Physical Activity Report Card Indicators and the United Nations Sustainable Development Goals: Insights From Global Matrix 4.0

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Diego Augusto Santos Silva Sports Center, Department of Physical Education, Federal University of Santa Catarina, Florianopolis, SC, Brazil

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Salomé Aubert Active Healthy Kids Global Alliance, Ottawa, ON, Canada

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Taru Manyanga Division of Medical Sciences, University of Northern British Columbia, Prince George, BC, Canada
Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada

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Eun-Young Lee School of Kinesiology and Health Studies, Queen’s University, Kingston, ON, Canada

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Deborah Salvo Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, USA

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Mark S. Tremblay Active Healthy Kids Global Alliance, Ottawa, ON, Canada
Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
Department of Health Sciences, Carleton University, Ottawa, ON, Canada

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DOI:
https://doi.org/10.1123/jpah.2024-0442
Keywords:
sedentary lifestyle; epidemiology; sports; social inequalities
First Published Online:
08 Oct 2024
In Print:
Volume 21: Issue 12
Page Range:
1372–1381
Free access

Background: The World Health Organization recognizes that physical activity (PA) during childhood is crucial for healthy development, aligning well with the achievement of several United Nations (UN) Sustainable Development Goals (SDGs). This study aimed to explore the associations between 10 key indicators of PA for children and adolescents assessed in the Global Matrix 4.0 project, and the UN SDGs. Methods: Data from 57 countries/jurisdictions of the Global Matrix 4.0 project were used. The UN SDG indicators were sourced from the SDG Transformation Center, which publishes each country’s performance on each of the 17 SDGs. Given the robust evidence supporting plausible links between PA and SDGs 3 (good health and well-being), 9 (industry, innovation, and infrastructure), 11 (sustainable cities and communities), 13 (climate action), and 16 (peace, justice, and strong institutions), these SDGs were investigated. Results: Countries/jurisdictions with good and moderate performance in achieving SDG 3, SDG 9, SDG 11, and SDG 16 had higher grades than countries/jurisdictions with fair performance in achieving these SDGs for the following indicators: Organized Sports and PA, Community and Environment, and Government Investments and Strategies. However, countries/jurisdictions with good performance in achieving SDG 13 had lower grades than countries/jurisdictions with fair performance in achieving SDG 13 for the following indicators: Organized Sports and PA, Community and Environment, and Government Investments and Strategies. Conclusions: Organized Sports and PA, Community and Environment, and Government Investments and Strategies were the indicators that demonstrated differences between countries/jurisdictions with good and poor performance in achieving the SDGs.

Regular physical activity for children and adolescents is associated with numerous health benefits, including better fitness, mental health, body composition, and cognitive function.1–3 Despite this evidence, global adherence to recommended physical activity guidelines among children and adolescents remains low.4–6 Recent data from 6 continents estimated that only 27% to 33% of school-aged children met physical activity guidelines in 2022,5 with lower rates in the Asia-Pacific, among girls, and children with disabilities.5,6

The challenges related to encouraging physical activity among children and adolescents are multifaceted.4,7–9 The absence of effective global action prioritizing physically active societies is apparent.8,9 The Global Action Plan on Physical Activity (GAPPA),8 launched in 2018 by the World Health Organization, targets a 15% reduction in global physical inactivity by 2030, including among adolescents. Emphasizing a systems approach, GAPPA advocates for societal norms promoting physical activity and the creation of safe spaces and programs at local, national, and international levels.8 This approach not only benefits health but also aligns with the United Nations Sustainable Development Goals (UN SDGs), offering potential social, economic, and environmental advantages.8,9Launched in 2015, the UN SDGs aim to eradicate poverty, protect the planet, and ensure global peace and prosperity by 2030.10–13 Comprising 17 SDGs and 169 targets, they address interconnected challenges across social, economic, and environmental realms.10,11 The GAPPA recognized physical activity’s potential to advance 13 of the SDGs, integrating it into societal agendas for comprehensive improvement.8 While plausible connections were demonstrated in 2021,14,15 Salvo et al14 highlighted physical activity’s benefits for 15 SDGs, supported by evidence and expert input. Notably, promoting physical activity positively impacts SDGs 3 (Good Health and Well-Being), 9 (Industry, Innovation, and Infrastructure), 11 (Sustainable Cities and Communities), 13 (Climate Action), and 16 (Peace, Justice, and Strong Institutions).

Since GAPPA’s release8 and evidence from Salvo et al,14 studies have explored the nexus between physical activity and SDGs in children and adolescents.15–17 One study proposed enhancing physical activity surveillance systems from birth to adolescence to advance SDGs.16 Specifically, Reilly et al16 presented examples of physical activity monitoring systems across different age groups that assist in achieving some SDGs and, for children and adolescents, highlighted the Active Healthy Kids Global Alliance (AHKGA) Global Matrix initiative as a system that has involved partnerships between developed and developing countries. Another study in Nigeria17 aimed to identify modifiable factors, including physical activity, to hasten SDG achievement but found no associations between adolescent physical activity levels and SDG proxy variables.

The present study explored the correlations between various indicators related to physical activity in countries/jurisdictions that participated in the fourth edition of the AHKGA Global Matrix initiative (G.M. 4.0). Physical activity indicators assessed in AHKGA G.M. 4.0 included behavioral indicators and sources-of-influence indicators. These indicators were examined in relation to the country/jurisdiction-level performance on the UN SDGs, particularly SDGs 3 (Good Health and Well-Being), 9 (Industry, Innovation, and Infrastructure), 11 (sustainable Cities and Communities), 13 (Climate Action), and 16 (Peace, Justice, and Strong Institutions). This research aimed to address 2 research questions: (1) do countries/jurisdictions that perform better (or worse) in achieving the UN SDGs also show better (or worse) physical activity indicators for children and adolescents? (2) do the differences (or similarities) among these countries/jurisdictions in terms of SDG achievement occur across the various physical activity indicators for children and adolescents, or only for certain indicators explored in the G.M. 4.0?

Methods

Study Overview

This cross-sectional, ecological observational study used data from 2 country-level databases. One database focused on physical activity indicators for children and adolescents,4,5,18 while the other database pertained to the performance of countries in achieving each of the 17 UN SDGs.12,13

Physical Activity Indicators

The database regarding physical activity indicators for children and adolescents (∼5–17 y old) originated from the fourth edition of the G.M. 4.0,18 which involved 57 countries/jurisdictions from 6 continents.4,5 The 10 physical activity indicators common to all countries/jurisdictions included in the G.M. 4.0 were: Overall Physical Activity, Organized Sport and Physical Activity, Active Play, Active Transportation, Sedentary Behavior, Physical Fitness, Family and Peers, School, Community and Environment, and Government Investments and Strategies.4,5 For each of the indicators, a grade from “A+” (indicating excellent performance) to “F” (indicating poor performance) was assigned. When the available data were inadequate for a grade assignment, the indicator was marked as incomplete—“INC.”5 A brief methodological description of G.M. 4.0 can be found in (Supplementary Tables S1–S4 in Supplementary Materials (available online), and it is also available in the literature.4,5

United Nations Sustainable Development Goals

The database regarding countries’ performance in achieving the 17 UN SDGs originates from the SDG Transformation Center and was prepared by the Sustainable Development Solutions Network.12,13 Annually, the SDG Transformation Center reviews the progress made by countries toward the SDGs since their adoption by the 193 UN Member States in 2015,12,13 (see Supplementary Table S5 in Supplementary Materials [available online]) which shows the main goal of each of the SDGs.

The SDG Transformation Center database comprises data from 195 UN member states. Here we used data exclusively from countries/jurisdictions participating in the G.M. 4.0 project. Some of these lacked specific data due to their status as territories under other UN member states. Specifically, the Channel Islands (Guernsey and Jersey), Chinese Taipei, England, Greenland, the Hong Kong Special Administrative Region (SAR), Scotland, and the autonomous communities of the Basque Country, Extremadura, and the Region of Murcia in Spain lacked data. For the Channel Islands, England, and Scotland, we used the UK data. For Chinese Taipei and Hong Kong (SAR), we used China’s data, and for Greenland, we used Denmark’s. Data for the autonomous communities in Spain were obtained from the Spain-specific section of the SDG Transformation Center database. The 2023 report by the Sustainable Development Solutions Network, used in our study, was pivotal for assessing progress toward the 17 UN SDGs, marking the midpoint toward 2030 and highlighting each country’s progress toward the SDG goals.12,13

For each of the 17 UN SDGs, and for the aggregate of all SDGs, the SDG Transformation Center database provides an SDG Index score. These SDG Index scores were employed in the present study for data analysis. The SDG Index is an assessment of each country’s performance on the 17 UN SDGs, giving equal weight to each Goal. The score signifies a country’s position between the worst possible outcome (score of 0) and the target (score of 100). The SDG Index helps identify priorities for further actions and indicate whether countries are on track or off track to achieve the goals and targets by 2030. The 2023 SDG Index edition included 97 global indicators.12 Two-thirds of the data come from official statistics (typically UN custodian agencies) with one-third from nontraditional statistics, including research centers, universities, and nongovernmental organizations.12 Published since 2015, the SDG Index has been peer-reviewed and the global edition has been statistically audited by the European Commission in 2019 and by Nature Geoscience and Cambridge University Press.12 More details are published elsewhere.13 Supplementary Table S6 in Supplementary Materials (available online) shows the performance index for each UN SDG in the study’s countries/jurisdictions.

For this study, the performance of each country/jurisdiction in achieving the objectives set forth by each of the 17 UN SDGs was quantitatively assessed using SDG Index scores, which range from 0 to 100. Subsequently, these entities were categorized into 3 distinct performance tiers—fair, moderate, and good—based on their respective positions within the tertile distribution of the SDG Index scores. This classification framework facilitates a nuanced analysis of each country/jurisdiction’s progress toward attaining the benchmarks established by the UN SDGs. Supplementary Table S7 in Supplementary Materials (available online) presents the distribution tertiles for the SDG Index scores of countries/jurisdictions in achieving the objectives of each UN SDG.

The findings presented in this article focus on the objectives outlined in UN SDGs 3 (Good Health and Well-being), 9 (Industry, Innovation, and Infrastructure), 11 (Sustainable Cities and Communities), 13 (Climate Action), and 16 (Peace, Justice, and Strong Institutions). These specific SDGs were recognized for having the strongest evidence supporting the potential global health co-benefits of promoting physical activity.14 Although our analysis focuses on these SDGs, results pertaining to all UN SDGs have been documented in the Supplementary Materials (available online). This inclusive approach facilitates further exploration and analysis by readers, encouraging a broader understanding of the relationship of physical activity across the spectrum of SDGs.

Data Processing

The normality distribution of each grade (numerical value) associated with the physical activity indicators, as well as the SDG Index scores for each of the UN SDGs, was assessed using the Shapiro–Wilk normality test. This test’s null hypothesis posits that the data are drawn from a normally distributed population.19 The outcomes of these normality assessments are detailed in Supplementary Table S8 in Supplementary Materials (available online), and when necessary, nonparametric statistical tests were employed to analyze these data.

Descriptive statistics, including means, medians, SDs, and variances, summarized the data set. Pearson correlation coefficient (r) and Spearman’s rank correlation coefficient (rho) were used to explore relationships between physical activity indicator grades and countries’ SDG performance. Coefficient values were categorized according to literature guidelines (<0.20: very weak, 0.20–0.39: weak, 0.40–0.59: moderate, 0.60–0.79: strong, >0.80: very strong).20

Countries/jurisdictions were classified based on UN SDG achievement, and physical activity indicators were compared across groups. For symmetrically distributed indicators, one-way analysis of variance was employed, followed by Bonferroni post hoc tests. Asymmetric distributions were analyzed using the Kruskal–Wallis test with Bonferroni adjustments. The mean value of the grade for each physical activity indicator within subgroups of countries/jurisdictions was calculated to determine the final grading assignment. We adopted a significance level of 5%.

Results

Descriptive statistics for physical activity indicators and UN SDG Index scores across the 57 participating countries/jurisdictions in the G.M. 4.0 are provided in Supplementary Tables S9 and S10 in Supplementary Materials (available online).

Table 1 presents a correlation matrix between UN SDGs achievement index and physical activity indicator grades among children and adolescents across participating countries/jurisdictions. Moderate positive correlations were found between Organized Sports and Physical Activity grades and SDG 3 (Good Health and Well-being; rho = .449), and SDG 16 (Peace, Justice, and Strong Institutions; r = .415). Weak positive correlations existed between Organized Sports and Physical Activity grades and SDG 9 (Industry, Innovation, and Infrastructure; r = .357). Conversely, a weak negative correlation was noted between Organized Sports and Physical Activity grades and SDG 13 (Climate Action; r = −.376). Higher grades for Active Transportation (r = .294) and Sedentary Behavior (r = .379) correlated with better SDG 13 (Climate Action) performance. Sedentary Behavior grades negatively correlated with SDG 9 (Industry, Innovation, and Infrastructure; r = −.339) and SDG 11 (Sustainable Cities and Communities; r = −.336; Table 1).

Table 1

Correlation Matrix Between Physical Activity Indicators for Children and Adolescents and the United Nations SDGs

SDG indexPhysical activity indicators—Global Matrix 4.0
OPA□SP‡AP□AT‡SB‡PF‡F&P‡SCH‡C&E‡GOV‡
SDG 3□.111a.449c,**.042a.040a−.242b.099a.148a.159.567c,*.329b,*
SDG 9‡.066a.357b,*−.028a−.050a−.339b,*.206b.039a.231b.484c,**.402c,**
SDG 11‡.001a.257b−.035a−.075a−.336b,*.047a.060a.214b.393b,**.398b,**
SDG 13‡−.149a−.376b,**.187a.294b,*.379b,**−.064b.131a−.111−.522c,**−.339b,**
SDG 16‡.194a.415c,*.034a−.069a−.177a.215b.198a.300b,*.557c,**.371b,**

Abbreviations: AP, Active Play; AT, Active Transportation; C&E, Community and Environment; F&P, Family and Peers; GOV, Government; OPA, Overall Physical Activity; PF, Physical Fitness; SB, Sedentary Behavior; SCH, School; SDG, Sustainable Development Goals; SP, Organized Sport and Physical activity. Note: SDG 3 = good health and well-being;  SDG 9 = industry, innovation and infrastructure; SDG 11 = sustainable cities and communities; SDG 13 = climate action; SDG 16 = peace, justice, and strong institutions. Global Matrix 4.0 Project.

*P < .05, **P < .001. □Spearman correlation coefficient (rho). ‡Pearson correlation coefficient (r).

aVery weak correlations. bWeak correlations. cModerate correlations.

Grades for the School indicator demonstrated a weak positive correlation with performance in achieving SDG 16 (Peace, Justice, and Strong Institutions; r = .300). Community and Environment indicator grades correlated weakly positively with SDG 11 (Sustainable Cities and Communities; r = .393), and moderately positively with SDG 3 (Good Health and Well-being; r = .567), SDG 9 (Industry, Innovation, and Infrastructure; r = .484), and SDG 16 (Peace, Justice, and Strong Institutions; r = .557). However, a moderate negative correlation existed between Community and Environment grades and SDG 13 (Climate Action; r = −.552). Government Investments and Strategies indicator grades showed a weak positive correlation with SDG 3 (Good Health and Well-being) (rho = .329), SDG 11 (Sustainable Cities and Communities) (r = .398), and SDG 16 (Peace, Justice, and Strong Institutions) (r = .371), and a moderate positive correlation with SDG 9 (Industry, Innovation, and Infrastructure) (r = .402). Conversely, a weak negative correlation was noted between Government Investments and Strategies indicator grades and SDG 13 (Climate Action) performance (r = −.339; Table 1).

Table 2 summarizes correlations between physical activity indicator grades and the performance index for achieving the targets of UN SDGs 3, 9, 11, 13, and 16. Additional correlations with other UN SDGs are detailed in Supplementary Table S11 in Supplementary Materials (available online).

Table 2

Summary of Correlation Findings Between Physical Activity Indicators and the United Nations SDGs

Findings
Behavioral Indicators
 Overall Physical Activity• No correlation with the SDG performance index was found.
 Organized Sport and Physical activity• Moderate positive correlation with the SDG 3 and the SDG 16 achievement index.

• Weak positive correlation with the SDG 9 achievement index.

• Weak negative correlation with the SDG 13 achievement index.
 Active Play• No correlation with the SDG performance index was found.
 Active Transportation• Weak positive correlation with the SDG 13 achievement index.
 Sedentary Behavior• Weak negative correlation with the SDG 9 and the SDG 11 achievement index.

• Weak positive correlation with the SDG 13 achievement index.
 Physical Fitness• No correlation with the SDG performance index was found.
Sources-of-influence indicators
 Family and Peers• No correlation with the SDG performance index was found.
 School• Weak positive correlation with the SDG 16 achievement index.
 Community and Environment• Moderate positive correlation with the SDG 3, SDG 9, and the SDG 16 achievement index.

• Weak positive correlation with the SDG 11 achievement index.

• Moderate negative correlation with the SDG 13 achievement index.
 Government• Moderate positive correlation with the SDG 9 achievement index.

• Weak positive correlation with the SDG 3, SDG 11, and the SDG 16 achievement index.

• Weak negative correlation with the SDG 13 achievement index.

Abbreviation: SDG, Sustainable Development Goals. Note: SDG 3 = good health and well-being;  SDG 9 = industry, innovation and infrastructure; SDG 11 = sustainable cities and communities; SDG 13 = climate action; SDG 16 = peace, justice, and strong institutions.

Table 3 compares physical activity indicator grades among children and adolescents from G.M. 4.0 participant countries/jurisdictions, categorized by their SDG 3 (Good Health and Well-being) target achievement. Countries/jurisdictions with good performance in achieving SDG 3 (Good Health and Well-being) targets had higher Organized Sports and Physical Activity indicator grades (Grade C+) compared to those with fair performance (Grade D+; P = .015). Additionally, those with good and moderate SDG 3 (Good Health and Well-being) performance had better Community and Environment (Grades B− and C+, respectively), and Government Investments and Strategies (Grades C+ and C−, respectively) indicator grades compared to fair performers (P < .05).

Table 3

Comparison of PA Indicators in Children and Adolescents According to Country/Jurisdiction Performance Considering Sustainable Development Goal 3 (Good Health and Well-Being)

 SDG 3: Good health and well-being
Classification of countries/jurisdictions□
Fair performance (n = 18)Moderate performance (n = 24)Good performance (n = 15)P
GradeMean (SD)GradeMean (SD)GradeMean (SD)
Overall PAD5.2 (2.3)D+6.0 (3.4)D+6.1 (3.0).799
Organized sports and PAD+6.5 (1.9)aC−7.6 (2.5)a,bC+9.2 (2.5)b.015*
Active playC−7.3 (3.8)D+6.9 (2.1)C8.2 (2.6).457
Active transportationC8.0 (2.4)C−7.1 (2.4)C8.8 (2.7).138
Sedentary behaviorC−7.1 (2.4)D5.6 (1.8)D5.9 (2.1).067
Physical fitnessC−7.3 (3.3)C−7.8 (2.4)C−7.8 (2.1).890
Family and peersC8.3 (4.3)C−7.0 (2.4)C8.8 (2.6).210
SchoolC8.6 (3.5)B−10.8 (2.8)C+9.7 (1.7).068
Community and environmentD+6.9 (1.6)aC+9.6 (2.5)bB−10.8 (2.8)b<.001*
Government investments and strategiesC−7.6 (2.6)aC+9.3 (2.6)bC+9.7 (2.3)b.045*

Abbreviations: PA, physical activity; SDG, Sustainable Development Goal. Note: Global Matrix 4.0 Project. Superscript letters: Bonferroni post hoc test where the same letters indicate no statistical difference between the groups (P > .05) and different letters indicate statistical differences between the groups (P < .05).

□Countries/jurisdictions with fair performance: Argentina, Botswana, Brazil, Colombia, Ethiopia, India, Indonesia, Lebanon, Malaysia, Mexico, Montenegro, Nepal, Serbia, South Africa, Thailand, Philippines, Vietnam, Zimbabwe; Countries/jurisdictions with moderate performance: Channel Islands (Guernsey, United Kingdom), Channel Islands (Jersey, United Kingdom), Chile, China, Croatia, Czechia, England (United Kingdom), Estonia, Germany, Hong Kong SAR (China), Hungary, Korea, Republic, Lithuania, New Zealand, Poland, Portugal, Scotland (United Kingdom), Slovak Republic, Slovenia, Taiwan (Chinese Taipei), United Arab Emirates, the United States, Uruguay, Wales (United Kingdom); Countries/jurisdictions with good performance: Australia, Canada, Denmark, Finland, France, Greenland, Ireland, Israel, Japan, Singapore, Spain, Basque Country (Spain), Extremadura (Spain), Region of Murcia (Spain), Sweden.

*P value: analysis of variance (1-way).

The countries/jurisdictions with good performance in achieving SDG 9 (Industry, Innovation and Infrastructure) targets had higher Organized Sports and Physical Activity indicator grades (Grade C vs Grade D+, P = .012), and Government Investments and Strategies indicator grades (Grade B− vs Grade C−, P = .017) compared to fair performers. Similarly, countries/jurisdictions with good and moderate SDG 9 (Industry, Innovation and Infrastructure) performance had superior Community and Environment indicator grades (Grade B−) compared to fair performers (Grade C−; P < .001; Table 4).

Table 4

Comparison of PA Indicators in Children and Adolescents According to Country/Jurisdiction Performance Considering Sustainable Development Goal 9 (Industry, Innovation, and Infrastructure)

 SDG 9: Industry, innovation and infrastructure
Classification of countries/jurisdictions□
Fair performance (n = 19)Moderate performance (n = 21)Good performance (n = 17)P
GradeMean (SD)GradeMean (SD)GradeMean (SD)
Overall PAD5.4 (2.6)D+6.1 (3.2)D5.9 (3.1).875
Organized sports and PAD+6.3 (2.1)aC8.2 (2.4)a,bC8.8 (2.5)b.012*
Active playC−7.2 (3.6)C−7.1 (2.7)C8.0 (1.2).850
Active transportationC8.2 (2.1)C−7.1 (2.7)C8.2 (2.8).294
Sedentary behaviorC−7.0 (2.4)D5.9 (1.9)D5.5 (2.0).098
Physical fitnessD+6.5 (2.9)C8.3 (2.8)C−7.8 (1.7).884
Family and peersC8.2 (4.1)C−7.6 (2.7)C−7.8 (2.6).128
SchoolC8.7 (3.4)B−10.4 (2.7)B−10.5 (2.4).125
Community and environmentC−7.1 (1.7)aB−10.1 (2.8)bB−10.3 (2.6)b<.001*
Government investments and strategiesC−7.5 (2.4)aC+9.2 (2.8)a,bB−10.1 (2.1)b.017*

Abbreviations: PA, physical activity; SDG, Sustainable Development Goal. Note: Global Matrix 4.0 Project. Superscript letters: Bonferroni post hoc test where the same letters indicate no statistical difference between the groups (P > .05) and different letters indicate statistical differences between the groups (P < .05). 

□Countries/jurisdictions with fair performance: Argentina, Botswana, Brazil, Colombia, Ethiopia, India, Indonesia, Lebanon, Mexico, Montenegro, Nepal, Serbia, Slovak Republic, South Africa, Thailand, Philippines, Uruguay, Vietnam, Zimbabwe; Countries/jurisdictions with moderate performance: Canada, Chile, China, Croatia, Czechia, Estonia, Hong Kong SAR (China), Hungary, Ireland, Lithuania, Malaysia, New Zealand, Poland, Portugal, Slovenia, Spain, Basque Country (Spain), Extremadura (Spain), Region of Murcia (Spain), Taiwan (Chinese Taipei), United Arab Emirates; Countries/jurisdictions with good performance: Australia, Channel Islands (Guernsey, United Kingdom), Channel Islands (Jersey, United Kingdom), Denmark, England (United Kingdom), Finland, France, Germany, Greenland, Israel, Korea, Republic, Japan, Scotland (United Kingdom), Singapore, Sweden, the United States, Wales (United Kingdom).

*P value: analysis of variance (1-way).

The countries/jurisdictions with good performance in achieving SDG 11 (Sustainable Cities and Communities) targets had higher Organized Sports and Physical Activity indicator grades (Grade C vs Grade D+, P = .038) than fair performers. Furthermore, countries/jurisdictions with good (Grade C+) and moderate (Grade B−) SDG 11 (Sustainable Cities and Communities) performance had superior Government Investments and Strategies indicator grades compared to fair performers (Grade C−; P < .05). Conversely, countries/jurisdictions with fair performance in achieving SDG 11 (Sustainable Cities and Communities) targets had better Sedentary Behavior indicator grades (Grade C−) than those with good (Grade D) and moderate (Grade D) performance (P < .05; Table 5).

Table 5

Comparison of PA Indicators in Children and Adolescents According to Country/Jurisdiction Performance Considering Sustainable Development Goal 11 (Sustainable Cities and Communities)

 SDG 11: Sustainable cities and communities
Classification of countries/jurisdictions□
Fair performance (n = 19)Moderate performance (n = 18)Good performance (n = 19)P
GradeMean (SD)GradeMean (SD)GradeMean (SD)
Overall PAD5.6 (2.6)D5.8 (3.2)D+6.0 (3.2).981
Organized sports and PAD+6.4 (2.5)aC8.1 (1.8)a,bC8.6 (2.8)b.038*
Active playC−7.2 (3.4)D+6.7 (2.2)C8.0 (2.4).597
Active transportationC−7.9 (2.5)C−7.2 (2.8)C8.2 (2.3).529
Sedentary behaviorC−7.3 (2.0)aD5.8 (1.9)bD5.2 (2.1)b.014*
Physical fitnessC−7.5 (2.9)C−7.9 (2.8)C−7.6 (1.8).947
Family and peersC−7.1 (3.9)C−7.9 (2.8)C8.4 (2.6).598
SchoolC8.6 (3.3)B−10.8 (3.0)B−10.2 (1.7).075
Community and environmentC−7.8 (2.6)C+9.4 (3.0)B−10.1 (2.4).068
Government investments and strategiesC−7.5 (2.6)aB−10.0 (2.6)bC+9.2 (2.2)b.015*

Abbreviations: PA, physical activity; SDG, Sustainable Development Goal. Note: Global Matrix 4.0 Project. Superscript letters: Bonferroni post hoc test where the same letters indicate no statistical difference between the groups (P > .05) and different letters indicate statistical differences between the groups (P < .05).

□Countries/jurisdictions with fair performance: Botswana, Brazil, China, Colombia, Croatia, Ethiopia, Hong Kong SAR (China), India, Indonesia, Lebanon, Lithuania, Malaysia, Montenegro, Nepal, Serbia, South Africa, Taiwan (Chinese Taipei), Philippines, Zimbabwe; Countries/jurisdictions with moderate performance: Argentina, Australia, Chile, Germany, Hungary, Israel, Korea, Republic, Japan, Mexico, New Zealand, Poland, Portugal, Slovak Republic, Slovenia, Sweden, Thailand, United Arab Emirates, the United States, Vietnam; Countries/jurisdictions with good performance: Canada, Channel Islands (Guernsey, United Kingdom), Channel Islands (Jersey, United Kingdom), Czechia, Denmark, England (United Kingdom), Estonia, Finland, France, Greenland, Ireland, Scotland (United Kingdom), Singapore, Spain, Basque Country (Spain), Extremadura (Spain), Region of Murcia (Spain), Uruguay, Wales (United Kingdom).

*P value: analysis of variance (ANOVA) one-way.

The countries/jurisdictions with good performance in achieving SDG 13 (Climate Action) targets had better Sedentary Behavior indicator grades (Grade C− vs Grade D, P = .009) than moderate performers. Conversely, countries/jurisdictions with fair performance in achieving SDG 13 (Climate Action) targets had higher grades for Organized Sports and Physical Activity (Grade C+ vs Grade D+, P = .01), Community and Environment (Grade B vs Grade C−, P < .001), and Government Investments and Strategies (Grade B− vs Grade C−, P < .001) indicators compared to good performers (Table 6).

Table 6

Comparison of PA Indicators in Children and Adolescents According to Country/Jurisdiction Performance Considering Sustainable Development Goal 13 (Climate Action)

 SDG 13: Climate action
Classification of countries/jurisdictions□
Fair performance (n = 18)Moderate performance (n = 20)Good performance (n = 19)P
GradeMean (SD)GradeMean (SD)GradeMean (SD)
Overall PAD+6.7 (3.2)D5.3 (2.9)D5.3 (2.6).380
Organized sports and PAC+9.0 (2.2)aC8.0 (2.6)a,bD+6.3 (2.1)b.010*
Active playC−7.2 (1.9)C−7.1 (3.2)C−7.7 (3.2).667
Active transportationC−7.2 (2.9)C8.2 (2.4)C−7.8 (2.3).564
Sedentary behaviorD5.9 (1.9)a,bD5.3 (2.0)aC−7.3 (2.1)b.009*
Physical fitnessC8.2 (2.4)C−7.4 (2.5)C−7.3 (2.9).738
Family and peersC−7.6 (2.3)C8.0 (3.1)C8.0 (4.0).952
SchoolB−10.1 (2.5)B−10.6 (2.4)C8.8 (3.6).203
Community and environmentB11.1 (2.6)aC+9.0 (2.5)a,bC−7.3 (1.9)b<.001*
Government investments and strategiesB−10.6 (2.4)aC8.9 (2.3)a,bC−7.3 (2.4)b<.001*

Abbreviations: PA, physical activity; SDG, Sustainable Development Goal. Note: Global Matrix 4.0 Project. Superscript letters: Bonferroni post hoc test where the same letters indicate no statistical difference between the groups (P > .05) and different letters indicate statistical differences between the groups (P < .05). 

□Countries/jurisdictions with fair performance: Australia, Canada, Denmark, Estonia, Finland, Germany, Greenland, Ireland, Israel, Korea, Republic, Lithuania, New Zealand, Singapore, Slovak Republic, Slovenia, Sweden, United Arab Emirates, the United States; Countries/jurisdictions with moderate performance: Channel Islands (Guernsey, United Kingdom), Channel Islands (Jersey, United Kingdom), Chile, China, Czechia, England (United Kingdom), France, Hong Kong SAR (China), Hungary, Japan, Malaysia, Poland, Scotland (United Kingdom), Spain, Basque Country (Spain), Extremadura (Spain), Region of Murcia (Spain), Taiwan (Chinese Taipei), Thailand, Wales (United Kingdom); Countries/jurisdictions with good performance: Argentina, Botswana, Brazil, Croatia, Colombia, Ethiopia, India, Indonesia, Lebanon, Mexico, Montenegro, Nepal, Portugal, Serbia, South Africa, Philippines, Uruguay, Vietnam, Zimbabwe. Global Matrix 4.0 Project.

*P value: analysis of variance (ANOVA) one-way.

Regarding SDG 16 (Peace, Justice and Strong Institutions; Table 7), countries/jurisdictions with good performance in achieving the targets of this SDG had higher grades for Organized Sports and Physical Activity (Grade C+ vs Grade D+, P = .001), Community and Environment (Grade B vs Grade C−, P < .001), and Government Investments and Strategies (Grade B− vs Grade C−, P = .045) indicators compared to fair performers. Additionally, those with good and moderate SDG 16 (Peace, Justice and Strong Institutions) performance had better School indicator grades (Grade B−) compared to fair performers (Grade C; P = .024).

Table 7

Comparison of PA Indicators in Children and Adolescents According to Country/Jurisdiction Performance Considering Sustainable Development Goal 16 (Peace, Justice and Strong Institutions)

 SDG 16: Peace, justice and strong institutions
Classification of countries/jurisdictions□
Fair performance (n = 19)Moderate performance (n = 19)Good performance (n = 19)P-value
GradeMean (SD)GradeMean (SD)GradeMean (SD)
Overall PAD5.0 (2.4)D5.9 (3.4)D+6.5 (2.9).340
Organized sports and PAD+6.1 (2.4)aC−7.5 (2.2)a,bC+9.3 (2.0)b.001*
Active playD5.9 (3.4)C8.9 (1.9)C−7.4 (2.0).117
Active transportationC8.1 (2.3)C−7.5 (2.7)C−7.8 (2.0).779
Sedentary behaviorD+6.7 (2.2)D+6.4 (2.1)D5.3 (1.9).146
Physical fitnessD+6.7 (3.3)C8.0 (2.5)C8.1 (1.7).509
Family and peersC−7.4 (4.0)C8.3 (3.2)C−7.7 (2.2).771
SchoolC8.3 (3.5)aB−10.9 (2.8)bB−10.3 (1.5)b.024*
Community and environmentC−7.1 (2.5)aC+9.2 (2.3)a,bB11.0 (2.3)b<.001*
Government investments and strategiesC−7.8 (2.7)aC8.8 (2.7)a,bB−10.0 (2.1)b.045*

Abbreviations: PA, physical activity; SDG, Sustainable Development Goal. Note: Global Matrix 4.0 Project. Superscript letters: Bonferroni post hoc test where the same letters indicate no statistical difference between the groups (P > .05) and different letters indicate statistical differences between the groups (P < .05).

□Countries/jurisdictions with fair performance: Argentina, Botswana, Brazil, China, Colombia, Ethiopia, Hong Kong SAR (China), India, Indonesia, Lebanon, Malaysia, Mexico, Nepal, South Africa, Taiwan (Chinese Taipei), Thailand, Philippines, Vietnam, Zimbabwe; Countries/jurisdictions with moderate performance: Chile, Croatia, France, Hungary, Israel, Korea, Republic, Montenegro, Poland, Portugal, Serbia, Slovak Republic, Slovenia, Spain, Basque Country (Spain), Extremadura (Spain), Region of Murcia (Spain), United Arab Emirates, the United States, Uruguay; Countries/jurisdictions with good performance: Australia, Canada, Channel Islands (Guernsey, United Kingdom), Channel Islands (Jersey, United Kingdom), Czechia, Denmark, England (United Kingdom), Estonia, Finland, Germany, Greenland, Ireland, Japan, Lithuania, New Zealand, Scotland (United Kingdom), Singapore, Sweden, Wales (United Kingdom). Global Matrix 4.0 Project.

*P value: analysis of variance (ANOVA) one-way.

Table 8 summarizes physical activity indicators with the highest grades, comparing countries/jurisdictions by their performance in achieving SDG 3 (Good Health and Well-being), SDG 9 (Industry, Innovation, and Infrastructure), SDG 11 (Sustainable Cities and Communities), SDG 13 (Climate Action), and SDG 16 (Peace, Justice, and Strong Institutions). Grades for Organized Sports and Physical Activity, Community and Environment, and Government Investments and Strategies indicators varied among groups. Countries/jurisdictions with good performance in SDG 3 (Good Health and Well-being), SDG 9 (Industry, Innovation, and Infrastructure), SDG 11 (Sustainable Cities and Communities), and SDG 16 (Peace, Justice, and Strong Institutions) had superior grades compared to fair performers. Conversely, fair performers in SDG 13 (Climate Action) had better grades for these indicators compared to good performers.

Table 8

Summary of the PA Indicators for Children and Adolescents With Better Grades According to the Countries/Jurisdictions’ Level of Performance for Achieving the Targets of the UN SDGs 3, 9, 11, 13, and 16

 Country performance level in UN SDG achievement
FairModerateGood
SDG 3: Good health and well-being—• Community and environment

• Government investments and strategies		• Organized sports and PA

• Community and environment

• Government investments and strategies
SDG 9: Industry, innovation, and infrastructure—• Community and environment• Organized sports and PA

• Community and environment

• Government investments and strategies
SDG 11: Sustainable cities and communities• Sedentary behavior• Government investments and strategies• Organized sports and PA

• Government investments and strategies
SDG 13: Climate action• Organized sports and PA

• Community and environment

• Government investments and strategies		—• Sedentary behavior
SDG 16: Peace, justice, and strong institutions-• School• Organized sports and PA

• School

• Community and environment

• Government investments and strategies

Abbreviations: PA, physical activity; SDG, Sustainable Development Goals; UN, United Nations. Note: Global Matrix 4.0 Project.

Supplementary Tables S12–S26 in Supplementary Materials (available online) compare physical activity indicators grades across countries/jurisdictions by UN SDGs achievement levels.

Discussion

We found moderate positive correlations between Organized Sport and Physical Activity grades and SDG 3 (Good Health and Well-being) and SDG 16 (Peace, Justice, and Strong Institutions) achievements, along with a weak positive correlation with SDG 9 (Industry, Innovation, and Infrastructure) in G.M. 4.0 countries/jurisdictions. Organized Sport and Physical Activity, a structured, goal-oriented, and competition-based physical activity subset,5 contributes to various SDGs.14,15 Robust evidence supports its benefits for physical and mental health, aligning with SDG 3 (Good Health and Well-being) targets to reduce noncommunicable disease mortality. Engaging children and youth in sports could be a strategy to lower mortality rate, since physically active lifestyles adopted in childhood and adolescence can persist into adulthood.21 A cohort study in the United Kingdom identified that males who played sports at age 11 and females who played sports at age 16 had lower risks of all-cause mortality from ages 23 to 55.21 Involvement in Organized Sport and Physical Activity encourages the sports industry to create new products and processes, promoting economic growth and investment in research, thereby aiding in achieving SDG 9 (Industry, Innovation, and Infrastructure) targets.22 Moreover, involvement in sports can serve as a platform for messages of inclusion, respect, and integration.23 Evidence from a systematic review with meta-analysis reported that youth involved in sports demonstrated greater respect for opponents and social conventions.24 This shows that sports practice can help develop values of respect for other society members, increasing the likelihood of achieving the targets of SDG 16 (Peace, Justice, and Strong Institutions).

Our research revealed moderate positive correlations between the Community and Environment indicator grades and the achievement index of SDG 3 (Good Health and Well-Being), SDG 9 (Industry, Innovation, and Infrastructure), and SDG 16 (Peace, Justice, and Strong Institutions) targets, along with a weak positive correlation with SDG 11 (Sustainable Cities and Communities) targets. Built or natural environments with opportunities for physical activity help communities adopt physically active lifestyles, promoting good health and well-being (ie, SDG 3 [Good Health and Well-Being]),14,15 reducing health care costs, and driving investments in other sectors (ie, SDG 9 [Industry, Innovation, and Infrastructure]).25 Open public spaces, a target of SDG 11 (Sustainable Cities and Communities),10,11 encourages physical activity and community engagement, contributing to well-being and sustainability.26,27 Additionally, communities with environments where children engage in physical activities are safer, with lower crime rates,28 aligning with SDG 16 (Peace, Justice, and Strong Institutions) targets.10,11 Therefore, promoting access to safe environments that encourage children’s physical activities can be a pathway to more sustainable societies.

We found a weak to moderate positive correlation between countries/jurisdictions’ grades for the Government Investments and Strategies indicator and the index of achieving SDG 3 (Good Health and Well-Being), SDG 9 (Industry, Innovation, and Infrastructure), SDG 11 (Sustainable Cities and Communities), and SDG 16 (Peace, Justice, and Strong Institutions) targets. Governmental leadership investing in policies, actions, professional training, and advocacy for physically active societies positively impacts physical activity levels among children and adolescents, directly affecting SDG 3 (Good Health and Well-Being) targets. Mobilizing resources for physical activity initiatives enhances innovation, industry, and the economic sector, relating to SDG 9 (Industry, Innovation, and Infrastructure) targets.8,9 SDG 11 (Sustainable Cities and Communities) targets include providing universal access to public and green spaces.10,11 Countries focused on physical activity policies ensure accessible public spaces for leisure and physical activity, impacting city sustainability.29 This also promotes community interaction,30 potentially reducing violence and aligning with SDG 16 (Peace, Justice, and Strong Institutions) targets.

Our findings identified a paradox in the relationship between countries/jurisdictions’ grades for the Sedentary Behavior indicator and the index of achieving SDG 9 (Industry, Innovation, and Infrastructure) and SDG 11 (Sustainable Cities and Communities) targets, noting a weak, but negative correlation. In the G.M. 4.0 initiative, sedentary behavior was primarily evaluated based on estimates of recreational screen time rather than direct measures of sedentary behavior.5 Although this is a valid measure in national and international guidelines,3 it presents nuances related to economic development6 and individuals’ economic levels.31 A study in 12 countries during the COVID-19 pandemic reported that children from low-economic-status families accrued more recreational screen time.31 Additionally, Silva et al,6 using G.M. 4.0 data, found that countries with low and medium human development index had lower grades for the Sedentary Behavior indicator compared to high and very high Human Development Index countries for male and female children, urban residents, and those with disabilities. Economically developed countries performing better in achieving SDG 9 (Industry, Innovation, and Infrastructure) and SDG 11 (Sustainable Cities and Communities) targets have advanced technology and industries for building recreation and leisure spaces for children.32 Conversely, countries with poorer performance in these SDGs face challenges in developing industry and innovation and have less sustainable cities with large urban conglomerates, hindering public leisure space provision.32 This may result in fewer opportunities for recreation and physical activity for children, who tend to spend more time in front of screens during their free time.6

Engaging children and adolescents in carbon-free activities, such as physical activities and outdoor time, may help mitigate climate change.33,34 Promoting active transportation reduces reliance on motorized vehicles, lowering atmospheric pollutants.14,15,33,34 Our study found a weak positive correlation between Active Transportation grades and SDG 13 (Climate Action) targets, indicating countries/jurisdictions with greater climate responsibility have more children using active transportation. However, Organized Sport and Physical Activity, Community and Environment, and Government Investments and Strategies grades showed weak to moderate negative correlations with SDG 13 (Climate Action) targets. Additionally, we found a weak positive correlation between Sedentary Behavior grades with SDG 13 (Climate Action) targets. These findings may seem paradoxical but can be partially explained by the ideological economic characteristics of the countries.33,34 Lee et al33 identified that most high-income countries/jurisdictions in the G.M. 4.0 initiative are economically neoliberal, characterized by consumerism and higher atmospheric pollutant emissions for economic profit. These countries/jurisdictions scored better on physical activity indicators but showed less climate responsibility.33 Sports, although beneficial, have a complex relationship with the environment.34 Although sports mobilize communities around climate issues, they also involve activities that emit pollutants, such as those related to the sports equipment industry, motorized urban mobility, and electricity consumption for events, contributing to significant emissions.34 Lee et al33 reported a moderate positive correlation between the grades of Organized Sport and Physical Activity and Community and Environment indicators in high-income countries/jurisdictions, suggesting these countries/jurisdictions promote sports practice and invest in community spaces but are less engaged in climate responsibility. Conversely, countries/jurisdictions with higher SDG 13 (Climate Action) achievement indices invest less in organized sports, reflecting lower leisure-time activity for children. These countries/jurisdictions, often low- and middle-income, rely on active transportation due to limited access to other modes,33 seen as a necessity rather than a choice.35

The grades for the School indicator were positively correlated with the index of achieving the SDG 16 (Peace, Justice, and Strong Institutions) targets. The School indicator in the G.M. 4.0 includes policies of active schools, physical education classes, physical activities offerings, and infrastructure for physical activity. The relationship between education, school environment, and promoting SDG 16 (Peace, Justice, and Strong Institutions) has been well discussed in the literature,36 emphasizing education’s role in promoting peace, justice, and strong institutions. We show that countries/jurisdictions with schools promoting physical activity (environment, policy, curriculum, and trained professionals) also have a greater commitment to achieving the SDG 16 (Peace, Justice, and Strong Institutions) targets.

The present research utilized data from AHKGA4,5,18 and the SDG Transformation Center.12,13 The AHKGA is dedicated to advancing the global initiative to promote physical activity among children, presenting the physical activity indicators that need improvement in each country/jurisdiction.4,5,18 The SDG Transformation Center monitors countries’ progress in achieving the goals of the 17 UN SDGs, presenting the SDG indicators that require enhancement in each nation.12,13 Both AHKGA and the SDG Transformation Center engage in activities aimed at reducing inequalities.4,5,12,13 The Supplementary Materials (available online) of the present article provide an analysis of the relationship between physical activity indicators from G.M. 4.0 and the performance index of countries regarding SDG 10 (Reduced Inequalities). Positive correlations were observed between the grades of Organized Sport and Physical Activity, School, and Community and Environment indicators with the targets of SDG 10 (Reduced Inequalities). These results suggest that the promotion of sports in school and community settings, through appropriate actions, programs, and environments, aligns with one of the targets of SDG 10 (Reduced Inequalities), which is to empower and promote the social, economic, and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion, or economic or other status.10,11 Thus, as countries equitably and inclusively promote sports in school and community environments, they will also be aligned with the reduction of inequalities.

Our findings highlight how promoting physical activity in children and adolescents’ aids in achieving UN SDGs targets. School environments that support physical activity, communities with conducive natural or built environments, and governmental policies investing in physical activities correlate with higher achievement of UN SDGs. The GAPPA objectives9 align with these targets, emphasizing that countries focused on sustainability should address physical activity influences. Additionally, promoting physical activity must align with climate responsibility,33 suggesting strategies like sustainable sports products, environmentally friendly sports events, and reducing pollutant emissions can contribute to achieving UN SDGs targets.34

This study’s strength lies in its global scope, encompassing diverse countries/jurisdictions across continents and various levels of development, thus providing a comprehensive view of UN SDGs achievement. Additionally, it benefits from utilizing databases known for their rigorous methodologies and transparency, such as AHKGA17 and the SDG Transformation Center.12,13 However, limitations exist, including reliance on aggregated country-level data, hindering individual-level extrapolations. However, utilizing individual-level data would not capture the broader upstream level observations provided by country-level analysis. The classification into UN SDGs achievement tertiles is a statistical approach devoid of practical implications regarding specific target attainment. Consultation of the SDG Transformation Center12,13 report is advised for detailed insights. Furthermore, our evaluation is limited by its small number of countries/jurisdictions, particularly from low and middle income regions like South America and Africa. This constraint undermines the generalizability of findings and statistical robustness, especially in addressing continents characterized by high social inequality.

Conclusions

It can be concluded that significant associations were found between performance in certain UN SDGs and physical activity indicators. Positive correlations were observed between performance in Organized Sport and Physical Activity, Community and Environment, and Government Investments and Strategies indicators and the attainment of SDGs 3 (Good Health and Well-Being), 9 (Industry, Innovation, and Infrastructure), 11 (Sustainable Cities and Communities), and 16 (Peace, Justice, and Strong Institutions), while negative correlations were found with SDG 13 (Climate Action). Additionally, Sedentary Behavior indicator grades showed positive correlations with SDG 13 (Climate Action), and negative correlations with SDGs 9 (Industry, Innovation, and Infrastructure), and 11 (Sustainable Cities and Communities).

Collectively, these findings suggest that policies and interventions aimed at promoting physical activity for children and adolescents can significantly contribute to the achievement of the SDGs. This study highlights the importance of interdisciplinary approaches and integrated policies to address global health and sustainable development challenges. We recommend that future research explore these relationships in more detailed contexts and consider the influence of other socioeconomic and environmental factors. This holistic and intersectional approach is essential for guiding effective policies and intervention programs aimed at promoting the health and well-being of future generations as we progress toward global sustainable development goals.

Acknowledgments

The authors are grateful for the involvement of all leaders and co-leaders from the 57 countries involved in the AHKGA’s Global Matrix 4.0 project. The authors are grateful for the involvement of the AHKGA for their collaboration with this paper. Dr Silva was supported in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)—Brazil (Finance Code 001), and also received partial support from by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)—Brazil (309589/2021-5).

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Aubert https://orcid.org/0000-0002-6127-2398

Manyanga https://orcid.org/0000-0001-5461-5981

Lee https://orcid.org/0000-0001-9580-8974

Salvo https://orcid.org/0000-0002-9726-0882

Tremblay https://orcid.org/0000-0002-8307-3568

Salvo is now affiliated with People, Health, and Place Lab, Department of Kinesiology and Health Education, The University of Texas at Austin; and Texas Center for Equity Promotion (TexCEP), College of Education, The University of Texas at Austin.

Promoting physical activity in children is related to achieving the United Nations Sustainable Development Goals (SDG).

Countries with better indicators for children’s physical activity show low performance in achieving SDG 13 (Climate Action).

Supplementary Materials

  • Collapse
  • Expand
Cover Journal of Physical Activity and Health
  • 1.

    Janssen I, Leblanc AG. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act. 2010;7:40. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Poitras VJ, Gray CE, Borghese MM, et al. Systematic review of the relationships between objectively measured physical activity and health indicators in school-aged children and youth. Appl Physiol Nutr Metab. 2016;41(6)(suppl 3):197–239. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Chaput JP, Willumsen J, Bull F, et al. 2020 WHO guidelines on physical activity and sedentary behaviour for children and adolescents aged 5–17 years: summary of the evidence. Int J Behav Nutr Phys Act. 2020;17(1):141. doi:

    • Crossref
    • Search Google Scholar
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  • 4.

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