Development and validation of the Global Adolescent and Child Physical Activity Questionnaire (GAC-PAQ) in 14 countries: study protocol.

INTRODUCTION: Global surveillance of physical activity (PA) of children and adolescents with questionnaires is limited by the use of instruments developed in high-income countries (HICs) lacking sociocultural adaptation, especially in low- and middle-income countries (LMICs); under-representation of some PA domains; and omission of active play, an important source of PA. Addressing these limitations would help improve international comparisons, and facilitate the cross-fertilisation of ideas to promote PA. We aim to develop and assess the reliability and validity of the app-based Global Adolescent and Child Physical Activity Questionnaire (GAC-PAQ) among 8-17 years old in 14 LMICs and HICs representing all continents; and generate the 'first available data' on active play in most participating countries. METHODS AND ANALYSIS: Our study involves eight stages: (1) systematic review of psychometric properties of existing PA questionnaires for children and adolescents; (2) development of the GAC-PAQ (first version); (3) content validity assessment with global experts; (4) cognitive interviews with children/adolescents and parents in all 14 countries; (5) development of a revised GAC-PAQ; (6) development and adaptation of the questionnaire app (application); (7) pilot-test of the app-based GAC-PAQ; and, (8) main study with a stratified, sex-balanced and urban/rural-balanced sample of 500 children/adolescents and one of their parents/guardians per country. Participants will complete the GAC-PAQ twice to assess 1-week test-retest reliability and wear an ActiGraph wGT3X-BT accelerometer for 9 days to test concurrent validity. To assess convergent validity, subsamples (50 adolescents/country) will simultaneously complete the PA module from existing international surveys. ETHICS AND DISSEMINATION: Approvals from research ethics boards and relevant organisations will be obtained in all participating countries. We anticipate that the GAC-PAQ will facilitate global surveillance of PA in children/adolescents. Our project includes a robust knowledge translation strategy sensitive to social determinants of health to inform inclusive surveillance and PA interventions globally.

Perceived Barriers to Physical Activity Among Youth Living in Rural and Urban Canadian Communities: A Nationally Representative Cross-Sectional Study.

BACKGROUND: We used nationally representative data to explore associations among location of residence (rural/urban) and perceived barriers to physical activity (PA) in Canadian youth. METHODS: We analyzed the 2017 Canadian Community Health Survey, Barriers to Physical Activity Rapid Response data for 12- to 17-year-old youth. Nine items from the survey assessing perceived barriers to PA were combined into 3 barrier domains: resources, motivational, and socioenvironmental. The likelihood of reporting barriers to PA based on rural-urban location was examined using survey-weighted binary logistic regression following a model fitting approach. Sociodemographic factors were modeled as covariates and tested in interaction with location. For each barrier domain, we derived the best-fitting model with fewest terms. RESULTS: There were no location-specific effects related to reporting any barrier or motivation-related PA barriers. We found a sex by location interaction predicting the likelihood of reporting resource-related barriers. Rural boys were less likely to report resource-related barriers compared with urban boys (odds ratio [OR] = 0.42 [0.20, 0.88]). Rural girls were more likely to report resource-related barriers compared with boys (OR = 3.72 [1.66, 8.30]). Regarding socioenvironmental barriers, we observed a significant body mass index by location interaction demonstrating that rural youth with body mass index outside the "normal range" showed a higher likelihood of reporting socioenvironmental barriers compared with urban youth (OR = 2.38 [1.32, 4.30]). For urban youth, body mass index was unrelated to reporting socioenvironmental barriers (OR = 1.07 [0.67, 1.71]). CONCLUSION: PA barriers are not universal among Canadian youth. Our analyses highlight the importance of testing interactions in similar studies as well as considering key sociodemographic characteristics when designing interventions.

Cardiorespiratory fitness is a strong and consistent predictor of morbidity and mortality among adults: an overview of meta-analyses representing over 20.9 million observations from 199 unique cohort studies.

OBJECTIVE: To examine and summarise evidence from meta-analyses of cohort studies that evaluated the predictive associations between baseline cardiorespiratory fitness (CRF) and health outcomes among adults. DESIGN: Overview of systematic reviews. DATA SOURCE: Five bibliographic databases were searched from January 2002 to March 2024. RESULTS: From the 9062 papers identified, we included 26 systematic reviews. We found eight meta-analyses that described five unique mortality outcomes among general populations. CRF had the largest risk reduction for all-cause mortality when comparing high versus low CRF (HR=0.47; 95% CI 0.39 to 0.56). A dose-response relationship for every 1-metabolic equivalent of task (MET) higher level of CRF was associated with a 11%-17% reduction in all-cause mortality (HR=0.89; 95% CI 0.86 to 0.92, and HR=0.83; 95% CI 0.78 to 0.88). For incident outcomes, nine meta-analyses described 12 unique outcomes. CRF was associated with the largest risk reduction in incident heart failure when comparing high versus low CRF (HR=0.31; 95% CI 0.19 to 0.49). A dose-response relationship for every 1-MET higher level of CRF was associated with a 18% reduction in heart failure (HR=0.82; 95% CI 0.79 to 0.84). Among those living with chronic conditions, nine meta-analyses described four unique outcomes in nine patient groups. CRF was associated with the largest risk reduction for cardiovascular mortality among those living with cardiovascular disease when comparing high versus low CRF (HR=0.27; 95% CI 0.16 to 0.48). The certainty of the evidence across all studies ranged from very low-to-moderate according to Grading of Recommendations, Assessment, Development and Evaluations. CONCLUSION: We found consistent evidence that high CRF is strongly associated with lower risk for a variety of mortality and incident chronic conditions in general and clinical populations.

Biopsychosocial Effects of a Conventional Exercise Program and Culturally Relevant Activities in Older Women From Mozambique.

AIM: This randomized controlled trial compared the effects of a Conventional Exercise Program (CEP) and Culturally Relevant Activities (CRA) on body mass, cardiovascular risk, functional fitness (strength, flexibility, cardiorespiratory fitness, and agility), self-efficacy, and self-esteem in older women dwelling in Mozambique. METHODS: Fifty-seven women (67 [7] y) underwent 60-minute sessions of CEP (n = 28) or CRA (n = 29) performed 3 days per week for 12 weeks. CRA included Mozambican traditional dances and games (intensity corresponding to scores 3-4 of BORG-CR10 scale), and CEP included 20-minute stationary cycling (65%-75% heart rate reserve) and a resistance training circuit (8 exercises, 15-repetition maximum). RESULTS: CEP and CRA (P < .05) showed increased percent fat (3.4% and 5.3%), waist circumference (3.3% and 5.8%), and cardiorespiratory fitness (14.4% and 9.4%), and decreased triglycerides (-20.0% and -77.8%). In CEP (P < .05), body mass (2.9%), body mass index (3.2%), and high-density lipoprotein (10.0%) increased, while glycemia (-4.8%) and total cholesterol (-9.8%) decreased. Blood pressure slightly increased in CEP (6.2%, P > .05) and CRA (4.3%, P < .05). Self-efficacy and self-esteem increased to similar levels in both groups (15%, P < .05). CONCLUSIONS: CEP and CRA were capable to improve biopsychosocial health-related variables in Mozambican older women. Culturally referenced PA interventions should be considered as an alternative in African countries.

Indicators of physical activity and nutritional status among children and adolescents in Zimbabwe: Findings from three global matrix initiatives.

Background: Regular physical activity is associated with several benefits among children and adolescents. Globally, only limited surveillance data, collected using harmonized approaches to accurately compare levels of physical activity among children and adolescents are available. Through its Global Matrix initiatives, Active Health Kids Global Alliance provides an opportunity for participating countries/jurisdictions to compare physical activity levels of children and adolescents based on ten common indicators. The 2022 Zimbabwe Report Card summarizes the best available evidence and assigns grades on these ten indicators of physical activity for children and adolescents. Methods: Through an iterative process, a team of national experts working in various sectors of physical activity used Active Healthy Kids Global Alliance's Global Matrix benchmarks and grading rubric, to assign Report Card grades on 10 indicators of physical activity (Overall Physical Activity, Organized Sport and Physical Activity, Active Play, Active Transportation, Sedentary Behaviours, Physical Fitness, School, Family and Peers, Community Environment, and Government) among 5-17-year-old children and adolescents in Zimbabwe. Published and unpublished data as well as policy documents informing grades for each indicator were summarized. An unweighted average of all studies with data for an indicator was used to inform the grade assignment. Where data were unavailable or insufficient to provide accurate estimates, an incomplete grade was assigned. The primary purpose of the present study was to synthesize and summarize the best available data and assign grades on 10 common indicators of physical activity for children and adolescents. The secondary objective was to compare Report Grades across three Global Matrix initiatives. Results: Grades for the ten common indicators for Global Matrix 4.0 plus Nutritional Status (B+) were assigned as follows: Overall Physical Activity (C+), Organized Sport and Physical Activity (B-), Active Play (C+), Active Transportation (B), Sedentary Behaviours (C), Physical Fitness (Incomplete), Family and Peers (Incomplete), School (C), Community and Environment (C-), Government (D). Generally, grades for individual behaviours (Physical Activity, Organized Sport and Physical Activity, Active Play, Active Transportation, Sedentary Behaviours) were higher than for sources of influence (Family and Peers, School, Community and Environment, Government). Across 3 Global Matrices, the grade for Overall Physical activity (C+) did not change, Community and Environment (F, D, C-) steadily improved over time; while those for Active Transportation, Sedentary Behaviours and Sports were unchanged for Global Matrix 2.0 and 3.0, but declined for Global Matrix 4.0. Conclusion: Although grades for individual behaviours were higher than those for sources of influence, overall, our findings show that the levels of physical activity among children and adolescents in Zimbabwe were lower than recommended. Robust surveillance data with large and representative samples are required to provide accurate estimates of physical activity participation among children and adolescents in Zimbabwe. Furthermore, policies and initiatives that promote equitable physical activity participation among children and adolescents are urgently needed in Zimbabwe.

Top 10 International Priorities for Physical Fitness Research and Surveillance Among Children and Adolescents: A Twin-Panel Delphi Study.

BACKGROUND: The measurement of physical fitness has a history that dates back nearly 200 years. Recently, there has been an increase in international research and surveillance on physical fitness creating a need for setting international priorities that could help guide future efforts. OBJECTIVE: This study aimed to produce a list of the top 10 international priorities for research and surveillance on physical fitness among children and adolescents. METHODS: Using a twin-panel Delphi method, two independent panels consisting of 46 international experts were identified (panel 1 = 28, panel 2 = 18). The panel participants were asked to list up to five priorities for research or surveillance (round 1), and then rated the items from their own panel on a 5-point Likert scale of importance (round 2). In round 3, experts were asked to rate the priorities identified by the other panel. RESULTS: There was strong between-panel agreement (panel 1: rs = 0.76, p < 0.01; panel 2: rs = 0.77, p < 0.01) in the priorities identified. The list of the final top 10 priorities included (i) "conduct longitudinal studies to assess changes in fitness and associations with health". This was followed by (ii) "use fitness surveillance to inform decision making", and (iii) "implement regular and consistent international/national fitness surveys using common measures". CONCLUSIONS: The priorities identified in this study provide guidance for future international collaborations and research efforts on the physical fitness of children and adolescents over the next decade and beyond.

Economic Freedom, Climate Culpability, and Physical Activity Indicators Among Children and Adolescents: Report Card Grades From the Global Matrix 4.0.

BACKGROUND: Macrolevel factors such as economic and climate factors can be associated with physical activity indicators. This study explored patterns and relationships between economic freedom, climate culpability, and Report Card grades on physical activity-related indicators among 57 countries/jurisdictions participating in the Global Matrix 4.0. METHODS: Participating countries/jurisdictions provided Report Card grades on 10 common indicators. Information on economic freedom and climatic factors were gathered from public data sources. Correlations between the key variables were provided by income groups (ie, low- and middle-income countries/jurisdictions and high-income countries/jurisdictions [HIC]). RESULTS: HIC were more economically neoliberal and more responsible for climate change than low- and middle-income countries. Annual temperature and precipitation were negatively correlated with behavioral/individual indicators in low- and middle-income countries but not in HIC. In HIC, correlations between climate culpability and behavioral/individual and economic indicators were more apparent. Overall, poorer grades were observed in highly culpable countries/jurisdictions in the highly free group, while in less/moderately free groups, less culpable countries/jurisdictions showed poorer grades than their counterparts in their respective group by economic freedom. CONCLUSIONS: Global-level physical activity promotion strategies should closely evaluate different areas that need interventions tailored by income groups, with careful considerations for inequities in the global political economy and climate change.

Association Between Physical Activity Indicators and Human Development Index at a National Level: Information From Global Matrix 4.0 Physical Activity Report Cards for Children and Adolescents.

BACKGROUND: The aim of this study was to explore the associations between the 10 key indicators of the Global Matrix 4.0 project and human development index (HDI) at a national level according to sex, age, area of residence, and ability levels. METHODS: Information from the 57 countries/localities included in the Global Matrix 4.0 project was compiled and presented according to the HDI of each country/locality for each of the 10 key indicators. Grades were assigned based on the benchmarks of the Global Matrix 4.0 project ranged between "A+" (best performance) and "F" (worst performance). RESULTS: The population subgroups of females, children, rural residents, with/without disabilities from countries/localities with higher HDI performed better in the organized sport and physical activity indicator than their peers from countries/localities with lower HDI. Children and adolescents living in rural areas of countries/localities with higher HDI showed better performance for active play, and children and adolescents living in urban areas of countries/localities with lower HDI showed better performance for the active transportation. Countries/localities with higher HDI showed better grades for sources of influence than the countries/localities with lower HDI. CONCLUSIONS: Physical activity patterns in some population subgroups of children and adolescents differed according to the development level of countries/localities.

Recent Secular Trends in Child and Adolescent Physical Activity and Sedentary Behavior Internationally: Analyses of Active Healthy Kids Global Alliance Global Matrices 1.0 to 4.0.

BACKGROUND: We examined recent global secular trends in 5 indicators of child and adolescent physical activity and sedentary behavior (Overall Physical Activity, Organized Sport and Physical Activity, Active Play, Active Transportation, and Sedentary Behavior) and 4 influences on these (Family and Peers, School, Community and Environment, and Government). METHODS: Active Healthy Kids Global Alliance letter grades (A+ to F) were assigned numbers from 15 to 2, with 0 assigned for missing/incomplete grades. Trends from Active Healthy Kids Global Alliance Global Matrices 1.0 (2014) to 4.0 (2022) were analyzed using linear mixed-effects models with level of economic development and gender inequity considered as potential moderators. RESULTS: Report card grades were generally relatively stable. Trends generally did not differ significantly by level of economic development (except for Active Transportation and Active Play), but gender inequality did significantly moderate trends for most of the indicators, with higher gender inequality associated with more adverse changes in grades. The number of "incomplete" grades decreased over time, but this did not reach statistical significance. CONCLUSIONS: While trends varied within and between countries, physical activity and sedentary behaviors, and the influences on these behaviors globally, were relatively stable over the past decade or so, albeit at undesirable levels.

Active Healthy Kids Global Alliance Global Matrix 4.0-A Resource for Physical Activity Researchers.

BACKGROUND: This brief report provides an overview of the Active Healthy Kids Global Alliance (AHKGA); an introduction to the Global Matrix 4.0; an explanation of the value and opportunities that the AHKGA efforts and assets provide to the physical activity research, policy, practice, and advocacy community; an outline of the series of papers related to the Global Matrix 4.0 in this issue of the Journal of Physical Activity and Health; and an invitation for future involvement. METHODS: The AHKGA was formed to help power the global movement to get kids moving. In 2019-2021, we recruited countries to participate in the Global Matrix 4.0, a worldwide initiative to assess, compare, and contrast the physical activity of children and adolescents. RESULTS: A total of 57 countries/jurisdictions (hereafter referred to as countries for simplicity) were recruited. The current activities of the AHKGA are summarized. The overall findings of the Global Matrix 4.0 are presented in a series of papers in this issue of the Journal of Physical Activity and Health. CONCLUSIONS: The Global Matrix 4.0 and other assets of the AHKGA are publicly available, and physical activity researchers, practitioners, policy makers, and advocates are encouraged to exploit these resources to further their efforts.

Physical activity promotion in rural health care settings: A rapid realist review.

Physical activity promotion in health care settings is poorly understood and has limited uptake among health care providers. The environmental and health care context of rural communities is unique from urban areas and may interact to influence intervention delivery and success. The aim of this rapid realist review was to synthesize knowledge related to the promotion of physical activity in rural health and social care settings. We searched Medline EBSCO, CINAHL, PsychINFO, and SPORTDiscus for relevant publications. We included qualitative or quantitative studies reporting on an intervention to promote physical activity in rural health (e.g., primary or community care) or social (e.g., elder support services) care settings. Studies without a rural focus or well-defined physical activity/exercise component were excluded. Populations of interest included adults and children in the general population or clinical sub-population. Intervention mechanisms from included studies were mapped to the Behaviour Change Wheel (capability, opportunity, motivation (COM-B)). Twenty studies were included in our review. Most interventions focused on older adults or people with chronic disease risk factors. The most successful intervention strategies leading to increased physical activity behaviour included wearable activity trackers, and check-ins or reminders from trusted sources. Interventions with mechanisms categorized as physical opportunity, automatic motivation, and psychological capability were more likely to be successful than other factors of the COM-B model. Successful intervention activities included a method for tracking progress, providing counselling, and follow-up reminders to prompt behaviour change. Cultivation of necessary community partnerships and adaptations for implementation of interventions in rural communities were not clearly described and may support successful outcomes in future studies.

A Comparison of Meeting Physical Activity and Screen Time Recommendations between Canadian Youth Living in Rural and Urban Communities: A Nationally Representative Cross-Sectional Analysis.

Meeting the physical activity (PA) and recreational screen time recommendations for children and young people is associated with several health benefits. The purpose of this study was to compare the odds of meeting PA and recreational screen time recommendations between the Canadian youth living in urban versus rural communities. We analyzed nationally representative cross-sectional data collected as part of the 2017-2018 cycles of the Canadian Community Health Survey among young people aged 12-17 years. PA and screen time were self-reported. Sex-specific multivariable logistic regression models were used to estimate the odds of meeting individual and combined PA and recreational screen time recommendations by rural and urban status after adjusting for individual, socioeconomic, and seasonal covariates. The odds of meeting the PA recommendation were not statistically significantly different among males (OR = 1.01, 95% CI: 0.86-1.18) or females (OR 1.05, 95% CI: 0.99-1.11) living in urban versus rural communities. The odds of meeting the recreational screen time recommendations were statistically significantly lower among male (OR = 0.71, 95% CI: 0.65-0.77) and female (OR = 0.71, 95% CI: 0.59-0.86) youth living in urban compared to those in rural communities. The odds of meeting the combined PA and screen time recommendations were statistically significantly lower among urban males (OR = 0.75, 95% CI: 0.71-0.81) but not females (OR = 0.82, 95% CI: 0.58-1.15) than those from rural communities. These findings suggest that residential context (i.e., urban versus rural) may have a differential impact on meeting the combined PA and screen time recommendations among the male and female Canadian youth. Future research should investigate these differences using device-based measures.

Measuring the Overall Burden of Early Childhood Malnutrition in Ghana: A Comparison of Estimates From Multiple Data Sources.

BACKGROUND: Childhood malnutrition contributes to nearly half (45%) of all deaths among children under 5 globally. The United Nations' Sustainable Development Goals (SDGs) aims to end all forms of malnutrition by 2030; however, measuring progress towards these goals is challenging, particularly in countries with emerging economies where nationally-representative data are limited. The primary objective of this study was to estimate the overall burden of childhood malnutrition in Ghana at national and regional levels using 3 data sources. METHODS: Using data from the long-standing Ghana Demographic and Health Surveys (GDHS), Ghana Multiple Indicator Cluster Survey (GMICS), and the emerging Ghana Socioeconomic Panel Survey (GSPS), we compared the prevalence of malnutrition using the extended composite index of anthropometric failure (eCIAF) for the period 2008- 2011. This study included data for children aged 6-59 months and calculated all anthropometric z-scores based on the World Health Organization (WHO) Growth Standards. We tested for differences in malnutrition subtypes using two-group configural frequency analysis (CFA). RESULTS: Of the 10 281 children (6532 from GMICS, 2141 from GDHS and 1608 from GSPS) included in the study, the only demographic difference observed was the children included in the GSPS were slightly older than those included in the GDHS and GMICS (median age of 36 vs 30 vs 33 months, P<.001). Based on the eCIAF, the overall prevalence of malnutrition at the national level was higher among children in the GSPS (57.3%, 95% CI: 53.9%-60.6%), followed by the GDHS (39.7%, 95% CI: 37.0%-42.5%), and then those in the GMICS (31.2%, 95% CI: 29.3%-33.1%). The two-group CFA showed that the 3 data sources also estimated different prevalence rates for most of the malnutrition subtypes included in the eCIAF. CONCLUSION: Depending on the data source adopted, our estimates of eCIAF showed that between one-third and half of all Ghanaian children aged 6-59 months had at least one form of malnutrition over the period 2008-2011. These eCIAF estimates should complement the commonly reported measures such as stunting and wasting when interpreting the severity of malnutrition in the country to inform policy decisions.

Global prevalence of physical activity for children and adolescents; inconsistencies, research gaps, and recommendations: a narrative review.

BACKGROUND: One of the strategic actions identified in the Global Action Plan on Physical Activity (PA) 2018-2030 is the enhancement of data systems and capabilities at national levels to support regular population surveillance of PA. Although national and international standardized surveillance of PA among children and adolescents has increased in recent years, challenges for the global surveillance of PA persist. The aims of this paper were to: (i) review, compare, and discuss the methodological inconsistencies in children and adolescents' physical activity prevalence estimates from intercontinental physical activity surveillance initiatives; (ii) identify methodological limitations, surveillance and research gaps. METHODS: Intercontinental physical activity surveillance initiatives for children and adolescents were identified by experts and through non-systematic literature searches. Prevalence of meeting PA guidelines by country, gender, and age were extracted when available. A tool was created to assess the quality of the included initiatives. Methods and PA prevalence were compared across data/studies and against the methodological/validity/translation differences. RESULTS: Eight intercontinental initiatives were identified as meeting the selection criteria. Methods and PA definition inconsistencies across and within included initiatives were observed, resulting in different estimated national prevalence of PA, and initiatives contradicting each other's cross-country comparisons. Three findings were consistent across all eight initiatives: insufficient level of PA of children and adolescents across the world; lower levels of PA among girls; and attenuation of PA levels with age. Resource-limited countries, younger children, children and adolescents not attending school, with disability or chronic conditions, and from rural areas were generally under/not represented. CONCLUSIONS: There are substantial inconsistencies across/within included initiatives, resulting in varying estimates of the PA situation of children and adolescents at the global, regional and national levels. The development of a new PA measurement instrument that would be globally accepted and harmonized is a global health priority to help improve the accuracy and reliability of global surveillance.

Prevalence and correlates of objectively measured weight status among urban and rural Mozambican primary schoolchildren: A cross-sectional study.

BACKGROUND: The coexistence of undernutrition (thinness) and overnutrition (overweight/obesity) among children and adolescents is a public health concern in low-middle-income countries. Accurate prevalence estimates of thinness and overweight/obesity among children and adolescents are unavailable in many low-middle-income countries due to lack of data. Here we describe the prevalences and examine correlates of objectively measured weight status among urban and rural schoolchildren in Mozambique. METHODS: A cross-sectional study design was applied to recruit 9-11-year-old schoolchildren (n = 683) from 17 urban and rural primary schools in Mozambique. Body mass index (BMI) was computed from objectively measured height and weight and participants' weight categories were determined using the World Health Organization cut-points. Actigraph GT3X + accelerometers were worn 24 hours per day for 7 days to assess movement behaviours. Multilevel multivariable modelling was conducted to estimate odds ratios and confidence intervals. RESULTS: Combined prevalence of overweight/obesity (11.4%) was significantly higher among urban participants compared to rural participants (5.7%; χ2 = 7.1; p = 0.008). Conversely, thinness was more prevalent among rural (6.3%) compared to urban (4.2%) participants. Passive school commute, not meeting daily moderate- to vigorous-intensity physical activity (MVPA) guidelines, and maternal BMI >25 kg/m2 were associated with overweight/obesity while possessing one or more functional cars at home, maternal BMI >25 kg/m2 and being an older participant were associated with thinness in the present sample. The proportion of total variance in the prevalences of obesity and/or thinness occurring at the school level was 8.7% and 8.3%, respectively. CONCLUSION: Prevalences of thinness, overweight/obesity and other key variables differ between urban and rural schoolchildren in Mozambique. MVPA, active transport and mother's BMI are important modifiable correlates of weight status among Mozambican schoolchildren. Results from this study demonstrate important differences between urban and rural schoolchildren that should not be ignored when designing interventions to manage malnutrition, formulating public health strategies, and interpreting findings.

Examining lifestyle behaviours and weight status of primary schoolchildren: using Mozambique to explore the data gaps in low- and middle-income countries.

The emergency of malnutrition and physical inactivity among children as serious public health challenges in low- and middle-income countries (LMICs) is concerning and requires urgent attention. The main objective of this dissertation was to examine relationships between lifestyle behaviours and weight status among schoolchildren in Mozambique and use findings to highlight important data gaps that exist in LMICs. Narrative literature searches conducted identified data gaps and research needs. A published protocol was used for this dissertation (n = 683) to facilitate data comparability. Anthropometric and accelerometry data were objectively measured while data about lifestyle behaviours and environmental factors were collected using context-adapted questionnaires. As part of this dissertation, 6 manuscripts were developed and submitted for publication in peer-reviewed scientific journals. Results showed a dearth of information and that overweight/obesity is an emerging public health concern, especially among urban children. Moderate- to vigorous-intensity physical activity (MVPA), active transport, and maternal body mass index (BMI) were important modifiable correlates of weight status for Mozambican children. Distinct differences in prevalences of lifestyle behaviours were observed between urban and rural children in Mozambique. Compared with children from 12 other countries, children from Mozambique had lower BMI, higher daily MVPA, lower daily sedentary time, and comparable sleep duration. Linear distributions of study site-specific BMI, minutes of daily MVPA, and daily sedentary time by country human development index were observed. Findings revealed important differences between urban and rural children, supporting the need to include both in study samples and especially in LMICs where most people live in rural areas.

Body mass index and movement behaviors among schoolchildren from 13 countries across a continuum of human development indices: A multinational cross-sectional study.

OBJECTIVE: This study describes the distributions of body mass index (BMI) and movement behaviors among schoolchildren from 13 countries across a continuum of human development. METHODS: Data were from a cross-sectional study of 9-11-year-old children (n = 8055) recruited from 269 urban schools in 13 countries, and an additional 7 rural schools in one of these countries (Mozambique). BMI was derived from objectively measured heights and weights. Moderate- to vigorous-intensity physical activity (MVPA), sedentary time (SED), and sleep duration were assessed by waist-worn Actigraph GT3X+ accelerometers. Linear models were used to describe the distributions of BMI z-scores, MVPA, SED, and sleep among sites across varying Human Development Indices (HDIs). RESULTS: Mean MVPA, SED, and sleep duration were 63.1 ± 27.3 minutes/day, 508.7 ± 72.4 minutes/day, and 8.8 ± 0.9 hours/night, respectively. Overall, 2.1% of the sample were thin, 19.5% overweight, and 11.7% were obese. Density curves (BMI z-scores and SED) for urban children in Mozambique showed significantly higher mean values compared with rural children. Boys had significantly higher mean MVPA compared with girls. Mean BMI z-scores were positively associated (ß = .02; P = .004) with HDI, mean daily MVPA minutes were negatively associated (ß = -.38; P = .025) with HDI, and mean SED time was positively associated with HDI (ß = 1.18; P = .049). No significant association (ß = .01; P = .29) was observed between sleep duration and HDI. CONCLUSION: Our findings show distinct differences in BMI and movement behavior profiles between urban and rural children in Mozambique. Mean BMI z-scores, MVPA, and SED differed by country HDI. These findings support the need to include both rural and urban participants in study samples.

Prevalence and correlates of adherence to movement guidelines among urban and rural children in Mozambique: a cross-sectional study.

BACKGROUND: Insufficient physical activity, short sleep duration, and excessive recreational screen time are increasing globally. Currently, there are little to no data describing prevalences and correlates of movement behaviours among children in low-middle-income countries. The few available reports do not include both urban and rural respondents, despite the large proportion of rural populations in low-middle-income countries. We compared the prevalence of meeting 24-h movement guidelines and examined correlates of meeting the guidelines in a sample of urban and rural Mozambican schoolchildren. METHODS: This is cross-sectional study of 9-11 year-old children (n = 683) recruited from 10 urban and 7 rural schools in Mozambique. Moderate- to vigorous-intensity physical activity (MVPA) and sleep duration were measured by waist-worn Actigraph GT3X+ accelerometers. Accelerometers were worn 24 h/day for up to 8 days. Recreational screen time was self-reported. Potential correlates of meeting 24-h movement guidelines were directly measured or obtained from validated items of context-adapted questionnaires. Multilevel multivariable logit models were used to determine the correlates of movement behaviours. Meeting 24-h movement guidelines was defined as ≥60 min/day of MVPA, ≤2 h/day of recreational screen time, and between 9 and 11 h/night of sleep. RESULTS: More rural (17.7%) than urban (3.6%) children met all three 24-h movement guidelines. Mean MVPA was lower (82.9 ± 29.5 min/day) among urban than rural children (96.7 ± 31.8 min/day). Rural children had longer sleep duration (8.9 ± 0.7 h/night) and shorter recreational screen time (2.7 ± 1.9 h/day) than their urban counterparts (8.7 ± 0.9 h/night and 5.0 ± 2.3 h/day respectively). Parental education (OR: 0.37; CI: 0.16-0.87), school location (OR: 0.21; CI: 0.09-0.52), and outdoor time (OR: 0.67; CI: 0.53-0.85) were significant correlates of meeting all three 24-h movement guidelines. CONCLUSIONS: Prevalence and correlates of meeting movement guidelines differed between urban and rural schoolchildren in Mozambique. On average, both groups had higher daily MVPA minutes, shorter sleep duration, and higher recreational screen time than the 24-h movement guidelines recommend. These findings (e.g., higher than recommended mean daily MVPA minutes) differ from those from high-income countries and highlight the need to sample from both urban and rural areas.

Correction to: The prevalence of underweight, overweight, obesity and associated risk factors among school-going adolescents in seven African countries.

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Indicators of Physical Activity Among Children and Youth in 9 Countries With Low to Medium Human Development Indices: A Global Matrix 3.0 Paper.

BACKGROUND: This study compares results of physical activity report cards from 9 countries with low to medium human development indices, participating in the Global Matrix 3.0 initiative. METHODS: Country-specific report cards were informed by relevant data and government policy documents, reporting on 10 core indicators of physical activity for children and youth. Data were synthesized by report card working groups following a harmonized process. Grade assignments for each indicator utilized a standard grading rubric. Indicators were grouped into one of 2 categories: daily behaviors and settings and sources of influence. Descriptive statistics (average grades) were computed after letter grades were converted into interval variables. Spearman's rank correlation coefficients were calculated for all correlation analyses. RESULTS: Mean grades for daily behaviors were higher (C) than those for settings and sources of influence (D+). Twenty-nine out of the possible 90 grades were assigned an incomplete. There were moderate to strong positive and negative relationships between different global indices and overall physical activity, organized sport and physical activity, active play, family, community and environment, and government. CONCLUSIONS: Findings demonstrate an urgent need for high-quality data at the country level in order to better characterize the physical activity levels of children and youth in countries with low to medium human development indices.