Movement Behaviour and Health Outcomes in Rural Children: A Systematic Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Protocol
2.2. Databases and Search Strategy
2.3. Inclusion and Eligibility Criteria
2.4. Study Selection
2.5. Quality Assessment
3. Results
3.1. Included Studies
3.2. Methodological Quality Assessment
3.3. General Aspects
3.4. Instruments Used
3.5. Physical Activity
3.5.1. Rural Sample
3.5.2. Rural × Urban Samples—Comparison
3.6. Sedentary Behaviour
3.6.1. Rural Sample
3.6.2. Rural × Urban Sample—Comparison
3.7. Health Outcomes
3.7.1. Rural Sample
3.7.2. Rural × Urban Comparison
4. Discussion
4.1. Physical Activity and Health-Related Outcomes in Rural Children
4.2. Differences in Physical Activity and Health-Related Outcomes between Rural and Urban Children
4.3. Differences in Sedentary Behaviour within and between Rural and Urban Areas
4.4. Limitations, Strengths, and Remarks
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Item | Question | Score |
---|---|---|
1 | Was the objective(s) of the study clearly defined(s)? | 0–2 |
2 | Were the characteristics of the participants presented in detail in the methods (number of subjects, sex, age, country/city)? | 0–2 |
3 | Was the sample size justified? | 0–2 |
4 | Were the instruments used clearly described in the methods section? | 0–2 |
5 | Were the statistical analyses clearly presented? | 0–2 |
6 | Were the results detailed (means and standard deviations and/or change/difference, effect size)? | 0–2 |
7 | Were the conclusions appropriate, giving the methods of study and the objectives? | 0–2 |
8 | Are there implications for practice given the results of the study? | 0–2 |
9 | Were the limitations of the study recognized and described by the authors? | 0–2 |
10 | Is there any future direction described by the authors? | 0–2 |
Total | 0–20 |
Continent | Study and Country (Region) | Sample Size | Instrument Used | Main Results | QS (%) |
---|---|---|---|---|---|
Age/School Grade | |||||
Africa | Benefice et al., 2001 [25] Senegal (Niakhar) | 406 13–14 years | Accelerometer | PA varied throughout the years, in time and intensity; the time spent in sedentary activities and light activities did not change over the years; there was an increase in VPA (from 1998 to 1999). | 80 |
Nhantumbo et al., 2008 [26] Mozambique (Calanga) | 845 7–16 years | Questionnaire | Girls presented higher means in recreational games; boys had higher means than girls in participation in sports activities; girls were more active overall and had higher values for domestic activities. | 80 | |
Prista et al., 2009 [27] Mozambique (Calanga) | 256 6–16 years | Accelerometer | Boys had more minutes of VPA than girls; the intensity of PA decreased significantly with age; domestic tasks were the predominant mode of PA. | 90 | |
Croteau et al., 2011 [28] Kenya (West region) | 72 8–12 years | Pedometer | The mean daily step was 14,558 ± 3993; boys were more active than girls; 79% of students reported walking or running to school (these children had a significantly higher average of daily steps compared to those who used other ways of transport). | 75 | |
Craig et al., 2013 [29] South Africa | 89 7, 11, 15 years | Accelerometer | The average time spent in MVPA was low: MVPA/day was higher for boys (7, 11, 15 years old) than for girls. Overall, participants had relatively high levels of PA. | 90 | |
Santos et al., 2013 [30] Mozambique (Calanga) | 209 7–15 years | Questionnaire | Boys spent less time in PA than girls; high levels of PA and low prevalence of METs were observed. | 85 | |
Minnaar et al., 2016 [6] South Africa | 78 5–14 years | Pedometer | 20% of the children were overweight or obese (62.5%, girls); Boys were more active in transportation than girls; children between 9 and 11 years took an average of 11,601 steps per day; non-significant associations were found between physical activity and BMI. | 90 | |
Asia | Cheah et al., 2014 [31] Malaysia (Sarawak) | 145 13–15 years | Pedometer | 11.7% of children were obese and 15.2% were overweight; boys recorded a higher average of steps per day compared to girls; the level of total PA was low. | 90 |
Williams et al., 2016 [32] Nepal (Eastern region) | 399 6–18 years | Accelerometer | Girls spent more time in sedentary behaviour than boys; at the ages of 13 and 14 years boys were more sedentary than girls during the week; boys were involved more in MVPA; children were more active during non-school days and teens were more active during school days. | 75 | |
Abe et al., 2020 [33] Japan (Unnan) | 1794 9–15 years | Questionnaire | 20.1% of the children reached the recommended levels of MVPA; boys were more likely to achieve the MVPA guidelines; children who liked to practice physical activity were more likely to meet the MVPA recommendations. | 85 | |
Bin Saad et al., 2020 [34] Malaysia (Kuching/Samarahan) | 227 4–6 years | Questionnaire | About 46% of children were physically active; among obese children, 70% were inactive; inactive children had more screen and video game time; older children were twice more likely to be physically active than their 4 year old peers. | 90 | |
Zhang et al., 2020 [35] China (Mojiang) | 2264 12–15 years | Questionnaire | The prevalence of overweight/obesity was 8.0% in the sample; adolescents who did not comply with the recommendations for PA and screen time presented a higher risk of overweight/obesity than those who fulfilled both recommendations. | 85 | |
Fukushima et al., 2021 [36] Japan (Unnan) | 821 3–6 years | Questionnaire | 66.2% of children achieved the PA guidelines at early childhood; boys were more active than girls; only 75 children and 42 children reported spending 60 min/day practicing PA during week days and weekend days, respectively. | 80 | |
Europe | Kelly et al., 2005 [37] Ireland (Carlow) | 41 4–5 years | Accelerometer | Irish children spent 19% of their time in LPA; boys spent more time in LPA; girls spent 2% of their time in MVPA, while boys spent 4%; girls spent 82% of the monitored time in sedentary behaviour while boys spent 74%. | 85 |
Ciesla et al.,2014 [38] Poland | 25,816 6–7 years | Questionnaire | 20.8% of boys and 18.2% of girls were overweight; boys played more hour at computer; among physically inactive children most were girls, while boys were the majority among those who practiced within the MVPA recommendations | 90 | |
Gutierrez et al., 2015 [39] Spain (Cuenca) | 956 10–12 years | Questionnaire | Girls were more sedentary and had a higher percentage of body fat; 27.6% of children were overweight and 7.2% had high levels of cardiometabolic risk factors; 69% attended school walking or cycling; boys, children with normal weight and without cardiometabolic risk lived closer to school. | 85 | |
Machado-Rodrigues et al., 2016 [40] Portugal | 254 13–16 years | Accelerometer | 21% of boys and 24% of girls were overweight; boys spend more time in PA and MVPA and girls spend more time in sedentary behaviour during the week. | 100 | |
Jonczyk et al., 2021 [41] Poland (Silesia) | 589 10–13 years | Questionnaire | 26.3% of the children were obese and 16.4% were overweight; more than 70% of the children went to school on foot; 36% dedicated less than 3 h/week to physical activity; a significant correlation between BMI and the number of hours/weeks spent on physical activity were observed among 10 year old girls and 11–12 year old boys; | 65 | |
North America | Pate et al., 1997 [42] USA (South Carolina) | 361 10–11 years | Questionnaire | 32.1% of the children were inactive; students who watched TV or played video games for ≥3 h/day were more likely to be inactive; Girls were twice more likely to be classified as less activity than boys. | 90 |
Harrell et al., 2003 [43] USA (North Carolina) | 1211 11–14 years | Questionnaire | Children whose parents had low socioeconomic status reported less sedentary activities than their peers; boys had higher levels of VPA than girls. | 85 | |
Davy et al., 2004 [44] USA (Scott County) | 205 11 years | Pedometer | 22% were at risk of overweight and 32% were overweight; BMI and average daily steps did not differ between boys and girls. | 80 | |
Treuth et al., 2005 [45] USA (Maryland) | 229 7–19 years | Accelerometer | Older girls had more fat mass than younger girls; boys had higher accelerometer counts compared to girls; higher body fat was associated with higher time spent on sedentary activities in girls; and lower body fat was associated with more time spent on LPA. | 80 | |
Moore et al., 2008 [46] USA (Georgia) | 116 4th, to 11th grade | Questionnaire | Children with high levels of PA reported more video game time on school days compared to their peers. Children with low levels of PA were three times more likely to be positive for metabolic syndrome and 2.4 times more likely to be overweight compared to those with high levels of PA. | 85 | |
Glover et al., 2011 [47] USA (South Carolina) | 98 6–11 years | Questionnaire | Approximately 55% of children practiced some sport; 66% watched TV for more than 2 h on school nights; 50% of participants used computers for about 2 h during the week. | 65 | |
Newton et al., 2011 [48] USA (Louisiana) | 272 4th to 6th grade | Accelerometer | Boys had 8 min more MVPA/day than girls; African-American children with low socioeconomic status had 36 min less sedentary behaviour compared to African-American children with average socioeconomic level. | 90 | |
Shriver et al., 2011 [49] USA (Oklahoma) | 237 8–10 years | Questionnaire | 38% of children were overweight or obese; almost 30% of children spent 60 min in MVPA the day before; children who watched TV the day before (79.3%) reported approximately 1 h watching; boys had more TV and computer time than girls; obese children spent less time in MPA and MVPA than their non-obese peers. | 90 | |
Limbers et al., 2014 [50] USA (Texas) | 189 8–19 years | Questionnaire | 23.9% of the children had excess body fat; girls were more likely to have excess body fat; PA and sedentary behaviour were not significant predictors for excess adiposity. | 90 | |
Cottrell et al., 2015 [51] USA (Virginia) | 566 5–15 years | Questionnaire | 31% of the children were overweight (14.8%) or obese (16.2%); children’s PA was significantly higher among low-income families than in all other categories. | 85 | |
Chow et al., 2016 [52] Canada (Saskatchewan) | 69 3–5 years | Accelerometer | The group that received PA and feeding intervention was involved significantly more in MVPA; sedentary behaviour decreased after the intervention. | 85 | |
Daly et al., 2017 [53] USA | 153 9–11 years | Accelerometer | 50% of the children were overweight or obese; 6th graders spent more time in sedentary behaviour (79.2%) than 3rd, 4th and 5th graders; 3rd (7.8%) and 5th graders (7.0%) participated more in MVPA than 6th graders (5.0%); children involved in MVPA had lower BMI, and children who spent more time in sedentary behaviour had higher BMI | 75 | |
Button et al., 2020 [54] Canada (Ontario) | 134 8–14 years | Accelerometer/ questionnaire | On average, children spent 7.4 h/day in sedentary behaviour; boys spent, on average, less 28.91 min daily in sedentary behaviour than girls; increasing age, the time spent in sedentary behaviour increases (14.37 min each year). | 85 | |
Brazendale et al., 2021 [55] USA (Florida) | 54 6–11 years | Accelerometer/ questionnaire | 22.2% of the children were overweight/obese; children had 75 ± 44 min of MVPA and 615 ± 154 of sedentary behaviour; children were less sedentary on school days than on the weekend; children accumulated less screen time on school days vs. weekdays. | 90 | |
Button et al., 2021 [56] Canada (Ontario) | 90 8–14 years | Accelerometer/ questionnaire | Boys had 26.49 min more MVPA than girls; for each increase of 1 ºC Canadian children reached 1.18 min more MVPA; children reached 24.38 min less MVPA on rainy days | 95 | |
Kellstedt et al., 2021 [57] USA (Nebraska) | 418 3rd to 6th grade | Questionnaire | 6th-grade children had lower mean MVPA compared to their 3rd- and 5th-grade peers; boys reported more minutes of MVPA than girls; children who participated in sports had more average daily minutes of MVPA than those who did not participate. | 90 | |
Oceania | Barnett et al., 2002 [58] Australia (North) | 231 3rd and 4th grade | Questionnaire | Similar levels of school physical activity between sexes; 33.2% of girls and 34.8% of boys were involved in MVPA; 9.2% of girls and 10% of boys were involved only in VPA; overall MVPA was 36.2%, and exclusively vigorous activity was 12.9%. | 65 |
South America | Fronza et al., 2015 [59] Brazil (Santa Catarina) | 294 10–19 years | Questionnaire | The prevalence of obesity was 20.4%; associations were observed only between TV time and age during weekdays; associations between excessive TV viewing during weekend days and the variables studied were not observed. | 90 |
Valdés-Badilla et al., 2015 [60] Chile (Temuco) | 23 7–12 years | Questionnaire | 13% of children were overweight and 21.7% were obese; children spent 2225.9 min/week in PA, spent 9592.1 METs/week, and remained 228.6 min/week seated; girls had more total physical activity/week than boys. | 65 |
Continent | Study and Country (Region) | Sample Size | Instrument Used | Main Results | QS (%) |
---|---|---|---|---|---|
Age/School Grade | |||||
Africa | Christoph et al., 2017 [61] Uganda (Mukono) | 148 11–16 years | Questionnaire | Active commuting was common in both locations; activities such as digging, herding animals, and looking for water were high among rural children; in general, the BMI was positively related to the female sex, living in rural area, and report being active a greater number of days/week; girls were less active. | 85 |
Kidokoro et al., 2021 [62] Kenia (Maasi and Nairobi) | 261 10–12 years | Accelerometer | Rural children had lower BMI than urban children; urban children had more TV and computer time; rural children met screen time guidelines to a greater extent, spent less time in sedentary behaviour, had more time in MVPA, and had more step count compared to urban ones. | 100 | |
Asia | Xu et al., 2008 [63] China (Nanjing) | 6848 12–18 years | Questionnaire | Rural children were less likely to be overweight than urban children; BMI and TV time were positively related only among rural male adolescents; students who watched TV for more than 7 h/week were 1,5 times more likely to be overweight. | 85 |
Itoi et al., 2012 [64] Japan (Tohoku) | 277 11–12 years | Accelerometer | Children in rural areas walked less to school and had lower step counts than urban children; children who had lower step counts/day and shorter walking time to school had higher BMI. | 95 | |
Karkera et al., 2014 [65] India (Mangalore) | 650 9–13 years | Questionnaire | Rural children performed more activities before and after school and spent more time in physical activities and less time watching TV compared to urban children | 75 | |
Baygi et al., 2015 [66] Iran | 5682 10–18 years | Questionnaire | In the least developed region (Southeast), children aged 10 to 13 years had less screen time. (TV and computer); in addition, regarding MVPA, 55.8% of children from the mentioned region, practiced <1 h/week, 34.0% spent between 1–2 h/week (the highest percentage among regions), and 10.2% spent >2 h/week. | 95 | |
Kundapur et al., 2017 [67] India (Mangalore) | 300 12–16 years | Questionnaire | There were differences in physical activity levels between boys; the total score of physical activity among rural adolescents was higher and going to school by bike was more frequent among boys in rural schools compared to their urban peers. | 75 | |
Lu et al., 2019 [68] China (Xangai) | 2175 7–12 years | Questionnaire | In the rural group, obesity among boys was 5.4%, while among girls it was 1.7%; the prevalence of children who used computer/watched TV for more than 3 h per day was 8.6% in the rural group, and 27.7% in the urban group; the prevalence of children who spent more than 3 h per day doing homework was 5.3% in the rural group and 21,2% in the urban group. | 50 | |
Europe | Loucaides et al., 2004 [69] Chipre | 256 11–12 years | Pedometer | During winter, urban children reached more average steps/day than rural children, and the opposite was observed during summer; urban children spent more time playing video games compared to rural children during winter; rural children spent more time outdoors than urban children in both winter and summer; parents of urban children reported transferring their children more often to places where they can be physically active (in winter and summer). | 80 |
Bathrellou et al., 2007 [70] Chipre | 1140 10–12 years | Questionnaire | Rural children spent more time in PA (of any kind) after school and reported being busier with outdoor tasks during the week; rural children played fewer sports than urban children; time spent in MVPA and screen time did not differ between urban and rural children; the prevalence of normal weight, overweight and obesity did not differ between rural and urban children. | 80 | |
Ara et al., 2007 [71] Spain (Aragon) | 1068 7–12 years | Questionnaire | The prevalence of overweight and obesity was similar between rural and urban children; physical activity did not differ according to the place of residence (rural or urban). | 70 | |
Bounova et al., 2010 [72] Greece (Evrytania) | 542 11–13 years | Questionnaire | Suburban girls achieved significantly lower VPA Scores than urban boys and rural boys; 57% of all subjects practiced MVPA for three days for more than 60 min; boys from suburban districts scored higher in VPA; for MVPA, rural children scored more than suburban per day; both rural and suburban adolescents tend to be less active on Sunday. | 85 | |
Craggs et al., 2011 [73] United Kingdom (England) | 1653 9–10 years | Accelerometer | The percentage of parents with higher education was greater among children from rural areas; mean level of physical activity differed between sex; no differences were found between environments; regardless of location, boys were more active than girls; overweight children were less active compared to normal-weight children; in addition to sex and overweight indexes, the preference for PA also showed associations with total PA. | 100 | |
Machado-Rodrigues et al., 2012 [74] Portugal | 362 13–16 years | Accelerometer | 18.0% of the children were overweight and 3.9% were obese; the prevalence of overweight and obesity was 17% and 5.1% among rural youth, and 20% and 1% among urban youth, respectively; rural boys spent more time in LPA during the week, while urban boys spent more time in MVPA at the weekend; urban girls spent more time in sedentary activities, less time in LPA and MVPA compared to rural girls; MVPA was positively correlated with cardiorespiratory fitness among rural and urban adolescents; adolescents with higher levels of cardiorespiratory fitness had a lower relative risk of being overweight and/or obese than young people classified as normal-weight. | 100 | |
Machado-Rodrigues et al., 2014 [75] Portugal | 362 13–16 years | Accelerometer | Urban boys spent less time in physical inactivity than rural boys, but no differences between groups on weekend days were observed; urban boys had less time in sedentary activities; rural boys spent more time in LPA during the week, while they spent more time in MVPA over the weekend; urban girls spent less time in sedentary activities and less time in LPA; urban girls spent less time in MVPA every day. | 90 | |
Morais et al., 2017 [76] Portugal (Vila de Rei) | 129 10–12 years | Questionnaire | There was little difference between adolescents who spent more than 2 h/day watching TV/playing video games (66.1%, urban; 80.0%, rural); more rural students did not perform other activities besides physical education classes at school; rural children walked more; living in a rural environment was not an independent predictor of overweight or obesity, or to increase the percentage of body fat. | 80 | |
Franco et al., 2020 [77] Spain (Badajoz) | 542 11–13 years | Questionnaire | During primary education students were moderately active, both rural and urban; in secondary education, urban children were more moderately active; children from rural areas practiced more MVPA; girls were more inactive in both environments; in secondary education, boys from the rural area were the most inactive; students in urban areas were more moderately and very active. | 75 | |
McCrorie et al., 2020 [78] United Kingdom (Scotland) | 774 10–11 years | Accelerometer | Rural children spent more minutes/day in LPA; urban children spent more minutes/day in sedentary activity; urban children had higher levels of MVPA during spring and significantly lower levels in winter, compared to their rural peers. | 95 | |
North America | Felton et al., 2002 [79] USA (South Carolina) | 1668 12–14 years | Questionnaire | Among black girls, those from rural areas practiced more VPA than urban girls; among white girls, those from urban areas were more vigorously active than those from rural areas; physical activity, in general, did not differ between urban and rural areas. | 70 |
Joens-Matre et al., 2008 [80] USA (Lewa) | 3416 8–12 years | Questionnaire | The prevalence of overweight was higher among rural children; rural children were 1.47 times more likely to be overweight than children from small towns; urban children were less active; boys were more active than girls; urban children also reported less activity after school and at night than children in rural areas. | 80 | |
Liu et al., 2008 [81] USA | 44,631 10–17 years | Questionnaire | Rural children were more likely to be overweight; among physically active children, rural children were more likely to be overweight; urban children were more likely to be physically inactive than rural children; urban girls were more likely to be physically inactive than rural girls; rural children were 21% less likely to be physically inactive than urban children. | 90 | |
Liu et al., 2012 [82] USA | 14,332 2–19 years | Questionnaire | The prevalence of overweight/obesity was higher among rural children; percentages of excessive total screen time did not differ between urban and rural children; rural children aged 2 to 11 years had higher odds of being overweight; among adolescents aged 12 to 19 years, the rural population was more likely to be overweight/obese. | 90 | |
Moore et al., 2014 [83] USA (North Carolina) | 804 4th–8th grade | Accelerometer | In boys, there were non-differences in MVPA/day between the urbanity categories; rural girls had more MVPA/day time and were more likely to accumulate more than 60 min MVPA/day compared to suburban and urban girls. | 85 | |
Cristiana et al., 2021 [4] USA | 1128 12–17 years | Questionnaire | 27.1% of rural adolescents were overweight; MVPA did not differ between rural and urban adolescents; rural adolescents presented a low screen time and a low probability of engaging in active commuting. | 100 | |
Oceania | Aucote et al., 2009 [84] Australia (Ballarat) | 393 10–12 years | Questionnaire | All subjects were more likely to engage in more than the recommended 14 h of small-screen sedentary activity per week; metropolitan children spent more time playing video games than regional and rural children; socioeconomic status was not a significant predictor of BMI in the studied sample. | 85 |
Hodgkin et al., 2010 [85] New Zealand | 2375 5–15 years | Questionnaire | Rural boys and girls had lower values for subcutaneous fat compared to their urban peers; children living in urban areas had lower levels of physical activity compared to those with better socioeconomic status; among Maori children, urbans were more active than rural ones; screen time was lower in rural children, but significantly different only at ages 5–7. | 90 | |
Dollman et al., 2012 [86] Australia | 2071 9–16 years | Questionnaire/ pedometer | Urban adolescents were less active than rural adolescents; urban youth reported lower MVPA; urban girls had lower MVPA than those from remote regions; daily steps were lower among boys and girls from major cities than those from peripheral regions; urban boys had more screen time per day than those from remote areas; TV time was shorter among boys from remote areas; among girls, total screen and TV time did not differ between categories. | 90 | |
Bell et al., 2016 [87] Australia (South Region) | 4637 9–11 years | Questionnaire | 36.7% of rural children practiced 60 min or more of PA/day and 18.8% spent more than 2 h on electronic devices, and both values were higher compared to their peers from urban areas; rural children were more likely to perform physical activity and comply with screen time recommendations than urban children; patterns of healthy lifestyle behaviours were significantly higher among rural children. | 90 | |
South America | Andrade Neto et al., 2014 [88] Brazil (Vitória and Santa Maria de Jetibá) | 1242 7–10 years | Questionnaire | Active commuting, regardless of the destination, was more frequent among urban children; rural children watched more TV but used less video games and computers, as well as had more average daily commuting time on foot or by bike to school; being female, living in urban areas, and being overweight was the profile of children who did not reach the recommendation of 300 min of physical activity/week. | 90 |
Lizana et al., 2016 [89] Chile (Valparaíso) | 363 8–13 years | Questionnaire | The prevalence of obesity was higher among urban girls; more than 90% of the children did not reach 7 h of MVPA/week; boys perform more PA than girls, regardless of the place of residence; the prevalence of obesity was 30.88% in urban children and 28.93% in rural children. | 90 | |
Flor-Garrido et al., 2016 [90] Equator (Paute) | 314 12–19 years | Questionnaire | The prevalence of overweight was lower in rural children; rural children spent fewer hours doing homework, fewer hours of physical/unplanned activity, and fewer screen hours. | 95 |
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Vieira, D.; Gomes, E.C.; Negrão, Â.S.; Thuany, M.; Gomes, T.N. Movement Behaviour and Health Outcomes in Rural Children: A Systematic Review. Int. J. Environ. Res. Public Health 2023, 20, 2514. https://doi.org/10.3390/ijerph20032514
Vieira D, Gomes EC, Negrão ÂS, Thuany M, Gomes TN. Movement Behaviour and Health Outcomes in Rural Children: A Systematic Review. International Journal of Environmental Research and Public Health. 2023; 20(3):2514. https://doi.org/10.3390/ijerph20032514
Chicago/Turabian StyleVieira, Douglas, Elenir Campelo Gomes, Ângelo Solano Negrão, Mabliny Thuany, and Thayse Natacha Gomes. 2023. "Movement Behaviour and Health Outcomes in Rural Children: A Systematic Review" International Journal of Environmental Research and Public Health 20, no. 3: 2514. https://doi.org/10.3390/ijerph20032514
APA StyleVieira, D., Gomes, E. C., Negrão, Â. S., Thuany, M., & Gomes, T. N. (2023). Movement Behaviour and Health Outcomes in Rural Children: A Systematic Review. International Journal of Environmental Research and Public Health, 20(3), 2514. https://doi.org/10.3390/ijerph20032514