behaviour was interpreted as the meaning in life was met.The nurses perceived that knowledge of residents’ background and life history was vital to understand the residents’ spiritual needs. Many patients struggled with what the nurses regarded as a sense of inferiority because they felt they were not accepted by the others. The nurses observed that vital values in residents’ lives were revealed in relationships, and these connections enabled the nurses to confirm the resident’s identity and to foster a sense of self-awareness. Nurses underlined that the residents also wanted to be identified for who they once were and in that way maintain a sense of self-worth and coherence. Similarly, confirming self-experiences might contribute to a feeling of belonging with the fellow people in the nursing home.The nurses thought that they may be the most important persons in the residents’ lives, and they perceived this role as a significant responsibility. The nurses observed that some residents were socially isolated, and therefore the nurses emphasised the importance of establishing an atmosphere of tenderness and love. Many residents enjoyed being escorted around, receiving a hug, holding hands, or just being near the nurses. One nurse expressed this closeness this way:A 2: “They do not have to feel that they have lost themselves completely, but that they still are a full-fledged human being. We can try to maintain and enhance the patient’s interests and preserve what is left. Then, they can feel like a whole person and not just one that loses more and more of “self” and “disappears”. (p 10)The nurses felt that the residents had great needs for social contact, both through physical proximity or just be with the residents. Although the social contact was mainly perceived by the nurses as positive and good, they also talked about the connection as exhausting in situations in which residents “clung” to them. One nurse stated:1 D: “When we sit, the residents sit, and when we walk in the corridor, the residents follow us, it's like carrying a backpack”. (p 11)I am just stupid” or “I am totally alone”. The nurses found that closeness and love were basic spiritual needs that were important to consider when residents struggled with low self-esteem and felt lonely.The nurses observed that residents related to relatives and other fellow residents and that the social relationships were important to them. Some of the residents expressed thoughts such as: “The nurses considered faith and beliefs to be important aspects of the residents’ lives. Nevertheless, these components were modestly discussed among the nurses. Commonly, the priest came and maintained worship in the nursing homes once a week and the nurses felt that this was helpful and that they could rely on the priest.The nurses considered the priest as a support in situations they did not know how to handle.They observed that residents expressed solemnity in the worship and that most residents wanted to attend. One nurse explained:1 E: “Even though they don’t consider themselves very religious, - showing respect for the priest and the church service is deeply ingrained in them”. (p 12)The nurses experienced that singing familiar hymns was of great significance to the residents. The nurses explained that residents knew the hymns and they wanted to sing. Although their memory was reduced, they remembered the hymns.D 4: I was called for to a lady who was very upset. I knew she was a Christian, so I asked if she wanted to sing a special song. And she did, - so we sang and she became quiet and fell asleep”. (p 3)The nurses reflect on religious activities related to faith and beliefs. The nurses found that some residents stated that they wanted religious acts in the form of prayer. The nurses helped the residents to express their faith, and one nurse with an immigrant background said:2 D: “A very religious lady asked me if we could say a prayer before she went to bed. So I asked her, “-you mean like say “The Lord’s prayer”, -right?” I told her I only knew it in Polish. “Yes, but can you fold your hands?” she asked. So we folded our hands, and I said that she could pray in Norwegian and I would do it silently in Polish. And that was OK with her. So that was a way to do it together, - a nice experience”. (p 2)Sometimes residents expressed their needs more indirectly through body language in the form of gesticulation. In such cases, background knowledge of the resident was useful. The nurses said that when they noticed religious symbols or a Bible in the room, they tried to support the residents according to what they understood was the resident’s values and beliefs.The nurses thought that spiritual needs affected all aspects of the residents’ life and that these needs were specifically visible in the care at the end of life. Many residents wanted to talk about death, but the nurses experienced that only few residents expressed that they were directly afraid of dying. Some residents claimed that their strongest fear was the fear of being alone and not the fear of death itself. For some residents, the discouragement was so intrusive that death was seen as an escape from the meaninglessness. One nurse told about an experience with a resident:Oh, finally somebody who understands me. People say you’re doing fine, and now we’re going to do this and that”. I think, - it’s important to take the patients seriously. They are tired, but they don’t need to be scared of dying. And that makes it easier for us if they tell us they want to die …”. (p 30)1 H: “The lady said: “Am I still alive today”? And I said yes you still are. She said she was tired of living. And I answered that I could understand that. And then she said: “The findings reveal that nurses related residents’ spiritual needs to both inner experiences and the outer relational life. They emphasised a broad understanding of residents’ spiritual needs, and the faith dimension was prominent.The aim of this study was to investigate nurses’ and care workers’ experience of spiritual needs in residents with dementia in nursing homes. The nurses’ understanding of spiritual needs in residents with dementia was mainly based on the residents’ non- verbal, and to some extent, verbal expressions. Background knowledge of the residents’ lives and issues related to values was important to interpret the residents' expressions. The comprehensive understanding and reflections were based on the main findings: spiritual needs experienced inter- and intra-personally and spiritual needs experienced trans-personally.The nurses’ experience of residents’ relatedness to dimensions experienced inter-personally and/or intra-personally  overlappThe findings in this study also revealed that the nurses’ recognition of the residents’ need for inner peace could be achieved through involvement in familiar activities . WalkingNurses were challenged by retrieving the residents’ previous sources of meaning instead of ignoring them, but this obstacle was not greatly discussed by the nurses. They also did not discuss how ignoring residents’previous sources of meaning contributed to decreasing the resident’s experience of self-awareness and coherence . Social Many of the nurses in this study were unsure whether they could address the resident’s need of faith in God in an appropriate manner. The nurses’ approach to the resident’s faith was trapped between their own attitudes and prejudices and a more traditional and accepted form of religious practice in which the priest played a central role. The nurses addressed the residents’faith in God in the form of self-transcendence ,34 and tAnother spiritual need that was not greatly discussed was questions regarding death. Nurses observed that residents was not afraid of death but of loneliness or dying alone. The residents’ questions about death were not widely discussed by the nurses and the reason they did not talk with the residents about the last phase of life was unclear. The residents’ loneliness was not acknowledged, although research shows that this factor is a major problem among many fragile elderly . The nurThe use of the phenomenological-hermeneutical method in focus group interviews has been questioned . The metFindings from this study cannot be generalised. Nevertheless, many of the issues and challenges can be recognised in different contexts within dementia care. Norway is considered to be a multi-cultural society to a greater extent than before. Yet the majority of residents in the nursing homes in this study where ethnic Norwegians and well known with the Norwegian church traditions. One limitation is therefore that the nurses had limited experience with different religions. A greater diversity could have expanded the perspectives some more.In this study, we found three detailed areas that may explain nurses’ and care workers’ experiences of spiritual needs in residents with dementia. First, nurses' experiences were mostly concentrated on residents’ needs for meaning, as experienced inter-personally, intra-personally, and trans-personally. Second, the nurses desired to create sources of meaning for the residents, in addition to making the resident’s own sources available as much as possible, yet they admitted this effort was difficult. Third, sources of meaning, according to Schnell’s  descriptThe study revealed there is a need to develop more knowledge about residents ‘spiritual needs and how these needs are expressed in people with dementia in nursing homes.Reed's  definitiThe authors declare they have no competing interests.Substantial contributions to conception and design: LØ, KK, SH, LJD. Acquisition of data, analysis and interpretation of data: LØ, KK, SH, LJD. Preparing, drafting and critically editing the manuscript: LØ, KK, SH, LJD. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6955/13/12/prepub


Evidence increasingly indicates that childhood obesity prevention efforts should begin as early as infancy. However, few interventions meet the needs of families whose infants are at increased obesity risk due to factors including income and maternal body mass index (BMI). Social media peer groups may offer a promising new way to provide these families with the knowledge, strategies, and support they need to adopt obesity prevention behaviors.The aim of this study is to develop and pilot test a Facebook-based peer group intervention for mothers, designed to prevent pediatric obesity and promote health beginning in infancy.We conducted in-depth semi-structured interviews with 29 mothers of infants and focus groups with 30 pediatric clinicians, to inform the development of a theory-based intervention. We then conducted a single-group pilot trial with 8 mothers to assess its feasibility and acceptability. All participants were recruited offline at pediatric primary care practices. Participants in the pilot trial joined a private Facebook group, moderated by a psychologist, with a weekly video-based curriculum, and also had the option to meet at a face-to-face event. Within the Facebook group, mothers were encouraged to chat, ask questions, and share photos and videos of themselves and babies practicing healthy behaviors. Consistent with the literature on obesity prevention, the curriculum addressed infant feeding, sleep, activity, and maternal well-being. Feasibility was assessed using the frequency and content of group participation by mothers, and acceptability was measured using online surveys and phone interviews.2, all Medicaid-insured, mean age 27, all Black), we designed the intervention to include frequent posts with new information, videos showing parents of infants demonstrating healthy behaviors, and an optional face-to-face meeting. We developed a privacy and safety plan that met the needs of participants as well as the requirements of the local institutional review board (IRB), which included use of a “secret” group and frequent screening of participant posts. Clinicians, 97% (29/30) women and 87% (26/30) pediatricians, preferred no direct involvement in the intervention, but were supportive of their patients’ participation. In our 8-week, single group pilot trial, all participants  viewed every weekly video post, and interacted frequently, with a weekly average of 4.4 posts/comments from each participant. All participant posts were related to parenting topics. Participants initiated conversations about behaviors related to healthy infant growth including solid food introduction, feeding volume, and managing stress. All 8 pilot group participants reported that they found the group helpful and would recommend it to others.Based on preferences of mothers interviewed  Overweight in infancy is common and associated with later obesity and adverse health outcomes -4. AccorIn 2011, the Institute of Medicine (IOM) emphasized the need for interventions in early childhood to prevent the subsequent development of obesity . To datePeer interventions delivered through social media represent a promising alternative to traditional peer interventions, home visiting, or pediatric office-based strategies to promote healthful behaviors and improve outcomes. In pediatrics, peer interventions have been successfully used to provide patients and families with information, support, and problem-solving skills, resulting in improved breastfeeding rates and reduced postpartum depression ,26. PeerSocial media is a prevalent communication format that is especially well-matched to the delivery of peer interventions. Use is widespread; 90% of online young adults use social media to connect with peers . A growiConsistent with the American Heart Association’s prioritization of social media as a tool to address obesity , we deveTo understand how to best implement prevention-oriented virtual peer groups with low-income mothers at high risk of having obese children, we conducted two different research studies designed to develop, refine, and pilot-test our approach. The Children’s Hospital of Philadelphia (CHOP) Institutional Review Board (IRB) determined that the intervention development study was exempt from review, and approved the pilot study.a priori sample size of up to 30 mothers and 30 clinicians since prior research suggests that this number is sufficient to achieve saturation on themes elicited in qualitative interviews  at the get together. It was good to meet her first and that way I was comfortable enough to talk in the group.Overall, participants who attended the in-person event had similar rates of participation compared to those who did not attend .In intervention development interviews, mothers discussing the role of a peer group in their lives anticipated that the primary benefits or reasons to participate would be (1) learning new things about parenting ; and (2) peer support and interaction with other mothers . When asked specifically what would be most helpful in keeping them engaged, responses reflected similar priorities. One participant replied:To know each mother’s experience, to know what they went through, what’s been on their mind….That would keep me involved.Many respondents  expressed a desire or need for support in this context, and described connecting with other mothers as a way to learn and potentially adopt better parenting behaviors. For example, in the words of one mother:The support [would be the most helpful thing]. Just knowing that you have somebody like your peers that’s there that can answer questions for you… [M]others telling you this is what they did and it worked for them.Another commented, "You would get to meet new people, learn different methods people are using to raise their kids.” A first-time mother anticipated “asking questions from mothers that already had kids.One respondent stated that if she’d had the opportunity to participate in such a peer group,I would have been more confident when [my baby] came home… taking care of her, knowing what to do, because everyone has different experience and you learn from other people.Another engagement strategy that mothers suggested was to keep the group active with frequent posts and new, up-to-date information about parenting. Both the frequency and quality of information were considered important. Mothers requested “New topics, not the same thing over and over again, learn new things,” and “Just making sure I have all the up to date, like, maybe articles and stuff like that on children and babies.” Based on this feedback, groups included frequent posts of new information that augmented the curriculum.When mothers were shown sample videos created for the group, several  noted that it was helpful to see actual parents and children in the videos, particularly when they demonstrated behaviors or activities. One commented:I connected with everybody [in the video] because they all were interacting with their babies, it’s not like they were just on there by themselves saying, “Oh this is what I do”. They was always holding their babies and show them what they do.Mothers suggested that watching these modeled behaviors would trigger action. One said:[A mother in the video] sung a song I’ve never heard of. I’d probably sing that with my son.The vast majority of intervention development interview respondents , none of whom had ever participated in a similar intervention, reported that they would feel comfortable participating in an intervention that used a “secret” Facebook group (a privacy setting which limits group visibility and access to those invited by the moderator). For more than half , this comfort level was due specifically to the “secret” privacy setting. The mothers interviewed liked that it would be “just moms and nobody else,” and “not letting the whole world see it,” so that “whatever I said would just be between a certain amount of people.” Another commented that “[Facebook is] pretty good with the secret groups.”Some mothers  felt that privacy was not a concern because they did not intend to share any information that they perceived as too personal. For example, one participant stated she would not be worried about privacy because “If I’m not comfortable saying it to your face, I’m not gonna post it.” Several clarified that they did not see parenting as a very private or sensitive topic: “I mean, as far as parenting, that’s fine pretty much, that stuff I’d feel comfortable with sharing.”In the abbreviated pilot trial, the “secret” group setting was used. No participant reported any breach of privacy or concern about privacy, either during or after the study.When asked about the ideal role of a group facilitator, many intervention development interview respondents  stated that they would want her to provide information or advice: “Just help answer questions, feeding, breastfeed, solid foods, I guess the leader would know all of that.” Seven specified explicitly (and others implied) that they would want the facilitator to be an experienced mother, who could draw upon her own experience to provide guidance to the group. “A hands on mom has most likely been through stuff, probably can give us realistic…ideas and other ways and methods.” Others said that they would want the facilitator to provide emotional support, keep group discussions on track, manage conflicts, or provide resources for low-income mothers. The group facilitator in the pilot trial was a PhD-level psychologist who was also an experienced mother with young children. She frequently posted in the group (14.4 posts per week on average), modeling healthy behaviors and providing information , and offering emotional support and encouragement , as well as guiding group discussion.Our monitoring plan was intended to prevent any harm to participants caused by inappropriate or offensive posts by other group members. This plan was described to mothers during intervention development interviews; all agreed that having all posts screened by the group leader before appearing on the group page would be both reasonable and helpful: “That’s great, you know, some people might post things other people may not want to see.” However, one noted that quick approval would be necessary to prevent the approval process from interfering with participation:I think that would be fine, as long as they approve them fast. You don’t wanna have to wait days for your post to be posted…. When you post something usually it’s on there right away. I’d give y’all a couple of hours, maybe.In the pilot trial, the group facilitator and one additional member of the research staff screened and approved posts regularly throughout each day, including weekends and at night, accessing the group from mobile devices to facilitate this process. Participants did not report any problems or concerns with this approach. Group members respected ground rules established to guide interactions. In fact, during the 2-month trial, only one comment was not approved for posting by the facilitator. This comment expressed a participant’s frustration with others in the group for not responding quickly to a question she had posted; the facilitator messaged the participant privately to discuss the post. The participant continued in the group with no further issues.We asked both mothers and clinicians about the best way, if any, to involve the pediatric practice in the intervention. Mothers were asked whether they would want any of their information from the group shared with their child’s pediatrician. Most were relatively comfortable with this: “I wouldn’t mind. If they wanna share something with the doctor that would be fine, because I know that would be kept confidential.”When asked about information sharing in the other direction, from pediatricians to the group leader, responses were more varied. Some mothers were comfortable with “good” information being shared:[I would want shared] that my baby is healthy, well taken care of, eating right, growing. All the good things.However, for information about problems or concerns, “It would depend on what problem,” and many participants would want to approve that information on a case-by-case basis before it was shared.In focus groups, clinicians expressed enthusiasm for the intervention, and were willing to receive and share information with the intervention team on an as-needed basis. However, clinicians preferred no direct involvement in the intervention. The intervention was designed as suggested with no direct pediatrician participation.Of the 10 eligible participants approached, 8 participants enrolled in the pilot study and successfully joined the Facebook group. One additional mother began enrollment and provided informed consent, but did not complete the enrollment survey and was unable to be contacted further; based on the limited information obtained, her characteristics were similar to the participants who enrolled successfully. Almost all of the participants reported accessing the group primarily via mobile phone; 2 used both phones and computers to access the group, and 1 reported using a tablet and a computer, but not a mobile phone. All were successfully able to view the group and create their own posts.All 8 participants successfully completed online surveys at baseline and study end, including items assessing infant feeding beliefs and behaviors . In inteThe Facebook format created a record of all group activities, facilitating analysis. All active participants viewed all of the weekly videos, and the group averaged 7 posts and 6 “likes” daily. Of the participant posts, 91.8% (257/280) were text, 6.4% (18/280) were photos, and 1.8% (5/280) were videos. All participant posts were related to parenting topics. Participants initiated conversations about behaviors related to infant growth, including topics such as solid food introduction, sleep schedules , feedingsic] got along so well without us even knowing each other.” Another mother added that “The group wasn’t really like a group of strangers talking, it was more like sisters helping each other out.”Participants were successful in supporting one another in a virtual group format. The theme of peer support emerged strongly in surveys and interviews of the mothers in the pilot group. One participant commented that, “I felt like part of a group when I was participating and I felt like I helped someone along the way and vice versa.” Reflecting how close participants in virtual peer group could become, one wrote, “…all of us as MOMS came together n , because I was able to see it. I’m a visual kind of person.Although videos were preferred, 2 participants commented that they appreciated having the information presented in multiple formats: “The videos were helpful, I liked it better with the steps written out under the video post.”[The facilitator] was good. Because she…posted the information in multiple ways, written out and in the videos.All pilot group participants had only positive feedback about the group facilitator’s role. In interviews, one participant commented that, “[She] was great, very informative, gave great advice, answered all my questions, answered questions very quickly.” Another said:I loved her, she was very cool. Big sister type thing. I felt like I could talk to her about anything.Others specifically appreciated her level of involvement in the group:Some leaders give you stuff to do and then are absent. She was around and attentive, anything you posted she would comment on….Input from low-income mothers and the clinicians who care for their children guided our development of a prevention-oriented Facebook peer group intervention that was feasible, acceptable, and engaging to participants. Based on mothers’ preferences, we designed the intervention to include frequent posts with new information, videos showing parents demonstrating behaviors associated with obesity prevention, and a face-to-face group event prior to starting the Facebook group intervention. We developed a privacy and safety plan that met the needs of participants as well as the requirements of the local IRB, including use of a “secret” group and frequent screening of participant posts. In our 8-week pilot group, all participants viewed every weekly video post and interacted frequently, with each participant posting or commenting an average of 4.4 times per week. All 8 pilot group participants reported that they found the group helpful and would recommend it to others.Although our pilot group was small, rates of participation and satisfaction with the intervention were remarkably high compared with other social media-based peer group interventions in the literature. For example, an 8-week physical activity intervention delivered via Facebook group and text messages to 29 African-American women had 0.2 posts per participant per week, 22 times lower than in our group . Rates oThere are many potential contributing factors to the high levels of engagement in our group. Though other social media peer groups designed for demographically similar groups have not been as successful in maintaining engagement ,47, the Participants told us that protecting their privacy and safety was essential to the success of the group. Having a “secret” group setting that restricted group access to members was especially important for many participants to feel comfortable sharing information about themselves and their children. This finding has been supported by similar research; several Facebook-based interventions in the literature also used a “private” or “secret” group setting ,54,55. IOne question that remains to be answered is the role of face-to-face meetings as a component of social media interventions. Other recent Facebook-based interventions have incorporated one or more in-person meetings ,56, and The primary limitation of this study is its small sample size, particularly in the pilot trial. This study was designed to develop a Facebook peer intervention; a randomized controlled trial of a longer intervention curriculum, with more participants and multiple peer groups, is currently under way. In addition, the mothers participating in this study represent a specific and narrow sample of women, whose children are at increased risk of obesity due to maternal BMI, race, and income. While this group represents a population in particular need of support, their experiences and opinions of a social media-based peer intervention may differ from those of other populations. In the pilot trial, the population was further limited to mobile phone owners; 2 mothers were excluded from participating for this reason. The majority of mothers approached did own a mobile phone, however, as do a growing majority of adults in the United States, including those with low income .Furthermore, this study tested intervention delivery using Facebook groups, and it is unclear as social media evolves how the intervention may adapt to changing Facebook features or translate to other platforms. Still, the principle of delivering a moderated peer group to low-income mothers using familiar technology will likely remain relevant. Finally, this study assessed the feasibility of measuring the intended behavioral and health outcomes of the intervention. However, future studies, such as the ongoing pilot trial, are needed in order to actually understand the impact that this social media peer group intervention may have on participants’ knowledge, attitudes, behaviors, and health.This intervention provides a model for the design and use of private social media groups as a platform to deliver peer-based interventions to change health behaviors. Our results indicate that such groups are both feasible and acceptable, even among extremely low-income populations whose children are at high risk for obesity and other adverse health outcomes.


The key issue of the origin of life is the origin of a complex system rather than the abiotic formation of various organic substances, small and large. To consider this “origin problem” it is advantageous to abstract some principles from biology and statistical physics to guide our approach. Referring to these principles, we aim to construct a chemical system called “protometabolism,” which would be a precursor of metabolism. Weltanschauung demands consistent understanding of physics and biology. Consequently, the origin study is its key ingredient.What is the cultural significance of the study of the origin of life? Physics as an empirical science depends on observations by us, macroeukaryotes. On the other hand, physicists wish to deduce everything we can observe from physics. Thus, a naturalistic The origin of life has been studied for more than a century; it is more than 50 years since Miller’s  epoch-maThere are many attempts to define life and the so-called NASA definition Joyce  seems thI.[Ontogeny] Without FR no CS emerges within a short time scale II.[Pasteur’s principle] FR emerges only from CS.  To make FR spontaneously without CS, a long time scale, III.[Harsh world] Both CS and FR are vulnerable to noise and never survive beyond the time scale We are, however, more modest than the predecessors, so we will not try to define life. Instead, we will try to find a larger set  which includes living things that is not as hard as life itself to characterize and that excludes all obvious non-organisms like computers. Everyone agrees that organisms are complex systems, and that life is a complex phenomenon, although no clear understanding of the word “complex” seems agreed upon. Therefore, we wish to try to characterize the supset above as the set of complex systems/objects. To this end we need a critical analysis of the concept “complexity” Oono , 2012: Cmemento mori, if you are interested in complex systems. That is, for example, how cell dies is an important research topic of biology as a study of complex systems. Intuitively, FR is less vulnerable to noise than CS, but cannot multiply in contrast to CS. Incidentally, notice that viruses are CS.III + I implies CS . During the resource accumulation period during which a CS becomes mature, the repairing of damages in CS is required. Recall that the main energetic cost in the bacterial life process is amino acid and protein synthesis, consuming A CS is needed to harness free energy through metabolism, but the Pasteur chain FR → E. coli, that surely contains all the building blocks of life.The origin of life is not a question about the abiotic synthesis of biomolecules, but rather about a system, which includes a precursor of the metabolic system. We will never be able to make life from an organism-free soup available by sonicating a culture solution full of To construct a plausible scenario for the origin of metabolism, we first look at extant metabolic pathways and distill a few “principles” we believe must be obeyed. Every metabolic pathway must be controllable. Most metabolic pathways are kinetically hard without enzymes. No spontaneous reactions as unruly as the HCN polymerization appear. This suggests that even prebiotically the precursor reactions do not proceed without catalysts, and that no spontaneously feasible reactions are crucial. The lack of spontaneity may be a key feature of biological systems. Even at the earliest stages of biological evolution, and possibly before, spontaneity should have been restricted.Because straight is the gate, and narrow is the way, which leadeth unto life, and few there be that find it (Matt. 7 [14]).Reactions with high activation energy barriers, are potentially regulated and controlled more easily, so they can be exploited to make organized systems. On the other hand, very spontaneous reactions are too uncontrollable to be used as a part of an organization, if they could stand by themselves without help from enzymes.Since enzymes usually preserve the purely organic-chemistry reaction mechanisms,not connected to the network beforehand. If the added chemical and any component of the network do not react, the added chemical can only be a part of the environment of the network.A chemical network is a set of chemicals that are connected with each other via reactions (or reaction chains) and these reactions actually proceed . Suppose we add a chemical that is 2, H2, CO2, etc.). The most important observation is, as stressed by Fuchs  the existence of a rather universal carbon anabolic hub, (ii) non-primordiality of methanogens, and (iii) impossibility of utilizing small molecules  as Russel, Taylor and others  are all sophisticated complex enzymes,2, H2, CO2, etc. Thus, the origin of life must have required more reduced and/or larger compounds such as NH3, CO, acetate, etc.The third important observation may be that enzymes handling small molecules (such as NIf we prepare a sufficiently concentrated “(pre)biosoup” and keep it warm for 1 Ga in a closed bathtub, what will happen?As Bénard convection illustrates, an auxiliary condition that maintains the system only slightly out of equilibrium drastically changes underlying probability assignment to elementary microstates. Thus, some convenient nonequilibrium boundary conditions must be imposed externally for the origin of life. Since the origin of life is an origin of chemical system, free energy and raw chemical materials must be supplied. Then, the most natural nonequilibrium condition is a sort of “fountain” of high energy compounds. This type of the boundary condition is what we call the “fountain of life.” It can be a fountain of a single or a few compounds .Incidentally, in emphasizing disequilibrium, some seem to conclude that irreversible thermodynamics is relevant to the origin problem, but this is misleading.is possible. If E. coli culture solution). One might say light (UV), electric discharges (thunder), cosmic rays, etc., could supply sufficient high energy, but unless these high energy sources are organized (or harnessed) as chemical free energy, we cannot use them to construct a chemically organized system.If there is no supply of high-chemical-potential materials, nothing would happen, even if all the building blocks are somehow amply supplied . Spontaneous unruly reactions are avoided, and only those reactions that require catalysts are sought, following the principle of the narrow gates; that is, kinetically hard reactions with large Our starting point should be C2 compounds, possibly acetate and related compounds , i.e., (some sort of) the fountain(s) of life.A very serious consequence of the chemical continuity is that there could not be the “pure” RNA world  is thermodynamically very unfavorable, so some special means is needed. In extant anabolic reactions, ATP is used to overcome thermodynamic hill climbing. However, ATP is quite inert without appropriate enzymes, so more reactive high energy compounds are needed. To this end Gale’s observation  in the presence of uracil as a catalyst (Hagan 32−) formed from the corrosion of schreibersite (Fe3P) in aqueous solution , but this compound does not look easy to synthesize prebiotically without ATP. One idea to circumvent this difficulty is to use borate, which has been shown to stabilize certain enols as exploited by Benner et al. . It may We wish to add one important consequence of protometabolism. Chemical continuity logically implies that precursors of metabolism before the origin of life must not be distinguished clearly from biotic reactions through isotope studies, because the origin of protometabolism and even fairly complete carbon anabolisms with enzyme precursors of oligopeptides must have been far before the origin of life; only when the origin of life and the origin of metabolism may be identified can we conclude that isotope studies are meaningful.We have briefly discussed the very beginning portion of protometabolism and next discuss how a polymerless protometabolism could evolve to a full-fledged metabolism. If protometabolic pathways can be realized geochemically and show chemical continuity with modern metabolism, the next step is to replace purely geochemical catalysts with precursors of enzymes, perhaps oligopeptides and cofactors. A relevant observation is that dipeptide chirality can affect the chirality of the products of certain reactions . Is there any way to make compartmentalization (cellularization) and use of the fountain of life compatible? A way is to regard a fountain as a compartment. That is, there is a possibility that initially, “cells” were not microscopic. Notice that a cell must be equipped with a reasonably complete metabolic system to sustain itself. Thus, for a microscopic cell to be possible, all the reactions must be microscopically regulated and compartmentalized. Without efficient enzymes this is quite unlikely. There must not have been any microscopic cells until protometabolism was complete to a certain extent.Usually, cells are considered from the beginning microscopic, but different possibilities should be seriously considered. The simplest possibility is that the metabolic unit is a macroscopic system; if it is constructed around a fountain, it is possible that the system around the fountain may be a prototype of the cell. For a cell to wean from the fountain, it must contain a fairly complete metabolic system, which must be made compact. Such a compact system is possible only after considerable sophistication; some technological advancement is required for a cell to be small. Thus, the protocell system should not necessarily be microscopic and weaned from the fountain. This picture of “macroscopic protocell system” fits well with our nonequilibrium-driven scenario.


We conducted participatory research with children as co-researchers, framed as a project to give children the opportunity to discuss their views and ideas about their school playgrounds. At three schools, six children (9–12 years old) met over five to seven group meetings. Data analysis included children’s conclusions obtained during the project and the researcher’s analysis of written reports of all meetings. Children indicated a strong desire for fun and active play, with physical playground characteristics and safety, rules and supervision, peer-interactions, and variation in equipment/games as important determinants. Our results indicate that improving activity-friendliness of playgrounds requires an integrated and multi-faceted approach. It also indicates that children, as primary users, are able to identify barriers for active play that are easily overlooked, unknown or differently perceived by adults. Hence, we believe that structural involvement of children in designing, developing and improving playgrounds may increase children’s’ active play and consequently PA levels during recess.School playgrounds are important physical activity (PA) environments for children, yet only a small number of children reaches the target of 40% of moderate-to-vigorous PA time during recess. The aim of this study was to explore children’s perspectives ( The beneficial health effects of physical activity (PA) are well established . Howeveri.e., stay at school throughout the day including lunchtime) [Schools are important settings to encourage children to be physically active , since anchtime) . Dutch cnchtime) . 2/child), fixed (unspecified) [The development of playgrounds that stimulate children to be physically active may be an effective strategy to enhance children’s PA levels. Two systematic reviews on the role of playground characteristics in playground PA showed that experimental studies gave moderate evidence for an effect of multi-component interventions on playground PA levels of primary schoolchildren . Inconclecified)  and loosecified) ,12. No aecified) . The ecoecified) ,14. The Overall, research regarding children’s perspectives of the activity-friendliness of playgrounds is scarce. This is surprising, since increasing understanding of the primary users’ perspectives of playgrounds through qualitative research could result in new insights regarding environmental influences on playground PA ,16, incli.e., in which academic researchers and children actively collaborate in one or more phases of the research process [To date, the use of a participatory approach,  process , is not  process ,23,24. I process ,23,25. T process ,27,28. P process ,30. Finai.e., collaborating with children as co-researchers, and focused on children in the last years of primary school (aged 9–12 years). The aim of this study was to explore child-identified determinants of activity-friendly school playgrounds. We used a participatory research approach, The study was reviewed by the VU University Medical Ethical Committee (reference number: 2013/278). After obtaining permission from the school head, both participating children and their parents received an information letter on the goals and procedures of the study, and both were asked to provide written informed consent. This study used a participatory research design that was framed as a project giving primary schoolchildren the opportunity to discuss their views and ideas about their school playground and PA. Children were invited as co-researchers and could actively influence the form and content of the research process as well as the dissemination of their findings. Children indicated which playground topics they wanted to examine and how they wanted to do this. Children summarized their findings during this process, thereby actively contributing to the data analysis. i.e., participatory action research). Nevertheless, several methods were used to communicate the study findings to those who were able to create positive changes [Schools were screened for being open and having an interest in using the children’s suggestions to improve the school playground. However, this study was not specifically set up to undertake action on this as part of the research  and the Public Health Service of Amsterdam (n = 12). Inclusion criteria included: that the schools were open to and interested in ideas from their pupils about their playground as well as implementing some of these ideas. Schools were screened for these criteria through an interview with the teacher who was the primary contact person for this project. To ensure variation in socioeconomic status of the school neighbourhood, socioeconomic status scores for 2010 were obtained from The Netherlands Institute for Social Research [Thirty-four primary schools in and around Amsterdam were invited to participate, through emails, follow-up phone calls and the professional networks of the researchers  and the available time for the project. Meetings were held during school hours in a room located within the building and in the school playground. To help to create an informal environment, the room was generally not a traditional classroom  [In each school, the children met with the researcher in five to seven group meetings of approximately 1–1itorium) . The researcher introduced the overall subject of the project in a neutral way by asking children to explore their ideas regarding playgrounds that were suitable for PA (which was described as “moving”). During the meetings multiple playground topics were discussed, often introduced by the children and sometimes by the researcher. The researcher facilitated the group process, among others by sharing knowledge and skills, providing materials, managing discussions, paying attention to how to work in a pleasant and “professional” way and keeping track of time. Children chose the research techniques (see “Results”) helping them to express their ideas ,28,37. DChildren were encouraged to propose home assignments that could serve as preparation for the next meeting. They received a journal for personal notes, home assignments and copies of group work such as meeting summaries. In addition, the journal contained a short questionnaire with items on gender, age, motivation to participate and initial opinion about the playground. At the end of the project, children completed an evaluation questionnaire  withi.e., investigator triangulation). At School 1, only one academic researcher participated. After each group meeting, the researchers reviewed the content and the group process, including their role as facilitators, to identify issues that needed further investigation and to consider possible facilitation strategies that could be used during the next meeting. All group meetings were audiotaped and together with observations summarized in detailed written meeting reports.At Schools 2 and 3, two academic researchers participated in the group meetings, thereby reducing observer bias  and keeping a playground diary. Additionally, children chose activities from a list of suggestions of the researcher, including an exploratory walk across the school playground, role playing and answering question cards. When discussing to whom and how to present their findings, children decided to summarize and present their findings in a PowerPoint presentation to their school head, members of the playground discussion group  and their playground supervisors. These people were invited to the presentation , as the children believed they were in the position of actually changing the playground. A boy initially hesitated to invite those playground supervisors that were not friendly in his eyes. The group replied as follows. Girl: “The researcher observed that the approach of separating playground topics in different questions was sometimes perceived as artificial and redundant to children, because to them the topics were closely interrelated and therefore often discussed simultaneously. In addition, postponing the preparation of the final product to the end of the project resulted in repetition of discussions as well. Therefore, to optimize children’s research process, children at Schools 2 and 3 worked on the final product from the start of the project, as a vehicle guiding the process. Miss, this really helped me come up with ideas because we were outside (in the playground)”. Ideas were subsequently reflected upon and ordered by the children following questions of the researcher. Hereafter, children used the meetings to prepare, rehearse and present a PowerPoint presentation about their ideas to a self-selected audience. The audience consisted of their teacher, classmates and children of the youngest groups (aged 4–6 years). The latter were invited because the participating children considered it a right of the younger children—as the primary users of the small playground—to hear about and give feedback on their ideas. The school head and the children’s counsellor were invited as well, but unfortunately were unable to come. Upon a suggestion of one of the children the researcher informed the school head by mailing her the presentation. For the most part, all children were present during the group meetings, except for one occasion when a boy was absent because of illness. At School 2, the first group meeting was largely dedicated to formulating a project plan. The researcher asked the children to suggest important playground issues and to whom and how the children wanted to present their findings at the end of the project. The children decided focusing their research on what they called “the small playground” . At School 3, children decided to communicate through group emails and WhatsApp messages as well. These informal interactions helped the researcher to develop a relationship of trust with the children, to establish rapport and to gain a deeper understanding of the ideas that were discussed during the group meetings. Informal communications were not audiotaped but described later in written meeting reports.i.e., when they prepared their final product). Second, the researchers identified and interpreted main playground issues in the course of the project and these were communicated to the children for feedback and further investigation during subsequent meetings. Third, all written meeting reports were carefully read by the researcher and analyzed using the qualitative data analysis software program ATLAS.ti 5.2 . Part of the reports was analyzed through open coding, in which the researcher identified text fragments corresponding to single playground subjects. These fragments were given a code, e.g., undamaged, clean. Then the reports were analyzed using a combination of open and axial coding, in which codes were redefined , new codes emerged  and related codes were summarized into categories , e.g., state of maintenance. Using selective coding, these categories were then integrated into themes that reflected the core of our results, e.g., physical characteristics. Although the described process seems more or less linear, it was in fact iterative, creating a scheme of codes, categories and themes that reflected the content of all reports [Data analysis went through several iterative stages and was partly integrated within the data collection phase. First, children were asked to draw conclusions during and at the end of the project  For example, we can jump on a trampoline, then you have to try to jump really high for example. In the sandpit, with the sandpit as starting point, who can run the fastest and then you have to jump over the sandpit and then there are nets you have to go underneath”. Girl 2: “Yeah, breaking records.” (School 2).In talking about their playground behaviour and playground preferences, it appeared that most children have a strong wish to be physically active in the playground, e.g., to run, climb, jump, swing, slide, play soccer and do traditional and self-invented playground games. Illustrative is the contribution of two girls to a brainstorm explaining their wish to set up competitions. Girl 1: “Soccer and basketball were also referred to as “sports”. Some children expressed a desire to engage in more sedentary activities as well, including sitting, talking, reading, lying in the sun and playing with electronic devices. Children often referred to these sedentary play activities as “playing” as well. Some children explained that sedentary activities, including moping and messing around, resulted from a shortage in play opportunities or play ideas.Well, I think “why” is a bit strange too. Because when you say: “Yes, I play tag. Why do you play tag? Because it’s fun.” But that goes for most things. (…) Why do you play soccer? Because it’s fun. But that applies for most things, just because it’s fun.” (School 1). A boy said: “You‘ve got to have fun in the playground.” (School 1).Children emphasized the experience of fun as an important aspect of play and frequently spoke about it as a condition for engaging in play activities. The following two accounts are illustrative. A girl explained that it is strange to ask children why they do certain activities in the playground: “Normally it’s not that enjoyable, because there’s not a lot you can do here.” . A girl explained: “I want to have more fun in that playground, because it’s just really boring.” (School 2). The major themes that children indicated as influencing their opportunities to participate in fun active play in the playground were summarized as: (1) physical characteristics; (2) physical safety; (3) rules and supervision; and (4) peers. In line with this, children’s evaluations of their playground were in general related to its opportunities for “fun active play”. When these were perceived as sufficient, children described their playground as “enjoyable”, while limited opportunities resulted in evaluating the playground as “boring” or “stupid”: “As school playgrounds are foremost a physical setting, children had much to say about physical characteristics of their playground. Children’s discussions focused on play space, play equipment, state of maintenance and aesthetic elements.I think those walls get in the way a bit. When you want to run around, the walls are in the way all the time.” (School 1). The importance of free space was also illustrated by some children who expressed their irritation about space that was often obstructed by bikes: “Near that container too, which is a very good place to hide, but there are bikes everywhere, so you can’t use that area.” . Further, an overcrowded playground was described as limiting the available play space, because children are getting in the way.Children agreed that large playgrounds were preferred over small playgrounds. More room to play—especially to run—was one of the mentioned arguments. Children explained that large playgrounds are also attractive because they can harbour more fixed play equipment. Importantly, they experienced that fixed play equipment could also hinder their play opportunities, especially when the equipment is placed close together. This is because they limit the amount of available and uninterrupted free space that children need for specific play activities. For example, a girl explained: “Then we go three steps up, four down and who makes a mistake is finished.” (School 1). Many felt that more equipment would improve the play opportunities and hence the fun factor of the playground. It was discussed that more of the same equipment enables more children to engage in a specific play activity, whereas more different kinds of equipment allows children to vary play activities. For example, a girl clarified: “It’s all a bit of the same, there should be some different things.” (School 2). Moreover, a varied supply would better meet individual play preferences of children. As a girl explained about her wish to have tennis equipment: “For example, some children don’t want to play basketball, don’t want to play soccer and then they can play tennis for example. And then you need a tennis ball and a racket for example.” (School 3).Children reported that both fixed and loose equipment have an important role in their playground play. Most children were enthusiastic about equipment such as climbing frames, swings, slides, tumble bars, soccer/basketball fields with goals, table tennis tables, trampolines and seesaws (fixed equipment), stilts, elastics, balls and accompanying materials such as rackets and bats (loose equipment). Besides equipment that is designed for play, also alternative play materials emerged from discussions, such as lampposts, stairs, fences, edges and nature. A girl explained how stairs were used for play: “It’s more for the little ones, they like it.” (School 2). In general, participating children criticized their current playground for the few opportunities for fun active play. Two—partly interrelated—motives underlay their criticism: lack of challenge and height aspects. First, the equipment should have a level of difficulty that fits their age so that playing with the equipment is exciting and not too easy. For example, the children preferred a mix of low and high climbing frames and stepping stones with less and more separation distance (suitable for both younger and older children). Second, some children experienced that they were too tall for some of the available equipment: “Those tumble bars are higher, which makes tumbling easier.With these bars, your hair sweeps the ground.” . Opinions on the existence of gender differences in equipment preferences were mixed. Children were often strongly motivated to have playgrounds that are attractive for both younger and (themselves as) older children and emphasized that variation in play equipment is essential to achieve this. In response to the researcher’s question as to why a seesaw should be added after a girl had recently mentioned that seesaws are boring: “I didn’t dare use the slide because of the shocks I get when I use it.” . In addition, some explained that slides should be longer, “Because you’re on the slide for longer, and because it’s faster then.”  . Many children expressed their enthusiasm about equipment in which more than one child can be involved at one time. For example, multiplayer swings and multiplayer slides were preferred over single ones. About balls, children reported that not every ball is fun to play with. Aspects such as hardness and whether a ball can bounce influence play opportunities. Equipment quality was considered important in view of the required resistance against damage.Conversations about play equipment did not only focus on the composition of the total of play equipment, but also concentrated on characteristics of individual play materials. Children talked about discomfort they experienced with some current equipment and made suggestions on how to improve equipment in the light of active play and fun. The following examples are illustrative. Some children felt uncomfortable about using the slide, because of experiencing static electricity shocks: “You see, there are more who want to play soccer, but it’s not possible right now and they all sit at this moment.” (School 3). Second, the positioning of soccer goals underneath baskets results in inaccessible baskets: “You can’t use that anyway, because everybody plays soccer there.” . Third, loose play equipment that is the property of individual children instead of the school can result in reduced access, since non-owners have to ask and get permission before they can play with the equipment. Fourth, soccer schedules, indicating which group can use the soccer field on what day, resulted in reduced access to the game of soccer. Although children considered the use of a schedule fair—it guarantees that each group gets a turn—they were unsatisfied about the limited possibilities to play soccer. One child suggested breaking up the recess into two smaller ones per day, so that each group could have the field more often. Another introduced the idea to create a second soccer field. Access to equipment emerged as an important issue from discussions. Children reported several factors that hindered access. First, when lots of children have recess simultaneously, most equipment is occupied and consequently children have to wait their turn. This was also experienced as a source for arguments between children. Some children reported that occupied equipment and space caused them to engage in less interesting active play or non-active play such as sitting and chatting. For example, during the playground walk, a girl explained while pointing to some children: “It’s a natural toilet, a toilet for homeless people.” (School 2). Further, it was explained that a messy playground could result in getting messy yourself. While some did not mind, others did not appreciate that. Regular cleaning, for example by teachers, an external cleaning service, children or those who make it dirty, was mentioned as a strategy to improve hygiene. Another proposed solution included covering equipment such as the sandpit with sheets outside recess time. Other suggestions for the sandpit were to freshen the sand on a regular basis, to make it smaller or to remove it entirely. Children considered it important that their school playground was undamaged and clean. For example, broken or worn-out equipment and pavement should be repaired or replaced. Children of Schools 1 and 2 had a lot to say about playground hygiene. It was described that some places and equipment were dirty and stinking due to urine, vermin, mud, sand or moisture, and therefore could not be used with pleasure. A boy about the slide: “It, like, gives off such a negative feeling.”  . Multicoloured playgrounds with natural or lively colours were proposed instead. A fenced playground was not always liked, since some children mentioned that it looked a little like a prison. In addition, not all children were convinced that their current fence was effective in combating the problems they mentioned as arguments for fencing . Nature such as trees, bushes, flowers, plants and grass were valued for their beauty and the play opportunities they provide. It was explained that nature can for example be used for hide and seek games, climbing and rolling on the ground. Some children wanted to have a vegetable and fruit garden, e.g., “Such a garden with soil and then plant stuff.” . In addition, there was enthusiasm about the idea to have animals in the playground. Some children felt disappointed about the absence of urban wildlife: “When your class arrives on the playground first, that moment when nobody’s been there yet, then you might see three pigeons there, but that’s all.” . Some suggested to keep farm animals and pets in the playground. Though a boy commented that it would be difficult to guarantee care and money for them. Many children identified a cosy and friendly appearance as an important quality of enjoyable playgrounds. Some children expressed dissatisfaction about the current grey look of their playground: “Children were concerned about their own and other’s safety in the playground during recess, especially that of the younger ones. Children described that they become hurt due to accidental falling, slipping and colliding with one another and felt that several characteristics of the playground environment could influence the risk for injuries. Safety concerns included surface safety, equipment safety and safety of playground surroundings.Not as soft as a pillow or something similar, but somewhat softer than stone.” . At the same time, many children experienced that the soft tiles currently present in their playground were hardly softer than normal paving stones. At open areas, simple paving stones were accepted. At School 3, some places had sand and gravel on top of a hard surface. This combination was strongly disliked for safety reasons, as illustrated by the following account: “Well look, you have, say, that gravel, and when you fall, say, little pieces of gravel cut into your hand.” . In addition, broken, loose and wobbling tiles were considered dangerous because they cause children to stumble and fall on the ground. One child reported to have slipped on leaves. Soft surface was preferred underneath play equipment to provide fall attenuation: “At another playground they had something else (rubber handles) and when you climb, your hands don’t get hurt.” (School 2). Second, some children discussed that the risk for bad falls increases with increasing height of play frames, in particular for younger children. e.g., a boy in response to a girl’s wish to add a higher climbing frame: “Yes, but what if those little children climb in the bigger ones? Then they fall from it.” (School 1). A playground supervisor that is continuously present to watch over and help children in trouble and restricting use of high frames to older children were suggested as solutions. Children discussed several experiences and ideas in which they related the design of playground equipment to play safety. Two examples illustrate this. First, some experiences showed the importance of material choice in play equipment. It was said that wooden equipment holds the risk of splinters in your fingers. Further, it was experienced that the ropes of a horizontal climbing net were rather uncomfortable to hold. As a possible improvement, a girl suggested: “Yes, because then the ball rolls (on the road) and then… bam, along comes a car.” (School 3). Children explained that the current warning sign for car drivers had no effect and they suggested to move it to a more visible location and to add a pedestrian crossing. Two of the discussed safety issues were related to the direct surroundings of the school playground: fence safety and traffic safety. At School 2, children evaluated the fence points of the medium-high fence that surrounded their playground as dangerous, since children had hurt themselves when they tried to climb over the fence. At School 3, children felt that fast driving cars near the playground created dangerous situations during recess. A girl explained about running after the ball: “They should let you do more. (…) It could be a nice playground if you could do more. There are some fun things, but you’re not allowed to play with them”. In a mocking tone she considered the supervisors’ attitude: “There should be zero risk that you fall or get hurt.” (School 1). According to a rule at Schools 2 and 3, part of the playground was for younger and the remaining for older children. This separation was viewed as a loss of play opportunities: “The playground for the younger children is lots of fun and you can do all kinds of things there, but we’re not allowed to go there.” (School 3). Another boy said: “Only young children are allowed, but older children also enjoy going on the slide.” (School 3). Children reported that they sometimes (secretly) violated rules. Children’s discussions on rules focused on both undesired and desired rules as well as on consistency of rules, transparency about rules and application of rules. Children indicated that they do not like to be restricted by rules in their freedom to play the way they want to play in the playground. At School 1, children expressed strong dissatisfaction about the high number of rules forbidding certain active play. For example, children indicated that it was not allowed to climb in trees, to run fast after one another, to stand on a play wall and to play on the stairs. They regarded their playground supervisors as over-concerned about their physical safety and considered this an important cause for many of the restrictions. A girl explained: “I think it’s stupid that when playing outside you are not allowed coming there. Why is that not allowed?” . The same went for who is responsible for making up the rules, as illustrated by the following conversation. Girl 1: “Does somebody set up the rules that are told by the supervisors?” (…) Girl 2: “Because then we could get angry at that person.” Girl 1: “And then we could make that person change these.” (School 1). Moreover, conversations showed that not all children understood the rules in the same way. At School 1, this could be explained by the researcher’s observation that playground supervisors often had their “own” rules. At School 3, there was a lack of clarity about soccer field reservations due to poor visibility of the schedule. It appeared that children did not always recognize the arguments for specific rules and some expressed a wish to get to know these, for example: “To be honest, I understand why it’s not allowed in the playground, because people can get hit on the head by a ball. If that would happen to me, I’d also think it wasn’t very nice.” . However, playing alternative games with soft balls beyond the soccer field should not be forbidden. At School 3, children wanted rules for soccer (see “Peers”). On the researcher’s question how playground rules could be improved, children at School 1 suggested that they should be consulted about which rules would be good, and a suggestion box should be introduced where they can deliver ideas about rules. Of course, it would be necessary then that adults also act upon children’s input. Another rule that was discussed included the length of recess periods. Some children indicated that they wanted more recess time in order to have more play time in the playground. Despite criticism on the number and content of rules, a recess in the playground without rules was not preferred either. At least this was the case at School 1, where rules were a major issue. At School 1, children were decisive that rules about social manners are desired and should be strictly maintained. These included: do not bully, kick and hit one another. Teasing is only allowed when not only the teaser but also the teased one feels it is humorous. Further, the reasonableness and consistency of rules were considered important. For example, children accepted the rule stating that playing soccer beyond the soccer field was not allowed because of safety issues: “The supervisors should be less strict, we think, because they get angry very easily and get tough.” (School 1). It was explained that rules were often too strictly maintained and not always communicated in a friendly way (tone and wording). Some nuancing in applying them was desired. For example, it was not allowed to throw hard (icy) snowballs during snow fights, yet supervisors considered almost every snowball hard. That children value nuancing was also seen at School 3. With a happy voice a girl explained about hanging on a basket: “That’s actually not allowed, but it always makes our Sir laugh and he doesn’t forbid us.” (School 3). Further, sanctions imposed on violating rules were felt to be too severe. For example, it was mentioned that supervisors often took their ball away. A boy suggested explaining the supervisors that this punishment strongly decreases children’s play opportunities, since a ball is necessary for many games. The enforcement of rules by playground supervisors was of great interest to children of School 1, since they were rather unhappy with the current situation. As summarized by a boy: “The rules that are really necessary  are hardly paid attention to.” (School 1). They expected their supervisors to actively act upon unacceptable behaviour between children. More in general, children viewed a role for supervisors in helping children to solve arguments and to create a kind, peaceful and happy atmosphere in the playground. An active, friendly and caring attitude was considered an important characteristic of the ideal supervisor. A boy about his favourite supervisor: “He’s really cool; sings the whole time, is an Ajax (Dutch soccer team) fan, giving everybody a high five. But the others scream like “no, no, don’t do that”.” (School 1). Unfortunately, the ideal attitude was not often seen among their current supervisors, according to the children. A playground with many supervisors was not preferred, in particular not when they behave passively and uninterested. Children felt that their supervisors did not pay enough attention to maintaining rules about issues that really mattered to children. A girl explained: “When you’re alone in the playground, when your friends are ill, then there’s hardly anything to do”. Another girl added: “Well, actually, nothing at all… except for walking on stilts.” (School 1).Children reported that play fellows are important for engaging in fun and active play in the playground. Conversations showed a desire to play with others, friends often being preferred over random children, in contrast to playing alone. Group games, both traditional and self-invented ones, were much liked. The presence of others was related to play opportunities in the playground. A girl explained that: “We don’t like the way the boys react sometimes. Not all boys behave like that, but sometimes they do, some boys. And then we just pass the ball to them and don’t try it ourselves.We don’t dare to, to really do our best.” (School 3). It was suggested to make a sign stating that boys and girls are equal, in addition to a schedule indicating that boys and girls should alternate possession of the ball. Further, it was mentioned that some older children were not so kind to younger children. For example, children shared experiences about older children who pushed them aside, did not give them a turn in games and said unfriendly things. A boy reported similar events about the behaviour of friends vs. non-friends. Fights and angry reactions of others were felt to make playing in the playground less fun. Illustrative is an account of a girl who explained why a specific (non-school) playground visit from the past was fun: “The nice thing was that everybody was together. There weren’t even any arguments.” (School 3).On the other hand, it was experienced that others could frustrate play activities as well, as a result of which play opportunities could not always be used or enjoyed to their full extent. Children talked about several events during which other children disrupted their play on purpose. One story illustrated that regular unfriendly or unpleasant behaviour of boys towards girls during soccer  resulted in girls becoming less active than they wanted. A girl explained: “Look, those children are skipping. But when you do that for a very long time, it becomes boring. Don’t you ever have that? That when you do something so often, it becomes boring?” (School 3). Children viewed a relationship between boredom of the playground and their age group. The following account is illustrative: “Group 4 sees it (the playground) as normal, but it’s starting to get boring for them. For group 3, the playground’s really fun, because they’re allowed to play there now and to them it’s still new.But to us (group 7), it’s still pretty old.” . At a certain moment all play opportunities have been used over and over again and then children can get tired of the playground. However, some children hold the opinion that playing soccer always remains fun. Children explained that after a while playing in the playground can become boring due to repetition and a lack of variation in activities. In a conversation with the researcher in the playground, a girl said: “When something new is put down you eventually become fed up of that as well.” (School 1). A similar solution was proposed at School 3, but instead of static equipment a boy suggested to choose for flexible equipment. He showed the others a system that was made up of different play elements, such as tubes, steps, slides and walls, which could be assembled in multiple ways. As he explained: “Then it (play equipment) changes continually and then it becomes fun again.” (School 3). The others agreed and were very enthusiastic about it. Lastly, it was suggested to search for new playground games at the Internet, so that the same playground could be approached in a new and fresh way. At School 1, children suggested introducing new equipment to overcome this problem. However, as a girl described: “They (children) play outside a lot”. Researcher: “What do you mean”? Girl 1: “Children play in the playground, we know what they want”. Girl 2 added: “We understand it better”. Girl 1 commented: “Adults have really boring ideas”. Most children stated that they felt at ease during the project , were able to express their opinion  and that something was done with their recommendations . They also mentioned a range of learning outcomes, including what children consider a good playground, how to collaborate (School 1), form your opinion about the playground, not be nervous at presentations, create ideas (School 2), that playgrounds can be boring, how to change the playground and why, how to make a film (School 3) and how research works (Schools 1 and 3). Two children reported that they learned nothing, whereas three children did not answer the question on learning outcomes. In addition, children expressed the hope that adults would learn how children think about playgrounds and how playgrounds can be improved  and that children know a lot, have an opinion and that adults can listen to it (School 1). Children mentioned different reasons for participating in the study. For example, they thought the project would be interesting and fun (13/18 children), they wanted to improve their playground (5/18) or considered their playground boring (2/18). The majority of the children felt that the playground could be improved . At the end of the project, all children found the project to be fun and interesting. Most felt they were experts in playgrounds . At School 3, the following conversation developed about children as experts. Girl 1: “Understanding the child-perspective of school playgrounds is necessary to gain a deeper understanding of determinants of children’s playground PA. This study explored 9–12 years old primary schoolchildren’s perceptions of their school playground, using a participatory research design that gave children a voice as co-researchers. The results suggest that children have a desire to use the playground as a PA or “active play” environment during recess, as long as the available play opportunities allow playing to be fun. Otherwise, children tend to engage in sedentary activities. Children identified physical characteristics, perceived physical safety, rules and supervision, and social interactions with peers as important domains of determinants of play opportunities for fun and active playground play. To keep a playground attractive over time, variation in and renewal of equipment and games were recommended. This is especially relevant to older children, since they already played for years in the playground. Our finding that fun is an important aspect of active play is in line with previous work reporting that children characterize play as fun, along with descriptions such as spontaneous, energizing, preventing boredom, interactions with friends, less structured and freedom ,41,42. E2/child) was found to be associated with higher playground PA [et al. [The present study showed that children relate the amount of play space to opportunities for fun and active playground play, thereby supporting previous qualitative studies ,21,42,47round PA . King et [et al.  found thet al. [The importance of sufficient and accessible play equipment for playground PA has been reported previously  enables the identification of general patterns that can be transferred when you understand the contextual conditions of both the original settings and the new setting [This study has several limitations. First, at School 1 the group meetings were more structured by the academic researcher than at Schools 2 and 3. However, as indicated in the process evaluation, we believe that children were not limited in their freedom to express their perspectives and introduce new issues. Moreover, the researcher was aware of the increasing relationship of trust, among others indicated by some children developing from shy towards more expressing and self-confident. Second, our results may be limited in generalizability as only motivated children participated. However, we experienced that nearly all of the approached children were enthusiastic and willing to participate, including both shy and reserved children as well as more assertive children. In addition, though only a small number of children per school could participate in the meetings, the findings were well-received by their classmates (Schools 2 and 3). Hence, we believe the results are representative for the participating schools. Third, there is the issue of generalizability of the results for primary schools in general. Participatory research is by definition locally situated, meaning that the generated knowledge is context-specific and the findings should be interpreted accordingly. Nonetheless, comparing local projects  can do a variety of activities ; (2) are allowed to do a variety of activities ; and (3) can do these activities safely . What matters is how children themselves experience these conditions. Familiarity with the playground increases as children grow older, making variation in equipment and games more important. This implicates that playgrounds should have a flexible design to remain attractive for physical activity for all school-aged children. This is the first participatory study of 9–12 years old children’s perspectives of determinants of activity-friendly school playgrounds, by inviting them as co-researchers. Our findings are an important contribution to both the literature and practice as they provide concrete, Our findings highlight the importance of an integrated and multi-facetted approach to developing activity-friendly playgrounds that stimulate children to be physically active during recess. A physically attractive playground with lots of play equipment is not sufficient to get children active. Children should be able to use and enjoy these play opportunities, which asks for a perceived physically safe and supportive social playground environment as well. We view an important role for children in the development of activity-friendly playgrounds. Our research shows that, as the primary users, children know the playground environment inside out and are able to identify barriers for active play that are easily overlooked, unknown or differently-perceived by adults. An important characteristic of participatory research is that it is context-specific implying that no “one size fits all school playground” exists. Our study identified important playground themes that should be evaluated in different playground contexts. We recommend schools to invite their pupils to express how they perceive these items in their own school playground. Future studies are needed to examine whether perspectives of activity-friendly school playgrounds differ between boys and girls, children of different age or children with different socio-economic backgrounds. We experienced that children are strongly motivated to express their views, especially when the research process involves play. Moreover, children come up with concrete solutions to problems and are aware of advantages and disadvantages of their ideas. Hence, we believe that more structural involvement of children in designing, developing and improving playground environments may increase the opportunities for fun and active play of these environments and consequently children’s PA levels during recess.