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Revista Brasileira de Cineantropometria & Desempenho Humano

Print version ISSN 1415-8426On-line version ISSN 1980-0037

Rev. bras. cineantropom. desempenho hum. vol.20 no.4 Florianópolis July/Aug. 2018

https://doi.org/10.5007/1980-0037.2018v20n4p367 

review article

The prevalence of global physical activity among young people: a systematic review for the Report Card Brazil 2018

A prevalência de atividade física global entre jovens: uma revisão sistemática para o Report Card Brazil 2018

Valter Cordeiro Barbosa Filho1 

Rafael Martins da Costa2 

Margarethe Thaisi Garro Knebel2 

Bruno Nunes de Oliveira2 

Camila Brasileiro de Araújo Silva3 

Kelly Samara da Silva2 

1Federal Institute of Ceará. Campus Boa Viagem. Boa Viagem, CE. Brazil.

2Federal University of Santa Catarina. Florianópolis, SC. Brazil.

3State University of Ceará. Fortaleza, CE. Brazil.


Abstract

The aim of this study was to summarize data on the prevalence of global physical activity (PA) among children and adolescents in Brazil. This systematic review included an electronic search in 8 databases (PubMed, Scopus,Web of Science, LILACS, SPORTDiscus,BIREME,Scielo, and Google Scholar) and a manual search in the references of retrieved studies.Observational studies that assessed global PA among Brazilian children and adolescents were included. A narrative approach toward results was adopted. An initial database search reached 3276 potentially relevant titles (2534 titles after duplicate analysis); 92 (62 different studies) met all inclusion criteria. Studies were carried out between 2001 and 2015; most studies were conducted in Southern and Northeastern Brazil.Three were nationwide surveys (4.8%), but no studies included children aged 0-5 years. Eighteen different instruments for PA measurement were used; only two studies used objectively-measured PA. The most used definition was ≥ 300 minutes/week of moderate-to-vigorous PA. The overall proportion of young people who were physically active ranged from 6.5% to 92.3%.Fourteen studies (22.6%) found a prevalence of ≥ 50%. Three nationwide surveys reported the prevalence of physically active students ranging from 29.0% to 66.0%. A wide variability of PA estimates were found. Important research gaps (e.g., studies with objectively-measured PA, children aged up to 6 years-old and in Northern Brazil) should be considered to develop new research studies in Brazil.

Key words Adolescent; Adolescent health; Brazil; Exercise; Public health

Resumo

Objetivou-se sumarizar dados sobre a prevalência de atividade física global (AF) entre crianças e adolescentes no Brasil. Esta revisão sistemática incluiu uma busca eletrônica em 8 bases de dados (PubMed, Scopus, Web of Science, LILACS, SPORTDiscus, BIREME, Scielo e Google Scholar) e uma busca manual nas referências de estudos recuperados. Estudos observacionais que avaliaram a AF global entre crianças e adolescentes brasileiros foram incluídos. Uma abordagem narrativa em relação aos resultados foi adotada. Uma pesquisa de banco de dados inicial atingiu 3276 títulos potencialmente relevantes (2534 títulos após análise duplicada); 92 (62 estudos diferentes) preencheram todos os critérios de inclusão. Os estudos foram realizados entre 2001 e 2015; a maioria dos estudos foi realizada no sul e nordeste do Brasil. Três foram pesquisas nacionais (4,8%), mas nenhum estudo incluiu crianças de 0 a 5 anos. Dezoito instrumentos diferentes para medida de PA foram utilizados; apenas dois estudos usaram PA medida objetivamente. A definição mais utilizada foi ? 300 minutos / semana de AF moderada a vigorosa. A proporção geral de jovens que eram fisicamente ativos variou de 6,5% a 92,3%. Quatorze estudos (22,6%) encontraram uma prevalência de ? 50%. Três pesquisas nacionais relataram a prevalência de estudantes fisicamente ativos variando de 29,0% a 66,0%. Uma ampla variabilidade de estimativas de PA foi encontrada. Lacunas importantes de pesquisa (por exemplo, estudos com PA medida objetivamente, crianças de até 6 anos de idade e no norte do Brasil) devem ser consideradas para o desenvolvimento de novas pesquisas no Brasil.

Palavras-chave Adolescente; Brasil; Exercício; Saúde do adolescente; Saúde pública

INTRODUCTION

Physical activity is strongly associated with development, health, and quality of life among children and adolescents1. Despite this, only two out of ten adolescents meet physical activity guidelines (60 or more minutes per day of moderate-to-vigorous physical activity) worldwide2. Nationwide data show a similar trend in Brazilian adolescents3. Thus, policies and programs for physical activity promotion are urgent, and monitoring how and whether intervention strategies can improve physical activity practices among young populations is an important component of public health action.

In 2014, researchers, health professionals, and stakeholders built The Active Healthy Kids Global Alliance, a network focused on advancing physical activity among children and adolescents from around the world. For this, physical activity indicators (e.g., meeting physical activity guidelines, active transportation, and others) have been monitored and described in a document called a “Report Card”, in order to be a useful tool for the advocacy of physical activity4 among young people. In 2016, data from 38 countries were included, including Brazil. A grade of C- (prevalence rates from 40% to 46%) was given for global physical activity levels based on data from studies with Brazilian adolescents - this was one of the lowest grades for Brazil’s 2016 Report Card5.

The present study aimed to systematically summarize the literature on the prevalence of global physical activity (based on international physical activity guidelines) among Brazilian children and adolescents. The summarized data were used to define the grade and recommendations for Brazil’s 2018 Report Card for the global physical activity indicator.

METHODOLOGICAL PROCEDURES

Measured Outcome

In this systematic review, physical activity outcome was defined as any bodily movement produced by skeletal muscles that require energy expenditure6. Studies were considered whether they measured global physical activity (e.g., different domains combined (leisure, transportation, home and/or school combined), in order to follow the global physical activity guidelines7.

Study Search Strategies

A systematic search was conducted in electronic databases Medline (PubMed), Scopus, Web of Science (Web of Knowledge), LILACS (Literatura Latino-Americana em Ciências da Saúde), SPORTDiscus, BIREME (Biblioteca Regional de Medicina), Scielo, and Google Scholar in February 2018. The search strategy included four groups of descriptors: outcome (physical activity), physical activity evaluation methods, population (young people) and country (see Supplementary Material). The Boolean operator “OR” was used for intragroup combinations, and the "AND" operator was used for intergroup combinations. The truncation symbols ($, * or "") specific to each database were also used to increase the range of searches for the descriptor variations. Searches were conducted with the descriptors in English and Portuguese, when required. The search of the electronic databases was supplemented by a screening of the reference list of retrieved articles in order to find potentially relevant titles and the personal library.

Identification of Eligible Studies

• Selection Process

The initial analysis was performed based on the reading of the manuscripts titles and, when there was doubt regarding the inclusion of the study, a reading of the abstract was carried out. After this analysis, articles were obtained in full text version and subsequently analyzed according to established selection criteria. Subsequently, the screening of the reference list was carried out. All the process was conducted by independent peers (RC/MK or BO/CS), and a third author (KS or VB) helped with disagreements.

• Selection Criteria

To be eligible for inclusion in this review, studies had to be: (I) articles published in peer-reviewed journals that were original research; (II) samples with Brazilian children and adolescents aged 0-18 years (or a mean age within these ranges, or separated data for individuals at this age range) (III) observational studies showing the prevalence of at least one of global physical activity (e.g., % of children and adolescents who accumulate a combined total of at least 60 minutes of daily moderate-to vigorous-intensity physical activity), regardless of whether the study dealt with this behavior as an exposure or an outcome; (IV) studies using different methods for PA assessment (e.g., self-report, structured interviews, objectivelymeasured PA, and steps per day); (V) a school-or population-based survey with information about the methodological procedures of representation of the target population (e.g., random sampling).

• Data Extraction and Synthesis

Information of each study was extracted by independent peers (RC/MK and BO/CS) and a third author (VB or KS) helped with disagreements. Extracted information included: authors and year of publication, local of the study, year of data collect, age range, sample type, sample size, percentage of girls, instrument description, instruments characteristics and mode of administration, and physical activity cut-off definitions. A narrative approach for the results was adopted because the heterogeneity of the study’s data (no meta-analyze was performed).

Also, the proportion of young people that were considered physically active (based on the physical activity definition in each study), as well as the proportion of this outcome for boys and girls separately, when presented.

Results of the studies were presented in alphabetical and chronological order by first author name and year of publication, respectively. The results were organized in order to present methodological aspects (Table 1) and the prevalence of global physical activity (Table 2) of the included studies.

Table 1. Description of the studies on the global physical activity among Brazilian children and adolescents. 

Reference Local Sample type Sample (% of girls) Age(years) Instrument Mode of administra-tion; recall time
Abreu and Caiaffa82 National Population-based 7169 (54.2) 15-24 IPAQ Self-reported; PR-W
Alves Júnior et al.a 40 São José, SC School-based 820 (56.0) 14-17 Undefined Questionnaire Uninformed; PR-W
Andaki et al. 85 Viçosa, MG School-based 187 (56.7) 9.9 Undefined Questionnaire Self-reported; PR-W
Andrade Neto et al.86 Santa Maria de Jetibá, ES Vitória, ES School-based 1770 (55.1) 7-10. Undefined Questionnaire (V) Not Described
Arruda and Lopes87 Lages, SC School-based 1024 (0) 10-17 Bouchard diary adapted Self-reported
Barros et al. 66 Recife, PE School-based 3764 (59.5) 14-19 GSHS Self-reported; PR-W
Bastos, Araújo and Hallal63 Pelotas, RS School-based 857 (52) 10-19 Undefined Questionnaire (V) Not Described
Beck et al.45 Três de Maio, RS School-based 660 (52) 14-19 Undefined Questionnaire Not Described
Bergmann et al.b 16 Uruguaiana, RS School-based 1455 (50.9) 10-17 PAQ-C and PAQ-A Self-reported; PR-W
Campos et al.46 Curitiba, PR School-based 497 (47.6) 14-19 Undefined Questionnaire Self-reported; HA-W
Carvalho et al.77 Nordeste School-based 421 (59.6) 9-19 IPAQ Self-reported; PR-W
Cavalcanti et al.c 67 Recife, PE School-based 4138 (59.8) 14-19 GSHS Not Described
Ceschini, Andrade and Figueira Júnior36 São Paulo, SP School-based 1844 (46.5) 15-20 IPAQ Self-reported; PR-W
Ceschini et al.88 São Paulo, SP School-based 3845 (52.6) 14-19 IPAQ Self-reported; PR-W
Coelho et al.89 OuroPreto, MG School-based 661 (47.8) 10-14 Undefined Questionnaire Not Described
Cureau et al.26 Santa Maria, RS School-based 1132 (53.9) 14-19 Undefined Questionnaire Not Described
Dambros, Lopes and Santos47 Santa Maria, RS School-based 450 (45.3) 14-18 Undefined Questionnaire (V) Not Described
Dumith et al.20 Caracol, PI School-based 1112 (53.3) 13-19 Undefined Questionnaire Self-reported; HA-W
Farias Júnior14 Florianópolis, SC School-based 1949 (50.6) 12-18 Bouchard diary adapted Self-reported; 3 days
Farias Júnior78 João Pessoa, PB School-based 2566 (55.9) 14- 18 Undefined Questionnaire (V) Self-reported; PR-W
Farias Júnior et al.e 11 Santa Catarina School-based 5028 (59.3) 15-19 GSHS Self-reported; HA-W
Farias Júnior et al.g 79 João Pessoa, PB School-based 2874 (57.8) 14-19 GSHS Self-reported; PR-W
Farias Júnior et al.g 69 João Pessoa, PB School-based 2874 (57.8) 14-19 Undefined Questionnaire Not Described
Farias Júnior et al.g 73 João Pessoa, PB School-based 2859 (57.8) 14-19 PACE and QAFA Self-reported; PR-W
Farias Júnior, Reis and Hallalg 70 João Pessoa, PB School-based 2859 (57.8) 16,5 Undefined Questionnaire Self-reported; PR-D
Fermino et al.h 49 Curitiba, PR School-based 1518 (59.2) 14-18 Undefined Questionnaire Self-reported; HA-W
Freire et al.90 Montes Claros, MG School-based 763 (48.2) 15-19 Undefined Questionnaire Self-reported
Guilherme et al.37 Paranavaí, PR School-based 566 (49.3) 10-14 GSHS Not Described
Hallal et al.d 84 National School-based 60.973 13-15 GSHS Self-reported; PR-W
Leão et al.f 19 Aracajú, SE School-based 2030 (63.2) 13-18 Undefined Questionnaire (V) Not Described
Legnani et al.56 Foz do Iguacu, PR School-based 453 (59) 15-18 GSHS Not Described
Leites, Bastos and Bastos57 Porto Alegre, RS School-based 967 (49.6) 10-19 Undefined Questionnaire Not Described
Lima et al.h 64 Curitiba, PR School-based 1474 (59) 14-18 Undefined Questionnaire Not Described
Lima and Silvaa 41 São José, SC School-based 1103 (54.5) 14-19 GSHS Self-reported; PR-W
Loche 10 Santa Catarina School-based 5083 (59.4) 15-19 Undefined Questionnaire (V) Not Described
Lucena et al.g 71 João Pessoa, PB School-based 2874 (57.8) 14-19 Undefined Questionnaire (V) Self-reported; PR-W
Malta et al.d 83 National School-based 60.973 (53.3) 13-14 Undefined Questionnaire Not Described
Malta et al.i 32 National School-based 109.104 (52.1) 13-16 GSHS Not Described
Martins, Lima and Silvaa 42 São José, SC School-based 1132 (54.2) 14-19 GSHS Self-reported; HA-W
Matsudo et al.102 São Paulo Population-based 2001 (52.4) 14-77 IPAQ Self-reported; PR-W
Meireles et al.91 Belo Horizonte, MG School-based 1042 (47.2) 11-17 Undefined Questionnaire Uninformed
Mendonça and Farias Júniorg 72 João Pessoa, PB School-based 2859 (57.8) 14-19 PAQ-A Self-reported; PR-D
Mendonça et al.g 80 João Pessoa, PB School-based 2874 (57.8) 14-19 Undefined Questionnaire Self-reported; PR-D
Menezes and Duarte21 Sergipe School-based 3992 (63.1) 14-19 GSHS Not Described
Moraes et al.j 59 Maringá, PR School-based 991 (54.5) 14-18 IPAQ Self-reported; PR-W
Moraes and Falcão58 Maringá, PR School-based 991 (54.5) 14-18 PAQ-A Not Described
Nakamura et al.92 Rio Claro, SP School-based 467 (54) 14-17 PAQ-C Self-reported; PR-W
Nascente et al.22 Goiânia, GO School-based 862 (52.8) 14-18 IPAQ Self-reported; PR-W
Nascimento-Ferreira et al.103 Imperatriz, MA School-based 869 (53.4) 14-19 PAQ-A Self-reported; PR-D
Nunes et al.a 43 São José, SC School-based 916 (55.4) 14-19 YRBSS Self-reported; PR-W
Pelegrini and Petroskik 60 Florianópolis, SC School-based 595 (67.1) 14-18 IPAQ Self-reported; PR-W
Pereira, Bergmann and Bergmannb 17 Uruguaiana, RS School-based 1455 (50.9) 10-17 PAQ-C and PAQ-A Self-reported; PR-D e PR-W
Peres et al.l 93 Piracicaba, SP School-based 269 (56.1) 10-14 QAFA Self-reported; HA-M
Petribú et al.m 74 Caruaru, PE School-based 600 (62.5) 15-20 COMCAP Not Described
Prado et al.h 53 Curitiba, PR School-based 1469 (59.2) 14-18 YRBSS Self-reported; PR-W
Quadros et al. 23 Amargosa, BA . School-based 1139 (55.6) 6-18 Pedometer Monitoramento;PR-W
Raizel et al.24 Cuiabá, MT School-based 364 (59) 12-19 GSHS Not Described
Regis et al.n 25 Pernambuco School-based 6234 (59.7) 14-19 GSHS Not Described
Reichert et al.61 Pelotas, RS Population-based 457 (47.9) 12-14 Accelerometer Monitoramento;PR-W
Reis et al.h 54 Curitiba, PR School-based 1650 (59.6) 14-18 Undefined Questionnaire Self-reported; PR-W
Rezende et al.i 33 National School-based 109.104 (57) 14-15 Undefined Questionnaire Self-reported; HA-W
Rivera et al.o 12 Maceió, AL School-based 1253 (56.3) 7-17 PAQ-C Self-reported; PR-W
Rodrigues et al.81 Cuiabá, MT School-based 1139 (55.6) 14-19 Undefined Questionnaire Not Described
Romanzini et al.55 Londrina, PR School-based 644 (61.6) 16,4,0 IPAQ Self-reported; PR-W
Romero et al.l 94 Piracicaba, SP School-based 328 (54.3) 10-15 QAFA Self-reported; PR-W e PR-Y
Salvador, Kitoko and Gambardella95 Vitória, ES School-based 400 (47.3) 8-17 Undefined Questionnaire Self-reported; PR-Y
Santos et al.h 51 Curitiba, PR School-based 1615 (59.69) 14-18 Undefined Questionnaire Not Described
Santos et al.35 Uberaba, MG School-based 649 (52.1) 9-12 LAF Self-reported; PR-D
Santos et al.n 96 Pernambuco School-based 6264 (59.7) 14-19 GSHS Not Described
Santos et al.c 31 Pernambuco School-based 4207 (59.8) 14-19 PAQ-C* Self-reported; PR-W
Silva (2015) 34 National School-based 109.104(52.2) 13-15 Undefined Questionnaire Self-reported; PR-W
Silva and Silvap 28 Aracajú, SE School-based 2057 (62.7) 13-18 YRBSS Self-reported; PR-W
Silva et al.o 13 Maceió, AL School-based 706 (56.3) 7-17 PAQ Self-reported; PR-W
Silva et al.e 8 Santa Catarina School-based 5028 (59.3) 15-19 COMPAC Self-reported; HA-W
Silva et al.97 Aracajú, SE School-based 1028 (56.7). 13-16 PAQ-C Self-reported; PR-W
Silva et al.e 9 Santa Catarina School-based 5028 (59.3) 15-19 COMPAC Self-reported; HA-W
Silva et al.p 18 Aracajú, SE School-based 2105 (63.0) 13-18 YRBSS Self-reported; PR-W
Silva et al.27 Santa Catarina School-based 6529 (53.9) 15-19 COMPAC Self-reported; HA-W
Silva et al.64 Ponta Grossa, PR School-based 653 (57,9) 14-19 IPAQ Self-reported; PR-W
Silva et al.k 65 Florianópolis, SC School-based 696 (62.1) 15-18 IPAQ Self-reported; PR-W
Silva et al.15 Arapiraca, SE School-based 571 (52.7) 8-10 QUAFDA Self-reported; PR-D
Silva, Silva and Oliveiraf 18 Aracajú, SE School-based 2259 (62.3) 13-18 PAQ-C Self-reported; PR-W
Silva, Smith-Menezes and Duarte29 Sergipe School-based 3992 (61.3) 14-19 GSHS Not Described
Souza98 Canoas, RS School-based 293 (66.9) 17 IPAQ Self-reported; PR-W
Souza et al.76 Salvador, BA School-based 694 (52.7) 10-14 Undefined Questionnaire (V) Not Described
Souza et al.h 52 Curitiba, PR School-based 1698 (59.4) 14-18 Undefined Questionnaire Self-reported; HA-W
Straatmann e Veiga99 Niterói, RJ School-based .697 (59.6) 12-19 IPAQ Self-reported; PR-W
Sune et al.62 Capão da Canoa, RS School-based 719 (50.2) 11-13 Questionnaire on habitual physical activities (Russell R. Pate) Not Described
Tassitano et al.m 75 Caruaru, PE School-based 600 (62.5) 15-20 COMCAP Not Described
Tenório et al.c 68 Pernambuco School-based 4210 (59.8) 14-19 GSHS Not Described
Vieira et al.100 Natal, RN School-based 347 (72) 12-18 Undefined Questionnaire Not Described
Vitta et al.101 Bauru, SP School-based 524 (46.9) 10-14 PAQ-C Self-reported; PR-W

Note. Superscript equal letters over author’s name refer to distinct articles from the same study; Undefined Questionnaire: Original instrument not identified by the authors, but questions were reported; (V): Questionnaire presented criterion, content and/or construct validity; States of Brazil: AL: Alagoas; BA: Bahia; DF: Distrito Federal; ES: Espírito Santo; GO: Goiás; MA: Maranhão; MG: Minas Gerais; MT: Mato Grosso; PB: Paraíba; PE: Pernambuco; PI: Piauí; PR: Paraná; RJ: Rio de Janeiro; RN: Rio Grande do Norte; RS: Rio Grande do Sul; SC: Santa Catarina; SE: Sergipe; SP: São Paulo. (PAQ-C): Physical Activity Questionnaire for Older Children; (PAQ-A): Physical Activity Questionnaire for Adolescents; (PAQ-C*): Activity Questionnaire for Children and Adolescents; (GSHS): Global School-based Student Health Survey; (YRBSS): Youth Risk Behavior Surveillance; (Saúde na Boa): Good Health Questionnaire; (QAFA): Physical Activity Questionnaire for Adolescents; (LAF): List of Physical Activities; (PAQ): Physical Activity Questionaire; (COMCAP): Risk Behaviors in Catarinese Adolescents; (QUAFDA): Previous Day Physical Activity Questionnaire; (IPAQ): International Physical Activity Questionnaire; (COMPAC): Behaviors of Catarinense Adolescents; (PeNSE 2012): National School Health Survey.

a- Brazilian Guide for Evaluation of Health-Related Physical Fitness and Life Habits - Stage I;

b- Estudo em Uruguaiana/RS – protocol do Comitê de Ética em Pesquisa: 042/2010;

c- Estilos de Vida e Comportamentos de Risco à Saúde em Estudantes do Ensino Médio no Estado de Pernambuco;

d– Pesquisa Nacional de Saúde do Escolar, edição 2009 – PeNSE 2009;

e– Estilo de Vida e Comportamentos de Risco dos Jovens Catarinenses, edição 2001 – COMPAC 2001;

f– Estudo em Sergipe – protocolo do Comitê de Ética em Pesquisa da Universidade Federal de Sergipe (CEP/UFS): 5724.0.000.107-10.;

g- Physical activity level and associated factors among high school adolescents in João Pessoa, city, - PB: an ecological approach.;

h- Determinantes da Atividade Física e Obesidade em Escolares do Ensino Médio da Rede Pública da Cidade de Curitiba, Paraná, Brasil.;

i- Pesquisa Nacional de Saúde do Escolar, edição 2012 – PeNSE 2012;

j– Estudo em Maringá/PR – Aprovado pelo Comitê de Ética em Pesquisa com Seres Humanos do Centro Universitário de Maringá.;

k– Níveis de atividade física, aptidão física e comportamento social relacionados à saúde em escolares de Florianópolis, SC.;

l- Consumo dietético e AF como determinantes das mudanças do IMC de uma coorte de adolescentes matriculados da rede pública de ensino da cidade de Piracicaba/SP.;

m– Estudo em Caruaru/PE – protocolo do Comitê de Ética em Pesquisa com Seres Humanos da Faculdades ASCES: 44/2007.;

n– Physical activity practice and health risk behaviors in high school students in the State of Pernambuco: a temporal trend study.;

o– Estudo em Maceió-AL – Aprovado pelo Comitê de Ética do Hospital Universitário da Universidade Federal de Alagoas.;

p– Estudo em Aracajú/SE – Aprovado pelo Ethics Committee on Human Research of the Federal University of Sergipe.

Table 2 Description of prevalence of physical activity (%) in studies including Brazilian children and adolescents. 

Reference Local Definition Prevalence of Physical Activity
All Boys Girls
Abreu and Caiaffa82 National IPAQ version 8 definition. 66.0% n.a. n.a.
Alves Júnior et al.a 40 São José, SC >60 min./day of MVPA 22.9% n.a. n.a.
Andaki et al.85 Viçosa, MG >60 min./day of MVPA n.a. 68.1% 36.7%
Andrade Neto etal.86 Santa Maria de Jetibá, ES Vitória, ES >300 min./weekof MVPA 18.4% Urban area: 75.5%
Rural area: 90.8%
Urban area: 69.2%
Rural area: 84.6%
Arruda and Lopes87 Lages, SC >39,9 kcal/kg/day 58.8% n.a. n.a.
Barros et al.# 66 Recife, PE >60 min./day of MVPA 34.0% 40.1% 29.8%
Bastos, Araújo and Hallal# 63 Pelotas, RS >300 min./week of MVPA 30.2% 43.5% 17.9%
Beck et al.# 45 Três de Maio, RS >300 min./weekof MVPA 38.8% 47.6% 30.6%
Bergmann et al.b $ 16 Uruguaiana, RS PAQ-C / PAQ-A: (4 and 5 points) 08.3% n.a. n.a.
Campos et al.# 46 Curitiba, PR >37 kcal/kg/dia n.a. 82.7% 77.4%
Carvalho et al.# 77 Northeast IPAQ short version; definition. 69.8% n.a. n.a.
Cavalcanti et al.c 67 Recife, PE >60 min./day of MVPA 5.3% 4.1% 6.5%
Ceschini, Andrade and Figueira Júnior36 São Paulo, SP >300 min./week of MVPA 36.1% 39.4% 32.2%
Ceschini et al.# 88 São Paulo, SP >300 min./week of MVPA 37.5% 50.3% 25.9%
Coelho et al.89 Ouro Preto, MG >300 min./week of MVPA 29.2% (6-9 years old).
70.8% (10-14 years old)
n.a. n.a.
Cureau et al.# 26 Santa Maria, RS >300 min./week of MVPA 46.5% n.a. n.a.
Dambros, Lopes and Santos# 47 Santa Maria, RS >300 min./week of MVPA n.a. 75.0% 60.0%
Dumith et al.20 Caracol, PI >60 min./day of MVPA 12.6% 20.2% 05.9%
Farias Júnior# 14 Florianópolis, SC >37 kcal/kg/day 37.4% 48.6% 26.5%
Farias Júnior# 78 João Pessoa, PB >37 kcal/kg/day n.a. 54.5% 35.8%
Farias Júnior etal.e# 11 Santa Catarina >300 min./week of MVPA 63.5% 73.9% 56.3%
Farias Júnior et al.g 79 João Pessoa, PB >300 min./week of MVPA 50.2% 66.3% 38.5%
Farias Júnior etal.g 69 João Pessoa, PB >300 min./week of MVPA 50.2% 66.3% 38.5%
Farias Júnior et al.g 73 João Pessoa, PB >300 min./week of MVPA 20.1% (simplified)
50.2% (detailed)
28.3% (simplified);
66.3% (detailed)
14.1% (simplified);
38.5% (detailed)
Farias Júnior, Reis and Hallalg 70 João Pessoa, PB >300 min./week of MVPA n.a. 66.3% 38.5%
Fermino et al.h 49 Curitiba, PR >60 min./day of MVPA 14.5% 22.3% 09.1%
Freire et al.90 Montes Claros, MG Frequency of physi-cal activity practice (“always”/“frequently”). 45.2% n.a. n.a.
Guilherme et al.# 37 Paranavaí, PR >300 min./week of MVPA n.a. 46.9% 53.1%
Hallal et al.d 84 National >300 min./week of MVPA 43.1% 56.2% 31.3%
Leão et al.f 19 Aracajú, SE PAQ-C / PAQ-A: (4 and 5 points) 10.6% n.a. n.a.
Legnani et al.# 56 Foz do Iguaçú, PR >60 min./day of MVPA n.a. 21.7%& 22.1%&
Leites, Bastos and Bastos# 57 Porto Alegre, RS >300 min./week of MVPA n.a. Boys
10-12 years old:
44.0%
13-15 years old:
45.6%
16 -19 years old:
33.5%
Girls
10-12 years old:
20.3%
13-15 years old:
20.8%
16 -19 years old:
14.2%
Lima et al.h 64 Curitiba, PR >60 min./day of MVPA 14.3% 21.7% 09.2%
Lima and Silvaa 41 São José, SC >60 min./day of MVPA 22.8% 27.6% 18.8%
Loche # 10 Santa Catarina >300 min./week of MVPA 70.0% 79.0% 63.1%
Lucena et al.g 71 João Pessoa, PB >300 min./week of MVPA 50.2% 66.3% 38.5%
Malta et al.d 83 National >300 min./week of MVPA 43.1% 56,2% 31,3%
Malta et al. 32 National >60 min./day of MVPA Actives:
White (20.5%); Black (20.5%); Yellow (20.1%); Brown (19.6%); Indigenous (22.5%)
n.a. n.a.
Martins, Lima and Silvaa 42 São José, SC >60 min./day of MVPA % Actives: Poor Self-rated health (34.2%). Good Self-rated health (51.4%). n.a. n.a.
Matsudo et al.$ 102 São Paulo IPAQ definition n.a. 61.4% 50.5%
Meireles et al.91 Belo Horizonte, MG >300 min./week of MVPA 49.4% n.a. n.a.
Mendonça and Farias Júniorg 72 João Pessoa, PB >300 min./week of MVPA 50.2% 66.3% 38.5%
Mendonça et al.g 80 João Pessoa, PB >300 min./week of MVPA 50.2% 66.3% 38.5%
Menezes and Duarte# 21 Sergipe >60 min./day of MVPA 22.5% 29.0% 14.0%
Moraes et al.j # 59 Maringá, PR >300 min./week of MVPA 43.1% 44.3% 42.1%
Moraes and Falcão# 58 Maringá, PR >60 min./day of MVPA n.a. 44.0% 42.1%
Nakamura et al.92 Rio Claro, SP PAQ-C / PAQ-A: (4 and 5 points) 17.4% 26.8% 09.4%
Nascente et al.22 Goiânia, GO >300 min./week of MVPA 33.2% n.a. n.a.
Nascimento-Ferreira et al.103 Imperatriz, MA >60 min./day of MVPA 45.6% 42.7% 69.2%
Nunes et al.a 43 São José, SC >60 min./day of MVPA 22.7% 27.7% 18.7%
Pelegrini and Petroskik 60 Florianópolis, SC >300 min./week of MVPA n.a. Actives:
14 years = 78.6%;
15 years = 67.3%;
16 years = 84.8%;
17 years = 77.2%;
18 years = 90.0%
Ativas:
14 years = 57.1%;
15 years = 76.4%;
16 years = 76.2%;
17 years = 71.6%;
18 years = 59.1%.
Pereira, Bergmann and Bergmannb $ 17 Uruguaiana, RS PAQ-C / PAQ-A: (4 and 5 points) 08.3% n.a. n.a.
Peres et al.l 93 Piracicaba, SP >300 min./week of MVPA n.a. Overweight: 92.5%; Eutrophic: 93.1% Overweight: 78,9%; Eutrophic: 84,1%
Petribú et al.m 74 Caruaru, PE >60 min./day of MVPA Overweight individuals: 15.6%
Obese individuals: 3.8%
n.a. n.a.
Prado et al.h 53 Curitiba, PR >60 min./day of MVPA 14.5% 22.2% 09.2%
Quadros et al.# 23 Amargosa, BA 16,000 and 13,000 steps/ day for boys and girls (respectively). 35.7% n.a. n.a.
Raizel et al.# 24 Cuiabá, MT >60 min./day of MVPA 18.0% 31.0%* 09.0%*
Regis et al.n 25 Pernambuco >60 min./day of MVPA Urban area: 34.5%
Rural area: 37.3%
n.a. n.a.
Reichert et al.61 Pelotas, RS >60 min./day of MVPA 61.3% 69.8% 52.1%
Reis et al.h 54 Curitiba, PR >60 min./day of MVPA n.a. 21.7% 09.1%
Rezende et al. 33 Nacional >60 min./day of MVPA 29.0% 38.6% 20.1%
Rivera et al.o * 12 Maceió, AL >60 min./day of MVPA 06.5% n.a. n.a.
Rodrigues et al.81 Cuiabá, MT >300 min./week of MVPA 40.5% n.a. n.a.
Romanzini et al.# 55 Londrina, PR >300 min./week of MVPA 60.8% 66.7% 57.2%
Romero et al .l 94 Piracicaba, SP >300 min./week of MVPA 45.1%# n.a. n.a.
Salvador, Kitoko and Gambardella95 Vitória, ES 5+ hours per week of PA Normal weight: 79.2%;
overweight: 20.8%
n.a. n.a.
Santos et al.h 51 Curitiba, PR >60 min./day of MVPA n.a. 22.0% 09.1%
Santos et al.35 Uberaba, MG >60 min./day of MVPA 55.1% n.a. n.a.
Santos et al.n 96 Pernambuco >60 min./day of MVPA 35.1% 43.9% 29.2%
Santos et al.c 31 Pernambuco >60 min./day of MVPA 34.9%# 42.3% 29.8%
Silvai 34 National >60 min./day of MVPA n.a. 27.9% 13.1%
Silva and Silvap 28 Aracajú, SE >60 min./day of MVPA 18.1% 26.8% 12.9%
Silva et al.o # 13 Maceió, AL PAQ-C / PAQ-A: (3 to 5 points) 06.5% n.a. n.a.
Silva et al.e # 8 Santa Catarina >300 min./week of MVPA n.a. 78.9% 63.0%
Silva et al.97 Aracajú, SE PAQ-C / PAQ-A: (4 and 5 points) n.a. 2.0% 0.3%
Silva et al.e 9 Santa Catarina >300 min./week of MVPA 71.5% 72.1%# 71.2%#
Silva et al.p 18 Aracajú, SE >60 min./day of MVPA n.a. 27.2% 12.6%
Silva et al.# 27 Santa Catarina >300 min./week of MVPA n.a. 39.3% 23.7%
Silva et al.64 Ponta Grossa, PR >300 min./week of MVPA 92.3% n.a. n.a.
Silva et al.k 65 Florianópolis, SC >300 min./week of MVPA 68.2% 79.6% 71.6%
Silva et al.$ 15 Arapiraca, SE 37 or more points in the instrument score. 10.9%# n.a. n.a.
Silva, Silva and Oliveiraf 18 Aracajú, SE PAQ-C / PAQ-A: (3 to 5 points) n.a. 20.6% 04.8%
Silva, Smith-Menezes and Duarte29 Sergipe >300 min./week of MVPA 22.5% 18.4% 29.0%
Souza98 Canoas, RS >300 min./week of MVPA 47.7% n.a. n.a.
Souza et al.# 76 Salvador, BA >300 min./week of MVPA n.a. 72.0% 50.0%
Souza et al.h 52 Curitiba, PR >60 min./day of MVPA 14.5% 21.6% 09.6%
Straatmann and Veiga99 Niterói, RJ IPAQ short version: active= very active and active n.a. 69.1% 54.7%
Suné et al.$ 62 Capão da Canoa, RS 6 or more points in instrument score. 21.2% n.a. n.a.
Tassitano et al.m # 75 Caruaru, PE >60 min./day of MVPA 58.3% 77.2% 46.9%
Tenório et al.c # 68 Pernambuco >60 min./day of MVPA 34.9% 42.3% 29.8%
Normal weight:
Vieira et al.100 Natal, RN >300 min./week of MVPA 46.9%.overweight: n.a. n.a.
50.0%
Vitta et al.101 Bauru, SP PAQ-C / PAQ-A: (3 to 5 points) 23.5% 44.6% 18.7%

Note. States of Brazil: AL: Alagoas; BA: Bahia; DF: Distrito Federal; ES: Espírito Santo; GO: Goiás; MA: Maranhão; MG: Minas Gerais; MT: Mato Grosso; PB: Paraíba; PE: Pernambuco; PI: Piauí; PR: Paraná; RJ: Rio de Janeiro; RN: Rio Grande do Norte; RS: Rio Grande do Sul; SC: Santa Catarina; SE: Sergipe; SP: São Paulo n.a.: not avaliable.

a- Brazilian Guide for Evaluation of Health-Related Physical Fitness and Life Habits - Stage I;

b- Estudo em Uruguaiana/RS - protocol do Comitê de Ética em Pesquisa: 042/2010;

c- Estilos de Vida e Comportamentos de Risco à Saúde em Estudantes do Ensino Médio no Estado de Pernambuco;

d- Pesquisa Nacional de Saúde do Escolar, edição 2009 - PeNSE 2009;

e- Estilo de Vida e Comportamentos de Risco dos Jovens Catarinenses, edição 2001 - COMPAC 2001;

f- Estudo em Sergipe - protocolo do Comitê de Ética em Pesquisa da Universidade Federal de Sergipe (cEp/UFS): 5724.0.000.10710.;

g- Physical activity level and associated factors among high school adolescents in João Pessoa, city, - PB: an ecological approach.;

h- Determinantes da Atividade Física e Obesidade em Escolares do Ensino Médio da Rede Pública da Cidade de Curitiba, Paraná, Brasil.;

i- Pesquisa Nacional de Saúde do Escolar, edição 2012 - PeNSE 2012;

j- Estudo em Maringá/PR - Aprovado pelo Comitê de Ética em Pesquisa com Seres Humanos do Centro Universitário de Maringá.;

k- Níveis de atividade física, aptidão física e comportamento social relacionados à saúde em escolares de Florianópolis, SC.;

l- Consumo dietético e AF como determinantes das mudanças do IMC de uma coorte de adolescentes matriculados da rede pública de ensino da cidade de Piracicaba/SP.;

m- Physical activity practice and health risk behaviors in high school students in the State of Pernambuco: a temporal trend study.;

n- Estudo em Caruaru/PE - protocolo do Comitê de Ética em Pesquisa com Seres Humanos da Faculdades ASCES: 44/2007.;

o- Estudo em Maceió-AL - Aprovado pelo Comitê de Ética do Hospital Universitário da Universidade Federal de Alagoas.;

p- Estudo em Aracajú/SE - Aprovado pelo Ethics Committee on Human Research of the Federal University of Sergipe.

$%very active + %active;

#Calculated prevalences of physical activity: 100% - % of physical inactivity (original information provided in the articles);

&Data from brazilian adolecents;

*Scores 3, 4 and 5 summed.

RESULTS

The initial database search identified a total of 3276 potential studies (2534 titles after duplicate analysis). Another 15 references were included based on the search in the reference lists of studies. After the title and abstract screening, 2284 references were excluded, and 265 references were taken forward to the full-text screening. In the full-text analysis, 147 references were excluded (exclusion reasons detailed in Figure 1), and 92 met the inclusion criteria (which included data from 62 different studies).

Figure 1 Search process results according PRISMA flow diagram 

Included studies were carried out between 2001814 and 201515; most of them were performed in 2011 (12 studies)16,17,2631,1825. Twenty studies were performed between 2011 and 201515,16,2534,17,3543,1824. Most of included studies were located in the South and Northeast regions of Brazil: 22 (35.5%)8,9,4049,10,5059,11,6065,14,16,17,26,27,37 and 19 (30.6%)9,12,29,31,38,39,6671,13,7280,1821,23,25,28 studies, respectively. Fifteen studies (24.2%) were performed in the Southeast region, and three studies (4.8%)22,24,81 were conducted in the Center-West region. No included reference was from the Northern region of Brazil. Three included studies were national surveys (4.8%); one provided data from 17 capitals and the Federal District82 and the other two studies provided data from all of the 26 Brazilian capitals and the Federal District (National Survey of School Health)3234,83,84 (see Table 1).

Almost all studies (n = 59) were school-based surveys8,9,18-27,10,28,29,31-37,39,11,40-43,45-47,49-51,12,52-60,62,13,63-72,14,73-81,83,15,84-93,16,94-101,17. Three 61,82,102 were population-based studies. In terms of age, three (4.9%) studies included 6-10 year-old children29,85,86,52 (85.2%) studies included 10-19 year-old adolescents8,9,21,22,24-31,10,32-34,36-42,11,43,45-47,49-54,14,55-64,16,65-74,17,75,76,78-84,87,18,88,90-94,96-99,19,101,102,20, and six (9.8%) studies included individuals from both age groups12,13,23,35,77,89,95.

Included studies presented 18 different instruments for physical activity measurement. Nineteen studies did not report the instruments used, and from these, only six studies reported information that the used instruments were validated10,19,47,63,71,76,78,86. The most used instruments were: the International Physical Activity Questionnaire (IPAQ, 12 studies)22,36,88,99,102,55,59,60,64,65,76,77,82, the Global School-Health Survey instrument (GSHS, 8 studies)11,21,66-68,79,84,96,24,25,29,32,37,41,42,56, and the Physical Activity Questionnaire for Older Children and Adolescents (PAQ-C and PAQA, 10 studies)12,13,97,101,16-18,31,39,58,72,92. Finally, one study used pedometermeasured physical activity23 and one study used accelerometer-measured physical activity61 (Table 1).

The physical activity level was defined differently among the studies. The most used definition was based on the global recommendations for physical activity and health: the cut-off point of ≥ 300 minutes/week of moderate-to-vigorous physical activity was used in 26 studies8,10,45,47,55,57,59,60,63,64,69,70,11,71-73,76,79-81,83,84,86,22,88,89,91,93-95,97,98,26,27,29,36-38, and 17 studies20,21,39-43,49-53,24,54,56,58,61,65-68,74,75,25,85,96,28,31-35 used the cut-off point of ≥ 60 minutes/day of moderate-to-vigorous physical activity (Table 1).

The overall proportion of young people who were physically active ranged from 6.5%12 to 92.3%64. Considering the estimate of 41 studies8,9,25,27-29,31-34,36,37,10,45-47,49-55,11,56-61,63,65-67,14,68-76,78,18,79,80,83-86,88,92-94,19,96,97,99,101-103,20,21,24 that provided gender-stratified data, the prevalence of being physically active ranged from 0.3%9 to 84.6%86 in girls, and from 2.0%9 to 93.1%93 in boys. Fourteen studies (22.6%) demonstrated a proportion of active individuals ≥ 50%8,9,65,69-75,77,79,10,80,82,87,89,95,11,35,38,55,60,61,64. Among the three nationwide surveys included in this review, the proportions of physically active young people were 66.0% (Cancer National Institute - 2002/2003)82, 43.1% (National Survey of School Health-2009)84 and 29.0% (National Survey of School Health-2012)33 (Table 2).

Considering the results of adolescents according to age groups, the proportion of physically active children (up to 6-10 year-olds exclusively) ranged from 10.9%15 to 29.2%89. Studies with adolescents exclusively (10 years or older) presented proportions that ranged from 8.3%17 to 92.3%64 (Table 2).

Included studies that used the cutoff point of ≥ 300 minutes/week of moderate-to vigorous physical activity presented proportions of physically active individuals that ranged from 18.4%86 to 92.3%64. Studies using the cutoff point of ≥ 60 minutes/day moderate-to vigorous physical activity presented proportions of physically active individuals that ranged from 12.6%20 to 68.2%65. Studies using the cut-off score for PAQ-C/PAQ-A scores presented proportions ranging from 6.5%12 to 23.5%101. Studies that used the cutoff point of the IPAQ short presented proportions varying from 66.0%82 to 69.8%77.

Regarding objective measurements of PA, the population-based study that used accelerometers61 was conducted in South Brazil with 457 adolescents who were 12-14 years old. This study found overall prevalence of physically active of 61.3%61. A school-based study with 1139 6-8-year-old students from Northeastern Brazil the used pedometer-measured physical activity found an overall prevalence of 35.7% physically active individuals23 (Table 2).

Trends in the prevalence of physical activity were observed in three studies, which presented two waves of data collection. The National School Health Survey (2009 and 2012) described percentages of physically active students of 43.1% in 200983,84 to 29.0% in 201233. However, the number of questions used to define physical activity level was different between these surveys. The Health Risk Behaviors Project (COMPAC study, a study in Santa Catarina state) showed a prevalence of physically active boys and girls of 72.1% and 71.2% in 20019, and 39.3% and 23.7% in 2011, respectively27. A statewide survey in Pernambuco state presented the prevalence of physically active students of 34.9% in 200631,68 and 35.1% in 201196.

DISCUSSION

The objective of this systematic review was to synthesize the studies on the prevalence of physical activity in children and adolescents in Brazil. Our findings showed that there was a wide range between studies in the prevalence of physically active children and adolescents. However, thirty-five studies found a prevalence of physically active children and adolescents lower than 50%12,13,23-31,36,14,40-43,45,49-53,16,54,56-59,62,63,66-68,17,81,90-92,96-98,101,18-22, including two National School Health Surveys33,84. Thus, it seems that increasing physical activity practices among Brazilian children and adolescents is a priority.

The large variability between studies in prevalence rates may be explained by the distinctions in the instruments/questionnaires used. Recording period, instrument structure, wording of questionnaires, physical activity domains included, and cutoff points were aspects that varied between surveys (Table 1). For example, Farias Júnior et al.73 found that estimates of physically active adolescents using simplified and detailed instruments, can have a relative difference of 100% or higher. Subjective measures of physical activity are still predominantly used in epidemiological research in Brazil104 and other low- and middle-income countries due to the context of where the data is recorded and the low operational costs involved105. However, it is important that future studies consider developing and using validated and reliable instruments for physical activity measurement in epidemiological surveys in Brazil.

Inversely, this systematic review included only two studies with objectively-measured physical activity23,61. In Brazil, the high cost of objective measures of physical activity can still be a barrier to their use in comprehensive survey studies. Another obstacle to be overcome for optimizing the use of objective instruments, in particular accelerometers, is the problematic comparability between different models and outputs106. Comprehensive surveys using objectively-measured physical activity (e.g., accelerometers) are still on the rise in Brazil, and well-designed studies should be developed in order to reduce comparability issues of physical activity data.

Most of studies in Brazil highlighted physical activity distinctions for boys and girls, which was similar to the global estimate107. However, when considering age groups, no studies were found that investigated the prevalence of physically active preschool children (under 6 years old). An explanation for this result may be that the measurement of physical activity with subjective instruments is unreliable and most of questionnaires were not validated for younger children.

The results of this systematic review highlighted other trends in the research on physical activity prevalence in Brazil. Since 2001, there has been an increase in research on physical activity in children and adolescents with a concomitant evolution of the robustness of the studies developed in the Brazilian scientific community. This is also supported by two versions of the National Survey of School Health (2009 and 2012), which provided information for the Surveillance System for Risk Factors for Non-communicable Chronic Diseases 34,84. These results reflect the emphasis on epidemiological surveys in the Brazilian physical activity research agenda during this period.

The results showed that most of the studies were carried out in South and Northeast regions of Brazil. Previous systematic reviews104,108 found a large number of studies on physical activity and health in the South and Southeast regions of Brazil. Thus, a positive finding in the current review was the relevant number of included studies in Northeastern Brazil. This may be related to the number of research groups and graduate programs in Physical Education in this region of Brazil, which can stimulate new and well-designed research practices for studies in these areas. However, the development of studies in the Northern region of Brazil is urgent, because no studies of this region were included in the current review and physical activity promotion strategies for young populations in the Northern area need to consider context-specific needs and peculiarities. Research groups focused on physical activity and health should be stimulated and integrated with other multicenter studies to promote best research practice for studies on physical activity and health in this region.

This systematic review is important because research on the physical activity level of Brazilian children and adolescents was presented with new evidence in comparison to previous reviews of this topic109. Also, gaps and recommendations for studying physical activity were highlighted. However, a large variability in the measurement of physical activity between studies limited the possibilities of a quantitative synthesis (meta-analysis) of the physical activity prevalence rates from all studies and of a discussion of other relevant aspects of physical activity in Brazil, such as secular trends.

CONCLUSION

The current review found that there was great variability in the measurement of physical activity and cut-off points among the studies with children and adolescents in Brazil. The large range of physical activity prevalence was something remarkable in this review. However, 35 studies found a prevalence of physically active children and adolescents lower than 50%. Thus, it seems that physical activity practices among Brazilian children and adolescents is still a challenge for the country. Important research gaps (e.g., studies with objectively-measured physical activity, children aged up to 6 years old and in Northern Brazil) should be considered when developing new research studies in Brazil.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This study was funded by the authors.

Conflict of interest statement

The authors have no conflict of interests to declare.

SUPPLEMENTARY FILE

Example of descriptors used during the database search. 

Number Groups Descriptors
#1 Physical activity (outcome) (“physical activity” [Text Word] OR “motor activity” [MeSH Terms] OR “physical exercise” [Text Word] OR exercise [MeSH Terms] OR “exercise program” [Text Word] OR sports [MeSH Terms] OR sport [Text Word] OR leisure activit* [Text Word] OR recreation [Text Word])
#2 Evaluation methods (self-report OR checklist OR recall OR 24h OR interviews OR questionnaire OR diary OR assessment OR survey OR measurement OR Acceleromet* OR pedomet OR inclinomet OR (objectiv* AND measur*) OR (direct* AND measure*))
#3 Population (young people) (youth [Text Word] OR teenage [Text Word] OR adolescent [MeSH Terms] OR adolescent [Text Word] Or adolescence [Text Word] OR students [MeSH Terms] Or student [Text Word] OR child [Text Word] OR children [Text Word] OR “young people” [Text Word])
#4 Context (country) (Brazil* OR Brazilian)
Final search #1 AND #2 AND #3 AND #4

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Received: April 25, 2018; Accepted: July 15, 2018

Valter Cordeiro Barbosa FilhoFederal Institute of Education,Science and Techonology of Ceará, Boa ViagemCampus. Rod. Pres. Juscelino Kubitschek, Boa Viagem - CE, 63870-000, BrazilE-mail: valtercbf@gmail.com

Author Contributions

VCBF participated in the methodological design, search and evaluation of studies, writing the text and approved the final version of the manuscript. RMC, MCTGK, BNO and CBA participated in the methodological design, study search and selection, data extraction and synthesis, writing the text and approved the final version of the manuscript. KSS participated in the methodological design, evaluation of studies, writing the text and approved the final version of the manuscript.

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