1. Preschool and School Age Activities: Comparison of Urban and Suburban Populations Dorothy Damore, MD Weill Cornell Medical College New York, NY Published in Journal of Community Health 2002;27:203-211.

2. Objective To compare the activities of urban and suburban children in the New York metropolitan area

3. Background Leisure time activities may be related to the living environment. Studies have found greater illicit drug use and greater smokeless tobacco use in rural children and teenagers when compared with their urban counterparts. This substance abuse is associated with criminal activity. Finke L et al. J Drug Educ 1999;29:279-291. Kuria MW. East Afr Med J 1996;73:339. Olds RS. J Sch Health 1988;58:374-378. Gordon WR et al. Adolescence 1996;31:883-901.

4. Background The average American child watches between 21 and 27 hours of television a week which accounts for more time spent watching television than on any other activity except sleep including school and homework. AC Nielsen Company, Nielsen Media Research, 1989.

5. Background In certain individuals watching violent television programming relates to aggressive behavior. Violent television viewing in the third grade has been shown to correlate with aggressive behaviors 10 to 22 years later. Increased television viewing is associated with decreased sporting activities, decreased time spent outdoors and obesity. Cantor J. J Adolesc Health 2000;27:S30-34. Dietz WH et al. Curr Probl Pediatr 1991;8-31. Gortmaker SL et al. Arch Pediatr Adolesc Med 1996;150:356-362. Tucker LA. Adolescence 1986;21:797-806. Dietz WH et al. Pediatrics 1985;75:807-812.

6. Methods Prospective survey Convenience sample Conducted at one urban and one suburban primary care pediatric office Urban office in the Upper East Side of Manhattan Suburban office in Westchester County, just north of New York City

7. Methods The primary investigator asked the caretakers of preschool and school age children to complete a questionnaire about their child’s activities. Questionnaire available in Spanish Only one questionnaire per family Exclusion: children with physical handicaps

8. Questionnaire Activities included: –sports –time spent outdoors –reading –library use –video or television watching –computer use –summer camp 34 questions, 5 pages Took most parents 5 minutes to complete

9. Methods Preschool and school age activities were compared between urban and suburban populations. Suburban school age activities were compared between the school year and summer. Due to time constraints, data collection for the urban school age children during the summer was not performed.

10. Methods Assuming that 80% of urban children watched TV or videos for 3 or more hours a day and that a difference of 50% in the suburban children would be considered significant, to detect this difference with 80% power, a sample size of 45 in each group was determined using a chi-square test (two-tailed, alpha=0.05).

11. Methods Mann-Whitney test was used for numeric or quantitative variables. Fisher’s Exact test was used for categorical variables. Informed consent from a legal guardian The Institutional Review Board approval

12. Results Completed Questionnaires –66 urban preschool children –70 suburban preschool children –57 urban school age children –61 suburban school age children –63 suburban school age children during the summer

13. Results Refusal rates from 1 - 12% in the different groups Four questionnaires completed in Spanish

14. Preschool Results The preschool groups were similar in –mean age –gender –health insurance –parental level of education Urban preschool children had greater ethnic diversity (p<.01).

15. Preschool Results Suburban preschool children –spent more time outdoors, with 86% of suburban children spending 4 or more days outdoors per week versus 52% of urban children (p<.01) –were read to more frequently, with 97% of suburban children being read to 4 or more days per week versus 83% of urban children (p=.01) –visited the library more frequently, with 66% of suburban children visiting the library at least 1 to 3 times per month versus 47% of urban children (p=.03) –and more often attended summer camp (p<.01)

17. School Age Results The school age groups were similar in –mean age –gender –health insurance Urban school age children had greater ethnic diversity (p<.01). The parental level of education was greater in the suburban group (p=.01).

18. School Age Results Suburban school age children –spent more time outdoors, with 87% of suburban children spending 4 or more days outdoors per week compared with 54% of urban children (p<.01) –more frequently participated in a community sport league, 62% of suburban children vs. 23% of urban children (p<.01) –and more often attended summer camp (p<.01) Urban school age children –watched more TV or videos, with 25% of urban children watching more than 3 hours per day vs. 100% of suburban children watching 3 hours or less per day (p<.01)

20. Suburban School Age Children School Year vs. Summer Results The suburban groups, school year vs. summer, were similar in –mean age –gender –ethnicity –health insurance –parental level of education

21. Suburban School Age Children School Year vs. Summer Results School year –used the library more frequently, with 41% visiting the library at least 1 to 3 times per week during the school year vs. 18% during the summer (p=.01) Summer –spent more time outdoors, with 63% spending 1 hour or more per day outdoors during the summer vs. 23% during the school year (p<.01)

23. Discussion Suburban preschool and school age children spent more time outdoors. Suburban school age children tended to spend more time playing sports than urban school age children. Easier for suburban children to spend time outdoors near their homes. Transportation may be easier in suburban settings.

24. Discussion One study found greater physical activity to be associated with greater time spent outdoors. In contrast, adults living in urban settings have been found to be more active than those living in rural settings. Klesges RC et al. Health Psychol 1990;9:435-449. MMWR. 1998;47:1097-1100.

25. Discussion In our school age children, 36 – 53% played sports 4 or more days per week and 51 – 79% played sports more than 30 minutes a day. Vigorous activity for 3 days a week or more and 20 minutes or more at a time is one of the objectives of Healthy People 2000. Other studies have found that 60 – 80% of school age children meet this criteria. US Department of Health and Human Services, 1991. Molnar D et al. Eur J Pediatr 2000;159:S45-55. Andersen RE et al. JAMA 1998;279:938-942.

26. Discussion Most of our children 75 – 100% watched TV or videos, 3 hours or less per day. However, in the urban school age group, 25% watched 3 or more hours per day. The American Academy of Pediatrics recommends that Pediatricians encourage their parents to limit their child’s viewing of TV to less than 2 hours per day. In one study with over 4000 school age children, 67% watched >2 hours of TV per day and 26% watched >4 hours per day. Andersen RE et al. JAMA 1998;279:938-942.

27. Limitations Responses depended on parental interpretation of sports activities as well as parental estimations of the number of days and amount of time their children spent outdoors, playing sports, reading, using the library or using the computer. Most of the children had private insurance which makes the groups similar but may not apply to other children with different insurance.

28. Limitations Greater ethnic diversity was seen in the urban preschool and school age groups and a greater parental level of education in the suburban school age group which may account for some of the differences seen between the various groups. Since this study was conducted in the New York metropolitan area, other urban and suburban areas may have different findings.

29. Conclusions Important differences exist between the activities of urban and suburban children in two practices in the New York metropolitan area. Pediatricians caring for urban children may have an important opportunity to promote participation in sports and educational activities.