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Go Play Outside! Effects of a risk-reframing tool on mothers’ tolerance for, and parenting practices… Brussoni, Mariana; Ishikawa, Takuro; Han, Christina; Pike, Ian; Bundy, Anita; Faulkner, Guy; Mâsse, Louise C Mar 7, 2018

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STUDY PROTOCOL Open AccessGo Play Outside! Effects of a risk-reframingtool on mothers’ tolerance for, andparenting practices associated with,children’s risky play: study protocol for arandomized controlled trialMariana Brussoni1* , Takuro Ishikawa2, Christina Han2, Ian Pike2, Anita Bundy3, Guy Faulkner4 and Louise C. Mâsse5AbstractBackground: Children’s risky play is associated with a variety of positive developmental, physical and mental healthoutcomes, including greater physical activity, self-confidence and risk-management skills. Children’s opportunitiesfor risky play have eroded over time, limited by parents’ fears and beliefs about risk, particularly among mothers.We developed a digital tool and in-person Risk-reframing (RR) workshop to reframe parents’ perceptions of risk andchange parenting behaviours. The purpose of this paper is to describe our RR intervention, rationale and protocolfor a randomised controlled trial to examine whether it leads to increases in mothers’ tolerance of risk in play andgoal attainment relating to promoting their child’s opportunities for risky play.Methods: We use a randomised controlled trial design and will recruit a total of 501 mothers of children aged6–12 years. The RR digital tool is designed for a one-time visit and includes three chapters of self-reflection andexperiential learning tasks. The RR in-person tool is a 2-h facilitated workshop in which participants are guidedthrough discussion of the same tasks contained within the digital tool. The control condition consists of readingthe Position Statement on Active Outdoor Play.Primary outcome is increased tolerance of risk in play, as measured by the Tolerance of Risk in Play Scale. Secondaryoutcome is self-reported attainment of a behaviour-change goal that participants set for themselves.We will test the hypothesis that there will be differences between the experimental and control conditions with respectto tolerance of risk in play using mixed-effects models. We will test the hypothesis that there will be differences betweenthe experimental and control conditions with respect to goal attainment using logistic regression.Discussion: The results of this trial will have important implications for facilitating the widespread change in parents’ riskperception that is necessary for promoting broad societal understanding of the importance of children’s risky play. Inaddition, the findings may provide relevant information for the design of behaviour-change tools to increase parentaltolerance of risk.Trial registration: ClinicalTrials.gov, ID: NCT03374683. Retrospectively registered on 15 December 2017.Keywords: Outdoor play, Mothering, Independent mobility, Physical activity, Risk perception* Correspondence: mbrussoni@bcchr.ubc.ca1Department of Pediatrics, School of Population and Public Health, Universityof British Columbia, British Columbia Injury Research and Prevention Unit,British Columbia Children’s Hospital Research Institute, F511–4480 Oak Street,Vancouver, BC V6H 3V4, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Brussoni et al. Trials  (2018) 19:173 https://doi.org/10.1186/s13063-018-2552-4BackgroundAn abundance of evidence points to the fundamentalimportance of play for children’s development and well-being [1]. More recently, opportunities for unstructuredplay have been linked to children’s mental and physicalhealth, including promoting physical activity, mentalwellbeing, and executive function [2–4]. In particular,the importance of outdoor play for promoting physicalactivity has been recently capitalised upon by numerousgovernments and public health campaigns in order toaddress the growing obesity epidemic [5–8].The opportunity to engage with risk is a fundamentalpart of play. Typically occurring outdoors, risky playinvolves experimenting with uncertainty and overcomingfears [9]. Sandseter [9] outlines six categories of riskyplay, including play at speed (e.g. game of chase), heights(e.g. climbing trees), with tools (e.g. building a fort), neardangerous elements (e.g. fire, water, cliffs) and venturingout without adults (e.g. walking to school with friends).Scholarship investigating risky play has intensified in thelast decade and has identified that exposure to risky playcan help children to gain mastery, promote self-confidenceand social skills, and reduce anxiety and depression [10,11]. A systematic review found positive associations withphysical activity and social health, negative associationswith sedentary behaviour, and no association with injuryrisk [12]. Four- and 6-year-old children participating in a14-week intervention that involved engaging in activitiesreflecting the different types of risky play improved theirreaction time in detecting risk, increased self-esteem anddecreased conflict sensitivity relative to their pre-intervention performance, as well as when compared to anage-matched control group [13]. A cross-sectional studycompared 5-year-olds with and without ready access tounsupervised outdoor play opportunities and found moredeveloped motor skills, social behaviour, independence andconflict resolution in the former group [14]. Furthermore,experience with risk during childhood is believed to assistwith developing risk-management strategies, and the abilityto negotiate decisions about substance use, relationshipsand sexual behaviour during adolescence [15, 16].Children’s independent mobility, which refers to theirfreedom to travel around their neighbourhood by them-selves without adult supervision, is one example of out-door risky play and may be important for facilitatingother opportunities for risky play [9]. However, oppor-tunities for outdoor risky play regarding independentmobility have been increasingly eroded over time. InEngland, the percentage of children aged 7–11 yearswho were allowed to travel to school alone in 1971 was86%. This dropped to 35% in 1990 and then to 25% in2010 [17]. Australian research reported that 12% ofAustralian children aged 8–12 years were not permittedto go anywhere without an adult, and 32% had anindependent mobility range of less than one block [18].Canadian research with 9–13-year-old children foundthat on average 94.5% of the participants’ time was spentless than 400 m from their homes and that they spentonly a very small portion of their time in the largerneighbourhood context [19].Numerous international studies have identified thatparental fears, attitudes about social dangers, andperceptions of the value of free play and outdoor autonomyexert a strong influence on children’s outdoor risky playopportunities [20–28]. In a 16-nation study, traffic safetyconcerns, followed by fear of strangers, were the strongestfactors investigated that influenced parents’ decisionsregarding children’s independent mobility [29]. Children’srisk taking in play is also limited by fear of serious injuryand of disapproval and censure from other parents andadults [30, 31]. Such parental anxieties have led to a‘backseat’ and ‘bubble-wrapped’ generation, relying onautomobile-based commuting and little unstructuredoutdoor play time [26, 32].Societal shifts to promote children’s outdoor risky playmay benefit by reframing parents’ beliefs about risk,which in turn may reduce anxiety-based caregiving. Inparticular, because mothers typically express greaterconcerns and place more limits on children’s activitiesthan fathers, they are an important target audience forefforts to promote change [33, 34]. Bundy and colleaguesdeveloped the Risk-reframing (RR) workshop, a 2-h, in-person group session in which parents and educators areled through a series of reflection points designed tochange attitudes and behaviours related to children’soutdoor play [21, 35]. Its effectiveness has been previouslydocumented [36, 37]. However, the workshop format andlength have significant resource implications, limiting itsavailability and amenability to large-scale distribution.Digital tools for health-behaviour change have becomeincreasingly popular as vehicles for intervention delivery.They can provide an efficacious, convenient and cost-effective means of combining broad reach with thetailored approach of in-person interventions [38, 39].Using Bundy et al.’s [21, 35] RR workshop as a startingpoint, we used the principles of health-behaviour changeand social cognitive theory to develop a RR interventionto reframe parents’ attitudes and behaviours about theirchildren’s outdoor risky play [40, 41] consisting of an RRdigital tool (https://OutsidePlay.ca), and an in-personfacilitated workshop (with PowerPoint slides and facilitatormanual). Having two versions of the RR intervention mayhelp maximise the reach and flexibility of the intervention,such that it can be accessed independently by anyone andbe shared broadly with their network in addition to beingoffered as a workshop with a standardised delivery protocolby organisations, schools and recreation providers thatwork with parents. The purpose of this paper is to describeBrussoni et al. Trials  (2018) 19:173 Page 2 of 9the RR intervention, our rationale and protocol for arandomised controlled trial to evaluate whether itinfluences mothers’ attitudes and self-reported behavioursrelating to facilitating their child’s opportunities forrisky play.Study aims, research questions, and hypothesesOur aim is to assess the effectiveness of the RRintervention to increase mothers’ tolerance for riskyplay and attain a behaviour-change goal relating toproviding risky play opportunities for their 6–12-year-old children. We will test the two versions of theintervention:1. The RR digital tool2. The RR in-person, 2-h workshopWe hypothesise that:1. Mothers completing the RR digital tool will have asignificantly greater increase of tolerance for risk inplay than mothers in the control condition2. Mothers completing the RR in-person workshop willhave a significantly greater increase of tolerance forrisk in play than mothers in the control condition3. A greater proportion of mothers completing the RRdigital tool will attain their behaviour-change goal,than mothers in the control condition4. A greater proportion of mothers completing the RRin-person workshop will attain their behaviour-change goal than mothers in the control conditionMethodsStudy designThe study uses a single-blind (researchers and outcomeassessors), three-parallel-group randomised controlledtrial (RCT) design, to determine the superior effect ofthe RR digital tool and the RR in-person workshop overthe control condition. The trial was retrospectivelyregistered on 15 December 2017 with the United StatesNational Institute of Health’s Protocol Registration andResults System at https://clinicaltrials.gov (NCT03374683).The study flow chart can be seen in Fig. 1 and the StandardProtocol Items: Recommendations for Interventional Trials(SPIRIT) Checklist is available as Additional file 1. Scientificlead, study management and coordination, participantrecruitment, data collection and statistical analyses areperformed by the British Columbia Children’s HospitalResearch Institute, University of British Columbia.Once participants are deemed eligible for the study, theyare automatically allocated to one of the three conditionsby the REDCap electronic data capture tool hosted atBritish Columbia Children’s Hospital Research Institute [42]:(1) control; (2) the RR digital tool; and (3) the RR in-personworkshop. Participants in Condition 1 will be provided witha link to the Position Statement on Active Outdoor Play,which includes information on research and recommenda-tions for action [43, 44]. Participants in Condition 2 will beprovided with a link to the RR digital tool to completewithin the next week. Participants in Condition 3 will bescheduled to attend the RR in-person workshop. The ran-domisation schedule was generated beforehand in the seale-denvelop.com service using randomised permuted blocks ofsize 3, 6 and 9. The list was then transferred to REDCap.Fig. 1 Study flow chartBrussoni et al. Trials  (2018) 19:173 Page 3 of 9Participants have equal likelihood of assignment toeach condition (33%). They will not be blinded to allocationbecause the nature of the intervention does not allow it.They will be informed of their allocated treatment aftercompleting the baseline questionnaires. Allocation will beconcealed to the researchers at participant assignment anddata analysis. The RR in-person workshop facilitator doesnot need to be blinded to allocation as the other two armsdo not have a facilitator.Study participantsInclusion criteriaParticipant inclusion criteria include:1. Being a mother with primary custody of a child/children aged 6–12 years2. Residing in the Metro Vancouver Regional District,3. Being able to speak, read and understand EnglishParticipant recruitmentParticipants will be recruited through advertising on on-line forums and social media, distributing noticesthrough our networks, snowball sampling and postingnotices in community centres.Interested participants link to REDCap where they areprovided with a comprehensive cover letter describingthe study procedures and informing participants thatcompleting the survey questions indicates consent. Onceeligibility questions are answered, enrolled participantswill be sent a link to the baseline questionnaire packageto be completed in REDCap.To promote participant retention and completeoutcome data, a CDN$30 honorarium will be paid atbaseline (T1) and CDN$15 at each follow-up (T2 andT3) as compensation for participation. Non-respondentswill receive two email reminders to complete surveydata. Participants attending in-person RR workshops areprovided with an additional CDN$30 honorarium tocompensate them for any expenses incurred in attending,such as travel or childcare.Sample size considerationsThe Tolerance for Risk in Play Scale (TRiPS) is our mainstudy outcome. The TRiPS is scored on a logit scale andwe know from previous data collection among parentsof 5–13-year-old children that scores on the TRiPSrange from 0.20 to about 1.95 with standard deviationsin the range of 1.78 to 1.82 [45]. With a sample size of81 mothers in each condition, a test that averaged thedifferences in TRiPS score from baseline to the firstassessment will have 80% power at a 0.05 level of signifi-cance to detect a difference of 0.75 with the controlcondition when the standard deviation is 1.82 and thecorrelation between repeated observations is 0.75. Fromour previous work [46], we expect needing to completebaseline assessments among 501 mothers who will thenbe randomised into the three conditions. From ourprevious work [46], we are assuming a 65% retentionrate at our first assessment (n = 325) and a 75%retention rate at our second assessment, which wouldresult in a final sample of 244 mothers, corresponding to81 in each condition.InterventionRR digital toolWe adapted Bundy and colleagues’ RR in-person workshop[21, 36] using social cognitive theory [41] to incorporatehealth behaviour-change techniques (BCT) [40] that wereamenable to a stand-alone online platform that was effi-cient, taking little time to understand and use, and wouldnot require repeated visits to the tool [47]. For example,the use of associations, and reward and threat were notdeemed possible as they would require an external assessorand/or repeat visits to the tool. We sought to addresscommon concerns about risky play and engage partici-pants in self-reflection tasks to consider how these con-cepts applied to their parenting approach. The participantproceeds through three chapters, as outlined in Table 1.The tool takes 15–45 min to complete, depending onparticipants’ movement through each task. Table 1 alsooutlines the BCT and social cognitive theory constructsthat correspond to each task. Not reflected in the table arethe following social cognitive theory constructs: socialsupport, normative beliefs, and reinforcement and punish-ment. Social support (along with BCT 3.3 Social support(emotional)) is being addressed via encouraging partici-pants to share the digital tool with their co-parent andsocial networks to promote discussion and change. Relatedto this, sharing the digital tool with their network may helpprompt a shift in normative beliefs about risky play amongtheir peer group. Reinforcement and punishments are notaddressed because the tool involves interaction at one timepoint and these constructs would emerge after mothers tryto make changes. For example, a punishment could be thattheir child is injured while engaged in risky play; areinforcement could be that their child seems moreconfident since having more opportunities for risky play.Additional file 2 includes a description of measures we areusing to assess social cognitive theory constructs. Interestedreaders are also directed to Michie et al.’s [40] BCTtaxonomy for descriptions of each BCT, and to Glanz et al.[48] for a full description of social cognitive theory’sapplication to health-behaviour change.RR in-person workshopThe RR in-person workshop is a 2-h, facilitator-guideddiscussion of the same tasks as outlined in Table 1above. Participants are taken through each task usingBrussoni et al. Trials  (2018) 19:173 Page 4 of 9PowerPoint slides that include the videos from thedigital tool. The facilitator guide contains detailedguidance on discussion for each component and lengthof time to be dedicated to each slide. Participants areprovided with a paper booklet to complete that mimicsthe online tasks.For this RCT, a professional facilitator will be running allthe workshops to ensure consistency in delivery. She doesnot have any prior knowledge or expertise on the topic, norwill she be involved in collecting or analysing the data. Thiswas a deliberate choice in order to test real-world conditionswhere organisations with little or no background knowledgemay be running the workshop, and ensure that our materialsare sufficient to account for this. The workshops will include6–12 participants and will be run once the minimumnumber of participants are enrolled for a given session.Control conditionParticipants in the control condition are presented withthe Canadian Position Statement on Active OutdoorPlay [43, 44]. The Position Statement is available athttp://stage.participaction.com/sites/default/files/downloads/Participaction-PositionStatement-ActiveOutdoorPlay.pdf.This four-page document summarises the issues andresearch regarding children’s access to outdoor play andprovides recommendations for various stakeholders. Itwas developed by a cross-sectoral consortium ofresearchers, practitioners and stakeholders. It states that‘Access to active play in nature and outdoors – with itsrisks – is essential for healthy child development’ andrecommends increasing children’s opportunities for self-directed play in all settings [43, 44]. The Position State-ment includes recommendations for parents, educators,Table 1 Risk-reframing (RR) intervention content, behaviour-change technique (v1) and social cognitive theory constructRR intervention tasks Behaviour-change techniquea Social cognitive theory constructHome pageInformation and short video about risky play and why it is important,description of the tool components, logos of study partners5.1 Information about health consequences5.3 Information about social consequences5.6 Information about emotional consequences9.1 Credible source• Outcome expectations• KnowledgeChapter 1: Reflection1. Selecting a child who will be the focus of the tasks2. Values and traits most desired for the child in adulthood3. Child’s favourite activities4. Participant’s own favourite childhood activities5. What the participant got out of these childhood activities6. How do her child’s activities compare to what the participantremembers doing at that age?13.2 Framing/reframing13.3 Incompatible beliefs• Outcome expectations• KnowledgeChapter 2: What Would You Do?Participant is presented with three interactive video segmentswhere she chooses to either allow or not allow the child toengage in the activity. Once the choice is made the rest ofthe video plays with the results of that choice. She can alsosee the results of the other choice, if she likes. The threescenarios involve:1. Climbing a tree2. Walking home from school3. Building a fort1.2 Problem solving5.1 Information about health consequences5.3 Information about social andenvironmental consequences5.6 Information about emotionalconsequences6.1 Demonstration of behaviour9.3 Comparative imagining of future outcomes13.2 Framing/reframing15.3 Focus on past successes• Outcome expectations• Knowledge• Observational learning• Barriers and opportunities• Self-efficacy4. Common concerns: participant chooses from a list of fearsthat affect her in situations like the video scenarios (e.g. ‘ amconcerned my child is going to get seriously hurt.’)5. Things that helped me let go: participant chooses from a listof things that helped her let her child keep going in situationslike the video scenarios (e.g. ‘It is important to me that my childhas opportunities to learn, build skills and try new challenges.’)Chapter 3: Creating Your Plan1. Participant revisits the values and traits she wanted most forher child when they grow up, and is prompted to think aboutwhat she is doing to promote those things, and whether thereis anything she wants to change2. Setting goals: participant is prompted to set one realistic anddoable goal. Sample goals are provided3. Steps I would take to achieve my goal: participant is promptedto consider graduated steps to achieve the goal. Sample stepsare provided4. I will begin my plan: participant sets a date for beginning heraction plan5. Participant is invited to print out or email herself a PDF versionof her plan1.1 Goal setting (behaviour)1.2 Problem solving1.3 Goal setting (outcome)1.4 Action planning6.1 Demonstration of behaviour7.1 Prompts/cues8.7 Graded tasks9.3 Comparative imagining of future outcomes13.2 Framing/reframing13.3 Incompatible beliefs• Outcome expectations• Knowledge• Observational learning• Barriers and opportunities• Self-efficacy• Behavioural skills• IntentionsaThe behaviour-change technique (BCT) numbers in this column correspond with numbering in Michie et al.’s BCT taxonomy [40]Brussoni et al. Trials  (2018) 19:173 Page 5 of 9health professionals, administrators and various levels ofgovernments to address the barriers to children’soutdoor play. Recognising the role of widespread riskaversion in limiting play, the Position Statementaddresses common misconceptions and encourages thatdanger be differentiated from risk and outdoor play andfun be valued as much as safety.Study dataMeasurement occasions and follow-upParticipants will complete a questionnaire package atthree time points: baseline (T1), 1 week post intervention(T2) and 3 months post intervention (T3). Long-termchange is unlikely if participants do not make initialchanges, thus, the 1-week follow-up was selected to assessshort-term effectiveness, while still providing participantssufficient time to make their initial planned changes. The3-month follow-up will assess long-term effectivenessonce participants have had several months to reflect onthe intervention and implement change.Survey data will be collected and managed usingREDCap. See Fig. 2, the Standard Protocol Items: Recom-mendations for Intervention Trials (SPIRIT) schedule, foran overview of the study schedule and measures.Baseline data collection includes socio-demographicdata: age, ethnicity, marital status, education, employment,home dwelling type, household income and number ofchildren in the household. Participants will also completemeasures to assess primary and secondary outcomes ateach time point.Outcome measuresThe primary outcome measure is increase in the totalscore on the Tolerance of Risk in Play Scale (TRiPS), a31-item measure examining adults’ tolerance of riskduring children’s play, which has been psychometricallyvalidated [45]. The scale is based on Sandseter’s six-category model of risky play [9]. Goodness-of-fit statis-tics for TRiPS have been found to be in the acceptablerange [45]. Examination of logical item hierarchy indi-cated that items that were relatively difficult to endorse(e.g. ‘Would you let the child play near the edge of steepcliffs?’) were located higher on the hierarchy than thosethat were easier to endorse (e.g. ‘Would you let the childplay in the backyard supervised?’). The Person SeparationIndex was 2.63, indicating that the measure separatedpersons into more than two distinct groups, such as moreand less risk tolerant. The Person Reliability Index was0.87 indicating that the instrument was able to consistentlydifferentiate between those scoring high versus low. Self-perceived risk tolerance was highly positively associatedwith scores on TRiPS, and the mean score increased withage of the child [45].Fig. 2 Schedule of enrollment, intervention and assessmentsaccording to Standard Protocol Items: Recommendations forInterventional Trials (SPIRIT)Brussoni et al. Trials  (2018) 19:173 Page 6 of 9The secondary outcome measure is self-reported be-haviour change. Behaviour change is being measured bytheir self-reported progress on attaining the goal they setfor themselves within the RR tool. Participants will bereminded of their goal and asked: ‘Did you accomplishyour goal?’ with ‘Yes’ and ‘No’ response options.Adherence to interventionAdherence to the RR digital tool will be measured byexamining the percentage of content viewed, time spentonline and task completion [49]. Adherence to the in-person RR tool will be measured by examining work-shop attendance and task completion. Further outcomesand measures are described in detail in Additional file 2.All measures that were created for this study can be seenin Additional file 3.Data managementData will be entered by participants directly intoREDCap, which is hosted on a secure, firewall-protectedserver at British Columbia Children’s Hospital ResearchInstitute. The database is password protected and onlyaccessible by responsible staff. REDCap maintains anaudit trail that captures all user activity, including datamanipulation and export. Exported data will be stored ona secure, firewall-protected server at British ColumbiaChildren’s Hospital Research Institute in a password-protected file only accessible by responsible staff.Statistical analysisAnalysis strategy (including verification of modelassumptions) will follow Singer and Willet’s guidelines[50]. All participants allocated to one of the threeconditions will be included in the analysis, regardless ofdeviation from protocol, missed follow-up observations,or withdrawal. To test our hypotheses that motherscompleting either version of the RR tool will havesignificantly greater increase of tolerance for risk in play,we will compare the two intervention conditions withthe control condition. For modelling purposes, we willuse mixed-effects models using a correlation structurethat assumes model change over time. Selection of themost appropriate model will depend on the distributionalform of the data, whether the change is linear and non-linear and model selection will be based on residual analyses.To test our hypotheses that a higher proportion ofmothers in either version of the RR tool will reportattainment of behaviour-change goals (secondary out-come measure), we will use logistic regressions.Missing dataWe will use multiple imputation to manage missing dataand will report and justify our imputation strategies.Imputed data for multiple imputation will be analysed aspart of a sensitivity analysis.Statistical softwareThe latest version of R (R Foundation for StatisticalComputing, Vienna, Austria) and Stata (StataCorp LLC,College Station, TX, USA) will be used for statisticalanalysis and graphics.Quality assurance and monitoringWritten standard operating procedures are used for allstudy procedures to ensure data quality and consistentapplication of study protocols. State of recruitment, datacompleteness, control of correct randomisation and allo-cation of participants is regularly verified. Any deviationsfrom expected standards will be reported to, anddiscussed with, the project manager. Any protocol modi-fications will be reported to the University of BritishColumbia/Children’s and Women’s Health Centre ofBritish Columbia Research Ethics Board and the trialregistry, the United States National Institute of Health’sProtocol Registration and Results System.Ethical considerationsThe health risks of the RR interventions are negligible.The potential benefits are that participants learn moreabout the importance of children’s outdoor risky play.Also, potential benefits could come from changes inparenting practices that allow the child to engage inmore risky play. The study has been approved by theUniversity of British Columbia/Children’s and Women’sHealth Centre of British Columbia Research EthicsBoard (Certificate #H15–03271).DiscussionChildren’s engagement in risky play has been associatedwith a multitude of developmental, physical and mentalhealth outcomes. Despite this, children’s opportunitiesfor risky play show steady decline across generations[17–19]. Parent fears and exaggerated perceptions ofrisks, such as abduction and traffic injury, are a majordeterrent to children’s engagement in risky play [20–28].The RR tool seeks to address and reframe parents’beliefs about risk and shift their parenting approach.Using established behaviour-change techniques groundedin social cognitive theory, the RR tool provides an innova-tive evidence-based, rigorously designed method to influ-ence individual and societal views on children’s risky play.The digital tool can be easily and widely shared for broadreach, and the in-person workshop can be integrated intothe pre-existing curriculum of organisations that workwith parents.This study will comprehensively evaluate the effective-ness of the digital and in-person workshop versions ofBrussoni et al. Trials  (2018) 19:173 Page 7 of 9the RR tool. It will also add to the understanding of thepotential effectiveness of digital technology in influen-cing parental attitudes and behaviours with regard torisky play. The findings will provide rich data to informwidespread RR efforts to increase opportunities for out-door risky play among children.Trial statusRecruitment for the study began on 30 November 2017and is anticipated to be completed by 31 December 2018.Additional filesAdditional file 1: Standard Protocol Items: Recommendations forInterventional Trials (SPIRIT) Checklist. (DOC 121 kb)Additional file 2: Description of study measures and descriptions.(DOCX 114 kb)Additional file 3: Measures created for this study. (DOCX 101 kb)AbbreviationsBCT: Behaviour-change technique; RCT: Randomised controlled trial; RR: Risk-reframing; SPIRIT: Standard Protocol Items: Recommendations forIntervention Trials; TRiPS: Tolerance of Risk in Play ScaleAcknowledgementsWe thank John Jacob, Juan Tellez, Kevin Quach and Fahad Hasany from theStrategy and Innovation Office Digital Laboratory at the University of BritishColumbia Department of Pediatrics for providing partnership and technicalsupport in development and programming of the RR digital tool. We thankDrs. Jennifer Gardy, Brian Fisher and Anita Niehues for their ideas andcontributions to the development of the RR digital tool. We also thank PamFuselli, Heidi Campbell, Pierre Harrison, Brandy Tannenbaum and Dr.Guylaine Chabot for their review of, and comments on, an earlier version ofthe RR in-person workshop materials. We are further grateful to the LawsonFoundation for funding tool development and evaluation and to ChristineAlden for her personal engagement in the project.FundingThis study was funded by the Lawson Foundation, Grant #GRT 2015-68 and#GRT 2016-72. The Lawson Foundation was not involved in any aspect ofstudy design or writing of the manuscript. MB and LM are supported by sal-ary awards from the British Columbia Children’s Hospital Research Institute.GF is supported by a Canadian Institutes of Health Research-Public HealthAgency of Canada Chair in Applied Public Health.Availability of data and materialsAll data will be electronically archived at the British Columbia Children’sHospital Research Institute. The data set will be available from thecorresponding author upon reasonable request.Authors’ contributionsMB conceived of the study. AB and IP assisted MB with adaptation of theoriginal RR workshop for the purposes of the study. MB and LM leddevelopment of the study design, with contribution from GF, CH and theremaining authors. MB wrote the first and subsequent drafts of thismanuscript, with comments from TI and then the remaining authors. LM andTI advised on statistical analysis. All authors read and approved the finalmanuscript.Ethics approval and consent to participateThe University of British Columbia/Children’s and Women’s Health Centre ofBritish Columbia Research Ethics Board approved the study (Certificate#H15–03271). Participants provide informed consent within REDCap onceeligibility to participate is established.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Pediatrics, School of Population and Public Health, Universityof British Columbia, British Columbia Injury Research and Prevention Unit,British Columbia Children’s Hospital Research Institute, F511–4480 Oak Street,Vancouver, BC V6H 3V4, Canada. 2Department of Pediatrics, University ofBritish Columbia, British Columbia Injury Research and Prevention Unit, BritishColumbia Children’s Hospital Research Institute, F508–4480 Oak Street,Vancouver, BC V6H 3V4, Canada. 3Occupational Therapy, Colorado StateUniversity, Faculty of Health Sciences, University of Sydney, 1573 CampusDelivery, Fort Collins, CO 80523, USA. 4School of Kinesiology, University ofBritish Columbia, D.H. Copp Building, Room 4606, 2146 Health Sciences Mall,Vancouver, BC V6T 1Z3, Canada. 5School of Population and Public Health,University of British Columbia, British Columbia Injury Research andPrevention Unit, British Columbia Children’s Hospital Research Institute,F508–4480 Oak Street, Vancouver, BC V6H 3V4, Canada.Received: 15 December 2017 Accepted: 15 February 2018References1. Pellegrini AD. The role of play in human development. New York: OxfordUniversity Press; 2009.2. Whitebread D. Free play and children’s mental health. Lancet Child AdolescHealth. 2017;1:167–9.3. Burdette HL, Whitaker RC. Resurrecting free play in young children: lookingbeyond fitness and fatness to attention, affiliation, and affect. JAMA Pediatr.2005;159:46–50.4. Barker JE, Semenov AD, Michaelson L, Provan LS, Snyder HR, Munakata Y.Less-structured time in children’s daily lives predicts self-directed executivefunctioning. Front Psychol Frontiers. 2014;5:593.5. Healthy Active Living and Obesity Research Group. 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