School is considered a strategic space for developing education and health promotion,1–5 since it is a socially recognized institution, with a role in promoting formal learning, where students spend around one-third of their time.6 It also has the infrastructure and materials to support these activities and allow collaboration between education and health professionals and family members, and in most cases, is involved in the community in which the students live.7 In this perspective, United Nations Educational, Scientific, and Cultural Organization5 suggests that schools be a space for the promotion, protection, and cultivation of health, contributing to the well-being and development of socio-emotional skills, cognitive skills, and healthy habits in schoolchildren.
In this respect, as a curricular component of basic education, physical education (PE) is also committed to participating in the planning, implementation, and assessment of educational activities and health promotion in schools. Moreover, it may contribute to empower students to adopt more physically active and healthier lifestyles8,9 using experiences and contents10 that broaden their knowledge, beliefs, values, and positive attitudes compatible with healthy practices, including physical activity and less time spent on sedentary behavior. These behaviors are amenable to modification, focus of intervention to promote physical activity and health at school, are among the themes and contents related to health that are most closely related to the training of PE teachers and their mastery over them. Thus, they are more likely to be addressed in PE classes.1–5
However, PE classes have been conducted under adverse conditions, such as poor infrastructure, materials, equipment, low student participation, little class time for moderate to vigorous activities, replacement of classes by other unrelated activities, low professional qualification, little social recognition of the discipline and nonimplementation of a minimum curriculum.11,12 Taken together, these factors may hinder or even preclude educational measures that promote active and healthy lifestyles in these classes,8,9 underscoring physical activity and sedentary behavior, which are among the main PE topics in schools.
Interventions conducted in the context of PE classes to increase physical activity13 and reduce sedentary behavior13 have proven to be effective. They allow testing of different strategies (change in pedagogical practices, materials, or curriculum of PE classes) on an outcome of interest. Although these interventions are important, they have a low capacity to adequately represent daily school life as they are developed mainly with the change/availability of resources (material/financial/pedagogical). This differs from the reality observed particularly in low- and middle-income countries, where the proportion of schools with adequate resources for PE activities is low.5 In practice, what has proved to be effective in increasing physical activity and reducing sedentary behavior can be applied to the daily routine of schools at scale.
Thus, observational studies analyzed the association between PE class participation, physical activity, and sedentary behavior, but have found divergent results.14–21 This may be partly explained by the wide diversity of instruments (questionnaires, accelerometers, and pedometers) and ways of operationalizing physical activity measures (total time, minutes/day, and meeting recommendations)14,16 and sedentary behavior; use of instruments without and/or with insufficient validity levels19; different age groups and/or student grade levels; types of studies (longitudinal and cross sectional) and sampling (power and sample selection)15; variations in conditions and class characteristics.22,23 This heterogeneity hinders assessment of the possible influences of PE class participation on the physical activity and sedentary behavior of students. This reinforces the need to summarize the evidence of observational studies that tested whether PE class participation is associated with students’ engaging in physical activity and sedentary behavior.
Systematic reviews on the consequences of participating in PE classes are scarce,8,24,25 even more so when compared with those that discuss the consequences of physical activity and sedentary behavior for the health of children and adolescents. The systematic review identified (searches conducted on the PubMed, Web of Science, Scientific Electronic Library Online, and Education Resources Information Center and Scopus databases) analyzed studies published between 1983 and 2010, on the relation between PE class participation and health indicators and healthy behavior.7 Participation in PE classes was associated with higher physical activity levels. However, it did not include studies published in Portuguese and Spanish or sedentary behavior, searches were limited to 2010 and some databases, and the methodological quality of the studies was not assessed. This disregards the increased number of articles on this issue in the last 10 years (eg, a 49% rise between 2011 and 2020, on PubMed), including studies on sedentary behavior, longitudinal investigations, and students of several countries.23,25–27 In this respect, the aim of this review was to summarize the results and assess the methodological quality of studies that analyzed the relation between PE class participation, physical activity, and sedentary behavior in school aged.
Methods
This is a systematic review based on the recommendations suggested by PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) (see Supplement A [available online])28 and registered at PROSPERO (International Prospective Register of Systematic Reviews; CRD42020143162).
Eligibility Criteria
Included were original articles in English, Spanish, and Portuguese, of observational studies (cross sectional and longitudinal) published between January 2007 and August 2020 (chose to adopt an arbitrary search criterion that considered articles published in different languages in at least the last 10 years), observational studies were chosen to evaluate the daily routine of schools at a scale on the relation between PE class participation (any arbitrary variable that represents participation, time in class, enrollment or attendance in PE classes) and some measure of: (1) physical activity (eg, total activity time, or by domains, and number of steps) and/or (2) sedentary behavior (eg, time watching television, screen time, and total time), measured by different instruments (eg, questionnaires, diaries, accelerometers, pedometers), as long as they were dependent variables. The study was included if PE class participation was considered the independent variable.
Excluded were articles with no association/correlation/comparison between PE class participation and the behaviors analyzed, which used cardiorespiratory fitness as an indicator of physical activity, those with samples of special groups (eg, diabetic, hypertensive, and asthmatic patients) and those where the associations analyzed in the present study had been assessed in fewer than 3 studies.
Study Selection
The databases, descriptors, terms, and Boolean operators used in the searches are presented in (see Supplement B [available online]). For the selection of descriptors and search terms the Medical Subject Headings and Health Sciences Descriptors platforms were consulted, in addition to using similar terms and relevant synonyms on the topic.
The articles found were analyzed by Clarivate Endnotes (version 7.0) software and duplicates excluded. The article selection procedures were conducted by an assessor (DJS), and in the event of uncertainty, 2 authors (AOB and JCFJ) were consulted. The references of the articles were analyzed in order to identify studies not found in the electronic search. The article selection stages are described in Figure 1.
—PRISMA flowchart of article identification and selection procedures. aEight articles stratified their analyzes by sex and were counted as independent samples. PRISMA indicates Reporting Items for Systematic Reviews and Meta-Analyses.
Citation: Journal of Physical Activity and Health 19, 11; 10.1123/jpah.2022-0084
—PRISMA flowchart of article identification and selection procedures. aEight articles stratified their analyzes by sex and were counted as independent samples. PRISMA indicates Reporting Items for Systematic Reviews and Meta-Analyses.
Citation: Journal of Physical Activity and Health 19, 11; 10.1123/jpah.2022-0084
—PRISMA flowchart of article identification and selection procedures. aEight articles stratified their analyzes by sex and were counted as independent samples. PRISMA indicates Reporting Items for Systematic Reviews and Meta-Analyses.
Citation: Journal of Physical Activity and Health 19, 11; 10.1123/jpah.2022-0084
Assessment of the Methodological Quality
Assessment of the methodological quality of the studies was carried out independently by 2 assessors (DJS and AOB) and in cases of disagreement, a third assessor (JCFJ) was consulted. An instrument was not identified to assess all the items that the authors considered relevant to adequately assess the articles that included the review.
Thus, based on other checklists, a checklist developed by the authors was used to assess the methodological quality of the studies.29–31 It is composed of 13 items, divided into 3 domains: sampling (5 items), variable measurement (4 items), and statistical analysis (4 items) (see Supplement B [available online]). The checklist items were assessed as follows: yes = 1, no = 0, and not informed = NI, except for items 6 and 13 (yes = 2, partially = 1, no = 0, and not informed = NI). Based on the sum of the scores attributed to each checklist item, a score between 0 and 15 points was assigned. According to the score obtained, the studies were classified as high (between 70% and 100% of the maximum score), moderate (between 51% and 69%), and low quality (between 0% and 50%).32
Extraction and Data Synthesis
The following data were retrieved: author, year of publication, country of study, study design, sample size, age group, sex, type of study, main variables, participation in PE classes, instrument used to measure physical activity and/or sedentary behavior, statistical analysis used to determine the association between the variables studied and the main results of the associations. Studies that stratified results by sex and/or age group were counted as independent samples. To extract the main findings, the results of the analysis adjusted for possible confounders were considered,33,34 and crude analyses when the adjusted results were not presented. The data extraction procedures were conducted by DJS and reviewed by AOB.
As expected, there was high heterogeneity between studies (on methodological and statistical aspects), as well as the different ways of the evaluation of participation in PE and outcomes. The following methodological aspects were observed: (1) characteristics of the participants (sex and age), (2) measurement instruments, (3) operationalization of the variables, and (4) statistical analyses. Thus, we decided to adopt a synthesis approach, summarizing the results according to similar elements of the review question, when possible.
The consistency of the results was estimated according to the sex; year of publication; country; study design (longitudinal and cross sectional); measuring instrument (questionnaires, accelerometers, pedometers, and others); sample size; methodological quality of the studies (low, moderate, and high); and operationalization of the measure (PA: global, school, leisure, commuting, PA in days with vs without PE classes and SB: total, school, screen time, SB in days with vs without PE classes). These variables were chosen because previous reviews have highlighted that the consistency of evidence may change according to study’s characteristics.33,34
In summarizing the main results of the associations the following procedure was followed: significant association being positive (“+”) or negative/inverse (“–”), or no association (“0”). To evaluate the consistency of the associations, a criterion was adopted that considered the number of associations in a given direction, divided by the total number of results analyzed, multiplied by 100. For example, 10 inverse “−” associations (n = 10) in 15 analyzed studies (n = 15): (10/15) × 100 = 66% of the total associations were inverse “−.” The consistency of associations was classified and coded as 00 (when 0%–33% of the studies demonstrated an association), ?? (when 34%–59% of the studies with an association in one direction), and “++” or “--” (when 60%–100% of the studies with an association in one direction; Table 1).34
Characteristics of the Studies That Analyzed the Association Between PE Classes’ Participation in PA and Sedentary Behavior, 2007–2020
| Variables | n (%) |
|---|---|
| Year of publication | |
| ≥2013 | 41 (68) |
| <2013 | 19 (32) |
| Country | |
| United States | 11 (18) |
| Brazil | 14 (23) |
| Canada | 4 (7) |
| Multicenter | 4 (7) |
| Other countries | 27 (45) |
| Study design | |
| Cross sectional | 58 (97) |
| Longitudinal | 2 (3) |
| Instruments | |
| Questionnaires | 29 (48) |
| Accelerometer | 19 (32) |
| Pedometer | 7 (12) |
| Othersa | 5 (8) |
| Sample | |
| ≥1000 people | 27 (45) |
| <1000 people | 33 (55) |
| Outcome | |
| PA | 56 (93) |
| Sedentary behavior | 20 (33) |
| Operationalization of the measure of PA | |
| Global | 40 (72) |
| School | 4 (8) |
| Leisure | 3 (6) |
| Commuting | 1 (2) |
| PA in days with versus without PE classes | 11 (16) |
| Operationalization of the measure of SB | |
| Total | 6 (30) |
| School | 3 (15) |
| Screen time | 7 (35) |
| SB in days with versus without PE classes | 5 (25) |
| Methodological quality | |
| High (70%–100%) | 16 (27) |
| Moderate (51%–69%) | 31 (52) |
| Low (0%–50%) | 13 (22) |
Abbreviations: PA, physical activity; PE, physical education; SB, sedentary behavior. Note: n = 60 studies.
aRecording, direct observation, energy expenditure monitor, and diaries.
Results
Of the 11,897 articles identified, after exclusion of duplicates (n = 3275, 39.2% of the total) and 8558 articles (74.4%) in the reading phase, 60 studies6,13–21,23–27,35–82 met the inclusion criteria and were included in the systematic review. Eight of these23,36,44,48,56,58,61,63,68 stratified their analyses by sex and were summarized as independent results, obtaining 68 samples (Figure 1). Of the studies included, 58 were cross sectional6,13–18,20,21,23,24,27,35–67,69–82 and 2 longitudinal observational25,27 (Table 2).
Results of Observational Studies That Analyzed the Association of Participation in PE Classes With PA and Sedentary Behavior (Studies Reviewed n = 60, n = 68 Samples)
| Study | Participation in PE classes | Operationalization of the measure | Summary of results | Summary of results | |
|---|---|---|---|---|---|
| PA | SB | ||||
| Aguilar-Farias et al68 | Variation from 2.2% in Peru to 37.8% of students in El-Salvador reported participating in 2 or more classes per week. | Total time in SB and PA by intensity | No significant associations were observed between participation in PE classes and MVPA (B = 0.1; 95%CI: −0.04, 0.17) and SB (B = −0.1, 95%CI: −0.40 to 0.19). | 0 | 0 |
| Alderman et al36 | NS | Number of steps per day | Using ANOVA, it was possible to observe statistical differences between the PA level of students on days with and without the presence of PE classes, with the level of PA being higher on days with PE classes (F1,277 = 5.42, P < .05, ES = 0.76.) | + | NS |
| Aljuhani and Sandercock69 | NS | Time of MVPA: in days without PE; and on days with PE; days with PE excluding MVPA time from class schedule | Times spent in MVPA were 12.9, 14.7, and 14.8 min higher on PE days than on days without PE for all, inactive, and unfit schoolchildren, respectively. Results showed that 40% and 24% of the schoolchildren met the recommended levels of PA on PE days and days without PE, respectively. | + | NS |
| Al-Thani et al70 | 66.5% of students reported participating in 2 or more classes per week. | Participation in physical activities, sport and exercise, and screen time | Participation in PE classes was positively correlated with PA (r = .206, P < .001) and not associated with SB (r = .018, P = .18). | + | 0 |
| Amornsriwatanakul et al28 | 91.9% of students reported participating in 2 or more classes per week. | Number of days with ≥60 min (active = 60 in 7 d; inactive <7 d) | PE was not a significant predictor in sufficient achieving levels of PA (data not shown). | 0 | NS |
| Bergmann et al14 | 84.7% of students reported participating in one or more classes per week. | Total PA | Adolescents who reported participating in PE classes were more likely to be active (OR = 2.02; 95%CI: 1.05 to 3.89). | + | NS |
| Bezerra et al37 | 23.1% in 2006 and 17.4 of students in 2011 reported participating in 2 or more classes per week. | PA in leisure time (practice vs nonpractice) | Participating in at least one PE class per week increased the chances of teenagers being active (OR = 1.16; 95%CI: 1.09 to 1.24). | + | NS |
| Bezerra et al37 | 33.8% in 2006 and 26.3% of students in 2011 reported participating in 2 or more classes per week. | PA in leisure time (practice vs nonpractice) | Participating in at least one PE class per week increased the chances of teenagers being active (OR = 1.55; 95%CI: 1.40 to 1.71). | + | NS |
| Calahorro-Canada et al38 | NS | SB and MVPA time on weekdays with and without PE classes | Students with lower cardiorespiratory capacity accumulated more MVPA (50 min/d, vs 42.7 min/d P ≤ .05) and total PA (155.9 min/d vs 138 min/d, P ≤ .05) on PE class days than days without classes. | + | + |
| Ceschini et al39 | 49.5% of students reported participating in one or more classes per week. | Achievement of the PA guideline 300 min/wk | Schoolchildren who reported not participating in PE classes were more likely to be inactive when compared with those who reported participating (OR = 1.39; 95%CI: 1.29 to 1.53; P < .001). | + | NS |
| Cheah et al71 | 49.1% of students reported participating in 2 or more classes per week. | Achievement of the PA guideline 300 min/wk | Participating in at least one PE class per week increased the chances of adolescents being active (IRR: 1.54; 95%CI: 1.48 to 1.60; P < .001). | + | NS |
| Cheah et al40 | NS | Number of PA days lasting at least 60 min | The authors observed that a day of PE classes increases the time spent on physical activities by 0.200 (unconditional) and 0.151 (conditional) d. The probability of participating in PA also increases by 2.2% when the time spent in face-to-face teaching increases by 1 d. | + | NS |
| Chen et al15 | NS | Total time in MVPA and SB time in days with and without PE classes | MVPA and sedentary time in class showed significant positive correlations with daily MVPA and sedentary time, respectively (r = .35, P < .01; r = .55, P < .01). | + | + |
| Chen et al41 | NS | Time in PA outside the school period | Adolescents who reported attending PE classes less than twice a week were more likely to be in the highest tertile of time in PA (OR = 2.40; 95%CI: 1.41 to 4.10; P < .001). | + | NS |
| Cheung72 | NS | Time of MVPA and SB in days with PE, in days with PA after school (sport), and in days without PE or PA after school | The results indicated that the groups differed significantly in daily MVPA (F2,108 = 16.62, P < .00) and MVPA during school hours (F2,108 = 36.22, P < .00), and there was no significant difference in children’s sedentary behavior with school-based PA participation. | + | 0 |
| Costa et al42 | 42.7% of students reported participating in one or more classes per week. | Time of PA and SB during the school period | Children who participated in PE classes spent 11.8 min (95%CI: 15.7 to 7.9; P < .01) less in sedentary activities during the school period compared with those who participated. | NS | − |
| Dargavel et al43 | NS | Total time in MVPA | We found no significant relationship between total number of PE classes taken during secondary school and PA participation as an emerging adult. | + | NS |
| Dauenhauer and Keating23 | NS | Number of steps per day on days with and without PE classes and excluding steps taken during PE classes | The independent t test indicated that students who had PE classes for 60 min had a higher level of PA than on days with 30-min classes. | + | NS |
| Duan et al16 | 76.6% of students reported participating in 3 or more classes per week. | Total PA | Each 10-unit increase in toward PE was associated with an increased odds of 1.15 (95% CI: 1.09 to 1.20) for spending more than 1 h/d on MVPA. | + | NS |
| Duncan et al44 | NS | Total PA | Positive association between time spent in PE classes and higher levels of PA (β = 0.129; P < .01). | + | NS |
| El-ammari et al45 | 85.2% of students reported participating in 2 or more classes per week. | Achievement of the PA guideline and overexposure to screen | Adolescents who reported attending PE classes less than twice a week were more likely to be physically inactive (OR = 2.53; 95%CI: 1.15 to 5.57). | + | 0 |
| El-ammari et al45 | 85.2% of students reported participating in 2 or more classes per week. | Achievement of the PA guideline and overexposure to screen | There was no association between low participation in PE classes and physical inactivity (OR = 1.18; 95%CI: 0.51 to 2.760). | 0 | 0 |
| Farias Júnior et al22 | 33.1% of students reported participating in one or more classes per week. | Achievement of the PA guideline | Adolescents who participated in 2 or more PE classes were more likely to be physically active, being higher among adolescents who reported participating in 2 or more PE classes (PR = 1.17; 95%CI: 1.02 to 1.34 vs PR = 1.24; 95% CI: 1.12 to 1.37). | + | NS |
| Groffik et al73 | NS | PA level classification at school | Participants who engaged in PE met the determined PA recommendations significantly more than did their counterparts in all 4 recommendations (P < .001). Participation in PE was a main predictor in fulfillment of all types of PA recommendations: At least 500 steps/h, at least 25% PA, at least 20 min of MVPA (≥3 METs/school time), and at least 20 min of MVPA (≥60% HRmax/school time) – OR = 5.03; 95%CI: 3.67 to 6.90; P < .001. | + | NS |
| Herazo-Beltran et al74 | NS | PA level classification | The PE classes also help students reach the recommended levels of PA: They received 72% of the active ones compared with 34.1% of inactive ones, while 45.5% of the students during the classes of PE in the study were very active were categorized as inactive (P < .05). | + | NS |
| Herman et al46 | 22.1% of students reported participating in 3 or more classes per week. | Total time in SB | Adolescents who reported attending PE classes less than twice a week were more likely to be in the highest tertile of time in sedentary behavior (OR = 2.40; 95%CI: 1.41 to 4.10; P < .001). | NS | − |
| Hobin et al17 | 34.9% of students reported participating in one or more classes per week. | Achievement of the PA guideline | Positive association of participation in PE classes with MVPA (OR = 1.17; 95%CI: 1.02 to 1.34). | + | NS |
| Hobin et al47 | 74.7% of students reported participating in 2 or more classes per week. | Total time in PA | Adolescents who reported attending 2 or more PE classes per week were more likely to have higher levels of PA (OR = 1.86; 95%CI: 1.43 to 2.40). | + | NS |
| Kantanista et al48 | NS | PA level classification | On days with PE classes, adolescents accumulated more steps than on other days (Δ = 0.95, P < .001). | + | NS |
| Kantanista et al48 | NS | Number of days physically active | Positive association of participation in PE classes with MVPA (OR = 1.17; 95%CI: 1.02 to 1.34). | + | NS |
| Kerr et al75 | NA | MPA and VPA time in days with and without PE classes and total time in SB | Sedentary time was higher on non-PE days than on PE days (mean difference: 62 min, P < .001), and hard and very hard intensity PA was significantly higher on PE days compared with non-PE days (mean total difference: 33 min, all significant at P < .001). | + | − |
| Kirkham-King et al18 | NS | Total time in MVPA | Adolescents who reported attending PE more likely to be highest time in PA (OR = 1.80; 95%CI: 1.15 to 2.81; P < .001). | + | NS |
| Kobel et al49 | NS | Total time in MVPA in days with and without PE classes | On days with PE, children spent 144 (68) min in MVPA, whereas on days without PE, this time decreased significantly to 122 (63) min (P ≤ .01). | + | NS |
| Lima and Silva50 | 66.4% of students reported participating in one or more classes per week. | Fulfillment of PA recommendation | No significant differences were observed between participation in PE classes and meeting the PA recommendation (P = .087). | 0 | NS |
| Loprinzi et al51 | 46.9% of students reported participating in 5 or more classes per week. | Number of days physically active | Adolescents who had PE during school days had a higher enjoyment of participating in PE (B = 0.32; P < .01), engaged in more days of being physically active for 60 min/d (B = 1.02; P < .001). | + | NS |
| Määta et al76 | NS | Time in SB during school term | Inverse association of participation in PE classes with sedentary time (P = .035). | NS | − |
| Martins et al19 | 71.3% of students reported participating in one or more classes per week. | Screen time | Among students who participate in PE classes, the highest proportion watches more than 3 h of television (43.6% vs 56.4%, P = .04). | NS | + |
| Marttinen et al52 | NS | Number of steps | Adolescents were more physically active on days with PE classes than on weekends (Δ mean = 2150 steps; P < .01). | + | NS |
| Mayorga-Vega et al6 | NS | Total PA and SB time | Using ANOVA for repeated measures, it was possible to observe that on days with PE classes, the proportion of time spent in MVPA among adolescents was greater than on days without PE classes (8.05 [3.25] vs 6.10 [2.47], P < .001). | + | − |
| Meyer et al20 | NS | MVPA time in days with and without PE classes | Children accumulated more time in MVPA on days with PE classes than on days without classes (16.1 [29.0] min P < .001). | + | NS |
| Mooses et al53 | NS | Time of MVPA and SB in days with and without PE classes | Each additional minute of MVPA in PE was associated with 1.4 more minutes of MVPA daily. On days with PE, students had 12.8 (95%CI: 10.5 to 15.0) more minutes of MVPA and 9.7 (95% CI: 16.3 to 3.1) less minutes of SB compared with days without PE classes. | + | − |
| Morgan et al54 | NS | Number of steps in days with and without PE classes | On days with PE classes, adolescents accumulated more steps than on other days (Δ = 0.95, P < .001). | + | NS |
| Naiman et al55 | 76.2% of students reported participating in 2 or more classes per week. | Total time of MVPA | The number of PE classes provided in the week prior to collection was associated with a higher probability of students being highly active compared with minimally active (OR = 1.14; 95%CI: 1.05 to 1.24) | + | NS |
| Nakamura et al56 | 22% of students reported participating in 2 or more classes per week. | PA level classification | Boys who did not participate in PE classes (OR = 0.27; 95%CI: 0.13 to 0.57) had a lower prevalence of total PA than students who attended PE classes. | + | NS |
| Nakamura et al56 | 20% of students reported participating in 2 or more classes per week. | PA level classification | Girls who did not participate in PE classes (OR = 0.27; 95%CI: 0.13 to 1.57) had not a lower prevalence of total PA than students who attended PE classes. | 0 | NS |
| Pate et al57 | 55% in the eighth grade, 57.7% in the ninth grade, and 9.4% of students in the 12th grade reported participating in 2 or more classes per week. | Total MPA and VPA time | Mean time spent in physical activities of vigorous intensity significantly higher in adolescents who attended PE classes (OR = 1.17; 95%CI: 1.02 to 1.34). | + | NS |
| Peltzer and Pengpid58 | 24.9% of students reported participating in 2 or more classes per week. | Fulfillment of PA recommendation (≥5 d with ≥60 min) and leisure time sitting (excluding school period or doing homework) | Through logistic regression, it was possible to observe that participation in PE classes were protective factors for physical inactivity (OR = 0.28; 95%CI: 0.17 to 0.45). | + | 0 |
| Peltzer and Pengpid58 | 29.4% of students reported participating in 2 or more classes per week. | Fulfillment of PA recommendation (≥5 d with ≥60 min) and leisure time sitting (excluding school period or doing homework) | Through logistic regression, it was possible to observe that participation in PE classes were protective factors for physical inactivity (OR = 0.54; 95%CI: 0.38 to 0.79). | + | 0 |
| Rezende et al59 | 81.7% of students reported participating in one or more classes per week. | Fulfillment of the PA recommendation; active displacement | Among the adolescents who reached the minimum recommended time for PA domains contributed the following proportions to total PA (PR = 1.36; 95%CI: 1.29 to 1.44). | + | NS |
| Reznik et al60 | NS | Number of steps per day on days with and without PE | Multivariate analysis using hierarchical models revealed PE class participation as an independent predictor of schoolchildren’s PA (estimate = 442.6; P < .001). | + | NS |
| Sharma et al77 | 49.8% of students reported participating in 5 or more classes per week. | Fulfillment of PA recommendation | Adolescents who had PE classes 5 times/wk (PR = 0.94; 95%CI: 0.88 to 0.99) were less likely to report insufficient PA. | + | NS |
| Sigmund et al61 | NS | SB time at different times of the day | Participation in classes increased the duration of total MVPA compared with that during the day without PE classes for overweight/obese girls (P < .05; d = 0.67), normal weight girls (P < .05; d = 0.55). | + | − |
| Sigmund et al61 | NS | SB time at different times of the day | Participation in classes increased the duration of total MVPA compared with that during the day without PE classes for boys with normal weight (P < .005; d = 0.65). | + | − |
| Silva et al26 | 24.8% of students reported participating in 3 or more classes per week. | MVPA and LPA time during the day, during school hours and out of school | Children from countries with low development rates who reported attending PE classes per week were more likely to meet the PA recommendation (OR = 1.80; 95%CI: 1.7 to 2.77). | + | − |
| Silva et al26 | 24.8% of students reported participating in 3 or more classes per week. | MVPA and LPA time during the day, during school hours and out of school | Children from countries with low development rates who reported attending PE classes per week were more likely to meet the PA recommendation (OR = 2.17; 95%CI: 1.44 to 3.2). | + | − |
| Silva et al78 | 9.8% of students reported participating in 3 or more classes per week. | Achievement of the PA guideline and screen time | Adolescents who reported having PE classes were more likely to meet MVPA recommendations (1–2 PE class/wk – OR = 1.3; 95%CI: 1.1 to 1.5; >2 PE class/wk – OR = 2.0; 95%CI: 1.7 to 2.5), spent more time in PA outside of school hours (1–2 PE class/wk – OR = 1.6; 95%CI: 1.4 to 1.9; >2 PE class/wk – OR = 2.0; 95%CI: 1.5 to 2.6), and accumulated more PA (1–2 PE class/wk–OR = 1.9; 95%CI: 1.6 to 2.2; >2 PE class/wk – OR = 6.0; 95%CI: 4.0 to 8.9) than students who reported not taking PE classes. | + | − |
| Silva et al62 | 61.4% of students reported participating in one or more classes per week. | Total time in PA and SB | The prevalence of SB was higher among students who participated only in one PE class, when compared with those who had a higher frequency of participation PR = 0.73; 95%CI: 0.56 to 0.95, and no significant association was observed with PA. | 0 | − |
| Silva et al63 | 76.2% of students reported participating in one or more classes per week. | Achievement of the PA guideline | In adolescents, not participating in PE classes proved to be a risk factor for a low level of PA (PR = 1.05; 95%CI: 1.02 to 1.07). | + | NS |
| Silva et al63 | 81.4% of students reported participating in one or more classes per week. | Total time in PA | There was no statistical significance for the prevalence ratio between nonparticipation in PE classes and propensity to low level of PA. | 0 | NS |
| Tassitano et al64 | 45.1% of students reported participating in one or more classes per week. | Achievement of the PA guideline and screen time | A significant association between participation in 2 or more PE classes and PA (OR = 1.27; 95%CI: 1.06 to 1.53). | + | − |
| Tenório et al65 | 45.1% of students reported participating in one or more classes per week. | Achievement of the PA guideline and screen time | Significant association between participation in 2 or more PE classes and PA (OR = 1.27; 95%CI: 1.06 to 1.53) | + | − |
| To et al79 | NS | Achievement of the PA guideline | Students were more active at school on PE days versus non-PE days and weekdays versus weekends (P < .001). | + | NS |
| Vale et al66 | NS | PA level classification | Positive association of participation in PE classes with the number of active days in at least 60 min. | + | NS |
| Vancampfort et al80 | Participation in 5 or more classes ranges from 1.7% in Peru to 34% in the Philippines. | Achievement of the PA guideline | Those who participated in PE for ≥5 d/wk (OR = 1.12; 95%CI: 1.10 to 1.15) were more likely to meet PA guidelines. | + | NS |
| Viciana et al81 | NS | Achievement of the PA guideline and screen time | Results showed that there was a significant increase in the proportion of adolescents achieving the daily recommendation of MVPA on PE days (23.6%) than on non-PE days (14.6%) (P < .05), and no significant differences were observed between sedentary time in days with (798.0 min) and without PE (805.0), P = .279. | + | 0 |
| Woods et al67 | 10% of students received 120 min of PE per week. | Number of steps in days with and without PE classes and screen time | Positive association of participation in PE classes with the number of active days in at least 60 min. | + | NS |
| Telford et al21 | NS | MVPA time in the day and MVPA time during the school period on days with and without PE classes | Greater perception of involvement in PE classes it was associated with a higher level of PA (SE = P < .001). | + | NS |
| Telford et al21 | NS | Achievement of the PA guideline | Greater perception of involvement in PE classes not was associated with a higher level of PA (SE = P < .001). | 0 | NS |
| Yli-Piipari et al27 | NS | LPA and MVPA time in days with and without PE classes | The latent growth analysis showed a positive and significant relationship between the growth trajectories of participation in PE class tasks and participation in physical activities (r = .49 P < .05). | + | NS |
Abbreviations: ANOVA, analysis of variance; B, beta; IRR, incidence risk ratio; CI, confidence interval; HRmax, maximum heart rate; LPA, low PA; MET, Metabolic Equivalent; MVPA, moderate to vigorous PA; NS, not shown, not evaluated or not analyzed; OR, odds ratio; PA, physical activity; PE, physical education; PR, prevalence ratio; r, correlation coefficient; SB, sedentary behavior; VPA, vigorous PA. Note: −, inverse association; "0," null association; +, positive association.
Most of the studies (68%) were published since 20136,13,14,16–18,23–27,36,37,39–45,48–53,55,56,58–61,63,68–83 with students in the United States (18%),16,21,24,25,35,40,43,51,52,54,57,60,68 Brazil (23%),13,17,20,36,38,41,50,56,59,62–65,79 and Canada (7%)15,23,42,45,47,55 (Table 1). Sample size varied from 6768 to 109,10459 students, and student ages from 366 to 2017 years (Table 2). In the longitudinal studies, the follow-up period varied from 126 to 227 years.
Regarding methodological quality, 27%, 52%, and 22% of the studies were classified as high, moderate, and low methodological quality, respectively, with the items “assessor blinding” and “sample power” exhibiting the lowest positive assessment percentage. In longitudinal studies, most were considered moderate quality and the items “sample selection” and “statistical procedures” showed the lowest positive assessment percentage (see Supplement C [available online]).
Physical activity was investigated in 93% (n = 55)6,13–21,23–27,35–68 of the studies and sedentary behavior in 33% (n = 20).6,17,23,24,41,44,45,53,58,61,62,64,65,69,71,73,76,77,79,82 The most widely used instruments to measure these behaviors were questionnaires (48%)13–15,17,20,25–27,36,38,39,42,44,46–48,50,51,55,56,58,59,62–65,67 and accelerometers (32%)6,18,23,37,41,53,61,66,83,84 (Table 1). Participation in PE classes was measured in different ways: the number of classes per week (78%), provision of classes by school management (5%), duration of classes (12%), and enrollment and attendance in classes per semester (5%) (Table 3).
Characteristics of Observational Studies That Analyzed the Association of Participation in PE Classes With PA and Sedentary Behavior (Studies Reviewed n = 60, n = 68 Samples)
| Study | Country of study | Sample size | Sex | Age group | Study design | Variables | Measuring instruments | MQ |
|---|---|---|---|---|---|---|---|---|
| Aguilar-Farias et al68 | Chile | 148 | B and G | 9–11 y old | Cross-sectional | Demographic and socioeconomic, psychological, environmental, PA level, time in SB and participation in PE classes (time in classes per week) | PA and SB: Accelerometer ActiGraph GT3X+ | High |
| Alderman et al36 | United States | 279 | B and G | 11.8 (0.66) y old | Cross-sectional | PA level and participation in PE classes (number of classes per week) | PA: Pedometer Walk4Life LS252 | Moderate |
| Aljuhani and Sandercock69 | Saudi Arabia | 111 | B | 12–14 y old | Cross-sectional | Demographic and socioeconomic, nutritional status, PA level, and participation in PE classes (one class of 45 min/wk) | PA: Accelerometer ActiGraph wGT3X-BT | Moderate |
| Al-Thani et al70 | Qatar | 5.862 | B and G | 12–17 y old | Cross-sectional | Demographic and socioeconomic, SB, PA level, and frequency in PE classes (number of classes per week) | PA, SB, and PE: GSHS Questionnaire | Moderate |
| Amornsriwatanakul et al28 | Thailand | 13.255 | B and G | 6–17 y old | Cross-sectional | PA level and frequency in PE classes (provide PE classes) | PA and PE: Thailand Physical Activity Children Survey—Student Questionnaire | Moderate |
| Bergmann et al14 | Brazil | 1.455 | B and G | 10–17 y old | Cross-sectional | PA level and participation in PE classes (provide PE classes) | PA: Physical Activity Questionnaire for Older Children and Adolescents | High |
| Bezerra et al37 | Brazil | 1.690 (2006) and 2.525 (2011) | B | 14–19 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA and PE: Questionnaire Global School-Based Student Health Survey | Moderate |
| Bezerra et al37 | Brazil | 2.517 (2006) and 3.739 (2011) | G | 14–19 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA and PE: GSHS | Moderate |
| Calahorro-Canada et al38 | Spain | 150 | B and G | 8–19 y old | Cross-sectional | PA level, time in SB, and participation in PE classes (classes of 60 min/wk) | PA and SB: Accelerometer ActiGraph GT3x | Low |
| Ceschini et al39 | Brazil | 3.845 | B and G | 14–19 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA: International Physical Activity Questionnaire | Moderate |
| Cheah et al71 | Malaysia | 25.399 | B and G | 11–18 y old | Cross-sectional | Demographic and socioeconomic, nutritional status, PA level, and frequency in PE classes (number of classes per week) | PA and PE: GSHS | Moderate |
| Cheah et al40 | Malaysia | 2.991 | B and G | 16 and 17 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA and PE: Based on GSHS and Youth Risk Behavior Surveillance System Questionnaire | Low |
| Chen et al15 | United States | 67 | B and G | 11.75 (0.5) y old | Cross-sectional | PA level, time in SB, and frequency in PE classes (number of classes per week) | PA and SB: SenseWear MF-SW | Low |
| Chen et al41 | United States | 293 | B and G | 9.4 (0.9) y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA: 3-DayPhysical Activity Recall PE: Situational Interest Scale | Moderate |
| Cheung72 | China | 242 | B and G | 8.7 (1.6) y old | Cross-sectional | Demographic and socioeconomic, PA level, time in SB, and participation in PE classes (number of classes per week) | PA: Accelerometer ActiGraph GT3X+ PE: Questionnaire | Moderate |
| Costa et al42 | Brazil | 571 | B and G | 7–12 y old | Cross-sectional | Demographic and socioeconomic, SB, and frequency in PE classes (provide PE classes) | SB: Accelerometer ActiGraph GT3X+ PE: Consult the school administration | Moderate |
| Dargavel et al43 | Canada | 112 | B and G | 20.2 (1.78) y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA: International Physical Activity Questionnaire | Low |
| Dauenhauer and Keating23 | United States | 71 | B and G | 8–11 y old | Cross-sectional | PA level and participation in PE classes | PA: Pedometer Omron HJ-112 | Low |
| Duan et al16 | China | 1.793 | B and G | 12–15 y old | Cross-sectional | PA level and participation in PE classes (time in classes per week) | PA and SB: Questionnaire adapted from China Health and Nutrition Survey PE: Students Attitudes toward Physical Education Scale | Low |
| Duncan et al44 | United States | 353 | G | 10–14 y old | Cross-sectional | PA level and participation in PE classes | PA: Accelerometer ActiGraph GT3x+ for adolescents under 12 y old and Youth Risk Behavior Surveillance System Questionnaire for adolescents over 12 y old PE: Youth Risk Behavior Surveillance System Questionnaire | Moderate |
| El-ammari et al45 | Morocco | 358 | B | 14–19 y old | Cross-sectional | PA level, SB, and frequency in PE classes (number of class per week) | PA and SB: GSHS | High |
| El-ammari et al45 | Morocco | 406 | G | 14–19 y old | Cross-sectional | PA level, SB, and frequency in PE classes (number of class per week) | PA and SB: GSHS | High |
| Farias Júnior et al22 | Brazil | 2.874 | B and G | 14–19 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA: Questionnaire standardized self-filling | Moderate |
| Groffik et al73 | Multicenter (Poland and Czech Republic) | 921 | B and G | 16.2 (0.7) y old | Cross-sectional | Demographic and socioeconomic, PA level, and frequency in PE classes (number of classes per week) | PA: Accelerometer ActiTrainer and Pedometer | Moderate |
| Herazo-Beltran et al74 | Colombia | 3.598 | B and G | 10–14 y old | Cross-sectional | Demographic and socioeconomic, PA level, and frequency in PE classes (number of classes per week) | PA and PE: PAQ-C | Low |
| Herman et al46 | Canada | 534 | B and G | 8–10 y old | Cross-sectional | SB and frequency in PE classes (number of classes per week) | SB: Accelerometer ActiGraph and Questionnaire | Low |
| Hobin et al17 | Canada | 22.117 | B and G | 9–12 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA: Questionnaire SHAPES Physical Activity Module PE: Reminder | Moderate |
| Hobin et al47 | Canada | 2.379 | B and G | NS | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA: Questionnaire SHAPES Physical Activity Module PE: Reminder | Moderate |
| Kantanista et al48 | Poland | 3.249 | B | 14–16 y old | Cross-sectional | PA level and participation in PE classes | PA: Physical Activity Screening Measure Questionnaire PE: Teacher support scale | Low |
| Kantanista et al48 | Poland | 3.249 | G | 14–16 y old | Cross-sectional | PA level and participation in PE classes | PA: Physical Activity Screening Measure PE: Teacher support scale | Low |
| Kerr et al75 | England | 53 | B and G | 11.7 (0.3) y old | Cross-sectional | Demographic and socioeconomic, SB, PA level, and participation in PE classes | PA and SB: Accelerometer RT3X | Low |
| Kirkham-King et al18 | United States | 281 | B and G | NS | Cross-sectional | PA level and participation in PE classes | PA: Accelerometer ActiGraph GT1M | Moderate |
| Kobel et al49 | Germain | 294 | B and G | 7.1 (0.7) y old | Cross-sectional | PA level and participation in PE classes | PA: Energy expenditure monitor and body movement Actiheart | Moderate |
| Lima and Silva50 | Brazil | 1.103 | B and G | 14–19 y old | Cross-sectional | PA level and participation in PE classes (time of classes per week) | PA: Brazilian version of Questionnaire Youth Risk Behavior Surveillance System PE: Adolescent behavior of Santa Catarina Questionnaire | High |
| Loprinzi et al51 | United States | 459 | B and G | 12–15 y old | Cross-sectional | PA level and participation in PE classes | PA and PE: Questionnaire | High |
| Määta et al76 | Finland | 717 | B and G | 3–6 y old | Cross-sectional | Demographic and socioeconomic, school environment, SB, and participation in PE classes (time of classes per week) | SB: Accelerometer ActiGraph WGT3X | High |
| Martins et al19 | Brazil | 964 | B and G | 14–20 y old | Cross-sectional | Demographic and socioeconomic, SB, and participation in PE classes | SB: Questionnaire | Moderate |
| Marttinen et al52 | United States | 221 | B and G | 11.9 (0.9) y old | Cross-sectional | PA level and participation in PE classes | PA: Accelerometer MovBand | Moderate |
| Mayorga-Vega et al6 | Spain | 158 | B and G | 13–16 y old | Cross-sectional | PA level, SB, and participation in PE classes | PA and SB: Accelerometer ActiGraph GT3X | Moderate |
| Meyer et al20 | Switzerland | 676 | B and G | 9.3 (2.1) y old | Cross-sectional | PA level and participation in PE classes | PA: Accelerometer ActiGraph GT1M | High |
| Mooses et al53 | Estonia | 504 | B and G | 7–12 y old | Cross-sectional | PA level, SB, and participation in PE classes | PA and SB: Accelerometer ActiGraph GT3X | High |
| Morgan et al54 | United States | 485 | B and G | 9.5 (1.6) y old | Cross-sectional | PA level and participation in PE classes | PA: Pedometer Walk4Life LS2500 | Low |
| Naiman et al55 | Canada | 2.449 | B and G | NS | Cross-sectional | PA level and participation in PE classes | PA and PE: SHAPES-PAM Questionnaire | Moderate |
| Nakamura et al56 | Brazil | 213 | B | 14–17 y old | Cross-sectional | PA level and participation in PE classes | PE and PA: Physical Activity Questionnaire—Children | High |
| Nakamura et al56 | Brazil | 254 | G | 14–17 y old | Cross-sectional | PA level and participation in PE classes | PE and PA: Physical Activity Questionnaire—Children | High |
| Pate et al57 | United States | 5.444 | G | 13–18 y old | Cross-sectional | PA level and participation in PE classes | PA: 3-Day Physical Activity Recall | Low |
| Peltzer and Pengpid58 | Multicenter (Cambodia, Malaysia, Filipinas, and Vietnam) | 14.750 | B | 13–15 y old | Cross-sectional | PA level, SB, and participation in PE classes | PA, SB, and PE: GSHS | Moderate |
| Peltzer and Pengpid58 | Multicenter (Cambodia, Malaysia, Filipinas, and Vietnam) | 15.430 | G | 13–15 y old | Cross-sectional | PA level, SB, and participation in PE classes | PA, SB, and PE: GSHS | Moderate |
| Rezende et al59 | Brazil | 109.104 | B and G | 13–16 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA and PE: Questionnaire based on Global School-Based Student Health Survey and Youth Risk Behavior Surveillance System | High |
| Reznik et al60 | United States | 916 | B and G | 6.0 (0.7) y old | Cross-sectional | PA level and participation in PE classes | PA: Pedometer Yamax Digi-Walker SW 200 | Moderate |
| Sharma et al77 | Peru | 1.354 | B and G | 11–19 y old | Cross-sectional | Demographic and socioeconomic, PA level, and frequency in PE classes (number of classes per week) | PA and PE: GSHS | Moderate |
| Sigmund et al61 | Czech Republic | 170 | G | 9–11 y old | Cross-sectional | PA level, SB, and participation in PE classes | PA and SB: Accelerometer ActiTrainer | Moderate |
| Sigmund et al61 | Czech Republic | 168 | B | 9–11 y old | Cross-sectional | PA level, SB, and participation in PE classes | PA and SB: Accelerometer ActiTrainer | Moderate |
| Silva et al26 | Multicenter (Australia, South Africa, Brazil, Canada, China, Colômbia, United States, Filand, India, Kenya, Portugal, and United Kingdom) | 2.678 | B | 9–11 y old | Cross-sectional | PA level, SB, and frequency in PE classes (number of classes per week) | PA and SB: Accelerometer ActiGraph GT3X+ PE: Youth Risk Behavior Surveillance System Questionnaire | High |
| Silva et al26 | Multicenter (Australia, South Africa, Brazil, Canada, China, Colombia, United States, Filand, Índia, Quênia, Portugal, and the United Kingdom | 3.196 | G | 9–11 y old | Cross-sectional | PA level, SB, and frequency in PE classes (number of classes per week) | PA and SB: Accelerometer ActiGraph GT3X+ PE: Youth Risk Behavior Surveillance System Questionnaire | High |
| Silva et al78 | Brazil | 12.220 | B and G | 11–19 y old | Cross-sectional | Demographic and socioeconomic, nutritional status, SB, PA level, and frequency in PE classes (number of classes per week) | PA, SB, and PE: GSHS | High |
| Silva et al62 | Brazil | 5.028 | B and G | 15–19 y old | Cross-sectional | PA level, SB, and participation in PE classes PA level and frequency in PE classes (number of classes per week) | PA, SB, and PE: Adolescents behavior of Santa Catarina Questionnaire | Moderate |
| Silva et al63 | Brazil | 1.372 | G | 13–18 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA and PE: The Physical Activity Questionnaire for Children And Adolescent | High |
| Silva et al63 | Brazil | 833 | B | 13–18 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA and PE: The Physical Activity Questionnaire for Children And Adolescent | High |
| Tassitano et al64 | Brazil | 4.210 | B and G | 14–19 y old | Cross-sectional | PA level, SB, food consumption, and frequency in PE classes (number of classes per week) | PA, SB, food consumption and PE: GSHS | High |
| Tenório et al65 | Brazil | 4.210 | B and G | 14–19 y old | Cross-sectional | PA level and frequency in PE classes (number of classes per week) | PA and PE: GSHS | High |
| To et al79 | Vietnam | 619 | B and G | 9.7–12.6 y old | Cross-sectional | Demographic and socioeconomic, PA level, and participation in PE classes | PA: Pedometer SW200 | Moderate |
| Vale et al66 | Portugal | 193 | B and G | 3–5 y old | Cross-sectional | PA level and participation in PE classes | PA: Accelerometer ActiGraph GT1M | Moderate |
| Vancampfort et al80 | Multicentera | 142.118 | B and G | 13.8 (1.0) y old | Cross-sectional | Demographic and socioeconomic, PA level, and frequency in PE classes (number of class per week) | PA and PE: GSHS | Moderate |
| Viciana et al81 | Chile | 123 | B and G | 13.5 (0.7) y old | Cross-sectional | Demographic and socioeconomic, SB, PA level, and frequency in PE classes (number of class per week) | PA and SB: Accelerometer ActiGraph GT3X+ | Moderate |
| Woods et al,67 | Iran | 4.122 | B and G | 13–16 y | Cross-sectional | PA level and frequency in PE classes (number of class per week) | PA: Questionnaire prepared for the study PE: Question about class days per week and scale FIPE (Factors Influencing Enjoyment of Physical Education Enjoyment scale) | Moderate |
| Telford et al21 | Australia | 175 | B | 8 y old in baseline and 12 y in follow-up | Longitudinal | PA level and perception of involvement in PE classes | PA: Pedometer Walk4Life PE: Questionnaire about competence perceived in class | High |
| Telford et al21 | Australia | 186 | G | 8 y old in baseline and 12 y in follow-up | Longitudinal | PA level and participation in PE classes | PA: Pedometer Walk4Life PE: Questionnaire about competence perceived in class | High |
| Yli-Piipari et al27 | Greece | 812 | B and G | 12 and 13 y | Longitudinal | PA level and participation in PE classes | PA and PE: Questionnaire | Moderate |
Abbreviations: B, boys; G, girls; GSHS, Global School-Based Student Health Survey; MQ, methodological quality; PA, physical activity; PE physical education; SB, sedentary behavior.
aAfghanistan, Benin, Cambodia, Mozambique, Nepal, Tanzania, Bangladesh, Belize, Bolivia, East Timor, Egypt, El Salvador, Ghana, Guatemala, Guyana, Honduras, Indonesia, Kiribati, Laos, Maldives, Mauritania, Mongolia, Morocco, Pakistan, Philippines, Samoa, Solomon Islands, Sudan, Syria, Tonga, Vanuatu, Vietnam, Yemen, Algeria, Antigua, and Barbuda, Argentina, Costa Rica, Dominica, Mauritania, Fiji, Iraq, Namibia, Peru, Suriname, Thailand, and Tuvalu.
The most frequently analyzed physical activities were overall physical activity (72%) and the comparison between physical activity indicators on days with and without PE classes (17%). In 2 studies, physical activity was compared in and out of school, disregarding the time spent during PE classes. Sedentary behavior was operationalized as follows: screen time (35%), total time (30%), and comparison between sedentary behavior indicators on days with and without PE classes (25%) (Table 2).
In most of the study results (82%),6,13–16,18,20,21,23,24,35–43,45–49,51–55,57–61,64–67 PE class participation was associated with greater physical activity (Table 1). This result persisted even after analyses were stratified by study type (53/66 cross sectional and 2/3 longitudinal), methodological quality (12/15 high methodological quality and 32/36 moderate methodological quality), and measuring instrument (28/32 questionnaires and 10/10 accelerometers) (Table 1).
Table 1 shows the results of the consistency of the association between PE class participation and PE for the different study characteristics. Associations were consistent in all the stratifications, indicating that PE class participation is associated with physical activity (> 60%, “++”).
In 52% of the studies, there was an inverse relation6,23,41,45,53,64,65,79 between PE class participation and sedentary behavior. This association was observed in studies with high methodological quality (70%, “++”) and those that used accelerometers to measure sedentary behavior (85%, “++”) (Table 4). No longitudinal studies were found that investigated the relation between PE class participation and sedentary behavior. Stratification of analyses according to how sedentary behavior is operationalized classified the consistency of the association as null for the association between PE class participation and screen time (22%, “00”) and operationalization of sedentary behavior on days with versus without PE classes (25%, “00”) (Table 4).
Summary of the Results of Studies on the Relationship Between Participation in PE Classes, Physical Activity, and Sedentary Behavior (n = 68 samples)
| Physical activity | |||||
|---|---|---|---|---|---|
| Significant association | No significant association | Summary code | |||
| Variables | Reference | Association (+/−) | Reference | % | Result |
| Year of publication | |||||
| ≥2013 | 14–16,18,20,27,40,41,43,48,49,51–53,55,59,60,70,71,73–75,77–81,94,95, B26,37,45,58,61, G26,37,44,58,61,63 | + | 28,68,96, G21,45,56, B63 | 43/52 (83%) | ++ |
| <2013 | 69 | − | |||
| 17,22,23,36,39,47,54,64–67, G57 | + | 62 | 13/14 (93%) | ++ | |
| Country | |||||
| United States | 18,23,36,51,52,54,60, B26, G26,44,57 | + | 16/16 (100%) | ++ | |
| Brazil | 14,22,39,59,64,65,78, B37,56, G37 | + | 62,96, B63, G56 | 10/14 (75%) | ++ |
| Canada | 17,43,47,55, B26, G26 | + | 6/6 (100%) | ++ | |
| Outhers countries | 16,20,27,40,48,49,53,66,67,94,95, B21,45,58,61, G58,61 | + | 28, G21,45 | 19/22 (86%) | ++ |
| Study design | |||||
| Cross-sectional | 14–18,20,22,23,36,40,41,43,47–49,51–55,59,60,64–67,70,71,73–75,77–81,94,95, B26,37,45,56,58,61, G26,37,44,57,58,61,63 | + | 28,62,68,96, B63, G45,56 | 43/52 (83%) | ++ |
| 69 | − | ||||
| Longitudinal | 27, B21 | + | G21 | 5/6 (83%) | ++ |
| Instruments | |||||
| Questionnaires | 14,16,17,22,27,39,40,43,47,48,51,55,59,64,65,67,70,71,74,77,78,80, B37,45,56,58, G37,44,58,63 | 28,62,97, B63, G45,56 | 33/39 (85%) | ||
| Accelerometers | 18,20,53,66,73,75,81,94,95, B26,61, G26,44,61 | + | 68 | 15/17 (88%) | ++ |
| 69 | − | ||||
| Pedometers | 23,36,52,54,60,79, B21 | + | G21 | 7/8 (87%) | |
| Others* | 15,41,49, G57 | + | 3/3 (100%) | ++ | |
| Sample | |||||
| ≥1000 participants | 14,16,17,22,28,39,40,47,48,55,59,62,64,65,67,70,71,74,77,78,80,96 B26,37,58 G26,37,57,58,63 | 30/30 (100%) | ++ | ||
| <1000 | 15,18,20,23,27,36,41,43,49,51–54,60,66,73,75,79,81,94,95 B21,45,56,61 G44,61 | + | 68, B45,63 G21,56 | 28/33 (86%) | ++ |
| 69 | − | ||||
| Sex | |||||
| All | 14–18,20,22,23,27,36,39–41,43,47–49,51–55,59,60,64–67,70,71,73–75,77–81,94,95 | + | 28,62,68,96 | 44/49 (90%) | ++ |
| Boys | 21,26,37,45,56,58,61 | + | 63 | 8/10 (80%) | ++ |
| 69 | − | ||||
| Girls | 26,37,44,57,58,61,63 | + | 21,45,56 | 30/33 (73%) | ++ |
| Operationalization of the measure | |||||
| Global | 14–18,22,27,36,39–41,43,47–49,51,52,55,59,64,65,67,71,74,77,78,80,95, B15,21,26,45,56,58,61, G26,41,44,57,58,61,63 | + | 28,62,68,96, G21,45,56 | 43/50 (86%) | ++ |
| School | 73, B41,61, G41,61 | + | 5/5 (100%) | ++ | |
| Leisure | 70, B37, G37 | + | 4/4 (100%) | ++ | |
| PA in days with versus without PE classes | 20,53,54,60,66,72,75,79,81,94 | + | 10/10 (100%) | ++ | |
| Sedentary behavior | |||||
|---|---|---|---|---|---|
| Significant association | No significant association | Summary code | |||
| Reference | Association (+/−) | Reference | % | Result | |
| Year of publication | |||||
| ≥2013 | 42,46,53,95, B26,61, G26,61 | − | B45,58, G45,58 | 8/12 (66%) | ?? |
| <2013 | 64,65 | + | 2/4 (50%) | ?? | |
| 15,19 | − | ||||
| Country | |||||
| United States | 15 | + | 2/3 (66%) | ?? | |
| B26, G26 | − | ||||
| Brazil | 42,64,65,78, B26, G26 | − | 7/7 (100%) | − − | |
| Canada | 46, B26, G26 | − | 3/3 (100%) | − − | |
| Others countries | 75,76, B61, G61 | − | 68,70,81, B45,58, G45,58 | 7/10 (70%) | 00 |
| Study design | |||||
| Cross-sectional | 15,19,62 | + | 68,70,81, B45,58, G45,58 | 11/21 (52%) | ?? |
| 42,46,53,64,65,78,95, B26,61, G26,61 | − | ||||
| Instruments | |||||
| Questionnaires | 19,62,78 | + | 68,70,81, B45,58, G45,58 | 8/17 (47%) | 00 |
| 64,65,78 | − | ||||
| Accelerometer | 42,53,75,76,95, B26,61, G26,61 | − | 68,81 | 11/13 (85%) | − − |
| Sample | |||||
| ≥1000 students | 62 | + | B58, G58 | 4/7 (57%) | ?? |
| 64,65, B26, G26 | − | ||||
| <1000 students | 15,19 | + | B45, G45 | 6/10 (60%) | ?? |
| 42,46,53,96, B61, G61 | − | ||||
| Sex | |||||
| All | 15,19,62 | + | 6/9 (66%) | ?? | |
| 42,46,53,64,65,95 | − | ||||
| Boys | + | 45,58 | 2/4 (50%) | ?? | |
| 26,61 | − | ||||
| Girls | + | 45,58 | 2/4 (50%) | ?? | |
| 26,61 | − | ||||
| Operationalization of the measure | |||||
| Total | 46,75,95, B26,61, G26,61 | − | 68 | 7/8 (88%) | − − |
| School | 42,76, B61, G61 | − | 4/4 (100%) | − − | |
| School time | 64,65 | − | 70, B45,58, G45,58 | 2/9 (22%) | 00 |
| 19,62 | + | 2/9 (22%) | 00 | ||
| SB in days with versus without PE classes | 53 | − | 72,81 | 1/4 (25%) | 00 |
| 15 | + | 1/4 (25%) | 00 | ||
Abbreviations: B, boys; G, girls; PE, physical education.
Discussion
The results of the present systematic review demonstrated that PE class participation was associated with increased physical activity and less sedentary behavior. These findings were consistent even after they were stratified by design (cross sectional or longitudinal) and methodological quality of the studies (low, moderate, or high), and measuring instrument (questionnaires or objective measures). The results could not be stratified by sedentary behavior in relation to the type of design due to the absence of longitudinal studies.
These findings may have been explicated by several frameworks that will be presented in 3 possibilities. First, class participation exposes students to physical activities that may improve their knowledge about the importance of such activities and of reducing sedentary behavior for health, thereby contributing to the development of attitudes and beliefs favorable to increase in physical activity and reduction in sedentary behavior. Successful and enjoyable physical activity experiences and PE classes may awaken the interest and pleasure for physical activity, both in and out of school. Interventions performed at school and in PE classes demonstrated that the adolescents who participated increased physical activity away from school.12,83 This may indicate that classes with better structural and pedagogic conditions could contribute to increasing the physical activity of students beyond the school walls.
Second, the physical activity measure used in studies on this topic considered the activities engaged in during classes, and some of these activities are performed in PE classes. In this respect, the relation could be partly explained by the fact that only a fraction of the students’ physical activity time is spent in classes. Systematic reviews85,86 demonstrated that PE classes contribute to an average of 15 minutes of adolescents’ daily low to vigorous physical activity, representing 25% of the daily recommendation.87 Another aspect that should be considered is that approximately 60% of the reviewed studies were conducted with students from middle-income countries.24 Depending on the country and region, despite the short duration of moderate and vigorous activities in PE classes, it may be the adolescents’ only or main opportunity to practice physical activity.
The inverse association between PE class participation and total time spent on sedentary behavior may be related to how class participation contributes to greater student engagement in physical activities (eg, structured and unstructured individual and collective sports), which may reduce the time spent on sedentary behavior.88,89 Physically active children and adolescents spend less time on sedentary behavior.90 However, this association seems to depend on how sedentary behavior time is accumulated, given that no consistent associations were found between PE class participation and screen time or operationalization of sedentary behavior on days with versus without PE classes. Screen time accumulates predominantly in leisure activities that may not be influenced by PE class participation.
Third, physically active young people would be more likely to adopt healthy behavior such as being physically more active, having a healthy diet and spending less time on sedentary behavior.91,92 As such, students that participate more in classes would already enjoy physical activities and engage in them on a daily basis. Despite the fact that greater class participation is associated with an increase in physical activity, and that this relation has been observed in longitudinal studies and those with high methodological quality, the possibility that students who take part in the classes are more physically active, derive greater satisfaction and view the classes as yet another opportunity to engage in physical activity, cannot be overlooked.
One aspect that must be considered in relation to the associations found in this review does justice to the political education policies that determine the role (in terms of curriculum) of PE in schools around the world. There are significant differences concerning the curriculum assigned to the discipline.97 It seems likely that this reality would attenuate any possible association between PE, PA, and SB.
As such, this evidence must be interpreted with caution given a large number of cross-sectional studies included6,13–18,20,21,23,24,27,35–67 and the absence of longitudinal studies on the relation between PE and sedentary behavior. The different concepts and lack of clarity in the operational description adopted in the studies to define PE class participation compromises the assessment of the natural effect of PE class participation on the outcomes. There was a lack of uniform measuring of physical activity and sedentary behavior, including the use of different instruments and ways of operationalizing.
The high heterogeneity of the methodological procedures hindered meta-analyses and other analyses on the relation between PE class participation, physical activity, and sedentary behavior. New longitudinal studies are needed with students from different grades and school systems (public and private) that consider different physical activity indicators (eg, structured and unstructured individual and collective sports) and sedentary behavior (screen time and total time). It is important that studies not include time students spend on physical activity during the class as part of the PA measure. Rather, activities performed in and out of school should be considered and instruments/methods that assess real class participation, as well as the use of instruments to measure, present a structure that can segment the periods in which each physical activity is performed. Finally, it is recommended that analyses be adjusted for potential confounders, such as sex, self-efficacy, perceived competence, and nutritional status, given that they may influence these associations.1,23,59,64
This review presents a number of strong points: searches conducted in different databases, languages, and reference lists of the articles included in the review; use of a reference protocol for review writing (Reporting Items for Systematic Reviews and Meta-Analyses28); assessment of the methodological quality of studies based on the protocols used in previous studies; assessment of different operationalizations of outcomes. Our review is the first to include studies with an observational design (cross sectional and longitudinal), this type of study allows for establishing relationships between variables in the student’s daily life without the influence of any intervention model. The study search and selection process conducted by a single author is a limitation of this review. However, the author took a training course to minimize this limitation before performing the different database searches.
The results of the present review demonstrated that students who participated in PE classes are more physically active and spend less daily time on sedentary behavior.
Implications for School Health
The results of this review reinforce the importance of teachers’ addressing “physical activity” and “sedentary behavior” (eg, concepts, definitions, determinants, assessment, health consequences, physical activity recommendations, and sedentary behavior, as well as being physically more active and less sedentary) in PE classes; providing enjoyable physical activities in a PE setting; developing guidelines on the types of activities and how students can reduce time spent on sedentary behavior and be physically active in different contexts during their school years.
These findings also reinforce the importance of PE classes in promoting more physically active lifestyles, as recommended by education and health agencies.1,3 The Centers for Disease Control and Prevention,1 United Nations Educational, Scientific, and Cultural Organization5, the Organization for Economic Cooperation and Development,93 and the World Health Organization (WHO)3 recommend that PE at school promote healthy behavior by implementing measures that increase physical activity and reduce the sedentary behavior of students.
These results may prompt teachers, students, managers, and society as a whole to promote physical activity and reduce sedentary behavior. The findings may also interest researchers, providing knowledge to develop school-based measures in education and health.
Acknowledgments
Author Contributions: DJS participated in the conception, writing, collection and analysis of data; AOB participated in the writing, collection and analysis of data; VCBF participated in the critical analysis of the article and made substantial considerations to the text; and JCFJ participated in the conception, writing and critical analysis of the manuscript.
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