Prevalence of meeting 24-hour movement guidelines and its associations with health indicators in people with disabilities: A systematic review and meta-analysis

doi:10.21203/rs.3.rs-3272045/v1

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Systematic Review

Prevalence of meeting 24-hour movement guidelines and its associations with health indicators in people with disabilities: A systematic review and meta-analysis

https://doi.org/10.21203/rs.3.rs-3272045/v1

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published 29 Feb, 2024

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Background

Meeting the 24-hour movement guidelines (i.e., physical activity, sedentary behavior, sleep) could generate health benefits to people with disabilities. However, no systematic reviews or meta-analyses have examined the prevalence of meeting these guidelines and associations with health indicators in this group. The purpose of this systematic review and meta-analysis was therefore to examine the prevalence of meeting the 24-hour movement guidelines and associations with health indicators among people with disabilities.

Methods

Major databases including PubMed, SPORTDiscus, Web of Science, PsycINFO, Embase, and Scopus were searched for studies published in English from inception to May 31, 2023. Studies reporting on the prevalence of meeting overall 24-hour movement guidelines or each of the 3 guidelines in people with disabilities were included. Meta-analyses with the random-effects model were used to determine the prevalence of meeting overall and individual 24-hour movement guidelines. Qualitative syntheses were employed to describe the associations between meeting the guidelines and health indicators.

Results

Twenty-four cross-sectional studies comprising 77510 participants (41.6% females) with disabilities aged 6–65 years from 8 countries were identified. Overall, 6.97% of the participants with disabilities met all three 24-hour movement guidelines, and 16.65% met none of the guidelines. Children and adolescents with disabilities had significantly lower prevalence of meeting all 3 guidelines (5.10%) than that of adults with disabilities (16.49%; P = 0.006). Participants with sensory impairments had significantly higher overall prevalence (13.89%) than those with neurodevelopmental disorders (4.67%; P = 0.001). The findings of qualitative synthesis generally indicated that people with disabilities who met all 3 guidelines reported better psychosocial health indicators such as social relationship and quality of life (9/9 studies) than those met none or only 1 of the guidelines. There was limited evidence or research for other health indicators (e.g., adiposity).

Conclusion

There is some evidence showing that the prevalence of meeting all three 24-hour movement guidelines in people with disabilities is low, particularly in groups of children and adolescents and neurodevelopmental disorders. Meanwhile, there is preliminary evidence suggesting that meeting all 3 guidelines is associated with better psychosocial health than meeting none of the guidelines. More studies are needed to provide further evidence.

Sports Medicine and Kinesiology

Physical activity

Screen time

Sleep

Well-being

Disability

Much of the current research on movement behaviors has focused on moderate-to-vigorous physical activity, which accounts for only a small proportion (< 5%) of human activity throughout the 24-hour day cycle.¹ In contrast, sleep and sedentary behavior account for approximately 80% of the 24-hour day.¹ Within a 24-hour period, an increase of time in one of these 24-hour movement behaviors (i.e., physical activity, sedentary behavior, sleep) will inevitably reduce the time of the other 2 behaviors to varying degrees. Additionally, previous studies have shown that each of the 24-hour movement behaviors is strongly associated with various health indicators, but these studies have explored single movement behavior instead of using an integrative approach/perspective.^2–4 In recent years, researchers have started to pay great attention to the interdependence of the 24-hour movement behaviors.^{5, 6} In 2016, the first 24-hour movement guidelines for children and adolescents aged 5–17 years were published in Canada,⁷ and subsequently the guidelines for other age groups such as the early childhood (0–4 years) and adults (18–64 years and over 65 years) were published.^{8, 9} For instance, within a 24-hour timeframe, Tremblay and colleagues⁷ suggest that children and adolescents should accumulate at least 1 hour of moderate-to-vigorous physical activity per day, less than 2 hours of recreational screen time, and have 9–11 hours (5–13 years) or 8–10 hours (14–17 years) of sleep.

Currently, adherence rates with the 24-hour movement guidelines in nondisabled people is concerning. That is, a survey based in 12 countries found that only 7.2% of children met all three 24-hour movement guidelines, while 18.9% met none, and adherence to physical activity, screen time, and sleep guidelines was 44.1%, 39.3% and 41.9%, respectively.¹⁰ Similarly, a meta-analysis of 387,437 participants from 23 countries found that only 7.12% of children and adolescents met all 3 guidelines, 19.21% did not meet any of the guidelines, and there were age and gender differences in prevalence of meeting the guidelines.¹¹ Meanwhile, researchers have also explored the health benefits of meeting the 24-hour movement behaviors.^{12, 13} For example, several studies employing correlational analyses have found that people who met more than 2 guidelines had higher cognitive function, better mental health, and lower all-cause mortality than those who did not meet any of the guidelines.^14–16 Employing compositional data analysis, researchers found that substituting sedentary behavior with physical activity was favorably associated with lower body mass index (BMI) as well as better motor competence and cardiometabolic health.^17–19 These findings speak the importance of adhering to the 24-hour movement guidelines among nondisabled people.

A number of sociodemographic groups have been identified as being at particular risk for low adherence with the 24-hour movement guidelines. For example, people with disabilities tend to engage in inadequate physical activity and sleep,^{20, 21} and excessive sedentary time,²² which may lead to adverse physical and psychological health, such as obesity²³ and mental health problems.²⁴ While most research, to date, has explored these 3 movement behaviors separately among people with disabilities, increased attention has been paid to examine them simultaneously through the 24-hour movement behaviors framework to understand adherence levels and potential multiplicative benefits of meeting more than 1 guideline.^{25, 26} For example, Li and colleagues²⁷ investigated adherence to the 24-hour movement guidelines and its relationship with health indicators among 1,165 adolescents with autism spectrum disorders (ASD) in 7 countries/regions, and found that only 2% of the participants met all 3 guidelines and 21.5% of them met none of the guidelines. Within this study, participants who met all 3 guidelines had lower BMI, higher quality of life and better general health than those met none of the guidelines.²⁷ Haegele and colleagues found similar results in adults with visual impairments, where only 18.6% of the participants met all three 24-hour movement guidelines, and this group of participants had higher levels of health-related quality of life compared to those who met none.²⁵ These findings highlight the concept of “the whole day matters”, and that the three 24-hour movement behaviors seem to be as important for health promotion among people with disabilities as they are for nondisabled peers.

To date, there has been no systematic review or meta-analysis that, to our best knowledge, has comprehensively examined the prevalence of meeting the 24-hour movement guidelines and its relationships with health indicators in people with disabilities. Synthesizing related findings across individual studies may help researchers, policymakers and health practitioners to understand the current evidence base, which can have significant implications for future research, health surveillance and early intervention for people with disabilities. Therefore, the present systematic review and meta-analysis was conducted to (a) assess the prevalence of meeting the overall and individual 24-hour movement guidelines, and (b) examine the associations between meeting 24-hour movement guidelines and health indicators in people with disabilities.

2.1. Protocol and registration

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement²⁸ and was registered in the International Prospective Register of Systematic Reviews (no. CRD42023420298).

2.2. Information sources and search strategy

Two researchers (JH, XL) searched six electronic databases including PubMed, PsycINFO, Scopus, Web of Science (core collection), SPORTDiscus, and Embase from their inception to May 31, 2023. Studies were identified using the following groups of search terms: (a) disability OR disabilities OR disabled OR impairment OR impaired OR “special needs”; (b) “physical activit*” OR sport* OR exercise OR “active play”; (c) sedentary OR sitting OR inactive OR “screen time” OR screentime; (d) sleep; and (e) (“movement behavio*” OR 24-h*) AND (guideline* OR recommendation*). Detailed search strategies are presented in Table S1. Additionally, reference lists of systematic reviews on the 24-hour movement guidelines and original studies included in this review were screened to identify potential studies further.

2.3. Eligibility criteria

Studies were included if they met the following criteria: (a) participants were identified as having a disability (e.g., ASD, intellectual disability [ID]); (b) the prevalence of all three 24-hour movement guidelines and/or the 3 individual guidelines were reported; (c) experimental or observational studies (e.g., cohort, cross-sectional); and (d) English peer-reviewed journal articles. Studies were excluded if: (a) participants were not reported as having a disability; (b) they did not report the prevalence of meeting overall 24-hour movement guidelines or the 3 individual guidelines; (c) they were qualitative studies, case studies, reviews, or conference abstracts; or (d) they were not published in English.

2.4. Selection process

All search records were imported into Endnote X9 (Thomson Research Soft, Stanford, CA, USA) to delete duplicate studies. Two researchers (JH, XL) then independently screened potentially relevant studies through title and abstract. Lastly, they conducted a full-text review of the remaining articles to identify eligible studies. Any disagreements in the selection process were resolved through negotiation with the third researcher (CL).

2.5. Data extraction

The following information of the included studies was extracted and summarized using Microsoft Excel 2019 (MicrosoftCorp, Redmond, WA, USA): first author, publication year, study design, country, sample size, age and sex of participants, method of measurement of the three 24-hour movement behaviors and health indicators. Meanwhile, prevalence of meeting all 3 guidelines, meeting each of the individual guidelines, and meeting no guidelines were extracted (see Table S2). In addition, these data were classified according to age group, geographical region, and disability type (see Tables S3-S5). One researcher extracted the information (JH), which was verified by another (XL). Any discrepancies in this process were resolved by discussion with the third researcher (CL).

2.6. Methodological quality assessment

The methodological quality of the included studies was assessed using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-sectional Studies.²⁹ The tool has been used for assessing the methodological quality of longitudinal and cross-sectional studies that examine the prevalence of meeting the 24-hour movement guidelines.^{11, 30} This tool consisted of a total of 14 items for evaluating methodological quality of longitudinal studies, of which 10 were for cross-sectional studies (see Table S6). Each item was scored as “yes” (1 point), “no” (0 point), “not reported” or “not applicable”. Of note, an item was considered “not reported” if there was an insufficient or unclear description, and a “not applicable” score was assigned when it was not possible to apply the criteria. The maximal possible score was 14 points for longitudinal studies and 10 for cross-sectional studies. Longitudinal studies were divided into 3 quality levels: high quality (> 9), moderate quality (4–9), and low quality (< 4); and for cross-sectional studies: high quality (> 7), moderate quality (3–7), and low quality (< 3).¹¹ Two researchers (JH, XL) independently assessed the study quality of the included studies, and any discrepancies were resolved in consultation with the third researcher (CL).

2.7. Data synthesis

The metaprop procedure³¹ in the Stata 17.0 software (StataCorp, College Station, TX, USA) was used to perform the meta-analysis. The outcomes included prevalence of meeting the 24-hour movement guidelines as well as the associations between meeting guidelines and health indicators. As the data on the associations were insufficient and heterogeneous (see Results) for conducting meta-analysis, a qualitative synthesis was used. The random-effects model with the DerSimonian and Laird method was applied to pool the prevalence of multiple studies.³¹ The 95% confidence intervals (95% CIs) for prevalence were established using the exact or Clopper-Pearson method,³² and the results were normalized through the Freeman-Tukey double arcsine transformation before calculating the pooled prevalence.³³ The degree of heterogeneity in the pooled prevalence was assessed using the I² statistic. Heterogeneity levels were categorized as low (< 25%), moderate (25–75%) or high (> 75%), respectively.³⁴ Publication bias was examined using the Doi plot and the Luis Furuya-Kanamori (LFK) index, an improved graphical and quantitative method for detecting bias in meta-analysis.³⁵ LFK values of < ± 1 represent no asymmetry, between − 1 and − 2 or 1 and 2 represent minor asymmetry, and > ± 2 represent major asymmetry.³⁵ Subgroup analyses were conducted by age group (children and adolescents [6–17 years] vs. adults [18–65 years]), geographical region (Asia vs. North America), and disability type (sensory impairments vs. neurodevelopmental disorders). The 2 main forms of sensory impairments are visual impairment and hearing impairment, while neurodevelopmental disorders include a wide range of disabilities involving some form of disruption to brain development, such as ASD, ID, and attention deficit/hyperactivity disorder (ADHD).^{36, 37}

3.1. Study selection

A total of 1910 records were identified through the search. After removing the duplicates, 1138 records were screened by reading the title and abstract. Subsequently, full texts of 93 records were consulted, of which 69 were excluded for several reasons. Finally, 24 studies were included in this systematic review, and all studies were included in the meta-analysis (see Fig. 1).

3.2. Study characteristics

The main characteristics of the 24 included studies are presented in Table 1. All studies were cross-sectional and were published between 2019 and 2023.^{25–27, 36, 38–57} A total of 77510 participants (female = 41.6%) aged 6–65 years were included, of whom 71879 were children and adolescents and 5631 were adults. Seventeen studies were conducted with children and adolescents only,^{26, 27, 38–45, 47, 48, 50, 51, 54, 56, 57} 6 were with adults only,^{25, 46, 49, 52, 53, 55} and 1 with both age groups.³⁶ In terms of disability type, 13 studies focused on neurodevelopmental disorders,^{26, 27, 39, 40, 43–45, 48–50, 54, 56, 57} while 7 were mainly for sensory impairments.^{25, 36, 38, 41, 46, 52, 53} Notably, 3 studies included a variety of disability types^{42, 51, 55} and 1 did not specify the type of disability.⁴⁷

Table 1

Characteristics of included studies (n = 24).
Author (year)	Country	Study design	Participants (n, %F)/Age	PA measure	ST measure	SD measure	Health indicators
Arbour-Nicitopoulos et al. (2021)³⁶	Canada	Cross-sectional	PSD (n = 54, 59.3%F); 12-21y	Self-report	Self-report	Self-report	NR
Brown et al. (2021a)⁴⁵	USA	Cross-sectional	Active epilepsy (n = 663, 50.5%F); 6-17y Inactive epilepsy (n = 526, 37.0%F); 6-17y	Proxy-report	Proxy-report	Proxy-report	Mental health disorder
Brown et al. (2021b)⁴⁴	USA	Cross-sectional	ND (n = 8554, 37.3%F); 6-17y	Proxy-report	Proxy-report	Proxy-report	Anxiety; Depression; General health
Haegele et al. (2019)³⁸	USA	Cross-sectional	VI (n = 241, 38.75%F); 6-12y VI (n = 255, 58.89%F); 13-17y	Proxy-report	Proxy-report	Proxy-report	NR
Haegele et al. (2020)⁴¹	USA	Cross-sectional	VI (n = 561, 55.9%F); 10-17y	Proxy-report	Proxy-report	Proxy-report	NR
Haegele et al. (2021a)⁴⁷	USA	Cross-sectional	Disabilities (n = 3582, 34.7%F); 10-17y	Proxy-report	Proxy-report	Proxy-report	BMI
Haegele et al. (2021b)⁴⁶	USA	Cross-sectional	VI (n = 182, 65.4%F); 44.8 ± 15.5y	Self-report	Self-report	Self-report	Depression
Haegele et al. (2022)²⁵	USA	Cross-sectional	VI (n = 195, 67.7%F); 44.81 ± 15.49y	Self-report	Self-report	Self-report	Quality of life
Healy et al. (2019)³⁹	USA	Cross-sectional	ASD (n = 507, 15.98%F); 6-12y ASD (n = 501, 19.36%F); 13-17y	Proxy-report	Proxy-report	Proxy-report	NR
Healy et al. (2020a)⁴³	Ireland	Cross-sectional	ASD (n = 36, 11.1%F); 9y	Proxy-report	Proxy-report	Proxy-report	NR
Healy et al. (2020b)⁴²	USA	Cross-sectional	CC (n = 10997, 45%F); 10-17y	Proxy-report	Proxy-report	Proxy-report	NR
Healy et al. (2021a)⁴⁸	USA	Cross-sectional	ASD (n = 46, 23.3%F); 7-19y	Accelerometer	Accelerometer	Accelerometer	BMI
Healy et al. (2021b)⁴⁹	USA	Cross-sectional	ASD (n = 361, 39.7%F); 18-50y	Self-report	Self-report	Self-report	NR
Kong et al. (2022)⁵⁰	USA	Cross-sectional	ASD (n = 956, 21.39%F); 6-17y	Proxy-report	Proxy-report	Proxy-report	Quality of life
Li et al. (2022)²⁷	7 countries	Cross-sectional	ASD (n = 1165, 24.4%F); 10-17y	Proxy-report	Proxy-report	Proxy-report	BMI; Quality of life; General health
Pan et al. (2022)⁵¹	USA	Cross-sectional	MBDD (n = 38571, 41.9%F); 6-17y	Proxy-report	Proxy-report	Proxy-report	NR
Porter et al. (2023)⁵⁵	Canada	Cross-sectional	CCD (n = 3336, 66.2%F); 21.8 ± 2.99y	Self-report	Self-report	Self-report	Mental health
Ronen et al. (2019)⁴⁰	Canada	Cross-sectional	Epilepsy (n = 163, 50.7%F); 10-17y	Self-report	Self-report	Self-report	NR
Ross et al. (2022a)⁵³	USA	Cross-sectional	Functional disabilities (n = 1070, 53.7%F); 18-65y	Self-report	Self-report	Self-report	NR
Ross et al. (2022b)⁵²	USA	Cross-sectional	VI (n = 466, 57.2%F); 18-65y	Self-report	Self-report	Self-report	NR
Taylor et al. (2023)⁵⁶	USA	Cross-sectional	ADHD (n = 3470, 30.45%F); 6-17y	Proxy-report	Proxy-report	Proxy-report	Cognitive difficulty; Social relationship
Wang et al. (2022)⁵⁴	USA	Cross-sectional	ADHD (n = 634, 29.3%F); 10-17y	Proxy-report	Proxy-report	Proxy-report	BMI; Flourishing
Xu et al. (2022)²⁶	China	Cross-sectional	ASD (n = 99, 35.35%F); 7-17y	Accelerometer	Proxy-report	Accelerometer	BMI
Xu et al. (2023)⁵⁷	China	Cross-sectional	ID (n = 319, 37.93%F); 6-17y	Accelerometer	Proxy-report	Accelerometer	BMI
Notes: NR = not reported; F = female; y = year; 7 countries = China (mainland), China (Hong Kong), Brazil, Finland, Singapore, South Korea, and USA.
Abbreviations: PA = physical activity; ST = sedentary time; SD = sleep duration; MBDD = mental, behavioral, and developmental disorders; VI = visual impairment; ASD = autism spectrum disorder; ADHD = attention deficit/ hyperactive disorder; PSD = physical and sensory disabilities; ND = neurodevelopmental disorders; ID = intellectual disability; CCD = chronic conditions and disabilities; CC = chronic conditions; BMI = body mass index.

The participants of included studies were recruited from different countries: 17 studies from the United States,^{25, 38, 39, 41, 42, 44–54, 56} 3 from Canada,^{36, 40, 55} 2 from China,^{26, 57} 1 from Ireland,⁴³ and 1 included samples from seven different countries/regions.²⁷ Regarding the measuring approach of the three 24-hour movement behaviors, physical activity was measured by proxy report (n = 13), self-report (n = 8) and accelerometer (n = 3). Similar patterns were observed for sedentary time and sleep duration. Regarding health indicators, 13 studies reported at least 1 health indicators (e.g., quality of life, obesity, mental health).^{25–27, 44–48, 50, 54–57}

3.3. Study quality assessment

Results of study quality assessment are presented in Table S6. Specifically, 21 of the included studies (87.5%) were considered to have high quality,^{25–27, 36, 38, 39, 41, 43–51, 53–57} and 3 were deemed with moderate quality.^{40, 42, 52} All the studies met the reporting criteria of research question, study population, and eligibility criteria (Items 1 to 4). In addition, no studies specified whether outcomes assessors were blinded (Item 12). Finally, only 3 studies did not adjust potential confounders related to adherence to the 24-hour movement guidelines in their statistical analysis.^{40, 42, 52}

3.4. Syntheses of results

3.4.1. Prevalence of meeting all three 24-hour movement guidelines

Among the 24 included studies, 21 studies with 29 effect sizes reported prevalence of meeting all three 24-hour movement guidelines in participants with disabilities (n = 76607). The meta-analytic results showed that the overall prevalence across the whole sample was 6.97% (I² = 97.06%; Fig. 2). The LFK index for the Doi plots suggested no significant publication bias (LFK index = -0.36; Fig. S1).

As shown in Table 2, subgroup analyses revealed that the 6–17 years group had a significantly lower overall prevalence (5.10%) than that of the 18–65 years group (16.49%; P = 0.006). In terms of geographical region, there was no significant group difference in overall prevalence between North America (8.02%) and Asia (4.63%; P = 0.405). Regarding the disability type, the overall prevalence was significantly higher in participants with sensory impairments (13.89%) than that in participants with neurodevelopmental disorders (4.67%; P = 0.001). There was substantial heterogeneity in these estimates (I² > 75%).

Table 2

Subgroup analysis for prevalence of 24-hour movement behaviors.
Types	Moderator	k (n)	Prevalence (95% CI)	I²	P value
All three guidelines	Age (year)
	6–17	24 (71337)	5.10% (4.27–5.99)	92.30%	0.006
	18–65	6 (5270)	16.49% (7.75–27.58)	98.33%
	Region
	North America	20 (75074)	8.02% (6.50–9.69)	97.65%	0.405
	Asia	6 (991)	4.63% (0.25–13.11)	95.44%
	Disability type
	Neurodevelopmental disorders	20 (18533)	4.67% (3.38–6.16)	92.51%	0.001
	Sensory impairments	8 (2279)	13.89% (7.30-21.11)	95.25%
None of the guidelines	Age (year)
	6–17	24 (71337)	18.22% (16.22–20.30)	96.45%	0.000
	18–65	4 (864)	6.80% (3.40-11.11)	71.48%
	Region
	North America	18 (71272)	16.83% (14.57–19.21)	97.65%	0.861
	Asia	6 (991)	16.02% (9.57–23.71)	88.70%
	Disability type
	Neurodevelopmental disorders	19 (17593)	18.78% (16.05–21.67)	93.49%	0.000
	Sensory impairments	4 (1404)	7.57% (4.33–11.60)	83.68%
Physical activity guideline	Age (year)
	6–17	27 (71879)	15.82% (13.30–18.50)	98.23%	0.000
	18–65	7 (5631)	57.03% (52.34–61.65)	86.74%
	Region
	North America	24 (75977)	26.46% (20.84–32.49)	99.59%	0.100
	Asia	6 (991)	13.89% (4.11–27.98)	96.60%
	Disability type
	Neurodevelopmental disorders	22 (18940)	18.09% (11.72–25.47)	99.17%	0.010
	Sensory impairments	8 (2288)	39.59% (24.72–55.51)	98.28%
Sedentary time guideline	Age (year)
	6–17	27 (71879)	43.55% (37.39–49.80)	99.48%	0.387
	18–65	7 (5631)	56.06% (28.97–81.35)	99.67%
	Region
	North America	24 (75977)	45.68% (38.67–52.78)	99.65%	0.073
	Asia	6 (991)	59.81% (46.09–72.79)	94.52%
	Disability type
	Neurodevelopmental disorders	22 (18940)	39.68% (29.76–50.05)	99.39%	0.005
	Sensory impairments	10 (2775)	64.16% (50.35–76.88)	98.17%
Sleep duration guideline	Age (year)
	6–17	27 (71879)	53.56% (49.17–57.92)	98.89%	0.358
	18–65	7 (5631)	56.23% (52.62–59.81)	76.92%
	Region
	North America	24 (75977)	52.02% (47.73–56.30)	99.99%	0.579
	Asia	6 (991)	55.70% (43.47–67.60)	93.07%
	Disability type
	Neurodevelopmental disorders	22 (18940)	53.29% (46.04–60.47)	98.72%	0.850
	Sensory impairments	10 (2775)	54.02% (51.55–56.48)	39.46%
Notes: k = number of effect sizes; n = total sample size; P value = P value for between-group difference.
Abbreviations: 95%CI = 95% confidence interval.

3.4.2. Prevalence of meeting none of the three 24-hour movement guidelines

Of the 24 included studies, 19 studies with 27 effect sizes reported overall prevalence of meeting none of the three 24-hour movement guidelines among people with disabilities (n = 72201). The meta-analytic results showed that 16.65% of the participants did not meet any of the guidelines (I² = 96.89%; Fig. 3). The Doi plots with LFK index indicated a large publication bias (LFK index = -3.90; Fig. S2).

As shown in Table 2, subgroup analyses revealed that the 6–17 years group (18.22%) reported a significant, higher overall prevalence of meeting none of the three 24-hour movement guidelines than that in the 18–65 years group (6.80%; P = 0.000). Geographic data analyses revealed that there was no significant group difference in the overall prevalence between North America (16.83%) and Asia (16.02%; P = 0.861). In terms of disability type, the overall prevalence was significantly lower in participants with sensory impairments (7.57%) than that in participants with neurodevelopmental disorders (18.78%; P = 0.000). There was generally substantial heterogeneity in these estimates (I² > 75%).

3.4.3. Prevalence of meeting the individual 24-hour movement guidelines

All the 24 included studies with 33 effect sizes reported prevalence of meeting the individual 24-hour movement guidelines. The meta-analytic results showed that 22.89% of the participants met the physical activity guideline (I² = 99.45%; Fig. S3), 47.10% met the sedentary time guideline (I² = 99.53%; Fig. S4), and 54.01% met the sleep guideline (I² = 98.65%; Fig. S5).

For the physical activity guideline, subgroup analyses showed that the 6–17 years group (15.82%) had a significantly lower prevalence rate than that of the 18–65 years group (57.03%; P = 0.000; I² > 75%), and the prevalence rate was significantly higher in participants with sensory impairments (39.59%) than that in participants with neurodevelopmental disorders (18.09%; P = 0.010; I² > 75%), but there was no significant region differences (P = 0.100; I² > 75%). For the sedentary time guideline, the results of subgroup analysis showed that participants with neurodevelopmental disorders (39.68%) had a lower prevalence rate than those with sensory impairments (64.16% ; P = 0.005; I² > 75%). However, there was no significant group differences in age and region (P = 0.387/0.073; I² > 75%). Finally, there were no significant age, region, and disability type differences in the prevalence of meeting the sleep duration guideline (P = 0.358–0.850; I² = 39.46%~99.99%).

3.4.4. Associations between meeting the 24-hour movement guidelines and health indicators

Thirteen out of the 24 included studies investigated the associations between meeting different combinations/number of the 24-hour movement guidelines and health indicators in participants with disabilities.^{25–27, 44–48, 50, 54–57} The relationship between meeting the 24-hour movement guidelines and adiposity was examined in 6 studies.^{26, 27, 47, 48, 54, 57} Of these, 3 studies found that meeting all 3 guidelines was significantly associated with lower odds of having overweight or obesity than meeting none, one, or any combination of 2 guidelines among children and adolescents with disabilities (e.g., ASD).^{26, 27, 47} However, another 2 studies found that meeting 24-hour movement guidelines was not significantly associated with the odds of being overweight or obese among children and adolescents with ID or ADHD.^{54, 57} Additionally, 1 study using compositional analysis found that reallocating time from physical activity and sedentary behavior to sleep duration decreased BMI in children and adolescents with ASD, and vice versa.⁴⁸

Nine studies examined the relationship between meeting 24-hour movement guidelines and psychosocial health (e.g., quality of life, depression, social relationship).^{25, 27, 44–46, 50, 54–56} Specifically, 3 studies found that participants with disabilities meeting all 3 guidelines had significantly higher quality of life than those meeting none of the guidelines.^{25, 27, 50} Another 4 studies found that, compared with those who met none of the guidelines, meeting at least 2 guidelines significantly decreased the odds for having anxiety and depression^44–46 as well as increased the odds for having general health.^{27, 44} One study indicated that meeting all 3 guidelines was favorably associated with the lowest psychological distress and highest mental well-being among adults with chronic health conditions and disabilities.⁵⁵ In addition, 1 study showed that meeting all 3 guidelines was associated with lower odds of having cognitive and social difficulties in relation to meet none of the guidelines in children and adolescents with ADHD.⁵⁶ Similarly, a final study found that meeting all 3 guidelines was significantly associated with higher flourishing level compared to meeting none or only 1 guideline in youth with ADHD.⁵

To the best of our knowledge, this is the first systematic review and meta-analysis to summarize the evidence on prevalence of meeting the 24-hour movement guidelines and its associations with health indicators among people with disabilities. A total of 24 studies including 77510 participants with disabilities from 8 countries were represented in this review. Collectively, the review indicated that only 6.97% of the participants across studies met all three 24-hour movement guidelines and there were significant age and disability type differences in guideline adherence. In addition, there was preliminary evidence suggesting that participants meeting all 3 guidelines generally reported better psychosocial health than those met none or only 1 guideline. Unfortunately, more than 10% participants (16.65%) across studies met none of the guidelines in comparison to those meeting all of the guidelines. As such, it is unlikely that people with disabilities are enjoying the psychosocial health benefits associated with meeting all, or even some, of the guidelines. For the individual movement behaviors, the highest adherence rate was for sleep duration (54.01%), followed by sedentary time (47.10%) and physical activity (22.89%). These findings can inform intervention priorities for movement behaviors in people with disabilities.

In a recent meta-analysis of 387437 healthy individuals aged 3–18 years from 23 countries, it was demonstrated that 7.12% of the participants met all three 24-hour movement guidelines.¹¹ This figure is slightly higher than that reported in the present review of people with disabilities (21 studies, 76607 participants) in which only 6.97% met all 3 guidelines. The present review also showed that while approximately half of the participants (24 studies, 77510 participants) met the sleep duration (54.01%) and sedentary time (47.10%) guidelines, only 22.89% met the physical activity guideline. This finding highlights that physical activity may be the main driver of not meeting all 3 guidelines among people with disabilities. Previous analyses have also identified that meeting the physical activity guideline is the biggest concern for people with disabilities.^{21, 56} This is because people with disabilities usually face a multitude of barriers to physical activity participation than their nondisabled peers, including personal, interpersonal and environmental factors.^{58, 59} Overall, previous studies along with ours make it clear that meeting the three 24-hour movement guidelines, especially the physical activity one, is very challenging for people with disabilities. Therefore, enhancing physical activity participation should be prioritized to increase the prevalence of meeting all 3 guidelines of this population.

Empirical studies have identified numerous factors such as sociodemographic factors, environmental factors, and family characteristics that may affect the prevalence of meeting the 24-hour movement guidelines among people without disabilities.^{12, 60} The current review examined whether age, region, and disability type could affect the adherence to the 24-hour movement guidelines in people with disabilities, and found that age and disability type were significantly associated with the prevalence of meeting all 3 guidelines and physical activity guideline, and disability type was also significantly associated with the adherence to the sedentary time guideline. Prior meta-analytic and empirical studies have found age to negatively associate with the prevalence of meeting all 3 guidelines in healthy children and adolescents.^{11, 12} The current review adds to the previous literature, revealing that children and adolescents with disabilities had a significantly lower overall prevalence of meeting all 3 guidelines (5.10%) than that of the adults with disabilities (16.49%). There are several possible explanations for this finding. First, the finding may be related to the differences in the movement guidelines for these 2 age groups. For example, for physical activity guidelines, adults only need to reach 150 minutes per week, while children and adolescents need to accumulate 60 minutes per day (420 minutes per week), which seems more challenging for the latter.^{7, 9} Second, adults with disabilities may have better behavioral self-management abilities than children and adolescents with disabilities, and thus adults with disabilities are more likely to achieve these movement behaviors as exemplified by the disparity in adherence to the physical activity guideline between the 2 age groups (15.82% for the children and adolescents group vs. 57.03% for the adults group). Finally, the adult group in this review was mainly with sensory and physical disabilities, while the children and adolescents group was mostly with neurodevelopmental disorders. In other words, the disability type rather than a true age difference may explain the finding. In support of this speculation, the current review found the prevalence of meeting all 3 guidelines was significantly higher in participants with sensory impairments (13.89%) than that in participants with neurodevelopmental disorders (4.67%). People with neurodevelopmental disorders tended to engage in less physical activity and more sedentary time than peers with sensory impairments as they may experience more social communication difficulties and behavioral problems.^{44, 59} Supporting this idea, the differences in adherence to the physical activity and sedentary time guidelines between the 2 disability type groups were observed in this review (sensory impairments group: 39.59%/64.16% vs. neurodevelopmental disorders group: 18.09%/39.68%). Taken together, these findings suggest the need to consider differences in age and disability type in future behavioral interventions for people with disabilities.

Several reviews have provided some evidence to suggest that meeting more of the 24-hour movement guidelines is generally associated with more favorable health indicators such as emotional health and quality of life in nondisabled people.^{6, 61} As an extension, the current review systematically synthesized evidence pertaining to this association among people with disabilities. The association between meeting the movement guideline and adiposity observed in the present review was mixed, with only 3 out of 6 studies indicating that participants with disabilities who met all 3 guidelines were less likely to be overweight and obese than those met none.^{26, 27, 47} Recent reviews on people without disabilities found that meeting more movement guidelines was inversely associated with adiposity among children and youth, but not in toddlers and preschoolers.^{5, 13} Their findings together with ours underscores the notion that the relationship between the 24-hour movement behaviors and adiposity is complicated, especially in people with disabilities, as their behavior is influenced by additional and unique factors such as comorbidities and medication usage.^{39, 47} Furthermore, 9 included studies in this review examined the relationship between 24-hour movement behaviors and psychosocial health, and all these studies showed that participants with disabilities meeting all 3 guidelines reported better psychosocial health such as quality of life and social relationship.^{25, 27, 44–46, 50, 54–56} These findings are consistent with previous systematic reviews, which showed that meeting more guidelines was positively associated with better psychosocial health among children and adolescents without disabilities.^{13, 62} However, considering the limited eligible studies and different psychosocial health indicators included in the present review, the associations between the 24-hour movement guidelines and health indicators warrant further exploration.

While the present review provides important evidence regarding the prevalence of 24-hour movement guidelines and its associations with health indicators among people with disabilities, several limitations need to be recognized. First, as all of the included studies in this review were cross-sectional, it is difficult to determine the causal relationships between 24-hour movement behaviors and health indicators. Further longitudinal and intervention studies are needed to infer the causality. Second, most of the movement behaviors in the included studies were measured using proxy-report and self-report, which are prone to response error. Future studies should consider supplementing subjective measures with objective tools (e.g., accelerometers) to enhance the reliability and validity of measurement. Third, not all of the included studies used the same 24-hour movement guidelines (e.g., Canadian framework),^{7, 9} which may reduce comparability. Finally, most of the included studies were conducted in the United States and were mostly represented by participants with neurodevelopment disorders, limiting the generalizability of the present findings. Therefore, future work should pay more attention to understudied disability groups from different geographical regions.

In conclusion, there is some evidence showing that the prevalence of meeting all three 24-hour movement guidelines in people with disabilities is low; meanwhile, age and disability type are moderators influencing the overall guidelines adherence. There is preliminary evidence suggesting that people with disabilities meeting all 3 guidelines have better psychosocial health than those meet none. These findings seem to suggest the need for integrating age- and disability type-specific strategies to support people with disabilities in developing and maintaining healthy movement behaviors. Moreover, future studies are suggested to further corroborate the current research findings for wider application and update of the 24-hour movement guidelines.

physical activity

sedentary time

sleep duration

MBDD

mental, behavioral, and developmental disorders

visual impairment

ASD

autism spectrum disorder

ADHD

attention deficit/ hyperactive disorder

PSD

physical and sensory disabilities

neurodevelopmental disorders

intellectual disability

CCD

chronic conditions and disabilities

chronic conditions

BMI

body mass index

95%CI

95% confidence interval.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

JH, CL, and XL conceptualized and designed this systematic review and meta-analysis; JH and XL performed the screen process, data extraction, quality assessment, and data analysis; JH, XL, and GL drafted the original manuscript; JAH, LZ, SC, and CL assisted in revising the manuscript. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors.

Acknowledgements

This research was funded by the National Social Science Fund in China [grant number 22BTY062].

Availability of data and materials

The datasets and any other materials used for the current study are available from the corresponding author on reasonable request.

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Prevalence of meeting 24-hour movement guidelines and its associations with health indicators in people with disabilities: A systematic review and meta-analysis

Status:

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Abstract

Background

Methods

Results

Conclusion

Figures

1. Introduction

2. Methods

2.1. Protocol and registration

2.2. Information sources and search strategy

2.3. Eligibility criteria

2.4. Selection process

2.5. Data extraction

2.6. Methodological quality assessment

2.7. Data synthesis

3. Results

3.1. Study selection

3.2. Study characteristics

3.3. Study quality assessment

3.4. Syntheses of results

3.4.1. Prevalence of meeting all three 24-hour movement guidelines

3.4.2. Prevalence of meeting none of the three 24-hour movement guidelines

3.4.3. Prevalence of meeting the individual 24-hour movement guidelines

3.4.4. Associations between meeting the 24-hour movement guidelines and health indicators

4. Discussion

5. Conclusion

Abbreviations

Declarations

Competing interests

Authors' contributions

Acknowledgements

Availability of data and materials

References

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