993715

research-article2021
SJP0010.1177/1403494821993715Bentsen et al.Short Title

Scandinavian Journal of Public Health, 1–9

Commentary

Education outside the classroom as upstream school

health promotion: ‘adding-in’ physical activity into
children’s everyday life and settings

Peter Bentsen1,2 , Lærke Mygind1,3,4 , Peter Elsborg1,5,

Glen Nielsen5 & Erik Mygind2

1Health Promotion Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark, 2Department of Geoscience and

Natural Resource Management, University of Copenhagen, Copenhagen, Denmark, 3Cognitive Neuroscience Unit, Deakin
University, Melbourne, Australia, 4Unit of Medical Psychology, University of Copenhagen, Copenhagen, Denmark, and
5Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark

Abstract
Introduction: It is central for public health to answer questions related to how to change health and wellbeing in populations
through interdisciplinarity and health in all policies and sectors. For a school physical activity promotion initiative to be
acceptable and thus feasible, the buy-in of teachers is fundamental. Therefore, school physical activity promotion should
be integrated into and support teaching activities. Aims: We discuss the use of education outside the classroom as a feasible
pedagogical approach that integrates and promotes physical activity for school children. Methods: We present and discuss
theoretical arguments and empirical evidence to argue and illustrate that education outside the classroom is a promising
approach for promoting physical activity. Results: Education outside the classroom is characterised by regular curriculum-
based experiential teaching activities outside the classroom with the inclusion of physical activity as a means to pedagogical
ends. School subjects are taught outside the classroom drawing on problem-based learning and experiential education.
Here, physical activity is integrated without compromising curriculum goals which increases teacher buy-in and thereby
intervention acceptability and feasibility. Empirical evidence suggests that education outside the classroom increases
boys’ moderate to vigorous physical activity and girls’ light intensity physical activity. We contend that the mechanisms
are a mix of place, pedagogy and pupil motivations. Conclusions: Education outside the classroom is a feasible and
acceptable approach to public health and physical activity promotion because it is integrated into children’s
everyday settings through curriculum time and applied broadly to child populations at a low cost. The practice
of education outside the classroom is context-dependent and culturally bound, and practices therefore need to
be adapted to the individual sociocultural context.

Keywords: Health promotion, learning, motor skills, movement integration, outdoor education, physical literacy

Introduction More than ever, public health needs effective and

Non-communicable diseases (NCDs), such as
cancer, cardiovascular diseases, diabetes and
chronic obstructive lung diseases, are an enormous
and increasing public health challenge. Numerous
studies have shown physical activity (PA) to be a
factor in reducing NCD risk [1]. Accordingly,
physical inactivity has been associated with a wide
range of preventable NCDs [2].
integrated strategies for promoting health and PA in
whole child and youth populations in their everyday
life and settings. A large narrative review of 142 stud-
ies investigating the association between PA and health
indicators in children and youth revealed strong evi-
dence of a positive relationship between PA and physi-
cal health indicators, such as body composition,
physical fitness and bone health [3]. Furthermore,

Correspondence: Peter Bentsen, Center for Clinical Research and Prevention, Hovedvejen, Entrance 5, Nordre Fasanvej 57, DK-2000 Frederiksberg,
Denmark. E-mail: peter.bentsen@regionh.dk

Date received 28 March 2020; reviewed 24 August 2020; 6 January 2021; accepted 13 January 2021

© Author(s) 2021
Article reuse guidelines: sagepub.com/journals-permissions
DOI: 10.1177/1403494821993715
https://doi.org/10.1177/1403494821993715
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2    Bentsen et al.
there is some support for a positive relationship
between PA and motor skill development and psycho-
social health in terms of quality of life, wellbeing and
reduced psychological distress [4]. Increased PA levels
can therefore be expected to have a strong impact on
children’s and young people’s overall health and
wellbeing.
The association between PA and learning is a
widely discussed topic. There is considerable evi-
dence suggesting that PA improves cognitive func-
tion [5]. A systematic review investigating the
relationships among PA, fitness, cognitive function
and academic achievement concluded that although
the evidence is inconsistent, the overall evidence sug-
gests a positive association among the concepts [6].
Accordingly, another recent systematic review con-
cluded that cardiorespiratory fitness enhances chil-
dren’s academic achievement [7]. As a consequence,
the evidence supporting the utility of PA to increase
academic performance or learning is growing (e.g.
Have et al.) [8].
The newest (draft) World Health Organization
(WHO) guidelines on PA and sedentary behaviour
recommend among other things that children and
adolescents (aged 5–17 years) should be active at
least an average of 60 minutes per day and limit sed-
entary time [9]. Unfortunately, PA levels among
children and youth are alarmingly low. At the
European level, four out of five teenagers do not
move as much as recommended [10]. The
International Sports and Culture Association
(ISCA) describes this trend as an ‘inactivity time
bomb’, as the costs for the treatment of follow-up
diseases will increase significantly over the coming
years [10]. In addition, girls often have a significantly
lower level of PA than boys throughout their youth,
and for both sexes the PA level decreases with age
[11]. Early life physical inactivity has a greater nega-
tive effect on the body, as it has not yet fully devel-
oped [12], and PA behaviours tend to persist
throughout the lifespan [13]. Correspondingly, the
risk of NCDs gradually accumulates during the life
course [12]. Recent evidence shows the importance
of a life course perspective, indicating that interven-
tion early in life has the highest impact and therefore
public health potential [12].
Intervention studies have shown that addressing
health determinants through socio-ecological inter-
ventions is an effective approach to increase PA levels
in children (e.g. Rhodes et  al.) [14]. The literature
shows that prevention interventions should take into
account the entire ‘life ecosystem’ of children and
youth [15]. Therefore, the everyday settings and their
influence on the PA of child and youth populations
should be considered.This so-called settings approach
is based on insights that the context affects the inter-
vention and is in itself an influential health determi-
nant [16]. Schools are considered an essential setting
for the promotion of PA among children [17], as chil-
dren spend approximately one-third of their time in
school for 9 months per year and a broad demography
may be obtained through schools [18]. Ambitious
holistic frameworks and whole-school approaches
such as health-promoting schools – based on a recip-
rocal relationship between health and education –
have been considered best practice for the past three
decades [19]. Often, such whole-school approaches
build on values such as empowerment, equity, democ-
racy and participation addressing all areas of school
life and beyond with the aim of tackling the complexi-
ties of health, wellbeing and social justice within socio-
ecological models. Recently, more attention has been
given to policy initiatives integrating health-promoting
activities into school curriculum time [20, 21].
While the health-promoting potential of schools is
increasingly recognised, it is necessary to keep in
mind the primary purpose of schools, namely knowl-
edge acquisition, learning and personal growth [20].
Schools’ success is primarily evaluated by compari-
sons of pupils’ educational attainment and academic
performance, which generates an incentive for school
leaders and teachers to focus on activities that are ori-
ented towards these goals. For a school-based PA pro-
motion initiative to be acceptable and thus
implementable, school leader and teacher buy-in is
fundamental. In other words, PA interventions should
at least not interfere with the primary purpose of
school, and at best it should be viewed as an asset to
this purpose. Further, school-based PA promotion
should be considered an ‘add-in’ to teaching activities
rather than an ‘add-on’ by teachers [22]. We use the
term ‘add-in’ to denote health-promoting activities
that become part of curriculum-based educational
activities without taking time away from core curricu-
lum obligations and time. In contrast, ‘add-on’ is used
to describe activities applied on top of the core cur-
riculum obligations as something extra during both
classroom teaching and school management.
Methods
In this commentary, we discuss opportunities in the
field of public health and school-based PA promotion
for child and youth populations. We draw on theoreti-
cal and empirical evidence and practical experience
and examples to debate and illustrate the potential for
and the challenges of school-based PA promotion
through the use of education outside the classroom
(EOtC). We argue that EOtC is a promising approach
to promote and integrate PA aimed at child and youth

populations in schools in a teacher-integrated ‘add-in’
fashion at a low cost.
Our argument is divided into five parts. Firstly, we
characterise EOtC and how EOtC differs from other
similar school PA promotion approaches. Secondly,
we describe the evidence base concerning EOtC and
PA promotion and, thirdly, possible mechanisms
between the practice of EOtC and PA. We then go on
to discuss the practical and political implications of
EOtC as school-based PA promotion. Finally, barri-
ers and challenges for EOtC as PA promotion are
discussed.
EOtC as upstream school health
promotion
What is EOtC?
The concept of EOtC, or udeskole, stems from
Norway but has recently gained more international
attention (e.g. O’Brien and Murray) [23]. In EOtC,
school subjects are taught outside the classroom in a
pupil-led, teacher-facilitated way based on experien-
tial education, in which PA is an integral part of
teaching and learning activities [24]. EOtC aims to
provide children with the opportunity to obtain per-
sonal and concrete learning experiences by using
their bodies and senses in ‘real’ natural settings; for
example, parks, or cultural settings such as museums.
EOtC can take place in a variety of locations; for
example, a school yard, graveyard, museum, factory,
park or forest, although it is often practised in natural
environments [25]. While the idea of excursions and
experiential learning is not new, EOtC implies regu-
lar activities; for example, on a weekly or biweekly
basis [26], and is integrated into everyday life and
curriculum in practising schools.
In short, EOtC is characterised by the following:
•• curriculum-based teaching and learning activities
outside the classroom but in school hours
•• setting-sensitive, problem-based, experiential
education
•• pupil-led, teacher-facilitated learning
•• inclusion of PA not as a goal but as a means to
pedagogical and didactical ends
•• regular activities on a weekly or biweekly basis.
In practice, this approach might involve mathematics
lessons in which algebra and geometrical concepts
are seen, felt and tested using the features of the par-
ticular setting. For younger children, this might
involve counting and measuring tree trunks, and for
older children perhaps weighing objects of varying
densities to explore dynamics of gravity. In language
or history lessons, the pupils might write poems or
stories about a statue seen during a city walk. A
EOtC as upstream school PA promotion   3
biology class could involve looking for signs of spring
in an urban park or investigating the optimal growth
conditions for algae using water samples from a local
pond.
A variety of school-based PA promotion initiatives
exist, including PA breaks during the school day, sup-
plementary physical education (PE) lessons, and the
support of active play during recess through the pro-
vision of equipment, PA homework, or special events
on weekends. EOtC has notable similarities to so-
called movement integration (MI) (for a review, see
Webster et al.) [21]. MI aims to infuse PA at any level
of intensity into general classroom education during
normal classroom time. As such, EOtC could be
framed as a programme used for MI, comparable to
other guides or programmes with activities integrated
into academic lessons that use PA to reinforce aca-
demic content by directly linking the core curricu-
lum and subject content to the activities. While the
main goals of EOtC include embodied learning,
knowledge acquisition and maintenance of school
motivation, and thus not PA promotion in itself,
EOtC may involve (and in practice often does
involve) both active breaks, PA-intensive academic
lessons and/or PA during transition periods (e.g.
active transport). In other words, while MI pro-
grammes and EOtC may seem to be built on similar
principles, the primary aims and modus operandi of
EOtC and MI are different (please see Table I).
What does the empirical body of knowledge say
about EOtC and PA?
A change in location from classrooms to outside the
school buildings and the use of different pedagogies
may theoretically lead to more accumulation of PA in
EOtC than in classroom teaching.
Case studies have indicated that Danish pupils’
mean activity levels were more than twice as high on
forest days as on traditional school days, and were
equal to mean activity levels on school days with two
PE lessons [27]. Similar findings were observed in
subsequent Norwegian and Danish studies (see
Becker et al. for a review) [28].
Becker et al. [28] identified a need for studies with
quasi-experimental or longitudinal designs and with
a greater number of participants to confirm these
tendencies further. Correspondingly, a large-scale
quasi-experimental Danish study, TEACHOUT,
investigated PA, wellbeing, social interaction and
learning among pupils in 28 EOtC classes who par-
ticipated weekly in EOtC over the course of a year
and compared outcomes with 20 parallel (control)
classes [26]. One sub-study by Schneller and col-
leagues [29] found that boys in EOtC classes spent
more time each week in moderate to vigorous
4    Bentsen et al.
Table I. Education outside the classroom illustrated by contrasting aim, initiation, mechanisms, modalities and delivery with movement
integration.
Education outside the classroom
Aim To foster embodied learning, knowledge
acquisition, maintenance of school motivation
and life skills during normal classroom time
Initiated by Teachers
Mechanism Experiential, problem-based education
Bodily interaction with environment
Spatial variation
Active breaks
Active transport
Modality Add-in
Delivery Teachers as part of normal curriculum time
PA: physical activity.
Figure 1.  Model illustrating how education outside the classroom facilitates increased and improved movement behaviour by mediation of
place, pedagogy and pupil motivation within teaching sessions in school.
physical activity (MVPA) than did their comparison
class counterparts, while no difference was found for
girls.For girls, EOtC days were associated with more
light physical activity (LPA) than were typical school
days with and without PE. Boys and girls spent a
higher proportion of time in MVPA and LPA, respec-
tively, in the EOtC domain than in the classroom
domain. In general, children spent lower proportions
of time being inactive on EOtC days than on all other
day types [29].
What are the possible mechanisms between
EOtC and PA promotion?
There are many possible reasons why EOtC is associ-
ated with increased PA compared to traditional class-
room-based education. The location, the pedagogy,
the learning approach and the social interaction are
Movement integration
To infuse PA at any level of intensity into general
classroom education during normal classroom time
Researchers
Active breaks
PA-intensive academic lessons
Supplementary physical education lessons
Provision of equipment
PA homework
Special events on weekends
Courses and programmes
Professionals/teachers as part of, and in addition
to, curriculum time
all different. These differences may all affect both the
possibilities and the motivation for PA (please see
Figure 1).
The change in the physical location of the teaching
activities that occur during EOtC practice results in a
greatly increased number of possibilities for PA
behaviour. In Scandinavia, most EOtC is practised in
natural surroundings, such as parks, forests and fields,
and (more infrequently) in urban and cultural set-
tings, such as school yards, parking spaces and muse-
ums [25]. Ultimately, these are locations that are
vastly more spacious and varying than the typical
classroom which in itself allows, and perhaps also
even stimulates, energetic (and therefore also louder)
activities than would usually be feasible. Furthermore,
previous studies have indicated that the actual type of
location; that is, natural versus cultural environments,
of the EOtC seems important for how physically

active the pupils are (e.g. Mygind) [30]. In a qualita-
tive study, Titman [31] conducted 25 focus group
interviews with British children aged 5–12 years. One
conclusion of the study was that children prefer
nature-based settings over a built environment, and
the author interpreted this preference as a conse-
quence of increased possibilities for the children to
interact with their environment [31]. Correspondingly,
Fiskum and Jakobsen [32] found that outdoor educa-
tion increased the variability and decreased the regu-
lation of PA opportunities, which are the so-called
‘affordances’ for PA, as well as the opportunity to
activate these affordances.
As described earlier, EOtC is characterised as a
way of conducting problem-based, experiential edu-
cation [24]. Central to outdoor experiential educa-
tion as a pedagogical approach is the facilitation of
pupils’ interaction with their physical environment
and surroundings [33]. As part of a setting-sensitive,
experiential, problem-based learning process, PA in
EOtC often becomes a means to an end for the
pupils. In other words, when practised competently
by teachers, EOtC calls for bodily engagement in a
way that typical classroom-based activities; for exam-
ple, listening and reading and writing at a desk, do
not. This might make PA meaningful, even for pupils
who might dislike PA in other more sports or
PE-oriented contexts.
As movement in EOtC is often characterised by
being part of pupil-led problem-solving activities
organised in groups, the children participate in
physically active learning activities with a high
degree of pupil autonomy and social interaction. As
shown and described in self-determination theory
and research, self-determined motivation for an
activity occurs when participation in the activity
produces feelings of autonomy, relatedness and
competence [34]. In addition, when EOtC requires
physically active transport, the level of PA under-
taken by pupils in EOtC settings is, to a large
degree, an autonomous choice [35]. As described,
learning activities in EOtC are more often group
processes than in traditional classroom teaching – a
group process that might foster feelings of related-
ness. Finally, it can be argued that problem-based
learning may provide clear experiences of solving
actual problems and hence feelings of being com-
petent. In this way, it seems that PA taking place in
an EOtC context is, to a high degree, driven by self-
determined motivation, which is the kind of moti-
vation that has been shown to be most important
for the level of engagement and enjoyment of PA as
well as for future engagement in PA [36]. The vari-
ety of contexts in which EOtC is practised means
that the pupils engage in a wide and diverse range
of movement behaviours which is beneficial for
EOtC as upstream school PA promotion   5
their engagement in PA activities throughout their
life [37].
An additional mechanism by which EOtC affects
PA is the transport that is required when travelling to
the EOtC setting, which can be in close proximity to
the school or further away. Transport may facilitate
PA when the transportation is active (e.g. walking or
cycling from the school to the place where the out-
door teaching and learning activities take place) but
may also facilitate sedentary behaviour when passive
forms of transport (e.g. public transportation to and
from the school) are used [38].
What are the practical and political
implications of EOtC as PA promotion?
When considering EOtC as PA promotion, there are
several practical and political implications to con-
sider. Here, we argue that EOtC may be effective as
school-based health promotion, given the direct inte-
gration of PA with curriculum time and aims, exten-
sive teacher acceptability, the whole-population
application of EOtC and low associated costs.
Among those seeking to promote PA in education
and schooling, it is becoming increasingly more
accepted that integrating interventions and activities
with curriculum goals and time is crucial. A key fea-
ture of EOtC is its nature of implementation in the
existing educational system and teaching practices. As
such, EOtC is an integrative ‘add-in’ approach: pro-
gramme content and aims are delivered by the teach-
ers as an integrated part of the existing everyday
teaching practice [22]. Thus, programme outcomes
can be seen as additional and simultaneous benefits to
school performance and learning. For example, in
EOtC, PA may not be the immediate aim of a teaching
and learning session. Active transportation, walking or
biking to and from the site away from the school, and
the use of learning activities that require pupils to
move can potentially benefit both learning and physi-
cal health. This form of ‘adding-in’ PA into children’s
everyday life; that is, ‘integration within education and
school systems’, is in many ways, a response to or form
of the health in all policies being recommended by
public health advocates globally [39].
Teachers are at the forefront of the delivery of
school-based health promotion interventions, and
teacher acceptability is therefore key. EOtC seems to
be a particularly sustainable and effective upstream
health promotion given the buy-in of teachers [40].
Historically and conceptually, EOtC differs from MI
(MI aims to infuse PA at any level of intensity into
general classroom education during normal class-
room time; for a review see Webster et al.) [21] pro-
grammes in that EOtC is a teacher-initiated approach
and is often described as a grassroots movement
6    Bentsen et al.
[24] (please see Table I). MI, on the other hand, was
developed as a response to increasing sedentarism
among children; it is initiated by researchers and
implemented by teachers [21]. In terms of school-
based interventions, teacher buy-in is central to
immediate intervention feasibility and to the longer-
term continuation and impact of the activities. While
recent research in EOtC involves more direct
researcher control to improve the quality of the evi-
dence and implementation [26, 28], the approach
remains rooted in a tradition that is teacher-gener-
ated and for which many teachers see a multitude of
benefits. For example, a qualitative study found that
Danish primary school teachers perceived an
improvement in pupils’ academic learning and life
skills through the use of EOtC [40]. These improve-
ments were in accordance with teachers’ perceived
teaching goals as well as their personal values and
motivated the teachers to continue working with
EOtC. In addition, there are indications from quan-
titative case studies that EOtC promotes children’s
academic performance [28] and school motivation
[41]. Furthermore, while EOtC is practised in a
variety of settings, natural environments appear to
be the type of location most frequently used in
Denmark [25]. Exposure to natural environments is
associated with improvements in cognitive measures
related to academic performance, as well as a range
of mental, physical and social health outcomes [42].
Correspondingly, improvements in pupils’ social
and psychological wellbeing were observed in rela-
tion to EOtC [28, 43]. These added bonuses of
EOtC legitimise the use of EOtC through its facilita-
tion of the core business of the school setting, as well
as holistic child wellbeing, thus bolstering the
acceptability of EOtC as a school-based PA promo-
tion approach. The influence of EOtC on academic
outcomes is fundamental to the willingness of teach-
ers, school leaders and parents to engage with EOtC.
As such, these results are fundamental to the feasi-
bility and sustainability of EOtC as a school-based
PA promotion strategy.
Another characteristic and benefit of EOtC as a
form of PA promotion is that EOtC, at least in
Scandinavia [25], is applied broadly to child and
youth populations. EOtC is a low-cost intervention,
as it is delivered by ordinary teachers as part of nor-
mal curriculum time, rather than by trained special-
ists or researchers. As such, EOtC presents a
resource-efficient, feasible and acceptable health
promotion approach delivered in a universal setting
dominated by the public sector. This allows for EOtC
to be used widely and for children from all geograph-
ical and socioeconomic backgrounds to be reached;
for example, through regulation and legislation. As a
universal approach, EOtC avoids potentially coun-
terproductive stigmatisation of vulnerable popula-
tions and invites children, who otherwise struggle to
conform to typical classroom-based rules and regula-
tions, to unfold in a different pedagogical and didac-
tical space. Although EOtC does not specifically
target vulnerable groups who are considered at risk
of performing too little PA, EOtC promotes PA at a
structural level to promote the PA of all children and
youth, and in this way increases the number of chil-
dren reaching PA guidelines and recommendations
in the whole population. As such, individual-level
effects may be small, because EOtC does not directly
aim to promote PA, nor does it target children and
youth in specific need for enhanced PA. While EOtC
may not provide large effects for individuals, the
impacts of universal approaches for the wider popu-
lation are considerable [44]. Furthermore, evidence
suggests that childhood PA tracks into later life, sug-
gesting long-term impacts on adult generations [13].
What are the challenges and barriers to PA
promotion through EOtC?
A key criticism raised towards universal approaches
involves the risk of inadvertently increasing social
inequality in health [45]. For example, PA promotion
initiatives might cause children and youth who are
already physically active to engage in more PA, but
not the populations who are not sufficiently physi-
cally active. EOtC does not explicitly aim to enhance
levels of PA and is not necessarily planned towards
this goal. While some teachers might purposefully
plan to integrate PA into their EOtC practice, others
might not. It is therefore possible that accumulated
levels of PA will vary by the individual teachers, con-
texts and groups of pupils.
While the EOtC research is currently premature
as a basis for conclusions in this regard, there are
some indications that call for attention and poten-
tially action. In the above-mentioned TEACHOUT
study, a significant association between regular EOtC
activities and increased MVPA was found for boys,
but no difference was found for girls who only dis-
played increased LPA [29, 46]. In other words, both
boys and girls engage in more PA, but boys engage in
more MVPA than girls. Girls are consistently found
to engage in less PA than boys, a trend that continues
over the life course. Previous research has not been
based on sufficient sample sizes to allow for further
subgroup analyses to be performed. However, if the
gender difference in PA is indicative of a trend
towards already active children accumulating more
PA during EOtC and less active children accumulat-
ing less PA, actions may be required to adapt EOtC.

This indicates that, although one of our main argu-
ments for the use of EOtC is its ‘add-in’ nature, there
might be a need for teachers actively to include PA in
their activities to reach the group of children who do
not actively seize opportunities for PA, without com-
promising curriculum goals. As such, teachers might
need time and guidelines to help them implement
activities integrating PA and teach learning objectives
simultaneously. One of the ways in which EOtC pro-
motes PA is through active transport, and this also
seems to be a PA domain that effectively levels PA
differences between the sexes. However, transporta-
tion to EOtC settings is sometimes performed using
inactive means of transportation, such as riding on
buses, due to a lack of nearby facilities. This presents
a potentially costly, time-consuming and polluting
barrier to PA promotion through EOtC.
At present, Scandinavian teachers receive no spe-
cific EOtC pedagogical or didactical training unless
through private courses or networks. Therefore, the
quality of EOtC related to the educational value as
well as the level of integrated PA depends on the
competence and resources of the individual teacher.
This leads to variations in both educational and PA
promotion outcomes. Scandinavian countries are
often seen as countries of reference with regard to
EOtC [47], and we therefore consider it unlikely that
EOtC teacher education and teacher professional
development is more progressed elsewhere. Including
EOtC pedagogy and didactics in teacher education
and in-service training is a necessary step towards
ensuring more homogenous and high-level education
and PA outcomes. Political support for EOtC teacher
networks and local support staff could also increase
the confidence with which teachers use EOtC and
integrate PA into learning activities.
Another barrier and central stakeholder is the par-
ents, who might be sceptical about safety or academic
standards. For example, parental safety concerns
have been found to restrict levels of outdoor play
[48]. There is currently little research investigating if
this is a barrier specifically to EOtC implementation.
In a Danish case study which followed one class
using EOtC over a duration of 3 years, some parents
initially displayed some discomfort concerning aca-
demic standards and cold weather. These concerns
were absent towards the end of the 3 years (unpub-
lished data discussed in Mygind) [49].
Much of the evidence for EOtC as a means to pro-
mote PA discussed above stems from a high-income
country context, the Scandinavian countries in par-
ticular. The Scandinavian school systems are
inscribed in wealthy sociocultural contexts with
strong welfare states, where almost all children attend
school. In other parts of the world, where poverty
EOtC as upstream school PA promotion   7
and infrastructural restraints limit the opportunity
for children to attend school, other issues are likely to
be of greater importance for child health and educa-
tion than the use of EOtC. Compared to other high-
income countries, factors such as the following might
contribute to important differences in EOtC imple-
mentation: the national curricula; the level of flexibil-
ity given to teachers’ choice of themes, pedagogy and
methods; and the degree to which the education sys-
tem is oriented towards test performance. The geo-
graphical context might likewise restrict opportunities
for EOtC; for example, extreme heat or weather con-
ditions and potentially dangerous fauna and flora in
natural environments. Likewise, norms and percep-
tions pertaining to safety related to spending time
outdoors, particularly in nature, among teachers and
parents may differ across cultures and act as a barrier
to implementation [50]. Hence, we acknowledge that
EOtC as a form of PA promotion is currently most
well established in a Scandinavian context and may
provide other results in other contexts. However, we
encourage exploration of the approach in other edu-
cational contexts.
Conclusion
In this paper, we have debated and argued the use of
EOtC as a form of upstream PA promotion for child
and youth populations in school settings. We have
presented and discussed theoretical and empirical
evidence for the utility of EOtC as a primarily peda-
gogical and didactical ‘add-in’ approach that inte-
grates and promotes PA in schools. In EOtC, school
subjects are taught outside the classroom, drawing
on problem-based learning and experiential educa-
tion, where PA is an integral part of teaching and
learning activities. Empirical evidence suggests that
EOtC increases boys’ MVPA and girls’ LPA. We con-
tend that the mechanisms are a mix of place, peda-
gogy and pupil motivations; however, more research
is needed to understand the pathways and mecha-
nisms. EOtC is a promising approach to public health
and PA promotion because it is integrated into chil-
dren’s everyday life and settings through school cur-
riculum time and is applied broadly to child and
youth populations at a low cost. Empirical and anec-
dotal support for the benefits of EOtC on pupils’
school achievement, wellbeing and motivation for
learning indicates acceptability in a schooling con-
text, resulting in extensive buy-in by teachers and
school leaders. Such an ‘add-in’ approach to school
PA promotion provides a potential win-win approach
in which both public health and education stand to
gain. This intersectoral approach makes it possible to
reach a wider range of schools and pupils, mobilises
8    Bentsen et al.
additional resources for PA promotion and leads to
more sustainable activities. Teachers are the founda-
tion of school-based health promotion efforts, which
is a considerable advantage for EOtC as a PA promo-
tion initiative. However, potential limitations, includ-
ing how to ensure that girls are more active in the
EOtC setting and how to ensure high-quality facili-
ties for EOtC near schools, need to be addressed.
Furthermore, the evidence for the effect of EOtC on
school achievement, learning and wellbeing needs to
be explored and confirmed by more large-scale
experimental research.
Acknowledgements
The authors offer their warm thanks to Lawrence St
Leger and Jens Aagaard-Hansen for their considered
and helpful feedback on the early drafts of the manu-
script. They also thank their colleagues Mikkel Bo
Schneller, Mads Bølling, Camilla Roed Otte, Niels
Ejbye-Ernst and Karen Barfod for collaboration on
the TEACHOUT study, without which the idea and
background for this debate paper would not have
been conceived.
Author contributions
PB initiated the idea of a commentary. PB, LM, PE,
GN and EM contributed to the content and drafted
individual parts of the manuscript. All authors have
read and approved the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship, and/
or publication of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this
article.
Ethics approval and consent to participate
Not applicable.
ORCID iDs
Peter Bentsen https://orcid.org/0000-0002-2179
-6779
Lærke Mygind https://orcid.org/0000-0002-8027
-6589
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