“If You Don’t Have a Gym You’re Out of Luck”: Physical Education Teacher Perspectives of Recess and Extreme Heat in Arizona Schools

School recess is critical to support children's health and well-being; however, a growing issue affecting the consistent provision of recess is extreme heat. As prolonged and increasing temperatures disrupt traditional outdoor recess, there is a need to understand how schools are managing this challenge. The purpose of this cross-sectional study was to summarize teacher-reported health promotion modifications for recess during times of high heat and explore the impact on students and teachers. We conducted 10 focus group interviews with 28 teachers in Maricopa County, Arizona elementary schools, one of the hottest places in the United States with no standard guidance for recess in extreme heat conditions. Interview questions were aligned with a hierarchy of controls framework to categorize multilevel heat mitigation strategies schools used to manage heat challenges during recess. Three themes and seven subthemes were identified from a thematic analysis: "No right way - Health promotion modifications to recess in the heat," with three subthemes describing heat-related recess adaptations; "Variation in heat guidance and communication"; and "Challenges with recess during extreme heat days" with four subthemes of teacher/student barriers and burdens. In summary, teachers desire clear guidance to support recess during extreme heat events, yet appreciate flexibility to tailor approaches based on individual school circumstances. As heat waves increase in intensity and duration globally, there is a need to better understand what strategies are feasible and effective for schools to offer children the health benefits of traditional recess when outdoor activity is limited because of heat.