Prevalence of Meeting Youth Physical Activity Guidelines Across Income, Sex, Urbanicity, and Sport Participation: 2022–2023 National Survey of Children’s Health (NSCH)

Abstract

Purpose:

This cross-sectional study used data from the 2022–2023 National Survey of Children’s Health to examine the prevalence of American youth meeting physical activity (PA) guidelines by sociodemographic subgroups defined by income, sex, urbanicity, and sports participation.

Methods:

Weighted prevalence statistics were computed for meeting PA guidelines (≥60 minutes/day of PA) for groups defined by income [0–199% or ≥200% of federal poverty level (FPL)], sex (male, female), urbanicity (urban, rural), and past year sports participation (yes, no). Equity plots were generated to visualize prevalence of meeting guidelines across subgroups, with high SES (≥200% FPL), urban male sports participants as the reference group.

Findings:

The final analytic sample included 61,740 youth [M_age=11.6 years (SD=3.2), 51.2% male]. About 45% were sports participants, 88% were urban-dwelling, and less than 20% met PA guidelines. The prevalence of meeting guidelines ranged from 13.2% (95% CI: 11.6%–15.0%) among high SES, urban female non-sport participants to 31.1% (95% CI: 25.5%–37 .4%) among low SES, rural male non-sport participants. All comparisons were significantly different from the reference group except low SES, urban male sport participants; high SES, rural male non-sport participants; and low SES, rural females.

Conclusions:

Most American youth fail to meet PA guidelines, with lowest prevalences among female non-sport participants, regardless of SES and urbanicity status. Sports may be more important for PA among urban versus rural youth. The findings, which show a complex interplay between sociodemographic factors, PA, and sport, can be used to identify populations in need of targeted PA promotion programs.

INTRODUCTION

The benefits of youth meeting physical activity (PA) guidelines are well-established.^1–4 However, it is estimated that only 20% of American youth meet aerobic physical activity guidelines,⁵ defined as at least 60 minutes/day of moderate-to-vigorous intensity physical activity.⁶ Sports are considered one of the best investments for promoting youth physical activity,⁷ since it is the most popular type of physical activity among youth and sports participants are more likely to meet physical activity guidelines than non-sports participants.^8–11

There are well-established disparities in physical activity levels and sports participation by sex and socioeconomic status (SES).⁵ Males (versus females) and youth of high (versus low) SES consistently having higher physical activity and sports participation.^5,12–15 Although youth living in rural areas often experience fewer accessible sport options due to transportation barriers and lack of sport programs,^14,16 there is conflicting evidence around physical activity levels and sports participation by urbanicity status.^17–19 These findings may be due, in part, to lack of consideration for the intersectionality of SES, sex, urbanicity, and sport participation in relation to meeting physical activity guidelines. There is evidence to suggest that relation of urbanicity with youth sports participation and physical activity levels is moderated by sex,¹⁹ although additional research that accounts for both youth sex and household income is needed.

Examining physical activity levels among sociodemographic subgroups is crucial for addressing health inequities, as it can identify specific populations that are most at risk for inactivity. This information can be used to develop targeted public health policies and interventions that are aimed at increasing physical activity and addressing disparities among US youth. The purpose of this study was to examine the prevalence of American youth meeting physical activity guidelines by sociodemographic subgroups defined by household income, sex, urbanicity, and sport participation using data from the 2022–2023 National Survey of Children’s Health (NSCH). It is hypothesized that urban-dwelling male sport participants with high SES will have the highest prevalence of meeting physical activity guidelines.

METHODS

Data source and population

This study used data from the 2022–2023 National Survey of Children’s Health (NSCH), a mail- and online-based national study examining multiple aspects of health and wellbeing for non-institutionalized children aged 0–17 years in the US.²⁰ Survey topics included physical and mental health, and the child’s neighborhood and social context. A complete list of survey topics and survey procedures are available elsewhere.²⁰

A combined total of 109,265 surveys were completed for 2022 and 2023 with a weighted response rate of 39.1% for 2022 and 35.8% for 2023. Sports participation and physical activity data were only collected for youth ages 6–17 years, so youth less than 6 years old were excluded from the current study (n = 41,265). An additional 6,260 participants were excluded because their metropolitan statistical area (MSA) status (the urbanicity measure) was suppressed for confidentially, as described in more detail below. Written informed consent was collected from all guardians or parents.

Measures

The survey questions used in the present study are the same in both the 2022 and 2023 NCSH surveys. All questions were parent-report. Demographic variables include child age (in years), child sex (female, male), and household income [0–199% or ≥200% of the federal poverty level (FPL)]. For sports participation classification, parents were asked, “During the past 12 months, did this child participate in a sports team or did he or she take sports lessons after school or on weekends?” (Yes, No).

Metropolitan statistical area (MSA) status was used to define urbanicity and was classified as living within a metropolitan area (i.e. urban) or outside of a metropolitan area (i.e., rural). An MSA is defined as a county/counties that contain a city with a population of at least 50,000 people, plus adjacent counties with a high degree of economic and social integration with the core as measured through commuting ties.^21,22 To protect respondent confidentiality, MSA status is not reported in seventeen states and respondents from these states were excluded from analyses.

For physical activity, parents were asked, “During the past week, on how many days did this child exercise, play a sport, or participate in physical activity for at least 60 minutes?” (0 days, 1–3 days, 4–6 days, Every day). For the present study, responses were classified as either meeting (every day) or not meeting (0 days, 1–3 days, 4–6 days) physical activity guidelines. Socioeconomic subgroups were defined by the intersection of household income (0–199% or ≥200% FPL), sex (male or female), sport participation status (participant or nonparticipant), and urbanicity (rural or urban), which resulted in sixteen distinct groups.

Statistical Analyses

Analyses were conducted using Stata statistical software package (version 18.0; StataCorp, College Station, TX).²³ The Stata survey prefix command “svy” was employed to account for NSCH’s complex survey design and use of sampling weights. Sampling weights are provided in the NSCH dataset to support generation of population-based estimates.²⁰ These weights are the product of base sampling weights (inverse of probability that household is selected for screener), nonresponse adjustment factors, and adjustment to population controls.²⁴ The 2022–2023 NSCH combined dataset contained an adjusted sampling weight variable that accounted for combining 2 years of data. Missing values for child sex and race were imputed using hot-deck imputation.²⁴

Unweighted frequency and weighted prevalence statistics were computed for urbanicity status, physical activity and sports participation variables, and the child- and family-level characteristics. Survey-weighted proportions of meeting physical activity guidelines were estimated across sociodemographic subgroups, accounting for the complex survey design.

To visualize the prevalence of meeting physical activity guidelines across the sociodemographic groups, equity plots were generated using the user-written equiplot command in Stata.²⁵ Prior to generating the equity plot, weighted prevalence of meeting physical activity guidelines was calculated for all sixteen socioeconomic subgroups. Next, high SES (≥200% FPL), urban male sports participants were selected as a reference group. Pairwise comparisons for prevalence of meeting physical activity guidelines were conducted using adjusted Wald tests between the reference group with each of the other fifteen sociodemographic subgroups. Statistical significance was set at p<0.05.

RESULTS

The final analytic sample included 61,740 youth (Table 1). The sample had a mean age of 11.6 years (SD=3.2), was 51.2% male, and 61.5% had a household income 200% or more above the FPL. About 87.7% lived in an MSA, 44.7% participated in sports over the past 12 months, and 19.5% met physical activity guidelines.

Table 1.

Unweighted frequency and weighted prevalence statistics for demographic characteristics

Demographic Characteristics	n	Total (N=61,740)
Age, mean (SD)	61,740	11.6 (3.2)
Sex (%, 95% CI)
Male	31,964	51.2 (50.4 – 51.9)
Female	29,776	48.8 (48.1 – 49.6)
Urbanicity (%, 95% CI)
Rural	10,962	12.3 (11.9 – 12.8)
Urban	50,778	87.7 (87.2 – 88.1)
Met PA Guidelines (% Yes, 95% CI)	11,910	19.5 (18.9 – 20.1)
Sports Participation (% Yes, 95% CI)	36,393	45.7 (44.9 – 46.5)
Household Income Level (%, 95% CI)
0–199% of FPL	18,567	38.5 (37.7 – 39.3)
200% or more of FPL	43,173	61.5 (60.7 – 62.3)

SD: Standard Deviation; CI: Confidence Interval; PA: Physical Activity; FPL: Federal Poverty Level

The prevalence of meeting physical activity guidelines by socioeconomic groups is presented in Table 2. The prevalence of meeting physical activity guidelines ranged from 13.2% (95% CI: 11.6% - 15.0%) among high SES, urban female non-sport participants to 31.1% (95% CI: 25.5% - 37.4%) among low SES, rural male non-sport participants.

Table 2.

Unweighted frequency and weighted prevalence of meeting physical activity guidelines by sociodemographic subgroups (N=61,740)

Poverty Level	Gender	Sport Status	Urbanicity	n	Meeting Physical Activity Guidelines % (95% CI)
200% or more FPL	Male	Participant	Urban	12,963	24.7 (23.4 – 26.1)
			Rural	2,454	28.7 (25.8 – 31.8)
		Non-Participant	Urban	5,482	15.2 (13.1 – 17.6)
			Rural	1,036	22.1 (17.9 – 27.0)
	Female	Participant	Urban	10,877	16.1 (14.9 – 17.3)
			Rural	2,103	19.8 (17.2 – 22.6)
		Non-Participant	Urban	6,590	13.2 (11.6 – 15.0)
			Rural	1,095	13.7 (10.6 – 17.5)
0–199% FPL	Male	Participant	Urban	3,440	23.8 (21.3 – 26.6)
			Rural	1,032	29.8 (25.4 – 34.7)
		Non-Participant	Urban	3,877	19.8 (17.4 – 22.4)
			Rural	1,148	31.1 (25.5 – 37.4)
	Female	Participant	Urban	2,613	18.2 (15.8 – 21.0)
			Rural	824	26.4 (20.7 – 33.0)
		Non-Participant	Urban	4,057	15.4 (13.4 – 17.7)
			Rural	1,086	28.9 (23.8 – 34.6)

CI: Confidence Intervals; FPL: Federal Poverty Level

Figure 1 presents the equity plot with the prevalence of meeting physical activity guidelines by sociodemographic subgroup. The reference group (denoted in yellow) is high SES male sport participants living in urban areas. All comparisons were significantly different from the reference group except 1) low SES, urban male sport participants; 2) high SES, rural male non-sport participants; 3) low SES, rural female sport participants; and 4) low SES, rural female non-sport participants (all p>0.05).

Figure 1.

Equity plot comparing prevalence of meeting physical activity (PA) guidelines by sociodemographic groups

*denotes statistical significance at p≤0.05

PA: physical activity; SES: socioeconomic status

DISCUSSION

This study examined the prevalence of American youth meeting physical activity guidelines by sociodemographic subgroups based on household income, sex, urbanicity, and sport participation using data from the 2022–2023 National Survey of Children’s Health (NSCH). Less than 20% of youth met physical activity guidelines, and about 46% of youth participated in organized sports in the past year. The prevalence of meeting physical activity guidelines ranged from 13% to 31% among sociodemographic subgroups defined by household income, sex, sports participation, and urbanicity.

The equity plot allows for visual comparisons across sociodemographic groups, while denoting which comparisons with the reference group (high SES urban male sport participants) were significantly different. Contrary to the hypothesis, the reference group did not have the highest prevalence of meeting physical activity guidelines across all sociodemographic groups. While most urban youth were less active than the reference group – as expected, the results were more mixed among rural youth, with some groups showing a significantly higher or lower prevalence. Contrary to other studies,^26,27 the highest prevalence of meeting physical activity guidelines was shown among low SES, rural male non-sport participants. Overall, the lowest physical activity prevalences were shown among female non-sport participants, regardless of SES and urbanicity, aligning with the larger literature base.^13,14,28

The presented findings suggest that organized sport may be more important for physical activity among urban versus rural youth, who might engage in other forms of activity outside of organized sport. However, additional research is needed to understand what is driving physical activity levels among non-sport participants, particularly in rural areas. One study among Australian youth examined the relation between sport participation, physical activity, SES, and ‘geographic remoteness’,¹⁷ and showed a complex interplay between these factors, as physical activity was SES- or remoteness-prohibitive for only some forms of physical activity. It is possible that some rural-dwelling youth are engaging in more outdoor recreation activities (e.g., fishing, farming, hunting) or free play due to the increased access to open spaces and natural areas, as well as the reduced access to organized sport opportunities in these areas.^29,30 One study conducted among a national sample of American youth provides evidence that sedentary time is lower among rural versus urban youth,³¹ which could also help explain the presented findings.

The inconsistent findings for physical activity levels among sport participants could also reflect limitations around the sport participation measure within the NSCH, which did not capture intensity, frequency, duration, or type of sport, which likely vary across sociodemographic subgroups. For example, previous research among a national sample of American youth showed higher prevalence of sports participation among adolescent, rural-dwelling males than their urban counterparts,¹⁹ which was hypothesized to be a result of population size and the types of sports in rural areas (e.g., smaller population sizes combined with large roster sizes for team sports).^32,33 Future research should incorporate a more robust, comprehensive measure of sports participation to more accurately characterize potential disparities in youth sports.

This study has numerous strengths. First, this study contributes to the dearth of literature examining physical activity prevalence with consideration for the intersectionality of known determinants of physical activity and sports participation. Second, this study was conducted among a large, national sample, contributing to the generalizability of study findings. Third, the analyses were conducted using combined data from consecutive years of the NSCH survey, providing more precise parameter estimates compared with using one-year data.

Study limitations should also be noted. First, data are parent-report and therefore subject to response and recall bias. Second, the NSCH survey is cross-sectional, limiting the ability to make causal inferences. Third, the urbanicity measure (metropolitan statistical area), although one of the most widely used urban-rural classification systems (Hailu and Wasserman, 2016), is not designed to determine county rurality (Coburn et al., 2007). Non-MSA designation will likely capture rural and small urban districts, yet some rural areas may be included with MSAs and not captured as rural populations. Fourth, MSA status was suppressed for confidentiality for several states, which were excluded from analyses. Finally, as noted above, the measure of sports participation did not capture duration, intensity, frequency, or type of sports.

Conclusion

The purpose of this study was to examine the prevalence of meeting physical activity guidelines by sociodemographic subgroups defined by household income, sex, urbanicity, and sport participation among a national sample of American youth. Overall, most youth failed to meet physical activity guidelines regardless of sports participation, emphasizing the need for increased efforts to support physical activity among American youth both within and outside of the sport sector. These findings also highlight specific sociodemographic groups (e.g., non-sport females in both rural and urban areas) as priority populations due to the low prevalence of meeting guidelines among these groups (≤15%). The findings, which show a complex interplay between sociodemographic factors, physical activity, and sport, can be used to identify populations in need of targeted physical activity promotion programs.