behavioral determinants of physical activity across the life ......across the life course were...

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Behavioral determinants of physical activityacross the life course: a “DEterminants ofDIet and Physical ACtivity” (DEDIPAC)umbrella systematic literature reviewGiancarlo Condello1*† , Anna Puggina2†, Katina Aleksovska2†, Christoph Buck3, Con Burns4, Greet Cardon5,Angela Carlin6, Chantal Simon7, Donatella Ciarapica8, Tara Coppinger4, Cristina Cortis9, Sara D’Haese5,Marieke De Craemer5, Andrea Di Blasio10, Sylvia Hansen11, Licia Iacoviello12, Johann Issartel13, Pascal Izzicupo10,Lina Jaeschke14, Martina Kanning11, Aileen Kennedy15, Fiona Chun Man Ling6,16, Agnes Luzak17,Giorgio Napolitano10, Julie-Anne Nazare7, Camille Perchoux7, Caterina Pesce1, Tobias Pischon14, Angela Polito8,Alessandra Sannella9, Holger Schulz17, Rhoda Sohun6, Astrid Steinbrecher14, Wolfgang Schlicht11,Walter Ricciardi18,19, Ciaran MacDonncha6†, Laura Capranica1†, Stefania Boccia18†

and on behalf of the DEDIPAC consortium

Abstract

Background: Low levels of physical activity (PA) are a global concern and increasing PA engagement is becominga priority in current public health policies. Despite the large number of studies and reviews available, the evidenceregarding the behavioral determinants of PA is still inconclusive. Thus, the aim of this umbrella systematic literaturereview (SLR) was to summarize the evidence on the behavioral determinants of PA across the life course.

Methods: A systematic online search was conducted on MEDLINE, ISI Web of Science, Scopus, and SPORTDiscusdatabases. The search was limited to studies published in English from January, 2004 to April, 2016. SLRs andmeta-analyses (MAs) of observational studies that investigated the behavioral determinants of PA were consideredeligible. The extracted data were assessed based on the importance of the determinants, the strength of evidence,and the methodological quality. The full protocol is available from PROSPERO (PROSPERO 2014:CRD42015010616).

Results: Seventeen reviews on 35 behavioral determinants of PA were eligible for this umbrella SLR. Regardless ofage, the most investigated determinants were those related with ‘screen use’ and ‘smoking’. For youth, probablepositive evidence emerged for ‘previous PA’ and ‘independent mobility and active transport’ among children andadolescents. For the adult population, ‘transition to university’ and ‘pregnancy/having a child’ showed probablenegative associations.(Continued on next page)

* Correspondence: [email protected]†Equal contributors1Department of Movement, Human and Health Sciences, University of RomeForo Italico, P.za Lauro de Bosis, 15, 00135 Rome, ItalyFull list of author information is available at the end of the article

© The Author(s). 2017 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.

Condello et al. International Journal of Behavioral Nutritionand Physical Activity (2017) 14:58 DOI 10.1186/s12966-017-0510-2

http://crossmark.crossref.org/dialog/?doi=10.1186/s12966-017-0510-2&domain=pdfhttp://orcid.org/0000-0001-5092-3258mailto:[email protected]://creativecommons.org/licenses/by/4.0/http://creativecommons.org/publicdomain/zero/1.0/

(Continued from previous page)

Conclusions: Although the majority of the evidence was limited and most of the determinants were notassociated with PA, this umbrella SLR provided a comprehensive overview of the associations between behavioraldeterminants and PA. Youth should be physically active in the early years and increase active transportation to/fromschool, independent mobility, and ‘free-range activities’ without adult supervision, whilst adult PA behaviors aremostly influenced by the life events. Finally, more research is needed that incorporates prospective study designs,standardized definitions of PA, objective measurement methods of PA assessment, and the use of interactionist andmediational approaches for the evaluation of different behavioral determinants influencing PA behaviors.

Keywords: Physical activity, Behavioral determinants, Umbrella systematic literature review, Health promotion

BackgroundPhysical activity (PA) is widely recognized, together withappropriate nutritional and mental status, to be an im-portant component of healthy lifestyle [1]. Since thebenefits of being physically active for the prevention andthe management of the non-communicable diseases arewell known [2], the European Union (EU) is strongly en-gaged in promoting health-enhancing physical activity[3] for all individuals independently from age and socialstatus. However, in Europe, a large proportion of chil-dren, adolescents, adults, and older adults still adoptssedentary lifestyles [4] and, consequently, are more atrisk of non-communicable diseases.Several ecological models for the exploration of the

lifestyle choice have been proposed [5–8], including in-dividual (e.g., biological, psychological, and behavioralaspects), interpersonal (e.g., relationships with parents,relatives, peers, and socio-cultural networks), environ-mental (e.g., access/availability of tools/services, andproximal/distal built/natural surroundings), and policy(e.g., organizational and governmental aspects) dimen-sions. Within those dimensions, positive, negative, incon-clusive, or no associations might exist between severaldeterminants and PA. However, both determinants andPA present a great diversity in research designs, measure-ment approaches, populations studied, types of measure-ment, terminologies, which still make difficult to draw acomprehensive understanding. In general, the term ‘deter-minant’ is used to address causal variables also includingcorrelates (i.e., multiple variables intervening in cause-effect relationships), whilst mediators (i.e., variables influ-encing a cause-effect relationship between variables),moderators (i.e., variables effecting the strength of a rela-tionship between variables), and/or confounders (i.e., vari-ables associated with the outcome that distort theobserved relationships) are considered different variables[9, 10]. Furthermore, a lack of commonality exists in thePA terminology applied in the studies and different formsof PA are considered, ranging from unstructured daily ac-tivities, occupational PA, leisure time PA to structured PA(e.g., exercise, grassroots sports, and competitive sports)and considering the most relevant parameters of PA, such

as frequency (e.g., daily, weekly, monthly), duration (e.g.,total time of activity, rest intervals), and intensity (e.g., low,moderate, moderate-vigorous, vigorous, maximal efforts).Within the individual dimension, the determinants re-

lated to behaviour are widely investigated. Commonly,behavioral determinants have been already defined as“those that can be eliminated or reduces through life-style or behavioral changes” [11]. Thus, among all ages,investigations into the behavioral determinants consid-ered those related with major life changing events (e.g.,pregnancy and retirement) [12], habits (e.g., smokingand alcohol consumption) [13], sedentary behaviors (e.g.,TV viewing and video/computer game use) [14], andavailable mobility (e.g., active school transport and inde-pendent mobility) [15, 16]. They have been studied in anumber of primary epidemiological studies, systematicliterature reviews (SLRs), and meta-analyses (MAs).However, the diversity in research designs, theoreticaland measurement approaches, population groups, deter-minants investigated, and PA outcomes, across the lit-erature, makes it difficult to understand the evidenceand to draw appropriate conclusions on the importanceof these determinants in influencing PA behaviors.Recently, the European Commission endorsed a Joint

Programming Initiative to increase research capacityacross Member States to engage in a common researchagenda on a Healthy Diet for a Healthy Life [17] and theDEterminants of DIet and Physical ACtivity-KnowledgeHub (DEDIPAC-KH) project was created [18]. In orderto expand knowledge and to develop new insights andsolutions in PA, the Thematic Area 2 of the DEDIPAC-KH project organized and carried out an umbrella system-atic literature review (SLR) [19] on all the possible deter-minants of PA. Overall, seven categories of determinantsof PA have been identified: biological, psychological, be-havioral, physical, socio-cultural, socio-economic, and pol-icy determinants. Due to the amount of researchesavailable, the DEDIPAC-KH Management Team decidedto organize the findings in seven separated umbrella SLRs,each focused on a single category. The DEDIPAC-KHManagement Team is conscious that splitting the categor-ies may cause a lost in the analysis of the interactions

Condello et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:58 Page 2 of 23

between those categories of determinants which mayshare commonalities. However, this strategy was consid-ered necessary for a clear dissemination of insights on thedeterminants of PA.The aim of this umbrella SLR was to provide a system-

atic overview of studies investigating behavioral determi-nants of PA across the life course by evaluating existingSLRs and MAs. The summary also captures the differentstudy designs and definitions applied for behavioral de-terminants and PA. Additionally, overall results of theretrieved SLRs and MAs have been evaluated in terms ofthe importance of the determinants, the strength of theevidence, and the methodological quality.

MaterialsThe manuscript has been drafted following the PRISMAchecklist [20]. A common protocol of the seven um-brella SLRs (biological, psychological, behavioral, phys-ical, socio-cultural, socio-economic, and policy) wasregistered and is available on PROSPERO (Record ID:CRD42015010616), the international prospective registerof systematic reviews [21]. Review title, timescale, teamdetails, methods, and general information were all re-corded in the PROSPERO register prior completing dataextraction.

Search strategy and eligibility criteriaThe present study applied the same search strategy as wasused for the other umbrella SLRs of the DEDIPAC-KH.SLRs and MAs investigating the determinants of PAacross the life course were systematically searched onMEDLINE, ISI Web of Science, Scopus, and SPORTDis-cus. The search was limited to SLRs and MAs publishedin English, between January 2004 and April 2016. To avoidduplications of the earliest individual studies, reviews pub-lished before 2004 were not included. Table 1 shows theMEDLINE search strategy, and Fig. 1 summarizes the

process of the literature research, common to the subse-quent 7 umbrella SLRs. Thus, Table 1 provides the overalllist of searched terms, whilst Fig. 1 shows the count of theoverall excluded/included reviews, related and not-relatedwith behavioral determinants. SLRs or MAs of observa-tional primary studies on the association between any de-terminant and PA, exercise (Ex) or sport as the mainoutcome, were included in the seven umbrella SLRs. Thefollowing studies were excluded: i) SLRs and MAs ofintervention studies; ii) SLRs and MAs that focused onspecific population groups (e.g., chronic diseases); and iii)umbrella SLR’s on the same topic (e.g., reviews of SLRs orMAs of epidemiological studies on variables in associationwith PA). In line with Peel and colleagues [10], behavioraldeterminants were defined as “those that can be elimi-nated or reduced through lifestyle or behavioral changes”.

Selection processRelevant articles were independently screened and assessedby two reviewers belonging to the DEDIPAC-KH, whoscreened the titles, the abstracts, and the full texts. Beforethe final study inclusion or exclusion, a common decisionwas reached for each study. Any uncertainty and disagree-ment was resolved by consulting three further authors ofthe DEDIPAC-KH (BS, CL, PA).

Data extractionFor each included review, data was extracted on a prede-fined data extraction form, developed by the DEDIPAC-KH and checked by two authors (AK, PA). In reportingdata, authors agreed to use the terms “reviews” as thoseSLRs and MAs found eligible for the umbrella SLR, and‘primary studies’ as those studies included in the eligibleSLRs and MAs. Moreover, authors agreed to consider allof the terminologies and forms of PA, including unstruc-tured (i.e., PA linked with daily life) and structured (i.e.,

Table 1 Search strategy: key words used for the literature research

Set Search terms

#1 “physical activit*” OR “physical exercise*” OR sport OR “motor activit*” OR “locomotor activit*” OR athletic* OR fitness OR “physical movement*”OR “physical performance*” OR “aerobic exercise*” OR “physical effort*” OR “physical exertion*”

#2 determinant OR determinants OR correlate OR correlates OR mediator OR mediators OR moderator OR moderators OR contributor ORcontributors OR factor OR factors OR association OR modifier OR modifiers OR confounder OR confounders OR pattern OR patterns ORpredictor*

#3 demographic* OR motivation OR cognition OR emotion* OR attitude* OR “self-perception” OR “self-confidence” OR “self-efficacy” ORcompetence OR reward* OR success* OR challenge* OR knowledge OR belief* OR “personal trait*” OR “body image” OR satisfaction OR “timeavailability” OR “perceived environment” OR family OR peer* OR school* OR leader* OR coach* OR group* OR “climate” OR network* ORemployment OR retirement OR “educational level” OR SES OR “socioeconomic status” OR “local identity” OR “national identity” OR value* ORtradition* OR “social expectation*” OR “social trend*” OR “social barriere*” OR “availability of tool*” OR “availability of service*” OR “access to tool*”OR “access to service*” OR neighborhood OR “community route*” OR “school environment” OR “work environment” OR architecture ORurbanization OR transport OR traffic OR “facilit* in public space*” OR advertisement OR “availability of sport club*” OR “availability of fitnesscenter*” OR advocacy OR lobbying OR “corporate social responsibility” OR “physical activity promotion initiative*” OR legislation OR health OReducation OR tourism OR environment OR “urban planning” OR transport* OR sport OR sports OR culture OR dance OR theater OR “gendermainstreaming” OR “social inclusion” OR “fiscal measure*” OR program* OR plan OR plans OR communication OR media OR guideline*

#4 “systematic literature review” OR “meta-analysis”


exercise and sports) independently from their frequency,duration, and intensity.The following information was extracted from each in-

cluded review: year of publication, type of review (eitherSLR or MA), number of eligible primary studies in-cluded in the behavioral umbrella SLR over the totalnumber of primary studies included in the review, con-tinent/s of the included primary studies, primary studydesign, overall sample size, age range or mean age, gen-der proportion, year of publication range of included pri-mary studies, outcome details, type of determinant/s,aim of the review, overall results (qualitative or quantita-tive), overall recommendations, and limitations as pro-vided by the review itself.

Evaluation of importance of determinants andstrength of the evidenceThe results retrieved from the eligible primary studiesincluded in the reviews were summarized combining twoslightly modified grading scales, previously used bySleddens et al. [22]. The first scale, grades the importanceof the determinants, referring only to the consistency anddirection of the associations among the reviews, or the in-dividual primary studies. The second scale, grades thestrength of evidence, referring to the study design usedamong individual primary studies. For its importance, a de-terminant scored a “–” if all reviews, without exception, re-ported a negative association between the determinant and

the outcome and a “-” if the negative association was foundin more than 75% of the reviews or of the original primarystudies. The importance of the determinant was scored a“0” if the results were mixed, or more specifically, if thevariable was found to be a determinant and/or reported anassociation (either positive or negative) in 25 to 75% ofavailable reviews or of the primary studies of these reviews,but not in others. Furthermore, the importance of the de-terminant scored a “+” if a positive association was foundin more than 75% of the reviews or of the included primarystudies and a “++” if a positive association was found in allreviews, without exception. Despite in the literature thecodes “+” and “++” were used in presence of an associ-ation, independently from its direction (e.g., positive ornegative) [22], in the present SLR these codes denote boththe strength and positive direction of the association.The strength of the evidence was described as ‘convin-

cing’ (Ce) if it was based on a substantial (n > 10) numberof longitudinal observational studies showing associationsbetween the determinant and PA. The strength of the evi-dence was defined as ‘probable’ (Pe) if it was based on atleast two cohort studies or five cross-control studiesshowing associations between the determinant and PA.Furthermore, the strength of the evidence was given as‘limited suggestive evidence’ (Ls) if it was based mainly onfindings from cross-sectional studies showing associationsbetween the determinant and PA. Evidence was labelled as‘limited, no conclusive evidence’ (Lns) if the study findings

Fig. 1 Flowchart of the literature research by database


were suggestive but insufficient to provide an associationbetween the determinant and PA [and if no longitudinaldata available].

Quality assessmentThe methodological quality of the included reviews wasassessed using a modified version of the AMSTAR Check-list [23]. After a consensus between the DEDIPAC-KHpartners, the question (number 11) referring to the pres-ence of any conflict of interest was modified to allow forany conflict of interest to be evaluated in any of the in-cluded reviews but not in the primary studies included ineach review.Two authors belonging to the DEDIPAC-KH inde-

pendently evaluated the included reviews, using thesame methodology of Sleddens et al. [22]. Any uncer-tainty and disagreement was resolved by consultingthree further authors (SB, LC, AP). The eleven criteriawere evaluated and scored with 1 when the criterion wasapplicable to the analyzed review or with 0 when the cri-terion was not fulfilled, not applicable to the analyzed re-view, or could not be answered based on the informationprovided by the review. As a consequence, the total qual-ity score for each included review ranged from 0 to 11.The quality of the review was labelled as weak (score ran-ging from 0 to 3), moderate (score ranging from 4 to 7),or strong (score ranging from 8 to 11).

ResultsSLRs and MAs selection processAs summarized in Fig. 1, the systematic literature searchidentified 17,941 reviews that were potentially relevantfor inclusion in our umbrella SLR. After the removal ofduplicates, 15,147 reviews remained for screening. Afterreading title and abstract, 12,414 and 2,198 reviews, re-spectively, were excluded because they did not meet theinclusion criteria. Thus, a total of 535 full-text reviewswere assessed for eligibility. From these, another 472 re-views were removed because they did not meet the in-clusion criteria. Thus, after the full-text reading phase,the number of reviews eligible for the umbrella reviewwas 63. Of these, 46 reviews did not include behavioraldeterminants of PA. Therefore, the final number of re-views included in the present umbrella SLR on behav-ioral determinants of PA was 17 (15 SLRs and 2 MAs).

Characteristics of the reviews and quality assessmentThe characteristics of the 17 included reviews are summa-rized in Table 2. All the primary studies included in the in-dividual SLRs or MAs referring to non-behavioraldeterminants and PA were not considered. Most of the re-views included primary studies from multiple continents,mostly from Europe, North America, and Australia. Thepredominant study design used among the primary studies

was cross-sectional [12, 13, 15, 16, 24–33]. Nine reviewsincluded prospective and cohort studies, either as the onlyeligible study design [34, 35] or as part of the includedstudies [12, 15, 16, 25, 26, 29, 32]. In six reviews, it was notpossible to retrieve the total population sample size of theincluded primary studies because it was either not reportedor not complete [26, 27, 29, 30, 32, 33]. In the remainingstudies, the total population sample size ranged from 26[12] to 82,918 [13].Eleven reviews referred to primary studies that in-

cluded young people only. Among these, preschool chil-dren aged between 4 and 6 years old were assessed inone review [26], whilst children and adolescents (8–18years) were included in ten of the reviews [14–16, 28–30, 32–35]. Three reviews considered adults older than40 years [24, 25, 27], while three other reviews consid-ered the population as a whole [12, 13, 31]. Finally, thepercentage of the female participants, when reported,ranged from 0 [25] to 100% [16, 25, 35], though thatdata was absent in the majority of the studies [12–14,26–30, 32–34].

Measurements of PAFrom the 17 reviews included, 461 primary studies werefound eligible. Among these, 218 studies from 15 re-views used non-objective measurement methods of PAassessment (e.g., self-report, parental report, direct PAobservation) [12, 13, 15, 16, 24, 25, 27–35]. Objectivemeasurements of PA, either assessed by accelerometeror pedometer, were used in 201 of the eligible primarystudies and were included in nine of the included re-views [15, 16, 28–30, 32–35]. Eleven primary studies in-cluded in four reviews combined objective with non-objective measures of PA [15, 28, 29, 34]. Finally, 31 pri-mary studies from two reviews did not report the exactnumber of the studies that used objective and non-objective measures [14, 26].As reported in Table 3, the majority of the included re-

views evaluated overall PA as an outcome (n = 13) [12–16,24–26, 28, 29, 32, 34, 35]. One review also measuredmoderate-to-vigorous physical activity (MVPA) and activetransport [26] next to overall PA. Two reviews measuredoverall PA/Ex [27, 31], one review measured time-specificPA (i.e., school break time PA and after-school PA) [30]and one review measured recess PA [33].

Categorization of the included determinantsDuring the preliminary phase, 52 behavioral determi-nants of PA were identified. Among those, similar deter-minants were identified to form a single determinant.For example, the determinants ‘TV viewing’, ‘TV viewing/playing video games’, ‘television viewing/sedentary’, ‘enjoytelevision viewing’, ‘video/computer game use’, ‘computer’,‘screen time’, and ‘video games’ were merged into the


Table

2Characteristicsof

theinclud

edreview

s

Autho

r,Date

(Typeof

review

)[Ref]

Num

berof

eligiblestud

ies

includ

edin

theum

brella

review

/totalnu

mbe

rof

stud

iesinclud

edin

thereview

Con

tinen

t/sof

includ

edstud

ies

Stud

yde

sign

ofinclud

edstud

ies

Totalsam

plesize

ofinclud

edstud

y(Sam

plerang

e)

Age

rang

eor

mean(years)

ofeligiblestud

ies

Gen

der(female,%

rang

e)of

eligible

stud

ies

Year

rang

eof

includ

edstud

ies

BabakusWS,2012

(SLR)[24]

6/38

Europe

(n=6)

In-dep

thinterviews(n=2)

Focusgrou

p(n=1)

Semi-structuredinterviews

(n=1)

N.A.(n=2)

276(30–109)

N.A.(n=2)

40–83

N.A.(n=2)

39–53

N.A.(n=2)

1980–2012

BarnettI,2012

(SLR)[25]

19/19

North

America(n=11)

Europe

(n=6)

Australia(n=2)

Coh

ort(n=14)

Cross-sectio

nal(n=5)

62,455

(51–11,469)

45–99

0–100

1985–2010

Cragg

sC,2011

(SLR)[34]

13/46

North

America(n=11)

Europe

(n=2)

Prospe

ctive(n=13)

13,332

(40–3,878)

4–9(n=1)

10–13(n=8)

14–18(n=4)

N.A.

1986–2009

DeCraem

erM,

2012

(SLR)[26]

7/43

N.A.

Cross-sectio

nal(n=6)

Long

itudinal(n=1)

N.A.

4–6

N.A.

2003–2010

Engb

ergE,2012

(SLR)[12]

32/34

Europe

(n=7)

North

America(n=22)

Australia(n=3)

Cross-sectio

nalretrospective

(n=7)

Prospe

ctivelong

itudinal

(n=25)

276,558

(26–80,944)

17–70

N.A.

1992–2012

KaczynskiA

T,2008

(SLR)[13]

50/50

North

America(n=23)

Europe

(n=18)

Australia(n=3)

Asia(n=1)

Multip

leCon

tinen

ts(n=

1) N.A.(n=4)

Mostly

cross-sectional

381,807

(120–82,918)

6–89

N.A.

1970–2005

Koen

eman

MA,

2011

(SLR)[27]

2/34

Australia(n=1)

Asia(n=1)

Observatio

nal(n=2)

N.A.

40–80

N.A.

2007

Larouche

R,2014

(SLR)[15]

46/73

Europe

(n=25)

North

America(n=9)

SouthAmerica(n=1)

Asia(n=1)

Australia(n=9)

Russia(n=1)

Cross-sectio

nal(n=41)

Prospe

ctive(n=5)

66,489

(103–7,023)

5–17.9

532002–2012

LeeMC,2008

(SLR)[28]

24/32

North

America(n=9)

Europe

(n=10)

Australia(n=5)

Cross-sectio

nal(n=24)

33,756

(88–10,771)

5–18

N.A.

2002–2007

MarshallSJ,2004

(MA)[14]

24/54

N.A.

N.A.

1443,235

(36–20,766)

0–18

N.A.

1990–2002

PearsonN,2014

(MA)[29]

163/163

Multip

leCon

tinen

tsProspe

ctive(n=12)

Cross-sectio

nal(n=147)

N.A.

0–18

N.A.

1987–2013


Table

2Characteristicsof

theinclud

edreview

s(Con

tinued)

Prospe

ctiveandCross-sectio

nal

(n=4)

Ridg

ersND,2012

(SLR)[33]

3/53

Europe

(n=2)

Australia(n=1)

Cross-sectio

nal(n=2)

N.A.(n=1)

N.A.

5–18

N.A.

2006–2010

Scho

eppe

S,2013

(SLR)[16]

42/52

Europe

(n=25)

North

America(n=9)

Asia(n=1)

Australia(n=6)

Russia(n=1)

Cross-sectio

nal(n=39)

Long

itudinal(n=3)

55,896

(103–6,085)

3–18

39–100

2002–2012

StanleyRM

,2012

(SLR)[30]

6/22

Europe

(n=1)

North

America(n=4)

Australia(n=1)

Cross-sectio

nal(n=6)

N.A.

8–14

N.A.

1997–2010

TzormpatzakisN,

2007

(SLR)[31]

3/36

Europe

(n=3)

Cross-sectio

nal(n=3)

4,213

(171–1,000)

15–89

50–54

2002–2004

Uijtde

willinge

nL,

2014

(SLR)[35]

11/30

Europe

(n=5)

North

America(n=5)

Asia(n=1)

Prospe

ctive(n=11)

11,259

(155–5,451)

4–18

51–100

(n=10)

N.A.(n=1)

2005–2010

vande

rHorstK,

2007

(SLR)[32]

10/57

N.A.

Cross-sectio

nal(n=8)

Prospe

ctive(n=2)

N.A.

4–12

(n=3)

13–18(n=7)

N.A.

1999–2004

Notes:M

A:M

eta-Ana

lysis;SLR:

System

aticLiterature

Review

;N.A.:Not

App

licab

le


Table

3Results

oftheinclud

edreview

s

Autho

r,Date(Type

ofreview

)[Ref]

Outcome(s)

Determinant(s)

Review

aim

Overallqu

alitativeresults

ofthereview

Overall

quantitative

results

ofthereview

Overalllim

itatio

nsof

the

stud

yOverallRecommen

datio

ns

BabakusWS,2012

(SLR)[24]

OverallPA

Lang

uage

difficulties;lackof

time

Toassess

whatisknow

nabou

tthelevelsof

PAand

sede

ntarytim

eandto

contextualizethese

behaviorsam

ongSouth

Asian

wom

enwith

anim

migrant

backgrou

nd.

SouthAsian

wom

enareless

activethan

theothe

rethn

icgrou

psas

wellascompared

toSouthAsian

males;

know

ledg

eof

PAandits

bene

fitswas

foun

dto

belackingam

ongsouthAsian.

N.A.

Nostandardized

metho

dfor

quality

evaluatio

n;lack

ofde

tails

from

someof

the

includ

edpape

rs;

measuremen

tandde

finition

ofPA

variedwidely;

publicationandresearcher

bias

possibility;significant

heteroge

neity

amon

gstud

ies.

Moreresearch

shou

ldbe

dedicatedto

standardize

objectivePA

measuremen

tandto

unde

rstand

how

toutilize

theresourcesof

the

individu

alsandcommun

ities

toincrease

PAlevelsand

overallh

ealth

ofSouthAsian

wom

en;futureresearch

isne

eded

toassess

levelsof

sede

ntarytim

eand

contextualizesede

ntary

behaviors.

BarnettI,2012

(SLR)[25]

OverallPA

Workafterretirem

entfro

mmainoccupatio

n;retirem

ent

from

strenu

ousoccupatio

n;be

ingretired

for<5years;

lifelon

gparticipationin

PA;

beingmarried

Toexam

inechange

sand

pred

ictorsof

change

sin

PAacross

thetransitio

nto

retirem

ent;whe

ther

these

change

svary

bySES;what

isknow

nabou

tpred

ictors

ofchange

sin

PAacross

the

retirem

enttransitio

n.

Exercise

andleisure-tim

ePA

increasedafterthetransitio

nto

retirem

ent,whe

reas

the

finding

sregardingchange

sin

totalP

Awere

inconclusive;m

enincrease

theirPA

morethan

wom

en;

lower

SESisassociated

with

ade

crease

andhigh

SES

with

anincrease

inPA

.Eviden

ceon

othe

rpred

ictors

was

scarce,o

ften

inconsistent,and

metho

dologically

weak.

N.A.

Eviden

ceon

pred

ictorsof

change

was

scarce

and

metho

dologically

weak;no

lang

uage

orcoun

try

restrictio

ns;p

ublishe

dpe

er-

review

edjournalarticlesas

wellasgray

research

literaturewereinclud

ed;

multid

isciplinaryapproach

contrib

uted

tothe

heteroge

neity

oftheresults

andto

theun

feasibility

ofmeta-analysis.

Furthe

rstud

iesshou

ldinclud

eothe

rmeasuresof

SES,approp

riate

andvalid

PAmeasures,applyclear

andrelevant

defın

ition

sof

retirem

ent,andstud

ypred

ictorsof

PAchange

across

thetransitio

nto

retirem

ent;qu

alitative

stud

iesandlong

itudinal

stud

ieswith

long

erfollow-

uparene

eded

.

Cragg

sC,2011

(SLR)[34]

OverallPA

Vigo

rous

PA;p

articipationin

sportteam

sou

tsidescho

ol;

previous

PA;alcoh

olconsum

ption;

dietaryhabits;

smokingstatus;sed

entary

behavior

Tocollate

thecurren

teviden

cebase,h

ighlight

research

tren

dsand

limitatio

nsin

physical

activity

determ

inants

research,and

synthe

size

the

existin

geviden

ce.

Inconclusive

associations

wererepo

rted

forlarge

prop

ortio

nof

the

determ

inantsexam

ined

;girls

consistentlyrepo

rted

larger

declines

inPA

than

boys

inyoun

gerchildren;

parental

maritalstatuswas

consistentlyshow

nno

tto

beassociated

with

change

inactivity;h

ighe

rlevelsof

self-efficacywereassociated

with

smallerde

clines

comparedto

lower

levelsof

selfefficacyin

olde

rchildren

andadolescents.

N.A.

Possibility

ofpu

blicationbias

(includ

edpu

blishe

dstud

ies

only);he

teroge

neity

instud

ysamples,exposureand

outcom

emeasuresinclud

edin

thisreview

;som

estud

ies

draw

data

from

thesame

coho

rts;semi-q

uantitative

repo

rtingused

inthereview

that

limits

theclassification

oftheassociations.

Furthe

rresearch

shou

ldinclud

eob

jectivemeasures

ofPA

andusepreviously

validated

questio

nnairesto

assess

theinvestigated

determ

inants;m

orehigh

quality

research

isne

eded

inallage

grou

ps,especially

inyoun

gerchildren;

investigationinto

determ

inantsof

change

shou

ldtake

into

accoun

tof

specifıcph

ysicalintensities

such

asminutes

spen

tin

mod

erateor

vigo

rous

physicalactivity.

DeCraem

erM,

2012

(SLR)[26]

OverallPA

,MVPA,

activetransport

Participationin

organized

sports;televisionview

ing/

sede

ntary;en

joytelevision

view

ing;

child

hasno

energy

touseactivetransport

Tosystem

aticallyreview

the

correlates

ofPA

,sed

entary

andeatin

gbe

havior

inpreschoo

lchildren4-6years

old.

Atten

ding

aruralp

rescho

olwas

positivelyassociated

with

physicalactivity;

gend

er,age

and

socioe

cono

micstatus

were

notassociated

with

physical

N.A.

Somelim

itatio

nsregarding

thecoding

ofthe

associationof

thevariables;

new

catego

riesforeach

behavior

weremade.

Future

research

shou

ldfocus

oniden

tifying

thecommon

correlates

ofph

ysicalactivity,

sede

ntarybe

havior

and

eatin

gbe

havior

inpreschoo

l-age

dchildrenso


Table

3Results

oftheinclud

edreview

s(Con

tinued)

activity,w

hilean

inde

term

inateresultwas

foun

dforethn

icity;g

ende

randethn

icity

wereno

tassociated

with

sede

ntary

behavior

andinde

term

inate

results

werefoun

dforage

andsocioe

cono

micstatus;

preschoo

lersweremore

physicallyactiveas

wellas

sede

ntaryon

weekdays;

watchingtelevision

was

associated

with

ahigh

erconsum

ptionof

snacks

and

sweetbe

verage

s.

that

better

tailored

interven

tions

couldbe

develope

d.Furthe

rmore,

morelong

itudinalstudies

couldcontrib

utein

draw

ing

strong

erconclusion

son

determ

inantsof

theseEBRBs.

Engb

ergE,2012

(SLR)[12]

OverallPA

Transitio

nto

university;

change

inem

ploymen

tstatus;m

aritaltransition

sandchange

sin

relatio

nships;p

regn

ancy/

having

achild;experiencing

harassmen

tat

work,

violen

ceor

disaster;m

oving

into

aninstitu

tion

Toexam

ineliterature

concerning

theeffectsof

lifeeven

tson

change

sin

PA.

Mostof

thestud

iesreview

edshow

edstatistically

sign

ificant

change

sin

PAassociated

with

certainlife

even

ts;transition

toun

iversity,havingachild,

remarriage

andmassurban

disaster

wereassociated

with

decreasedPA

levels,

whileretirem

entwas

associated

with

increased

PA;experiencingmultip

lesimultane

ouslifeeven

tswereassociated

with

decreasedPA

inmen

and

wom

en;PAisoftenused

aspartof

arehabilitation

prog

rammefordiseases.

N.A.

Self-repo

rted

PAdata

are

likelyto

besomew

hat

limited;

anothe

rlim

itatio

nis

thepo

ssiblecross

contam

inationof

respon

ses

whe

nPA

levelsbe

fore

and

afteralifeeven

twere

assessed

atthesametim

e;thege

neralizationof

stud

yfinding

sto

lower

socioe

cono

micstatus

and

ethn

icminority

popu

latio

ns,

aswellasto

othe

rcoun

tries,

may

belim

itedbe

causePA

andlifeeven

tsvary;

limitatio

nsof

thestud

ies

includ

ethat

PAdata

were

notalwaysrepo

rted

inde

tail;somestud

iesdidno

tanalyze,statistically,the

magnitude

ofchange

inPA

;anothe

rim

portantlim

itatio

nisthat

lifeeven

tstend

tooverlap.

Future

stud

iesshou

ldexam

inege

nder

differences

intheeffectsof

lifeeven

tsandusevalidated

metho

dsin

assessingleisurePA

.Long

itudinalcoh

ortstud

ies

andclinicaltrialsfro

mdifferent

coun

triesand

cultu

resarene

eded

.Studies

with

long

erfollow-ups

are

necessaryto

exam

ineho

wlong

theeffectsof

life

even

tson

PApe

rsist.

KaczynskiA

T,2008

(SLR)[13]

OverallPA

Smoking

Tobe

tter

unde

rstand

the

co-occurrenceof

smoking

andph

ysicalinactivity

inbo

thadultsandyouth.

Inapproxim

ately61%

ofthe

stud

iesof

adultpo

pulatio

ns,

theassociationbe

tween

smokingandPA

was

negative,less

pron

ounced

foryouthandadolescents,

andam

ongmales

than

females.

N.A.

Someauthorsde

fined

asm

oker

assomeo

newho

smoked

atleaston

cein

the

past30

days

whe

reas

othe

rstud

iesused

thecriterio

nof

atleaston

ecigarettepe

rdayover

thepastmon

th.

Furthe

rcomplicating

interpretatio

nsisthefact

that

controlling

foror

includ

ingdifferent

variables

change

stheim

pact

ofthe

"predictor"variables

onthe

"outcome"

measures.Alm

ost

allo

ftheaforem

entio

ned

Researchersho

ping

toim

proveun

derstand

ingof

thejointrelatio

nbe

tween

PAandsm

okingne

edto

collect

data

atbo

ththe

individu

alandorganizatio

n(i.e.,enviro

nmen

t)levels.

Und

erstanding

the

mechanism

sby

which

depression

,lun

gfunctio

n,scho

olsetting,

orothe

rfactorsmed

iate

ormod

erate

thesm

okingandPA

relatio

nshiprequ

ires

measuremen

tof

these


Table

3Results

oftheinclud

edreview

s(Con

tinued)

stud

ieswerecross-sectional,

andso

inferringcausality

orthedirectionof

relatio

nships

isne

arim

possible.

variables

atmultip

le(preferablythreeor

more)

pointsin

time.By

expand

ing

thearrayof

investigative

metho

dsem

ployed

,researcherswillbe

better

equipp

edto

unde

rstand

linkage

sbe

tweensm

oking

andPA

andto

design

effectiveinterven

tions.

Koen

eman

MA,

2011

(SLR)[27]

OverallPA

,OverallEx,

OverallPA

/Ex

Baselineactivity

level;

smoking

Tosystem

aticallyreview

determ

inantsof

PAand

exercise

amon

ghe

althy

olde

radults.

Insufficien

teviden

cefor

mostassociations

betw

een

possiblede

term

inantsand

PAor

Ex.

N.A.

Theremay

bepo

ssibility

ofpu

blicationbias;a

wideage

rang

eisappliedthat

might

have

maskedsomeof

the

differences

betw

een

subsam

ples

inside

that

popu

latio

n;they

exclud

edsomespecificsubsam

ples

oftheolde

rpo

pulatio

n;overall

low

quality

ofthestud

ies

includ

ed

Thede

term

inantsof

PAne

edfurthe

rstud

ythat

includ

etheuseof

objective

measuresof

PAandexercise

andvalid

andreliable

measuresof

determ

inants.

Larouche

R,2014

(SLR)[15]

OverallPA

Activescho

oltransport

Tosystem

aticallyassess

the

quality

ofeviden

cewith

respectto

therelatio

nship

betw

eenactivescho

oltransportanddaily

PA,

cardiovascular

fitne

ss,and

body

compo

sitio

n.

Overall,81.6%

ofthestud

ies

show

edpo

sitiveassociations

betw

eenactivescho

oltransportandPA

levelswith

mod

eratequ

ality

ofeviden

ce.

N.A.

Meta-analyses

were

preclude

ddu

eto

thewide

heteroge

neity

instud

ymetho

dologies

andanalyses.

Furthe

r,thefunn

elplot

and

relatedstatisticalmetho

dsforde

tectingpu

blication

bias

couldno

tbe

used

becauseaconsistent

measure

ofeffect

across

stud

ieswas

notavailable.

Future

activescho

oltransportstud

iesshou

ldanalyzewalking

andcycling

separately.Futurestud

ies

couldevaluate

theim

pact

ofexistin

gprog

ramsthat

prom

oteactivescho

oltransporton

PAlevelsand

health

relatedou

tcom

es.

Future

stud

iesshou

ldconsider

assessingactive

scho

oltransportas

acontinuo

usvariable(i.e.,

frequ

ency

×distance).

LeeMC,2008

(SLR)[28]

OverallPA

Activecommutingto

scho

olThisarticlepresen

tsa

system

aticreview

ofthe

literatureon

active

commuting(walking

orbicycling)

andthe

outcom

esof

physical

activity

andweigh

t/ob

esity

inscho

ol-age

children.

Inmultip

lestud

iesin

anu

mbe

rof

coun

tries,a

sign

ificant

association

betw

eenph

ysicalactivity

andwalking

orcyclingto

scho

olhasbe

enno

ted

across

manyagegrou

psof

scho

olchildren.

Thestreng

thof

theassociationismixed

andasummaryestim

ateis

notpo

ssiblebe

causeof

the

heteroge

neity

instud

yde

sign

.Reg

ardlessof

this

association,

itremains

unclearas

towhe

ther

the

commutetrip

itselfisa

sign

ificant

compo

nent

oftotalp

hysicalactivity.

N.A.

Thede

finition

ofactive

commutingandthe

potentialfor

misclassification

bias;the

metho

dology

ofmeasurin

gph

ysicalactivity;

themajority

ofcross-

sectionalstudies.

Future

research

shou

ldfocus

onmeasurin

gtheim

pact

ofinterven

tions

that

succeedin

changing

commuting

behavior

andqu

antifying

the

contrib

utionof

the

commuteto

children’sdaily

activity.


Table

3Results

oftheinclud

edreview

s(Con

tinued)

MarshallSJ,2004

(MA)[14]

OverallPA

TVview

ing;

vide

o/compu

ter

gameuse

Toexam

inetheeviden

cethat

sede

ntarybe

haviors

displace

physicalactivity.

Possiblemechanism

slack

supp

ortin

geviden

ceand

claimsthat

TVview

ing,

playingvide

ogames

orusingcompu

tersdisplace

physicalactivity

receivevery

limitedem

piricalsupp

ort.

−0.096(95%

CI=

-0.080,-0.112)

-0.104

(95%

CI=

-0.080,-0.128)

Onlystud

ieswrittenin

English.

Moreexpe

rimen

talresearch

isne

eded

toreplicatethese

finding

sandexplore

possiblemechanism

s.

PearsonN,2014

(MA)[29]

OverallPA

Totalsed

entary

behavior;

compu

ter;ho

mew

ork;

internet;reading

;screen

time;television

;video

games;com

posite

sede

ntary

behavior

Theaim

ofthecurren

tstud

ywas

tosystem

atically

review

andmeta-analysis

peer-reviewed

research

describ

ingtheassociation

betw

eensede

ntarybe

havior

andPA

inchildrenand

adolescents.

Asign

ificant,b

utsm

all,

negativeassociationwas

foun

dbe

tweensede

ntary

behaviorsandph

ysical

activity

inchildrenand

adolescents;in

mod

erator

analyses,studies

that

recruitedsm

allersamples,

employed

objective

metho

dsof

measuremen

tor

wereassessed

tobe

ofhigh

ermetho

dological

quality

repo

rted

strong

erassociations,alth

ough

the

magnitude

ofeffect

remaine

dsm

allo

rsm

allto

mod

erate;sm

allinverse

associations

wereob

served

betw

eenspecificsede

ntary

behaviou

rs,including

Internet

use,screen

time

andTV

view

ing,

andph

ysical

activity.

−0.108(95%

CI=

-0.128,-0.087)

-0.018

(95%

CI=-0.038,0.001)

0.014(95%

CI=-0.043,0.095)

-0.051

(95%

CI=

-0.097,-0.006)

-0.009

(95%

CI=-0.039,0.021)

-0.080

(95%

CI=

-0.101,-0.060)

-0.064

(95%

CI=

-0.084,-0.045)

-0.002

(95%

CI=-0.043,0.040)

-0.265

(95%

CI=

-0.364,-0.165)

Dicho

tomizationof

acontinuo

usconstruct;

searches

wereconfined

tostud

iespu

blishe

din

peer-

review

edjournalsandthose

writtenin

English;

evaluatio

nof

associations

betw

een

sede

ntarybe

havior

andall

PAou

tcom

escombine

d,insteadof

different

PAdo

mains.

Furthe

rresearch

isrequ

ired

toclarify

therelativeand

interactingim

pact

ofPA

and

sede

ntarybe

havior

onweigh

tstatus

inthis

popu

latio

n.

Ridg

ersND,2012

(SLR)[33]

Recess

PASportactivities;p

hysical

conflictfre

quen

cy;d

ay-to-

dayvariability;play

ball

games;sed

entary

activities

Toexam

inethecorrelates

ofchildren’sand

adolescent’sPA

durin

gscho

olrecess

perio

ds.

Highe

rpe

rceived

encouragem

entfro

mparents,pe

ers,andthe

scho

olas

awho

lewas

associated

with

high

erself-

repo

rted

physicalactivity

levelsdu

ringrecess

perio

ds,

particularlyin

adolescents;

overallfacility

provision(i.e.,

sum

offacilitiesavailable)

was


with

physicalactivity;a

positiveassociationwas

foun

dbe

tweenun

fıxed

equipm

entandrecess

physicalactivity

inchildren;

boys

aremoreph

ysically

activedu

ringrecess.

N.A.

Themajority

aresm

all-sized

andcross-sectionalstudies;

meta-analysisisdifficultto

obtain

giventhelim

ited

numbe

rof

stud

iesandthe

lack

ofconsistencyin

correlates

assessed

;arang

eof

physicalactivity

measures

have

been

used

;differen

tcut-po

intsandob

servation

system

smay

have

influen

cedthestreng

thof

associations

observed

.

Furthe

rresearch

shou

ldinvestigatecorrelates

ofchildren’sandadolescents’

recess

physicalactivity

for

variables

that

wereno

tinvestigated

frequ

ently

but

indicatedpo

sitive

associations

with

physical

activity;further

research

usingob

jectivemeasuresis

need

edto

determ

ine

adolescents’recess

physical

activity

levels;futureresearch

shou

ldexam

inewhe

ther

increasing

access

toscho

olfacilitiesdu

ringrecess

perio

dsincreasesph

ysical

activity

levelsin

childrenand

adolescents;furthe

rresearch

isne

eded

tode

term

ine

whe

ther

specifıctype

sof

equipm

ent,or

theoverall

availabilityof

unfıxed


Table

3Results

oftheinclud

edreview

s(Con

tinued)

equipm

ent,areassociated

with

high

erlevelsof

physical

activity;futureresearch

shou

ldexam

inethe

correlates

ofbo

ysandgirls

physicalactivity

separately;

Moreresearch

isne

eded

concerning

correlates

ofPA

inrecess

perio

d,particularly

inadolescents.

Scho

eppe

S,2013

(SLR)[16]

OverallPA

Inde

pend

entmob

ility

with

outadultsupe

rvision

(Activetravelto

and/or

from

scho

olandactivetravelto

leisuretim

erelatedplaces);

inde

pend

entmob

ility

with

outadultsupe

rvision

(outdo

orplay);activetravel

with

orwith

outadult

supe

rvision(Activetravelto

and/or

from

scho

ol);active

travelwith

orwith

outadult

supe

rvision(Activetravelto

leisuretim

erelatedplaces)

Tosynthe

size

theeviden

ceforassociations

ofchildren’s

inde

pend

entmob

ility

and

activetravelto

vario

usde

stinations

with

physical

activity,sed

entary

behavior

andweigh

tstatus.

Children’sactivetravelto

and/or

from

scho

olwas

consistentlypo

sitively

associated

with

physical

activity;p

ositive

relatio

nships

werefoun

dbe

tweenactive

travelto

leisure-related

destinations

andph

ysical

activity;traveltovario

usplaces

includ

ingscho

ol,

shop

s,cine

mas

andfrien

d’s

homes

werepo

sitive

associated

with

mod

erate-

to-vigorou

sandoverall

physicalactivity;children

weremorelikelyto

increase

physicalactivity

levelswhe

ntheirou

tdoo

rplay

occurred

inde

pend

ently;associatio

nsbe

tweenactivescho

oltravel

andweigh

tstatus

were

inconsistent

across

the

stud

ies.

N.A

Few

stud

iesmeasurin

gactivetravelto

places

othe

rthan

scho

ol;use

ofdifferent

thresholds

forde

fining

objectivelymeasured

sede

ntarybe

havior

inchildren;

themeasuremen

tof

sede

ntaryactivities

inchildrenstilllacks

standardizationand

validation;

Socialand

physicalen

vironm

ents

cond

uciveto

children’s

inde

pend

entmob

ility

and

activetravelwereno

texplored

butcertainlyplay

aroleas

correlates

ofchildren’sph

ysicalactivity,

sede

ntarybe

havior

and

weigh

tstatus.

Future

stud

iesshou

ldseek

toinvestigateassociations

ofinde

pend

entmob

ility

and

activetravelwith

light

intensity

physicalactivity;

children’sdaily

activetravel

tovario

usde

stinations

beyond

thescho

olsetting

requ

iresfurthe

rattention,

aswellasinvestigatingdiverse

sede

ntarybe

haviorsbe

yond

simplyscreen

-based

activities

andde

fining

approp

riate

thresholds

for

objectivelymeasured

sede

ntarybe

havior

inchildren;

thepo

tentialo

finde

pend

entmob

ility

topreven

tsede

ntarybe

havior

andexcessiveweigh

tshou

ldbe

explored

infuture

observationalstudies;studies

shou

ldmeasure

inde

pend

entmob

ility

and

activetravelmore

thorou

ghlyby

considering

frequ

ency

anddu

ratio

nof

inde

pend

entmob

ility

and

activetravel,aswellas

whe

ther

childrenare

travellingalon

eor

with

peers,or

toproxim

alversus

distantde

stinations,and

whe

ther

theob

served

associations

differby

age

andge

nder.

StanleyRM

,2012

(SLR)[30]

Time-specificPA

(i.e.,schoo

lbreak

timePA

and

after-scho

olPA

)

TVview

ing/playingvide

ogames;use

offacilities;

mem

berof

organized

activities

Toiden

tifythecorrelates

ofchildrens'PA(8-14years)

occurringdu

ringthescho

olbreak-tim

eandafterscho

olpe

riods.

Boys

andyoun

gerchildren

tend

tobe

moreactive

durin

gbreak-tim

eandafter-

scho

ol;BMIinfemales

negativelyassociated

with

after-scho

olPA

,age

was

negativelyassociated

in

N.A.

Smalln

umbe

rof

stud

iesthat

vary

inmetho

dological

aspe

cts;po

ssibility

that

some

stud

iesaremisseddu

ring

thesearch

process;majority

ofcross-sectionalstudies;

somestud

iesstratified

Future

stud

iesusinga

contextspecificapproach

shou

ldiden

tifyandrepo

rtspecificfacilitiesrelevant

tothecontextin

questio

n,which

willcontrib

uteto

aclearerun

derstand

ingof


Table

3Results

oftheinclud

edreview

s(Con

tinued)

scho

ol-break

andafter

scho

ol;fam

ilyaffluen

ce,

access

toagym,accessto

four

ormorePA

prog

rams

andthecond

ition

ofa

playingfield

wereall

associated

with

scho

olbreak

timePA

inon

estud

y;access

tolooseandfixed

equipm

ent,playgrou

ndmarking

s,size

ofandaccess

toplay

spaceandtheleng

thof

scho

olbreaktim

ewereall


with

change

sin

scho

olbreak

timePA

ininterven

tion

stud

ies;in

theafter-scho

olpe

riod,

gend

er(with

boys

againmoreactive),you

nger

age,lower

body

massinde

x(fo

rfemales),lower

TVview

ing/playingvide

ogames

andgreateraccess

tofacilitieswereassociated

with

high

erlevelsof

after-

scho

olPA

intw

oor

more

stud

ies,whileparent

supe

rvisionwas

negatively

associated

with

females’

after-scho

olPA

inon

estud

y.

analyses

bysalient

variables

such

asage,ge

nder

and

intensity

ofPA

,resultin

gin

anover-rep

resentationof

thesestud

iesin

thereview

;therelativelynarrow

age

rang

especified

inthe

curren

treview

isalim

itatio

n.

context-specificPA

;future

stud

iesshou

ldchoo

semeasuremen

ttoolswith

approp

riate

psycho

metric

prop

erties;Needof

high

quality

eviden

ceup

onwhich

PAprom

otionin

youn

gpe

oplecanbe

tailoredto

specificsettings

and

contexts.

TzormpatzakisN,

2007

(SLR)[31]

OverallPA

/Ex

Lack

oftim

e;tim

econstraints;maritalstatus

Toevaluate

theeviden

cefro

mresearch

relevant

toparticipationin

PAand

exercise

inGreece.

Participationin

physical

activity

andexercise

inGreecewas

gene

rally

low;

men

exercise

more

vigo

rouslyandmoreactively

than

wom

en;the

main

reason

sforparticipation

werehe

alth,w

eigh

tcontrol,

fitne

ss,and

stress

managem

ent.Lack

ofleisure

timewas

themainpe

rceived

barrierto

increasing

levelsof

physicalactivity

andexercise;

men

seem

edto

exercise

morefre

quen

tlyandmore

vigo

rouslythan

wom

en;

sing

lepe

opleweremore

likelyto

beph

ysicallyactive

comparedto

thosewho

weremarriedor

divorced

/widow

ed;p

eoplelivingin

ruralareas

weremorelikely

tobe

physicallyactivethan

thoselivingin

urbanareas.

N.A.

Non

eof

thestud

iesused

objectivemeasuremen

tsand

also

they

used

different

self-

repo

rted

estim

ates

ofPA

;lack

ofapprop

riate

useof

theterm

s'exercise'and'PA';

none

oftheinstrumen

tswerevalidated

inGreece;

season

ality

effect,since

season

alvariatio

nexistsin

physicalactivity

participation.

PAprom

otionshou

ldbe

organizedin

asystem

atic

way;a

clearde

finition

ofvariables

isne

eded

;interven

tionstud

iesshou

ldbe

employed

inorde

rto

test

theefficiencyof

policies,

strategies

andcampaigns;

long

itudinalstudies

shou

ldbe

utilizedin

orde

rto

evaluate

tren

dsin

physical

activity

participationandthe

long

-term

effectsof

campaigns;a

clearpatternof

who

isconsidered

physically

activeandinactiveshou

ldbe

determ

ined

accordingto

internationally

establishe

dcriteria

inorde

rto

have

morevalid

andreliabledata;

stud

iesshou

ldno

tconcen

trateon

lyon

leisure

timeph

ysicalactivities

but


Table

3Results

oftheinclud

edreview

s(Con

tinued)

onthetotalp

hysicalactivity

profile

ofeach

participant.

Uijtde

willinge

nL,

2014

(SLR)[35]

OverallPA

Pastph

ysicalactivity;screen

time

Tosummarizeandup

date

theexistin

gliteratureon

determ

inantsof

PAand

sede

ntarybe

havior

inyoun

gpe

ople.

Mod

erateeviden

cefor

intentionas

ade

term

inant

ofchildren’sph

ysicalactivity,

andage(i.e.,older

children

weremoreactive),ethnicity

(i.e.,b

eing

ofAfrican–

American

descen

tde

term

ined

beingless

physicallyactive)

and

planning

asde

term

inantof

adolescent

physicalactivity.

N.A.

Includ

edstud

iesassessed

overallP

Aon

ly;usedtw

odatabaseson

ly;the

selected

lang

uage

ofpu

blicationwas

Englishon

ly.

Future

researches

shou

ldbe

focusedon

determ

inantsof

child

andadolescent

sede

ntarybe

havior

andon

environm

entald

eterminants

ofph

ysicalactivity

inbo

thchildrenandadolescents,

shou

ldusereliableandvalid

measuresof

both

determ

inantsas

wellasthe

actualbe

haviorsandshou

ldcond

uctprospe

ctivestud

ies

ofhigh

metho

dological

quality.

vande

rHorstK,

2007

(SLR)[32]

OverallPA

PE/schoo

lspo

rts;watching

TV;smoking;

television

/sede

ntarytim

e

Tosummarizeandup

date

theliteratureon

correlates

ofPA

,insufficient

PA,and

sede

ntarybe

havior

inyoun

gpe

ople.

Theresults

from

ourreview

sugg

estthat

correlates

ofph

ysicalactivity

forchildren

arege

nder,self-e

fficacy,

parentalph

ysicalactivity

for

boys,and

parentalsupp

ort.

Correlatesforadolescents'

physicalactivity

were

gend

er,p

aren

taledu

catio

n,attitud

e,self-efficacy,go

alorientation/motivation,

physicaled

ucation/scho

olsportsparticipation,

family

influen

ces,andfrien

dsupp

ort.Gen

der,self-efficacy,

andfamily/paren

talsup

port

wereassociated

with

physicalactivity,b

othin

childrenandadolescents.

N.A.

Publicationbias

may

bepresen

t;po

ssibility

ofmissed

stud

iesas

aresultof

the

search

strategy;the

main

outcom

ewas

overallP

Awith

outothe

rclassifications;

mostly

cross-sectional

stud

iesinclud

ed;b

ecause

ofthevariability,itwas

not

possibleto

assess

theoverall

streng

thof

theassociations.

Moreprospe

ctivestud

iesare

need

edandmoreresearch

includ

ingchildren.

Notes:M

Ameta-an

alysis,SLR

system

aticliteraturereview

,PAph

ysical

activ

ity,P

Eph

ysical

education,

MVP

Amod

erate-to-vigorou

sph

ysical

activ

ity,Exexercise,SES

socio-econ

omicstatus,EBR

Ben

ergy

balance-relatedbe

havior


determinant ‘screen use’. Differently, other similar deter-minants were identified to form a sub-group with a spe-cific label. For example, the determinants ‘being retired’,‘change in employment status’, and ‘moving into an insti-tution’ were part of the sub-group ‘job-related’. Thus, afinal consensus between authors had been achieved forthis categorization and the final number of behavioraldeterminants was 35 (Table 4). Any uncertainty and dis-agreement was resolved by consulting three further au-thors of the DEDIPAC-KH (BS, CL, PA).

Findings of the reviewsThe findings of the included reviews on the associationsbetween the behavioral determinants and PA, consider-ing different age groups and different types of PA, aresummarized in Table 4.

Preschool childrenOne review specifically assessed the behavioral correlatesof PA in preschool children that were aged between 4and 6 years old [26]. Among the correlates investigated,only those related with ‘screen use’ were negatively asso-ciated with MVPA in all the studies included in the re-view with a limited suggestive level of evidence (−−, Ls).Inconclusive findings were found regarding ‘participa-tion in organized sports’ (0, Lns) and ‘screen use’ (0,Lns) with respect to overall PA and no association wasfound between ‘children have no energy to use activetransport’ and active transport (0, Lns).

ChildrenFew determinants were investigated among childrenaged between 10 and 13 years old in respect to overallPA [34]. ‘Previous PA’ was the only determinant posi-tively associated with overall PA in more than 75% ofthe studies included in the review with a probable levelof evidence (+, Pe). Conversely, ‘participation in sportteams outside school’ (0, Ls) and ‘alcohol consumption’(0, Ls) were not associated with overall PA in children.Considering after-school PA, one review investigated thebehavioral correlates of PA in children between 8 and14 years old [30]. Among the correlates investigated,only those related with ‘screen use’ were negative associ-ated with after-school PA in more than 75% of the stud-ies included in the review with a limited suggestive levelof evidence (−, Ls). ‘Member of organized activities’ (0,Lns) was not associated with after-school PA, whilst for‘use of facilities’ the evidence was limited and inconclu-sive (0, Lns).

AdolescentsTwo reviews investigated the behavioral determinants[34] and correlates [32] of PA in adolescents aged be-tween 14 and 18 years [32, 34]. ‘PE/school sports’ [32]

and ‘previous PA’ [34] were both positively associatedwith overall PA in all the studies included in the review,without exception, both with a limited suggestive levelof evidence (++, Ls). ‘Vigorous PA’ was negatively associ-ated with overall PA in all the studies included in the re-view, without exception, with a limited suggestive levelof evidence (−−, Ls) [34]. No association was found be-tween ‘dietary habits’ and overall PA (0, Ls) [34].

Children and adolescentsTen reviews examined the behavioral determinants andcorrelates of PA for children and adolescents (≤18 yearsold) in relation to overall PA [13–16, 28, 29, 32, 34, 35]and recess PA [33]. Independent mobility and active trans-port’ [15, 16, 28] was positively associated with overall PAin more than 75% of the studies included in the reviews,with a probable level of evidence (+, Pe). ‘Homework’ [29]was positively associated with overall PA in all the studiesincluded in the review, without exception, with a limitedsuggestive level of evidence (++, Ls). In particular, a posi-tive effect size (r = 0.014, 95% CI = −0.043, 0.095) emergedfrom the results of the MA [29]. Conversely, ‘Internet use’,‘reading’, and ‘composite sedentary behavior’ were nega-tively associated with overall PA in all the studies includedin the review, without exception, with a limited suggestivelevel of evidence (−−, Ls). The results of the MA [29]showed small to moderate negative effect sizes for thethree determinants (r = −0.051, 95% CI = −0.097, −0.006;r = −0.009, 95% CI = −0.039, 0.021; r = −0.265, 95%CI = −0.364, −0.165, respectively). Limited evidence wasfound regarding ‘smoking’ (0, Ls) [13, 32, 34], ‘screen use’(0, Ls) [14, 29, 32, 35], ‘sedentary behavior’ (0, Ls) [34], and‘past physical activity’ (0, Ls) [35]. ‘Sports activities’, ‘playballgames’, and ‘physical conflict frequency’ were positivelyassociated with recess PA in all the studies included in thereview, without exception, with a limited suggestive level ofevidence (++, Ls) [33]. ‘Sedentary activities’ was negativelyassociated with recess PA in all the studies included in thereview, without exception, with a limited suggestive level ofevidence (−−, Ls) [33]. No association was found between‘day-to-day variability’ and recess PA (0, Lns) [33].

AdultsThree reviews assessed the behavioral determinants ofPA in adults older than 40 years [24, 25, 27]. ‘Baselineactivity level’ was positively associated with overall PA/Ex in all the studies included in the review, without ex-ception, with a limited suggestive level of evidence (++,Ls) [27]. Conversely, a negatively association was foundbetween ‘language difficulties’ [24] and overall PA/Ex inall the studies included in the review, without exception,with a limited suggestive level of evidence (−−, Ls). For‘being retired’ (0, Lns) and ‘lifelong participation in PA’(0, Ls), the evidence was limited and inconclusive [25].


Older adultsFor older adults (≥70 years), only one review [27] inves-tigated the association between ‘smoking’ and overallPA/Ex suggesting negative associations in all the studiesincluded in the review, without exception, with a limitedsuggestive level of evidence (−−, Ls).

All agesFive reviews examined the behavioral determinants of PAacross all ages [12, 13, 24, 25, 31]. A negative associationwas found between ‘moving into an institution’ and overallPA/Ex in all the studies included in the review, without ex-ception, with a limited suggestive level of evidence (−−, Ls)[12]. ‘Pregnancy/having a child’ and ‘transition to univer-sity’ were negatively associated with overall PA/Ex in morethan 75% of the studies included in the review with a prob-able level of evidence (−, Pe) [12], while ‘time limitation’was negatively associated with overall PA/Ex in more than75% of the studies included in the reviews with a limitedsuggestive level of evidence (−, Ls) [24, 31]. Finally, for‘marital status’ (0, Lns) [12, 25, 31], ‘smoking’ (0, Lns) [13],‘change in employment status’ (0, Ls), and ‘experiencingharassment at work, violence, and disaster’ (0, Ls) [12] theevidence was limited and inconclusive.

Evaluation of the quality of the SLRs and MAsThe results of the quality assessment using theAMSTAR checklist are reported in Table 5. Among the17 included reviews, the majority were of moderatequality (n = 13) [12, 14–16, 24–28, 30, 33–35], threewere weak [13, 31, 32], and only one was considered to

be of strong quality [29]. Among those reviews of mod-erate quality, five were scored with 4 points [12, 26, 28,30, 33], one with 5 points [16], four with 6 points [14,15, 24, 34], and three with 7 points [25, 27, 35].Few reviews provided all the characteristics of the pri-

mary studies [12, 13, 15, 16, 25, 28, 31, 34, 35] and noneof the reviews provided a full list of included and ex-cluded studies.

DiscussionThis umbrella SLR aimed to provide a comprehensive andsystematic overview of behavioral determinants of PAacross the life course, evaluating importance, strength ofthe evidence, and methodological quality. Through asystematic evaluation of the existing SLRs and MAs, anoverview of the associations between the considered be-havioral determinants and PA is presented to promote ef-fective health enhancing policies and identify gaps forfuture research strategies. To our knowledge, this is thefirst umbrella SLR that examined various potential behav-ioral determinants of PA across the life course.Whether or not individuals choose to engage in PA

behaviors is affected by a number of inter-dependentand multilevel factors. A relevant contribution of theDEDIPAC-KH project was the development of a dynamicframework of determinants of PA, which identified twomain themes related to the person and to the society,respectively [36]. Behavioral determinants are part ofthe individual theme, together with the biological andpsychological determinants, whereas the other themecomprises physical (e.g., environmental), socio-cultural,

Table 4 Summary of the results of the included reviews: the importance of a determinant and its strength of evidence


socio-economic, and policy determinants. Through thesystematic analysis of scientific evidence, the present find-ings expand the knowledge and the understanding of be-havioral determinants of PA to prepare the ground for acoherent approach towards PA behaviors research and in-terventions to favor active lifestyle choices.Overall, for the majority of determinants, the evidence

was limited and inconclusive or there was not an associ-ation with the different forms of PA. Furthermore, forseveral potential determinants it was not possible to as-certain definite conclusions on their association with PA.These findings urge researchers to consider new andinnovative approaches when investigating factors influ-encing PA behaviors.In relation to the investigated populations, more studies

(n = 11) focused on youth (e.g., ≤18 years) with respect tothose on individuals older than 18 years (n = 5). The rea-son for a greater focus on young populations might bedue to the fact that being physically active at the youngeststages of age is crucial to maintain high levels of PA at theadulthood [32, 37], decreasing the risk factors for non-communicable diseases [2] and having a favorable effecton public health [37]. Nonetheless, the understanding ofthe relationships between behavioral determinants and PAis also crucial among older adults as they are more vulner-able and more likely to have decreasing level of PA and in-creasing levels of sedentary behaviors.Among all the young population groups, 7 determi-

nants were positively associated and 6 determinantswere negatively associated with PA. A probable positiveassociation was evident between ‘previous PA’ and over-all PA in children, with the review showing a moderatequality [34], confirming the importance of PA in child-hood. Moreover, a probable positive association wasfound in three reviews [15, 16, 28] between ‘independentmobility and active transport’ and overall PA in childrenand adolescents, with the reviews showing a moderatequality. Larouche and colleagues [15] argued that it islikely that an active traveler is also more inclined to beactive throughout the day. However, other determinants(e.g., low socioeconomic status and lower income house-holds), which were not considered in their review, mayinfluence the relationship between ‘independent mobilityand active transport’ and PA. Furthermore, potentialbiases due to classification, such as active school trans-port only once per week and direction of active trans-port (e.g., only to school and not from school) could alsoplay a role. Other relevant aspects proposed bySchoeppe and colleagues [16] concern the positive asso-ciations of active travel to destination other than school,the health benefits for children of being involved in‘free-range’ activities, like active travel or play outdoorwithout adult supervision, and the higher frequency ofactive travel from school to home rather than from

home to school. Other determinants related to ‘sport/PAin and out of school’ [32, 33] and to ‘other daily activ-ities’ [29] were positively associated with PA but with alimited suggestive level of evidence. The present findingsare in line with the determinants related to school phys-ical activity and youth sport participation (e.g., “PA Pro-grams in School”, “Availability/Access/Proximity of PAOrganized Sport Facilities/Tools”, “PA Education (atSchool/Work)/Knowledge of Effects of PA”, “GroupActivities (Outdoor/Indoor)”, “Involvement in OrganizedSport”, “Time Spent Outdoor/Playing Spaces”) highlightedby the European PA determinants (EU-PAD) frameworkas having a high priority for research [36]. To improve thestrength of evidence, future research adopting longitudinalresearch designs is strongly needed. Indeed, motor skillsin early childhood, school physical education, and youthsports are important aspects for a holistic development ofchildren and adolescents, so an effective interaction be-tween researchers and policy makers should be establishedto promote of health-enhancing lifestyles in early years, inline with the recommendations of the Expert Group onHealth-Enhancing Physical Activity of the EuropeanCommission [38].The determinants ‘composite sedentary behavior’,

‘internet use’, ‘reading’, ‘sedentary activities’, and ‘vigorousPA’ [26, 29, 33, 34] were negatively associated with PAwith a limited suggestive level of evidence. Even thoughmainly based on cross-sectional studies, the negative as-sociations of ‘composite sedentary behavior’, ‘internetuse’, and ‘reading’ are corroborated by the results of theMA, showing small to moderate negative effect sizes[29]. Regarding ‘vigorous PA’, Bruner and colleagues [39]suggested that a decline in PA over the course of theschool year, in adolescents, is mainly due to a decreasein level of vigorous intensity activity rather than moder-ate intensity activity. Despite a clear dose-response spe-cificity of low, moderate, and vigorous PA intensities oncardiovascular risk, metabolic health, osteoporosis, im-mune function, and mental health [40], the relationshipbetween intensity (but also frequency, duration, andmode of activity) and adherence of PA is controversial[35, 41]. To deepen our understanding of the quality ofthe PA and to provide sound guidelines for PA prescrip-tions, further research on this area is recommended toconsider the intensity of PA on both absolute (e.g., oxy-gen uptake, oxygen uptake relative to body mass, kcal orkJ per minute, and METs) and relative (e.g., percentagesof maximal oxygen uptake, oxygen uptake reserve, heartrate reserve, maximal heart rate, Borg’s Rating ofPerceived Exertion) terms [42].The investigation of determinants in adults showed a

higher proportion of negative associations (n = 6) with re-spect to positive associations (n = 1). Regarding the nega-tive associations, a probable level of evidence was found


only for ‘transition to university’ and ‘pregnancy/having achild’ with respect to overall PA/Ex in all ages >18 years,with the review showing a moderate quality [12]. Further-more, ‘moving into an institution’ [12], ‘time limitation’[24, 31], ‘language difficulties’ [24], and ‘smoking’ [27] werenegatively associated but with a limited suggestive level ofevidence. Conversely, ‘baseline activity level’ was positivelyassociated with overall PA/Ex in adults ≥40 years but witha limited suggestive level of evidence and the quality ofthe review was moderate [27]. Although without a consist-ent convincing evidence among all the determinants, thesefindings highlight the possible impact of specific lifeevents (i.e., ‘transition to university’, ‘pregnancy/having achild’, and ‘moving into an institution’) on the relationshipbetween behavioral determinants and PA and the need foreffective interventions and planning to increase health-enhancing PA.An interactionist approach may help further our un-

derstanding of the role played by specific life events. Dif-ferent life events with shorter-term (e.g., pregnancy) orlonger-term effects (e.g., retirement) might exert theireffects on PA behaviors separately, in different lifephases. Differently, life events, whose shorter- andlonger-lasting effects partially overlap in time (e.g.,pregnancy and marital status) might generate inter-active effects. Moreover, the impact of life events on PAbehaviors might be moderated by other behavioral factors.For instance, the extent to which ‘retirement’ impacts ac-tual PA behavior may be moderated by past PA habits.Moreover, the relationship linking the influence of differ-ent behavioral determinants of PA may be mediational innature, with ‘time limitation’ probably mediating most ofthe life event effects on PA behaviors.However, not only people older than 18 years should

represent a target group population for the investigationof those life events and for considering health promotioninterventions. Adequate attention should be placed also tothose related to ‘job’, such as temporary or long-term un-employment, retirement, change in employment status, aswell as to those concerning the ‘marital status’, such asstarting a new close personal relationship, starting to livewith someone, marriage, separation, divorce, widowhood,interpersonal loss, which are frequent during adulthoodand may interfere and influence PA behaviors.This umbrella SLR demonstrated that some potential

determinants were found to be specific for each agegroup, whilst other determinants can be consideredacross all ages. For the latter, ‘screen use’ and ‘smoking’were the most often investigated determinants, with sixand four reviews examining the associations with severalforms of PA, respectively. Actually, ‘screen use’ comprisesseveral determinants, such as ‘TV viewing’, ‘TV viewing/playing video games’, ‘television viewing/sedentary’, ‘enjoytelevision viewing’, ‘video/computer game use’, ‘computer’,

‘screen time’, ‘video games’, which have been investigatedfor their potential associations with PA from preschoolchildren to adolescents. The negative association be-tween ‘enjoy television viewing’ and MVPA in preschoolchildren emphasized the need for intervention programsto decrease screen related behaviors in the early yearsage group [26]. A similar negative association was alsofound in children with respect to after-school time pe-riods (i.e., after-school PA) [30]. Particularly due to thefact that ‘TV viewing’ may negatively influence PA dur-ing time spent at home with high TV accessibility, inter-vention programs should be encouraged for increasingafter-school PA [30]. Future research should adopt longi-tudinal study designs to investigate the effectiveness oflong-term PA promoting strategies in children afterschool for several components, like fitness, health,cognitive functioning

behavioral determinants of physical activity across the life ......across the life course were...

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