The Comparison of Physical Activity Levels among School-age Adolescents in the Rural and Urban Areas of District Swat KPK, Pakistan- An Analytical Cross-Sectional Study

doi:10.21203/rs.3.rs-4569719/v1

Background

Obesity and overweight represent significant global public health concerns. Young adolescents are in particular increasingly experiencing obesity and overweight due to their sedentary lifestyles, excessive electronic media use, and lack of physical activity (PA). This trend is linked to the development of non-communicable diseases in later life. Moreover, data regarding the lack of PA is available in Pakistan, but a gap exists in the comparative analysis of physical activity levels between rural and urban adolescents. Rural and urban areas exhibit distinctions in both geographical settings and technological advancements, potentially influencing the PA levels of their respective inhabitants.

Purpose

The study aimed to compare physical activity levels among school-age adolescents in rural and urban areas of Swat, KPK, Pakistan. In addition, the study also aimed to explore how gender, age, grade, and school type influenced the PA levels of adolescents.

Method

A cross-sectional analytical study was carried out with a sample size of 287 school-age adolescents (aged 10 to 14 years) selected from 08 public and private middle schools in rural and urban areas of district Swat, KPK, Pakistan. The data about physical activity was collected using a researcher-administered questionnaire adapted from the Physical Activity Questionnaire for Older Children (PAQ-C). In addition, the Statistical Package for the Social Sciences (SPSS) version 22 was used for the analysis of data.

Findings

The mean PA score for rural adolescents was 3.65±0.38, whereas the mean PA score for urban adolescents was 2.22±0.47. Thus, there was a mean difference of 1.43 which was significant at 0.05 level of significance (t= 28.11, p value=<0.001). In addition, a significant difference between private and government school-age adolescents’ PA levels was found (t-value (3.73), df (285) p-value of (<0.001). Moreover, there was no significant difference in PA levels in terms of gender and grade of adolescents. Further, a very low negative correlation was found (r = -0.1) between the age and PA scores of school-age adolescents.

Conclusion

Place of residence has an impact on the PA level of adolescents because the study found a significant difference in the mean PA levels of school-age adolescents in rural and urban areas. It is recommended to conduct future research to identify the factors that contribute to disparities in PA among adolescents residing in rural and urban areas.

Adolescents

Physical activity levels

Rural-urban comparison

Public health

Physical activity (PA) is a fundamental component of human health and well-being. Regular physical activity has been linked to a variety of positive health outcomes, including better cardiovascular health, better weight control, a lower chance of developing chronic diseases, improved cognitive function, and an overall higher quality of life (1).

Likewise, Physical activity (PA) for school-age adolescents is very essential because adolescence is the stage of life in which more physical growth and cognitive and emotional development occur (2). Thus, it is very crucial to assess and monitor those behaviors and practices in adolescents which negatively affect their health. PA is the most important practice that has a rudimentary impact on adolescents’ health. So, it is essential to measure the PA levels in school-age adolescents because inactivity results in obesity, which ultimately leads to the development of non-communicable illnesses like hypertension and diabetes mellitus. In addition, the place of residence also impacts one’s health. If the environment in which a person lives is friendly and healthy then it would naturally have an optimistic effect on the individual’s health. Furthermore, one’s place of residence has a formative impact on one’s physical fitness (3).

Maintenance of health in adolescents is a very important aspect of human life. The health of this age group of adolescents will be maintained by adopting certain healthy behaviors like eating healthy, having regular checkups, avoiding substance use, etc. One of those behaviors is maintaining a healthy level of PA. If adolescents adopt good PA habits in their early developing age, it will be easy for them to continue it in the future. “The habits acquired during adolescence may continue into adulthood” (4). Kumar, Robinson (1) state that physical activities act as a potent medicine and it has many advantages for adolescents’ health, regular PA enhances cardiovascular functioning in adolescents, such as improving lipid profile, blood pressure, endothelial function, and insulin sensitivity. In addition, it increases calorie expenditure which aids in weight control. Furthermore, Weight-bearing exercises play vital roles in increasing muscle mass and achieving the highest bone density in adolescents. Moreover, PA has also positive effects on the mental health of adolescents as it increases the blood flow to the brain and enhances the circulating levels of norepinephrine and endorphins, which improves mood, self-esteem, and concentration while reducing stress and anxiety at the same time (1).

According to WHO, physical activity is defined as, “any bodily movement produced by skeletal muscles that require energy expenditure” (5). The new WHO guidelines also emphasize the importance of PA for children, adolescents, adults, and pregnant women. It states children and adolescents, need to engage in an average of sixty minutes per day of moderate to vigorous-intensity aerobic physical activity to get optimum health outcomes. (6). Hence, it can be deduced that although the prevalence of obesity in school adolescents is very high, providing adolescents with opportunities to indulge in rigorous physical activities and encouraging them to use them can help in counterbalancing the situation to a large extent.

Moreover, a considerable amount of research has taken place on the assessment of PA among school-age adolescents, but little is known about the comparison of PA among rural and urban school-age adolescents in Pakistan. Thus, it is very important to assess the levels of PA among rural and urban adolescents because the geographical environment has a very basic influence on PA. Comparing the urban and rural contexts, it can be deduced that in urban areas, people live in congested areas, and there are no open spaces for PA available to them like in rural areas. On the other hand, the urban and rural areas are different in terms of technological development. Meanwhile, the availability of advanced technological facilities in urban areas like the internet is high as compared to rural areas. So, due to these technological development and modern facilities, the lifestyles and habits of inhabitants in rural and urban areas are different from each other. In addition, the researchers’ attention was drawn to the seriousness of this issue after seeing school-age adolescents who were mostly engaged in playing mobile games, watching television, and using social media instead of participating in physical activities.

Previous research also shows that PA levels of rural and urban inhabitants are different. Particularly in developing countries, the levels of PA among adolescents in rural and urban areas vary significantly. A study conducted in India revealed that children and adolescents in rural areas were more physically active than children and adolescents in urban areas. The percentage of rural adolescents who were unable to achieve the adequate PA criterion was 16.8%, which was much lower than the percentage of urban adolescents, which was 33.2% (7).In addition, another study from India demonstrated a statistically significant difference in the levels of physical activity and physical fitness between rural and urban children. Additionally, their findings indicated that rural children exhibited greater flexibility and superior cardiovascular endurance compared to their urban counterparts (8). Furthermore, a study from Brazil found that students in rural areas were more physically active than those in urban areas. Rural students had healthier habits, with less exposure to electronic media and less sedentary behavior, leading to higher physical activity levels. Additionally, rural adolescents were more active due to participation in the labor market, agricultural tasks, and household chores(9).

Hence, the present study was planned with the aim to address this gap by comparing the PA levels of school-age adolescents in the rural and urban areas of district Swat, Khyber Pakhtunkhwa (KPK), Pakistan. Furthermore, the study explores how gender, age, grade, and type of school attended influence PA levels. By providing a comprehensive analysis of these factors, the research seeks to inform targeted interventions and policies that can effectively promote physical activity among adolescents, ultimately contributing to the prevention of NCDs and the promotion of healthier lifestyles.

The Study Design

An analytical cross-sectional study design was used for conducting this study to compare the levels of physical activity among rural and urban school-age adolescents in the district of Swat KPK, Pakistan.

The Study Population and Setting

This study was carried out in the district of Swat, Khyber Pakhtunkhwa, Pakistan. For this purpose, four middle schools (two private and two government) were selected in a rural area of Tehsil Bahrain and four middle schools (two private and two government) were selected in the urban area of Mingora city district, Swat, KPK, Pakistan. The tehsil Bahrain was selected as a rural area because it is a hilly area and the main source of income in farming. It is located around 50 kilometers away from Mingora City. On the other hand, Mingora city was selected as an urban area because it is the largest city in the district Swat. It is a highly populated area and has a population of around 331,377 according to the Pakistan Bureau of Statistics (10).

The Eligibility Criteria

The following eligibility criteria were used for the study:

The Inclusion Criteria

The students who met the following criteria were included in the study:

The age of the participants (adolescents) should be in the range of 10 to 14 years, and students of grades six to eight will be included in the study.
The study participants should be in good health and should have no such conditions that affect their physical activity like asthma, back pain, joint pain, polio, etc.

The Exclusion Criterion

The students having a known history of cardiopulmonary or neuromuscular problems were excluded from the study.

The Sample Size

The sample size was determined using openEpi Version 3.0 software, with a 95% confidence interval and a 5% margin of error. Initially, a sample size of 284 was calculated using the mean difference option in OpenEpi. Subsequently, to accommodate a 10% non-response rate, the sample size was adjusted to 312 participants. Consequently, each sample—representing rural and urban areas—consisted of 156 participants from respective schools.

The Sampling Strategy

A convenient sampling method was used in the selection of schools for this study among the government and private schools in the district Swat. The researcher approached 10 schools randomly in a rural area of tehsil Bahrain and 10 schools in the urban area of Mingora city. The researcher then selected those four schools whose administration voluntarily signed the permission letter.

In addition, a stratified random sampling technique was used in the selection of study participants in the selected schools. The participants were divided into the strata like grades 6^th, 7^th, and 8^th in each school and then a random sample was selected from each stratum. Moreover, 13 participants were selected from each stratum, i.e., each grade, a total of 39 participants from each school, and a total of 156 from each area were selected in the study. The students of class/grades 6^th,7^th, and 8^th were selected as a study population in the selected government and the private schools of district Swat, KPK Pakistan.

A total of 287 participants participated in the study, with an expected nonresponse rate of 10%, from the eight selected schools from rural and urban areas of district Swat, Pakistan.

The Data Collection Tool

The adopted questionnaire of the Physical Activity Questionnaire for Older Children (PAQ-C) was used by the researcher for the collection of data related to the level of physical activity of school-age adolescents. This questionnaire was developed by Crocker, Kowalski and Faulkner in 1997. It is a reliable and validated questionnaire. It has been used in many studies and research internationally. Moreover, the PAQ-C is appropriate for elementary school-aged children (grades 4 to 8^th) and for the age group of 8 to 14 years (11). For instance, the participants' age in this study was in the range of 10 to 14 years, and they were students in grades 6^th, 7^th,and 8^th, so this was an appropriate tool for this age group.

Similarly, some games in the questionnaire were not related to the local context, so the local games were added in front of those games by using slashes (/). Moreover, the sequence and numbering of the sequence of questions in the questionnaire have not been changed.

The questionnaire consisted of two sections: The first section contained demographic information of the student. On the other hand, the second section contained 10 questions related to the assessment of PA level of students in the last week. Equally importantly, the permission to use this questionnaire in this study was taken from the authors before the commencement of the study.

Data Analysis

The statistical software IBM SPSS version 22 was used to analyse the data. Moreover, the mean and standard deviation were calculated for the quantitative variables like age and level of physical activity, while frequency and proportion were calculated for qualitative variables like gender, school type (private and government schools), etc. Furthermore, the t-test for two independent samples was used to identify the difference in the means of physical activity levels between the two populations, i.e., rural and urban school-age adolescents. In addition, a t-test for two independent samples was also used to find the difference in the level of PA based on school type (private vs. government) and based on gender. Moreover, one-way ANOVA was used to compare the mean of physical activity based on the grade (6^th, 7^th, and 8^th). Lastly, a Pearson correlation was used to find out the association of age with PA level.

Ethical Considerations

This study was approved by the ERC of the Aga Khan University Karachi, Pakistan. Moreover, formal and written permission was taken from the district education officer (DEO) and the concerned principals of the selected schools before the commencement of data collection. In addition, the researcher also obtained signed consent from the parents/ guardians and written assent from the students participating in the study. More importantly, the confidentiality of the participants was maintained by giving codes to the questionnaires.

The Socio-Demographic Characteristics of School Age Adolescents

A total of 287 adolescents participated in this study from eight schools selected from the rural and urban areas of districts Swat, as illustrated in Table 1. Out of those, 142 (49.5 %) were from rural areas and 145 (50.5%) were from urban areas. In addition, 197 (68.6%) were male and 90 (31.4%) were female. Moreover, the study participants' ages ranged from 10 to 14 years, with a mean age of 12.99 ±0.96 years. Furthermore, 143 (49.8%) were from private schools and 144 (50.2%) were from government schools. Furthermore, 95 (33.1%) were from grade 6^th, 95 (33.1%) were from grade 7^th and 97 (33.8%) were from grade 8^th.

Table 1 The Socio-demographic characteristics of study participants

Variable Name

Frequency

n^a = 287

Percentage

%

Age of participant in years

(12.99±0.96)^*

Location of living

Rural

142

49.5

Urban

145

50.5

School Type

Private

143

49.8

Government

144

50.2

Grade of Study

6^th Grade

95

33.1

7^th grade

95

33.1

8^th grade)

97

33.8

Gender

Male

197

68.6

Female

90

31.4

^* The mean and standard deviation

^aSample Size

The Mean Physical Activity Score based on the Place of Residence (Rural vs. Urban)

The main objective of the study was:

To compare the levels of physical activity among rural and urban school-age adolescents in District Swat Pakistan.

The mean PA scores for both rural and urban school-age adolescents are represented in Table 2. The mean PA score for rural adolescents was 3.65±0.38, whereas the mean PA score for urban adolescents was 2.22±0.47. So, there was a difference in the mean PA score and a standard deviation between rural and urban school-age adolescents.

Inferential Statistics of Rural and Urban School-age Adolescents’ PA Score

A t-test for two independent samples was applied to test the hypothesis that there was a significant difference in the mean PA levels between rural and urban school-age adolescents. As illustrated in Table 2, the independent t-test results showed that the rural school-age adolescents had a mean PA score of 3.65, with a standard deviation of SD= 0.38 that reported a significant difference in the mean level of physical activity (t= 28.11, p value=<0.001) as compared to the urban adolescents, with a mean of 2.22 and standard deviation of 0.47. Hence, H1 was supported and it was concluded that there was a significant difference in the mean PA level between rural and urban school-age adolescents (p-value <0.05).

Table 2 Independent t-test for Comparing mean PA levels of School-age Adolescents based on their place of residence, school type, and gender.

Variable	Number of Participants (n)	Mean PA Score	Standard Deviation	Mean difference	df	t-value	p-value
Place of Residence				1.43	285	28.110	<.0001^*
Rural	142	3.65	.38
Urban	145	2.22	.47
School Type				0.36	285	3.73	<.0001^*
Private	143	2.74	0.91
Government	144	3.11	0.71
Gender				-.11	285	1.09	.274
Male	197	2.96	.80
Female	90	2.84	.90

^*significant results, p-value< 0.05

Abbreviation: PA= Physical Activity.

PA Level of School-age Adolescents Based on the Factors of School Type, Gender, Grade, and Age

The secondary objective of the study was:

To assess the association of physical activity with factors like age, grade, gender, and school type (private vs. government).

Mean PA Levels Difference based on the School Type of Adolescents

An independent samples t-test was conducted to assess the mean PA difference between the PA levels of private and government school-age adolescents. Table 2 illustrates that the t-value (3.73) is significant at a p value of (<0.001), which is less than alpha (0.05). So, the null hypothesis could be rejected at a 95% level of significance and it could be concluded that there was a significant difference in the mean PA levels of private and government school-age adolescents.

Differences in the Mean PA of Adolescents in Rural Private and Public Schools and Urban Private and Public Schools

The mean PA levels of adolescents in rural private and government schools were compared to identify any difference among them. It was identified that the mean PA score of rural private school-age adolescents was not much different from that of rural government school-age adolescents. The mean PA for rural private school-age adolescents was 3.61, and for rural government school-age adolescents was 3.69, so there was a slight difference between the means of these two groups i.e., Means Difference (MD)= 0.08. In addition, the mean PA for urban private school-age adolescents was compared with the urban government school-age adolescents. The mean PA for government school-age adolescents in urban areas was 2.52, and for private school-age adolescents in urban areas, it was 1.91. So, there was a difference in the mean PA of these groups in urban areas i.e., MD= 0.3 which was high as compared to the rural area mean PA of the same groups. The results are illustrated in Table 3.

Table 3 Differences in Mean Physical Activity among Rural and Urban Adolescents based on Gender, School Type, and Grade of Study.

Location of living of participant	School type	Gender of participant	Grade of Study	n	Mean PA Score
Rural		Female		59	3.4650
		Male		83	3.7904
	Private			70	3.6154
	Government			72	3.6939
			6th	47	3.8302
			7th	48	3.6276
			8th	47	3.5084
Urban		Female		31	1.6791
		Male		114	2.3671
	Private			73	1.9176
	Government			72	2.5267
			6th	48	2.3256
			7th	48	2.2007
			8th	49	2.1355

^aMean PA score: 1= low physical activity, 5= high physical activity

A Comparison of PA Levels of School-age Adolescents based on their Gender i.e., Male and Female

An independent t-test was applied to test the null hypothesis that there is no significant difference in the mean PA levels among male and female school-age adolescents. Moreover, the independent t-test showed that the male school-age adolescents had a mean PA score of 2.96, with a standard deviation of SD= 0.80 that reported no significant difference in the mean level of physical activity (t= 1.09, p value=0.274) when compared to the female school-age adolescents, with a mean of 2.84 and standard deviation of 0.90 as illustrated in table 2. Hence, H0 was supported and it could be concluded that there was no significant difference in the level of PA between male and female school-age adolescents (p-value >0.05). Although there was a slight difference in the means of PA levels between these groups i.e. -0.11, it was not significant (p value= 0.274).

The Difference in the Mean PA Score in Urban and Rural Males and Females

There was also a difference in the mean PA score among male and female students in rural areas. The mean PA for male students was 3.79, and for female students, it was 3.46, so there was a mean difference of 0.33. In addition, there was a difference in the mean PA score between male and female students in the urban areas. Furthermore, the mean PA score for male students in urban areas was 2.36, and for urban female students, it was 1.67, so there was a mean difference of 0.69. Therefore, it was concluded that the mean PA difference between urban male and female was higher than the mean PA difference between rural male and female students (i.e., MD for urban = 0.69, MD for rural = 0.33), as illustrated in Table 3.

Moreover, there was a significant difference between the mean PA of rural female adolescent students, as compared to the urban female adolescent students. The mean PA score for rural female adolescent students was 3.46, and for urban female adolescent students, it was 1.67. There was a difference of 1.79 between the means of PA for rural and urban female adolescent students. Furthermore, there was also a difference in the means of PA for rural and urban male adolescent students. The mean PA score for rural male adolescent students was 3.79 and for urban male adolescent students was 2.36. So, there was a difference of 1.43.

Comparing the Mean PA Levels of School-age Adolescents based on their Grades of Study (grades 6^th, 7^th, and 8^th)

The mean PA score for 6th-grade school-age adolescents in rural areas was 3.83, for 7^th grade, it was 3.62, and for 8th-grade students, it was 3.50. Moreover, there was a slight decrease in the mean PA score with the advancement of a grade of study of adolescents. Furthermore, the students in 6^th grade had more PA scores (M= 3.83) than 7^th and 8^th grades, and 7th-grade students had more PA scores (M=3.51) than 8th-grade students. In addition, the mean PA scores for 6^th, 7^th, and 8^th grade students in urban areas were 2.32, 2.20, and 2.13 respectively. There was also a decrease in mean PA level, with the advancement of a grade of study of adolescents in the urban areas. The results are illustrated in Table 3.

Inferential Statistics for Comparing the Means of PA Level of Different Grades of Students

H1. There are significant differences in mean PA scores among different grades of school-age adolescents.

To test the hypothesis, the school-age adolescents were divided into different groups based on their grades of study i.e. grade 6^th, grade 7^th, and grade 8^th. One-way ANOVA was applied, and Table 4 presents the results of one-way ANOVA. The one-way ANOVA results showed that there were no significant differences in the mean PA scores among different grades of study groups, (F=2.38, DF= 2,284, p value= 0.094).

Table 4 Mean Physical Activity Questionnaire Score based on the Grade of Study

ANOVA Table

	Sum of Squares	Df	Mean Square	F	(p-value)
Between Groups	3.322	2	1.661	2.386	.094
Within Groups	197.740	284	.696
Total	201.062	286

Correlation of Adolescents' PA Level with the Age (10 to 14 years)

H0. There is no correlation between the age of school-age adolescents and PA scores.

To test this hypothesis, the Pearson correlation was run in SPSS, because both the variables were quantitative ratio continuous in nature. Table 5 shows the results of the Pearson correlation. It is clear from the table that there is a very low negative correlation because the correlation coefficient (r) value was (r = -0.1) between the age and PA score of school-age adolescents. This correlation was insignificant because the P-value was greater than the level of significance of 0.05 (p-value = 0.09> 0.05). Hence, the null hypothesis cannot be rejected at a 0.05 level of significance.

Table 5 Correlation of Adolescents’ PA Level with the Age (10 to 14 years)

Age of participant in years

Sample size

n=287

Mean PA level of adolescents

Correlation Coefficient (r)

p-value

-.100

.092

The Mean Physical Activity Score based on the Place of Residence (Rural vs. Urban)

This study attempted to find out the difference in the mean Physical Activity (PA) levels of school-age adolescents in rural and urban areas of district Swat KPK, Pakistan. The findings of the current study revealed that there was a significant difference in the mean PA levels among rural and urban school-age adolescent. The mean PA level of rural adolescents was higher than that of their urban counterparts. This difference was statistically significant, as confirmed by the t-test for two independent samples.

Moreover, these findings are consistent with previous studies as a study conducted by Regis, Oliveira (9) in the State of Pernambuco, Brazil, to evaluate the levels of PA and sedentary behaviours of adolescents living in rural and urban areas. The results of their research indicated that rural adolescents exhibited higher levels of physical activity compared to their urban counterparts. They further reported that rural adolescents also displayed healthier habits, including reduced exposure to electronic media and decreased sedentary behaviour, contributing to increased PA participation. Additionally, their increased PA was attributed to their involvement in labour, agriculture, and household activities.

In addition, Wattelez, Frayon (12) also reported that About 66% of adolescents aged 11 to 16, including both genders, reported engaging in over 60 minutes of daily physical activity. Rural adolescents were notably more active, spending less sedentary time outside of school compared to their urban counterparts. Active physical activity was less common among urban adolescents, with both genders showing higher activity levels in rural areas (boys: 97 min/day, p = 0.018; girls: 133 vs. 115 vs. 93 min/day, p = 0.018).

Similarly, a cross-sectional study in Western Maharashtra, India, compared PA levels among rural and urban adolescents. Results revealed that 16.8% of rural adolescents did not meet PA requirements, significantly lower than the urban proportion of 33.2%. Rural adolescents showed greater interest in activities like commuting, cycling, and assisting with agricultural and household tasks compared to their urban counterparts. (7).

On the other hand, disparities in adolescent physical activity (PA) between US urban and rural areas are not well understood. A recent review reported mixed findings: 9 of 16 studies suggested lower PA with increased urbanization, indicating rural adolescents were more active. Only two studies in the southeastern US found higher "moderate to vigorous physical activities" (MVPA) in urban middle school students compared to their rural counterparts. (13).

However, this study finding is contrary to a study conducted in Rawalpindi, Pakistan, which showed that there was no significant difference in PA levels between rural and urban high school-age children. However, they found that height and weight were better in rural students, but the “Body mass index” (BMI) rate was higher in urban students (14). A possible explanation for this difference in the findings of both studies was the changes in the setting of the study. The rural areas of Swat district are characterized by hilly terrain, and the primary occupation is farming. Rural adolescents in this region actively engage in agricultural activities, preferring walking over motorized transport. Unlike Chaudhary et al.'s study, our research focuses on middle school adolescents in Swat, differing in sample size and data collection tools. Their study involved high school children (n=200) and utilized the PAQ-A and Y-PAQ, while ours included 312 participants and employed the PAQ-C.

Physical Activity and School Type (Private vs. Government)

The study findings depicted a difference in PA levels of adolescents in the rural and urban areas of district Swat based on their school type (private vs government). Moreover, the study results revealed that there was a significant difference in the PA levels of students attending private schools versus government schools. Further, the t-test statistics for two independent samples also showed that there was a significant difference in the two groups (private vs government school adolescents) PA levels.

Similar findings were also reported from other studies conducted in Pakistan. For instance, a study conducted by Jabeen, Zuberi (15) in Karachi, Pakistan, showed that the PA was higher in students who attended public (government) schools and whose parents encouraged their children for sports. On the other hand, low PA was noted in students who were in private schools, and whose parents did not encourage sports in their children.

Likewise, another study conducted in India showed that there was a higher level of PA in government school adolescents than in private school adolescents. In addition, they found that more than 70% of students in government schools were underweight compared to 35% in private schools (16). Similarly, the findings from a study conducted in Saudi Arabia showed that students from public schools were more active than their counterparts from private schools. The researchers rationalised that private schools’ adolescents often have higher socioeconomic status, thus having easier access to computers and technology, which, in turn, leads to sedentary behaviour. This sedentary behaviour in turn leads to reduced physical activity participation (17).

Most of the private schools in urban areas are built in congested environments, with the unavailability of PA facilities like playgrounds. These factors are also highlighted in the literature from developing countries. For instance, a study from Pakistan showed that the lack of playgrounds, lack of parental support for sports, and being female gender were associated with low PA in private schools (15). Another study highlighted that organisational factors such as the availability of playground in school is positively associated with increased levels of PA among school adolescents (18).

The Physical Activity and Gender

The study's findings revealed that the mean PA score for male adolescents was slightly higher than that for female adolescents. Thus, there was a low difference in the mean PA level between male and female adolescents, which was not significant at the 0.05 level of significance. Additionally, differences in mean PA levels were also noted among rural male and female adolescents. Furthermore, differences in mean PA levels were observed in urban male and female adolescents as well.

On the other hand, there were also differences in the mean PA levels among rural male adolescents and urban male adolescents. Similarly, there was a difference in the mean PA levels between rural female and urban female adolescents. Hence, these findings are consistent with other studies, as the study findings of Ishii, Shibata (19) showed that male and younger students were engaged in PA more often than female and higher-grade students.

Similarly, another study’s findings revealed that male adolescent students (44%) were found more physically active than female adolescent students (20%) (17). Moreover, a study conducted in Karachi, Pakistan, also revealed that the level of PA was higher in boys than girls (20). Likewise, another study from Pakistan supported that male adolescents attending public schools and receiving parental encouragement for sports exhibited higher levels of physical activity (p<0.05) than female adolescent students. They reported that that socio-environmental factors, such as parental preferences for boys to participate in physical activity rather than girls, overprotection of girls, modesty-related cultural barriers, and a lack of safe outdoor playgrounds for girls, may be the reasons behind the gender disparities in PA (15).

Moreover, the study found that there were differences in PA levels among rural male adolescents and urban males and among rural female adolescents and urban female adolescents. This finding was also reported by Wattelez, Frayon (12) who stated that there were differences in PA levels in rural male adolescents and urban male adolescents (74.79% in rural and 45.83% in urban). They also reported a difference in PA levels in rural female and urban female adolescents (75.78% in rural and 46.67%).

Low PA levels in adolescent girls may be attributed to societal and cultural restrictions on their participation in physical activities in open spaces. Parents often limit their daughters' involvement in PA to protect their modesty, reflecting gender discrimination. This cultural pressure, seen in Pakistan and elsewhere, hinders girls from freely moving in open spaces, contributing to their low PA and perpetuating gender discrimination. (21, 22).

The Physical Activity and Study Grade

This research also attempted to find out the difference in PA levels among adolescents based on their grades of study (grade 6^th, 7^th and 8^th). The study findings revealed that there was a slight reduction in PA level with the advancement of the grade of study. For example, the students in grade 6^th were more physically active than grade 7^th students, and grade 7^th students were more physically active than grade 8^th students. Although, there was a slight difference in the mean PA levels among different grades students, the ANOVA results showed that it was insignificant at 0.05 level of significance.

Moreover, in accordance with the present results, previous studies have also demonstrated that the PA levels decrease with the advancement of grades of study of students. For instance, the findings of a study by Pate, Saunders (23) demonstrated that the PA levels decreased in students aged 10 to 14 years, as they progressed from elementary class to high school. In addition, their findings also revealed that the decline in PA with advancement of grade was higher in girls than boys.

Likewise, another study’s findings from China showed that PA gradually decreases in students, as they progress to a high level of education because physical education is not given as much importance in colleges and universities as it is given at the middle school level (24). Similarly, a systematic review and meta-analysis findings indicated that MVPA levels drop in students as they progress from lower class to higher class. The findings exhibited that the proportion of time spent in MVPA by middle school students was higher (48.6%) than the proportion of time spent in MVPA by high school students (35.9%) (25).

A possible explanation for this drop in PA level with the advancement of level of study would be the heavier academic workload in higher classes as compared to the lower classes. In addition, in colleges and universities, Physical Education (PE) is not given as much importance as it is given at the primary and elementary levels. For example, the study findings of Oluyinka and Endozo (26) showed that lack of time due to a busy lesson schedule and prioritising academic success over exercise are significant factors hindering physical activity participation among higher grades students. Moreover, the study findings of Liu, He (24) also revealed that PA levels decrease in students as they progress to higher classes because physical education is not given as much importance in colleges and universities as it is given at the middle school level.

Association of Physical Activity with Age of Adolescents

This study also aimed to explore the association of PA with the age of school-age adolescents. The study findings revealed that there was a negative correlation of PA with the age of adolescents. It was also found that the PA level decreased with the increase in age of adolescents. Although there was a negative correlation between age with PA, the value of the correlation coefficient (r value= -.1) showed that it was a very low negative correlation. So, the correlation was insignificant because the p-value (0.09) was greater than the level of significance (0.05). Thus, these results are in line with those of previous studies, as one of the significant findings of the study of Marques, Henriques-Neto (27) was that the participation of adolescents in sufficient PA decreased with age in both boys and girls. Moreover, their study unveiled a decline in daily physical activity participation, with the percentage dropping from 28.2% for boys aged 11-12 years to 21.2% for boys aged 16-17 years. Similarly, among girls, the proportion decreased from 19.4% at the age of 11-12 years to 11.1% at the age of 16-17 years.

Similar findings were also reported by Cooper, Goodman (28) who revealed that total physical activity and the percentage of time spent in MVPA declined progressively in each age group after the age of 5 years. There was an overall 4.2% decrease in PA level each year as compared to age five (3.7% for boys and 4.6% for girls). Light physical activity decreased as sedentary time increased, paralleling the decline in overall physical activity and the percentage of time spent in MVPA between age groups. Similarly, another study revealed that there was a steep age-related decline in overall physical activity in children aged 10 to 17 years, with a slower rate after that age. PA declines at 1.76 minutes per hour per year (23).

Likewise, the findings of the Baldursdottir, Valdimarsdottir (29) study found that as age increased, PA declined, with more than half of adolescents in upper-secondary schools failing to meet the necessary daily PA requirements. The proportion of children who nearly never participated in MVPA declined from 26.3% at age 10 to 8.9% at age 14. Although the findings of the study showed that the level of PA decreased as the age of adolescents increased, the Pearson correlation coefficient value (r= -0.1) showed that it was insignificant. The possible explanation for it would be that the age range in the study was not high because only students of middle classes, grades 6th to 8th were included, and the age range of those students was from 10 to 14 years. So, if more aged students were included like the students beyond the age of 14 years, then maybe the r-value could be significant.

Moreover, the study findings of Baldursdottir, Valdimarsdottir (29) also showed that the level of PA decreased with the advancement of age and with the transition of students from elementary to high school. Their findings further suggested that PA increased from the age of 10 to around the age of 14, then reduced, with only 43% of 16 to 19-year-old adolescents participating in MVPA four times per week. In addition, another potential explanation for this insignificant correlation would be that there were young students in high grade (grade 8^th) and older students in lower grade (grade 6^th). As discussed earlier, the level of PA decreased with the advancement of the grade of study, so there were young students in higher classes less physically active than the older students in lower classes. This finding was also reported by Gulzar (20) that as students progress through the grades, the study pressure builds, and they are subsequently unable to allocate time to leisure and physical activities.

The Study’s Strengths and Limitations

Strengths of the study include being the first to compare physical activity levels among school-age adolescents in the Swat district, Khyber Pakhtunkhwa, Pakistan. The use of a random sampling technique enhances the study's credibility by providing a representative sample. The findings, highlighting differences in physical activity between rural and urban adolescents, serve as a baseline for future research and policy development in Pakistan. The study can inform interventions for reducing non-communicable diseases and support policymakers, educational institutions, and stakeholders in enhancing adolescent physical activity. The utilization of the validated 'Physical Activity Questionnaire for Older Children (PAQ-C)' adds reliability to the data collection process.

However, limitations exist, such as the reliance on convenience sampling for school selection due to reluctance from some administrations. Although random methods were initially attempted, this approach may have limited the comprehensiveness of the findings. Additionally, the study acknowledges the potential for recall bias in participants reporting their physical activity levels for the previous week, which could impact the data's reliability.

The study compared physical activity (PA) levels among rural and urban adolescents in District Swat, Pakistan. Significant differences were found, with rural adolescents showing higher activity levels. Private school students had lower PA, possibly due to lack of playgrounds and easy access to technology. Gender differences in PA were slight, and no significant variation was observed among different grade levels, likely due to the inclusion of young adolescents. Age showed a weak negative correlation with PA, consistent with previous research.

The study accomplished its objective of highlighting rural-urban differences in adolescent PA levels. Future research should delve deeper into the factors influencing these differences. Policymakers need to prioritize PA improvement among adolescents, with schools playing a key role in awareness and provision of PA facilities. Collaboration between health policymakers, school administrators, and healthcare workers is crucial for enhancing PA levels and promoting a healthier society, potentially reducing non-communicable disease burdens.

ANOVA	Analysis of Variance
BMI	Body Mass Index
DEO	District Education Officer
DF	Degrees of Freedom
ERC	Ethical Review Committee
H0	Null Hypothesis
H1	Alternate Hypothesis
KPK	Khyber Pakhtunkhwa
M	Mean
MD	Means Difference
MVPA	Moderate to Vigorous Physical Activity
n	Sample Size
PA	Physical Activity
PAQ-A	Physical Activity Questionnaire-Adolescent
PAQ-C	Physical Activity Questionnaire for Older Children
PE	Physical Education
r	Correlation Coefficient
SD	Standard Deviation
SPSS	Statistical Package for Social Sciences
US	United States
USA	United States of America
WHO	World Health Organization
Y-PAQ	Youth Physical Activity Questionnaire

Ethics approval and consent to participate

This study was approved by the Ethical Review Committee of Aga Khan University, Karachi, Pakistan (2023-8653-25336). In addition, written permissions were obtained from the district education officer and the school principals. Moreover, written consent was collected from the parents of the adolescents, and written assent was obtained from the participants of the study prior to data collection.

Consent for publication

Not applicable

Availability of data and material

The hard copies of the Physical Activity Questionnaire for Older Children (PAQ-C) were used for data collection, and the data is available in SPSS format. This can be provided by the corresponding author upon reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

No funding is available for the publication of this article.

Authors’ Contributions

Mr. Imran Uddin is the primary author of the study, contributing to all stages of research, including data collection, data analysis, and the writing of the manuscript Dr. Saleema Gulzar supervised the entire study and provided appropriate guidance throughout. Dr. Sabeen Shah guided the study and offered assistance in the writing of the manuscript. Ms. Fauzia Hasnani, a biostatistician, aided in the data analysis and also provided guidance in the writing of the manuscript.

Acknowledgments

The authors express their gratitude to the graduate office of Aga Khan University School of Nursing and Midwifery for their assistance and contribution to the development and achievement of this research. Additionally, the authors extend their thanks to Ms. Ambreen Ishrat, an English editor, for her language editing and suggestions.

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The Comparison of Physical Activity Levels among School-age Adolescents in the Rural and Urban Areas of District Swat KPK, Pakistan- An Analytical Cross-Sectional Study

Status:

Version 1

Abstract

Introduction

Methodology

Results

The Socio-Demographic Characteristics of School Age Adolescents

The Mean Physical Activity Score based on the Place of Residence (Rural vs. Urban)

Inferential Statistics of Rural and Urban School-age Adolescents’ PA Score

PA Level of School-age Adolescents Based on the Factors of School Type, Gender, Grade, and Age

Mean PA Levels Difference based on the School Type of Adolescents

Differences in the Mean PA of Adolescents in Rural Private and Public Schools and Urban Private and Public Schools

A Comparison of PA Levels of School-age Adolescents based on their Gender i.e., Male and Female

The Difference in the Mean PA Score in Urban and Rural Males and Females

Comparing the Mean PA Levels of School-age Adolescents based on their Grades of Study (grades 6^th, 7^th, and 8^th)

Inferential Statistics for Comparing the Means of PA Level of Different Grades of Students

Correlation of Adolescents' PA Level with the Age (10 to 14 years)

Discussion

Conclusion

Abbreviations

Declarations

References

Status:

Version 1

The Comparison of Physical Activity Levels among School-age Adolescents in the Rural and Urban Areas of District Swat KPK, Pakistan- An Analytical Cross-Sectional Study

Status:

Version 1

Abstract

Introduction

Methodology

Results

The Socio-Demographic Characteristics of School Age Adolescents

The Mean Physical Activity Score based on the Place of Residence (Rural vs. Urban)

Inferential Statistics of Rural and Urban School-age Adolescents’ PA Score

PA Level of School-age Adolescents Based on the Factors of School Type, Gender, Grade, and Age

Mean PA Levels Difference based on the School Type of Adolescents

Differences in the Mean PA of Adolescents in Rural Private and Public Schools and Urban Private and Public Schools

A Comparison of PA Levels of School-age Adolescents based on their Gender i.e., Male and Female

The Difference in the Mean PA Score in Urban and Rural Males and Females

Comparing the Mean PA Levels of School-age Adolescents based on their Grades of Study (grades 6th, 7th, and 8th)

Inferential Statistics for Comparing the Means of PA Level of Different Grades of Students

Correlation of Adolescents' PA Level with the Age (10 to 14 years)

Discussion

Conclusion

Abbreviations

Declarations

References

Status:

Version 1

Comparing the Mean PA Levels of School-age Adolescents based on their Grades of Study (grades 6^th, 7^th, and 8^th)