Physical activity and sedentary behavior among school-going adolescents in low- and middle-income countries: insights from the global school-based health survey

Introduction

Regular participation in physical activity (PA) generates many health benefits, such as improved muscular and cardiorespiratory fitness (Zheng et al., 2023), healthy bone development (Cox et al., 2020; Fan et al., 2022; Shi et al., 2022), improved well-being (e.g., self-perception, self-esteem, and happiness), and a reduced incidence of ill-being (e.g., depression, anxiety, stress) (Liu et al., 2023; Mavilidi et al., 2021). The World Health Organization (WHO) suggests that children and adolescents should accumulate at least 60 min of moderate- to vigorous-intensity PA daily (Bull et al., 2020; Chaput et al., 2020). In contrast, sedentary behavior (SB) has been linked to negative health outcomes such as obesity, cardiovascular disease, and poor mental health (Chen & Yan, 2020; Liu et al., 2022; Shen et al., 2020; Tremblay et al., 2016). The duration of SB is positively correlated with digestive function and cardiovascular disease risk in adolescents (Jorde & Grimnes, 2011). Cabanas-Sánchez et al. (2019) noted that adolescents with more PA interventions had a greater degree of prosocial behavior and that SB was not conducive to adolescents’ emotional regulation or teamwork. Similarly, Chaput et al. (2020) discussed the 24-h movement guidelines for Canadian youth and concluded that integrating PA with SB and sleep avoids the limitations of focusing only on exercise behavior and that this fundamental shift lays the foundation for the overall well-being of adolescents. School-aged children and youth with high PA, high sleep, and low SB generally have more desirable markers for obesity and cardiometabolic health than children and youth with a combination of low PA, low sleep, and high SB (Saunders et al., 2016; Tremblay et al., 2016).

When national income levels are taken as a starting point, sitting time is more strongly associated with compounding outcomes for people in low- and middle-income countries (LMICs) than for those in high-income countries (Darfour-Oduro et al., 2018). Compared with individuals who reported sitting for less than 4 h/day and having high levels of PA, participants who sat for eight or more hours per day had a 17% to 50% greater risk of comorbid outcomes across all levels of PA, and this risk decreased as PA levels increased (Lear et al., 2017). Previous studies have shown significant variations in PA levels across different regions, with relatively low rates of physical inactivity observed in some countries, such as Myanmar (74.8%), and rates as high as 90.7% in Cambodia (Peltzer & Pengpid, 2016). These differences may stem from various factors, such as culture, infrastructure, education level, and socioeconomic conditions (Darfour-Oduro, Andrade & Grigsby-Toussaint, 2020). This understanding aligns with the perspective of Chen et al. (2016), who suggested that urbanization may prompt lifestyle changes that lead to decreased levels of PA. Furthermore, several studies have demonstrated that age, gender, and family economic status may influence participation in physical activity (Manyanga et al., 2014). Koyanagi, Stubbs & Vancampfort (2018) speculate that this may be because sitting is generally associated with higher socioeconomic status and better-paying jobs in high-income countries. Similarly, Barbosa Filho et al. (2016) reported that middle- and upper-income people were more likely to be sedentary because of work, while middle- and lower-income people were more likely to be sedentary because of TV watching or mobile phone use, which may lead to longer periods of sedentary time and more unhealthy snacking. Mielke et al. (2017) noted that physical inactivity among young people is very common worldwide; 81% of young people do not meet the WHO recommendation of at least 1 h of PA per day and that there is some correlation with the level of development; for example, this is true for 79% of young people in LMICs, 84% in high- and middle-income countries, and 79% in high-income countries. Muzenda et al. (2022a) compared the differences between sitting and health risks in high- and middle-income countries and found that when individuals sat for more than 8 h/day, the risk of all-cause and cardiovascular death increased by 29% in low- and middle-income countries compared with 8% in high- and middle-income countries. The authors speculate that this may be because income levels lead to differences in sedentary patterns and their effects (Milton, Macniven & Bauman, 2014). In addition, people in middle- and high-income countries exercise more, while people in low- and middle-income countries exercise less. The higher people’s income is, the more attention they pay to exercise and a healthy lifestyle; this has become an internationally recognized phenomenon (Barbosa Filho et al., 2016). Using physical education interventions in LMICs as a starting point, Ashdown-Franks et al. (2019a) argue that most physical education classes in LMICs do not meet the MVPA recommendations (≥50% MVPA) and that students from low-income minority communities participate in even less PA in school. Black and Asian children are less likely than other children to perform sufficient PA (Vancampfort et al., 2018).

The Global School Student Health Survey (GSHS) is administered to young people in many countries around the world in an effort to develop better health programs (Dema et al., 2019; Page et al., 2013). The GSHS collects basic information about individuals, such as grade, gender, and height (Motamed-Gorji et al., 2019). In addition, the survey includes young people’s recent living habits and obtains information about whether students ate breakfast and other habits for the past 30 days to avoid inaccurate data due to broad answers (Choo, 2013). Drug intervention and sedentary behavior were part of the larger profile, including the frequency of alcohol consumption, drug exposure, and screen time (Long et al., 2021). In addition, Campisi et al. (2020) highlighted this survey because it captures teens’ social relationships, such as whether they are bullied or get into fights. The contribution of the GSHS is that, on the one hand, it evaluates whether the physical condition of teenagers follows the growth law and makes timely suggestions for prevention (World Health Organization, 2017); on the other hand, given the dynamic and unstable situation of teenagers, regular health surveys can improve their psychological quality (Pengpid & Peltzer, 2019). Hoogstoel et al. (2021) concluded that the GSHS promotes sustainable and healthy habits among adolescents and to strengthen students’ ability to cope with social relationships and setbacks. Similarly, Arat & Wong (2016) proposed that participation in the GSHS could subjectively improve the health awareness of adolescents and that the provision of a health index could help students understand methods for evaluating health, thus improving the effectiveness of active intervention. Since the GSHS is conducted on a global scale and has a large amount of data, it is helpful to assess the factors that affect adolescents’ health habits from different perspectives, such as the region and type of school, to propose more targeted suggestions for families, schools and governments (Noel, 2019).

Compared to high-income countries, adolescents in LMICs are typically in the early stages of understanding physical activity and often display low levels of physical activity. Additionally, according to the current literature, there is limited evidence linking PA and SB among school-going adolescents (13–19 years) from LMICs. To fill this research gap, this study primarily aims to synthesize the evidence about physical activity and sedentary behavior in school-going adolescents from LMICs based on the GSHS. It can be hypothesized that youth in low- or middle-income countries would have low levels of physical activity and high levels of sedentary behavior.

Methods

This systematic scoping review adhered to the methodological frameworks developed by Arksey & O’Malley (2005), Daudt, van Mossel & Scott (2013), Levac, Colquhoun & O’Brien (2010) and the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews (Tricco et al., 2018). Scoping review plays a pivotal role in providing a comprehensive overview of a specific research topic, enabling the mapping of the existing literature, clarification of key concepts, identification of research gaps, and outlining future research directions (Arksey & O’Malley, 2005).

Literature search and identification

A systematic literature search was conducted across four electronic databases (Web of Science, PubMed, ScienceDirect, EBSCO) on 18^th March 2023. The search strategy, outlined comprehensively in Additional File 1, encompasses keywords such as “physical activity”, “sedentary behavior”, “adolescents”, “low- and middle-income countries”, and “the Global Student-based Health Survey”. Following this, the title and abstract, as well as full-text documents, were independently examined by two authors using Endnote software (HL and WZ). The process of literature identification is visually represented in Fig. 1. In the case of discrepancies, a resolution was achieved through consultation with the third author (J Y).

Results

Discussion

Compared with adolescents in high-income countries, adolescents in LMICs are still in the initial stage of understanding physical activity (i.e., a low level of PA) (Owen et al., 2022). Therefore, they are reluctant to spend time on sports activities in venues with professional sports facilities. People in these areas have low educational levels, are exposed to fewer recreational activities, and pay little attention to their health. They prefer to spend their spare time on other recreational activities and are less willing to spend time on PA. Second, transportation in LMICs is often inconvenient, which affects the construction of sports venues and the transportation and installation of sports facilities, resulting in a shortage of sports facilities (Psaki et al., 2022). Due to the low economic level and slow development speed of these countries, the sports equipment cannot meet the needs of children’s sports activities, and new investments in the sports field cannot easily keep up with population growth (Muzenda et al., 2022a). These two factors cause a shortage of sports facilities in low- and middle-income areas. Third, a previous study noted that fewer children participate in physical exercise in LMICs (Snilstveit et al., 2016). Teenagers’ enthusiasm for participating in sports activities is not high because families in LMICs do not pay sufficient attention to their children’s participation in sports (Klasen & Crombag, 2013) or lack understanding and support. Furthermore, many children are afraid to participate or have no time to participate in sports activities, which hinders sports development (Shields & Synnot, 2016). Fourth, insufficient investment in sports funds in LMICs is also an important factor that affects sports development (Psaki et al., 2022). Because the local government has limited funds, it puts more funds into infrastructure construction and improving people’s living conditions, and the small amount of remaining funds can be used to develop sports. A number of studies have shown that private enterprises in LMICs are not willing to invest money in the development of sports (Bettin & Zazzaro, 2018; Giulianotti, Collison & Darnell, 2021; Schulenkorf & Schlenker, 2017) because it does not produce enough economic returns to enterprises in a short time. When private enterprises do not obtain enough profits, their enthusiasm for capital investment is not high. Fifth, LMICs have a lower level of technical skill in sports activities, lower training levels, and fewer sporting events due to limited funds. More importantly, LMICs lack excellent coaches, management, and professional talent, all of which lead to fewer local youth sports activities (Abdel-All et al., 2017; Atkins et al., 2016; Hennessy et al., 2022). Therefore, suggestions for low- and middle-income countries to pay more attention to physical education should first focus on educational system reform. Currently, for example, the main problems in China and India are insufficient educational resources for the population. Although measures cannot be implemented in the short term, some measures, such as the reform of the household registration system or the improvement of the education evaluation system, can be guaranteed through efforts. Another important measure is the continuous improvement of public health awareness because the popularization of basic health knowledge requires the support of the government and the media. This finding corresponds to Muzenda et al. (2022b) suggestion that low- and middle-income groups have a superficial understanding of the purpose and significance of sports and fail to internalize this into rational and conscious behavior. It is necessary to cultivate the awareness that sports participation is linked with personal development and economic improvement.

This study revealed that levels of physical activity and sedentary behavior are important indicators of health problems, including obesity and disease risk. There is a significant difference between PA and SB, with some studies showing a higher proportion (29.5%) of people meeting the World Health Organization’s recommended level of physical activity (Aubert et al., 2021). However, physical activity levels vary significantly between studies and regions, with relatively low rates of physical inactivity in some countries, such as Myanmar (74.8%), and rates as high as 90.7% in Cambodia (Peltzer & Pengpid, 2016). This difference may be related to a variety of factors, such as culture, infrastructure, education level, and socioeconomic factors (Darfour-Oduro et al., 2018). This finding corresponds to Firth et al. (2020) view that urbanization may lead to changes in people’s lifestyles, resulting in lower levels of physical activity. In addition, several studies have provided evidence that age, gender, and family economic status may influence participation in physical activity (Manyanga et al., 2014). Similar differences were observed for the incidence of sedentary behavior. The low prevalence of sedentary behavior in some developing countries (10.5%) and in developed countries (42.7%) may be related to factors such as the composition of the labor force, leisure habits, and modes of transport in different countries (Vancampfort et al., 2019a). This also raises questions about differences in the levels of physical activity and sedentary behavior among countries with different income levels. Liu et al. (2021) suggested that some countries have lower rates of sedentary behavior because they have more labor-intensive industries. In addition, increasing screen time and the use of electronic devices may lead to an increase in sedentary behavior. Darfour-Oduro, Andrade & Grigsby-Toussaint (2020) noted that school sports facilities, family education, and community environments that encourage physical activity among adolescents and reduce sedentary behavior are important for preventing obesity, developing physical health, and improving quality of life. Although the current study has provided valuable information about the level of physical activity and sedentary behavior in LMICs, the current analysis has several limitations due to its reliance on the conclusions of existing studies. The different methods and measurement indicators adopted in these studies may lead to certain biases in the comparison and analysis of results (Aubert et al., 2021). In addition, the analysis may not fully consider the specific circumstances of different countries and regions, such as policy, culture, and socioeconomic conditions. To gain a deeper understanding of the current state of physical activity and sedentary behavior, Darfour-Oduro et al. (2018) suggest that future studies could use a more consistent and standardized methodology and could survey a wider range of countries and regions. In addition, the factors that potentially affect physical activity and sedentary behavior can be studied to develop targeted interventions. This could include improving urban planning and public transport facilities, promoting physical education, and raising awareness about healthy lifestyles.

According to the adolescent PA and SB data provided by the GSHS, the incidence of insufficient PA and elevated SB in adolescents is very high (Durkee et al., 2016), and the characteristics differ according to sex and age. Interventions should be targeted to reduce SB based on gender and age because sedentary behavior and negative health outcomes have often been shown to be independently associated (Guthold et al., 2020). Due to the different physiological functions of men and women, girls are usually good at participating in low-intensity but durable sports, while boys are more interested in high-intensity sports. There are also differences in the types of exercise performed at different ages, and as the proportion of screen-related sedentary behavior increases with age, sedentary behavior in reading and learning fluctuates (Guthold et al., 2020). It may be necessary to promote other leisure activities, limit screen time, and incorporate sports breaks into students’ daily routines. It is concerning that these studies highlight significant gender and age differences, with girls being less active than boys and PA levels declining with age. These findings underscore the importance of developing targeted interventions and encouraging active lifestyles to improve overall health. However, a limitation may be that while the negative health effects of low PA and high SB have been highlighted, the interventions available to schools and physical education teachers have not been widely discussed (Hallal et al., 2012). Based on these findings, future research and action should focus on the details of interventions, such as how to create supportive environments for PA starting from the standard of safe sports space or how to maintain good sports facilities. Long-term observation and comparison experiments can be conducted to determine how physical education teachers can stimulate students’ motivation to live a healthy life, which can compensate for the shortcomings of previous studies that have tended to be theoretical and lacked implementation (Calestine et al., 2017). Schools should also play a central role in promoting PA by implementing a comprehensive physical education curriculum and providing extracurricular activities that cater to students’ diverse interests and abilities. More importantly, discussions on interventions need to focus on addressing gender and age differences in PA levels. Future research should to customize goals and strategies according to the unique needs of different population groups, especially to collect data on girls and older adolescents’ participation in PA because these two groups have usually been ignored in previous comparative studies (Hallal et al., 2012).

Gender differences in physical activity and sedentary behavior have been studied extensively. Peltzer & Pengpid (2016) suggested that girls from families with higher economic backgrounds are more likely to exhibit sedentary behavior, while boys, especially those from families with lower economic backgrounds, are more likely to be insufficiently physically active. This study provides comprehensive evidence for the link between gender differences, economic level and physical activity. Moreover, Ashdown-Franks et al. (2019b) confirmed the positive relationship between the frequency of drug use and sedentary behavior. However, the link between diet and physical activity has not been widely discussed, possibly because these two factors have a more direct impact on an individual’s health status, while the impact of physical activity is less significant (Vancampfort et al., 2019a). On the other hand, income level has proven to be a key factor that influences physical activity, although the effect of occupation type on sedentary behavior has not been discussed. Although some studies have begun to explore how culture influences physical activity and sedentary behavior, relatively little research has been conducted in this area. Issues such as whether consumer culture and celebrity influence may play a guiding role in physical activity and whether community culture can motivate regional residents warrant further exploration. Psychological factors, such as motivation and self-efficacy, may also affect individuals’ willingness to participate in sports activities (Zheng et al., 2023), and community environmental factors such as the availability of sports facilities may alter the effectiveness of sports (Liu et al., 2023). Therefore, based on the results from LMICs, it is necessary to comprehensively consider individual income, gender, and diet structure to optimize the selection of sports activities. Moreover, the promotion and support of physical activity by society and the community are important interventions.

Conclusion

The amalgamated evidence from 29 studies in this review emphasizes that in comparison with high-income countries, adolescents in LMICs are still in the initial phase of understanding physical activity and are characterized by low levels of PA. Moreover, PA and sedentary behavior among school-going adolescents in LMICs are influenced by various factors, including policies, cultural norms, socioeconomic conditions, gender and age. Future research should prioritize aiding low- and middle-income countries in assessing their own adolescent health promotion programs. This analysis should be tailored to the specific physical conditions of students in each region, and corresponding measures should be proposed. This approach holds significant practical importance for enhancing physical education and improving the physical well-being of students in low- and middle-income countries. It also contributes to advances in theoretical knowledge in this field.

Supplemental Information