This study aimed to examine the prevalence of adolescent active travel to school (ATS) across 31 countries and territories in Asia, overall and by age group, sex and body mass index (BMI) category.
Cross-sectional study.
31 Asian countries.
152 368 adolescents aged 13–17 years with complete data for age, sex, measured weight and height and active travel to school from 31 Asian countries from the Global School-based student Health Survey (GSHS).
Self-reported active travel to school categorised into passive (0 days) and active (1–7 days).
Overall prevalence of adolescent ATS in Asia based on random-effect meta-analysis was 55%, ranging from 18% (UAE) to 84% (Myanmar). There was limited subregional variation: 47% in the Eastern Mediterranean (EM), 56% in the South East Asia and 64% in the Western Pacific. Summarised by random-effect meta-analysis, being an older adolescent aged 16 years and older (vs younger age below 16 years: OR: 1.08; 95% CI: 1.00 to 1.16) was positively associated with ATS. This association was strongest in EM countries. Summarised by random-effect meta-analysis, females (vs males: OR: 0.79; 95% CI: 0.71 to 0.89) and adolescents with overweight/obesity (vs underweight and normal BMI: OR: 0.92; 95% CI: 0.86 to 0.99) were less likely to use ATS. Association with sex was strongest in EM countries. Heterogeneity was considerable in all meta-analyses.
The prevalence of adolescent ATS in Asia varies substantially. Overall, older and male adolescents, and adolescents with underweight and normal BMI category are more likely to actively travel to school. However, the main contributor to differences in ATS between and within regions remain unknown. Although there is substantial scope for improving ATS rates in Asia, any policy actions and interventions should be cognisant of local built, social and natural environmental contexts that may influence active travel behaviour.
This study pooled comparable estimates on active travel to school from 152 368 adolescents from 31 countries in Asia.
Data were collected using standardised sampling and data collection methods, enabling comparison across countries and subregions.
Data were from low-income and middle-income countries; thus, the extent to which these findings are generalisable to other, particularly high-income, countries in Asia is unclear.
Data collection was conducted in schools, and thus the conclusions drawn here are only relevant to adolescents in school.
Globally, non-communicable diseases (NCDs), notably cancers, cardiovascular diseases, type 2 diabetes and chronic respiratory illness, are responsible for about 40 million deaths each year.
Studies have reported that health benefits gained from physical activity in adolescence, defined as age 10–19 years,
Previous research in 63 low-income and middle-income countries (LMICs) showed that active travel to school is positively associated with adolescents’ physical activity,
Asia is the largest and most populous continent, with a population of 4.6 billion,
A few studies have been conducted in limited East and Southeast Asian countries. However, these studies had relatively small sample sizes (between 330 and 1518 participants),
The goal of this study was to examine the prevalence of adolescent ATS across 31 countries and territories in Asia, overall and by age group, sex and BMI category.
The reporting of this paper follows the Strengthening the Reporting of OBservational studies in Epidemiology guideline.
This study used data from the Global School-based Student Health Survey (GSHS), developed by WHO and the Center for Disease Control and Prevention (CDC) in collaboration with UNICEF, UNESCO and UNAIDS.
GSHS used a two-staged cluster sampling design to obtain a nationally representative sample of the adolescents. In the first stage, schools were randomly selected using the probability proportional to size sampling. In the second stage, classes were randomly selected in the selected schools, with varied number of classes depending on the school size. All students in the selected classes were eligible to participate in the survey, and the participation was anonymous and voluntary.
The GSHS surveys have been conducted in 185 mostly LMICs globally from 2003 to 2017. The survey consists of 10 core modules on adolescent health behaviours including physical activity and nutrition and protective factors, along with other optional modules. Data on response rates from each survey and characteristics of non-respondents were not available. Data cleaning and management, or data edits, were performed on all GSHS datasets: out of range edits, multiple response edits, logical consistency edits, height and weight edits, variable edits and record-level edits, where when the responses did not meet the requirement, they were set to missing. Observations with missing data were kept in the datasets. All GSHS datasets are freely available on WHO’s website:
This cross-sectional study used GSHS data from 31 Asian countries, as defined by the United Nations’ Statistics Division of geographic regions.
Data management was done using RStudio V.1.4. Prior to WHO data publication, out of range edits, multiple response edits, logical consistency edits, height and weight edits, variable edits and record-level edits were performed on all GSHS datasets.
The outcome variable, active travel to school, was self-reported using the question “During the past 7 days, on how many days did you walk or ride a bicycle to or from school?” with eight standard GSHS responses ranging from 0 to 7 days. In this study, travel to school was dichotomised into
Weighted prevalence of active travel to school in adolescents from 31 Asian countries using data from Global School-based Student Health Survey 2003–2017.
Independent variables included age, sex and BMI category. Age (in years) and sex (male or female) were self-reported. For analysis, age was categorised into two groups:
All statistical analyses were conducted using RStudio V.1.4. Only participants with complete data were included in the analyses (ranging from 34.2% to 97.4% by country). The 31 countries were categorised into three subregions: Eastern Mediterranean (which mostly consists of Middle Eastern countries); South East Asia (which consists of countries in the South and some countries in the Southeast Asia region) and Western Pacific (which consists of the rest of the countries in the Southeast Asia region along with countries in East and Central Asia). This categorisation was based on cultural and climate similarities shared by these countries, as well as WHO regional offices.
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Of the original 174 449 adolescents surveyed from the 31 countries, there were 152 368 (87.3%) adolescents aged 11–18 years with complete data included in the analysis. Participants were excluded due to missing values in one or more variables: n=893 for age, n=1518 for sex, n=19 996 for weight and height and n=2866 for travel to school. There was no significant difference between those included in this analysis, those excluded from this study and those excluded based on weight and height variables (
Characteristic of adolescents included in analyses from all 31 Asian countries
Country | Population* | Age category† | Sex | BMI category‡ | |||
Younger | Older | Male | Female | Underweight and normal | Overweight and obesity | ||
Eastern Mediterranean | |||||||
320 973 | 34% | 66% | 54% | 46% | 83% | 17% | |
67 431 | 54% | 46% | 50% | 50% | 58% | 42% | |
1 477 045 | 51% | 49% | 57% | 43% | 73% | 27% | |
195 315 | 37% | 63% | 52% | 48% | 76% | 24% | |
152 925 | 36% | 64% | 51% | 49% | 49% | 51% | |
231 936 | 44% | 56% | 46% | 54% | 72% | 28% | |
255 899 | 70% | 30% | 49% | 51% | 74% | 26% | |
47 730 | 30% | 70% | 47% | 53% | 76% | 24% | |
2 312 737 | 61% | 39% | 61% | 39% | 92% | 8.1% | |
7546 | 81% | 19% | 52% | 48% | 50% | 50% | |
1 229 410 | 75% | 25% | 51% | 49% | 73% | 27% | |
211 732 | 38% | 62% | 49% | 51% | 59% | 41% | |
584 111 | 57% | 43% | 64% | 36% | 88% | 12% | |
South East Asia | |||||||
4 534 799 | 64% | 36% | 64% | 36% | 89% | 11% | |
59 693 | 29% | 71% | 48% | 52% | 87% | 13% | |
1 529 631 | 65% | 35% | 58% | 42% | 88% | 12% | |
11 585 370 | 67% | 33% | 48% | 52% | 82% | 18% | |
12 521 | 35% | 65% | 49% | 51% | 88% | 12% | |
1 460 394 | 65% | 35% | 45% | 55% | 92% | 8.4% | |
1 869 854 | 54% | 46% | 48% | 52% | 92% | 8.0% | |
675 391 | 39% | 61% | 46% | 54% | 85% | 15% | |
3 134 435 | 50% | 50% | 45% | 55% | 81% | 19% | |
69 318 | 22% | 78% | 50% | 50% | 94% | 6.2% | |
Western Pacific | |||||||
25 645 | 49% | 51% | 49% | 51% | 63% | 37% | |
814 883 | 31% | 69% | 52% | 48% | 96% | 3.8% | |
721 037 | 73% | 27% | 51% | 49% | 82% | 18% | |
287 091 | 15% | 85% | 53% | 47% | 88% | 12% | |
2 181 675 | 41% | 59% | 50% | 50% | 76% | 24% | |
244 281 | 49% | 51% | 48% | 52% | 88% | 12% | |
6 021 848 | 49% | 51% | 49% | 51% | 90% | 10% | |
7 431 982 | 21% | 79% | 47% | 53% | 94% | 6.2% |
*Population represented by the sample.
†Age was categorised into younger (<16 years old) and older (≥16 years old).
‡BMI category was dichotomised by WHO categorisation of BMI-for-age among children aged 5–19 years.
BMI, body mass index.
The overall prevalence of adolescent ATS in Asia was 55% (see forest plot in
Weighted prevalence of active travel to school across 31 Asian countries using data from Global School-based Student Health Survey 2003–2017. PDR, People’s Democratic Republic.
Overall, older adolescents were 8% more likely to actively travel to school compared with younger adolescents (OR: 1.08; 95% CI: 1.00 to 1.16) (
Meta-analyses of logistic regressions for the associations of active travel to school and age, with younger adolescent as reference group (A), sex, with male as the reference group (B) and BMI category, with underweight and normal BMI as the reference group (C) in 31 Asian countries using data from Global School-based Student Health Survey 2003–2017. BMI, body mass index.
Overall heterogeneity (I2) was considerable in all three meta-analyses (age group: 64%, sex: 87% and BMI category: 51%) (
This study showed that 55% of Asian adolescents walk or cycle to school at least once per week. This prevalence varied substantially by country, with estimates varying from 18% (UAE) to 84% (Myanmar). However, regional variation was limited with 47% ATS prevalence noted in the Eastern Mediterranean, 56% in the South East Asia and 64% in the Western Pacific. Overall, older adolescents, male adolescents and adolescents with underweight/normal weight were more likely to use active modes than their counterparts. However, these associations varied across countries, suggesting that there may be substantial country-level variation in determinants of ATS.
The prevalence observed in the current study (55%) is broadly similar to that reported in previous studies from various countries and regions.
Despite limited regional variation, the Eastern Mediterranean had the lowest prevalence of adolescent ATS, which might reflect the high prevalence of physical inactivity in the general adolescent population in Eastern Mediterranean countries.
Similar to our findings, a study in Hong Kong reported that older adolescents were more likely to actively travel to school.
Findings from both our study and previous research using the GSHS and other global datasets demonstrated that female adolescents in Asia are less likely to actively travel to school than male adolescents.
Although adolescents with overweight and obesity BMI category were less likely to actively travel to school, this association was not observed in the subregion stratified analyses. Strong associations were only present in Cambodia and Vietnam, which is similar to findings from a Dutch population study where BMI was found to negatively influence later levels of active travel.
This study pooled estimates from 152 368 adolescents from 31 countries in Asia. Subregion and age-specific, sex-specific and BMI-specific estimates were also analysed. Data were collected using standardised sampling and data collection methods, enabling comparison across countries and subregions. However, the prevalence of ATS was obtained from one single self-reported question on both walking and cycling to school. Participating countries in the GSHS were also mostly those categorised as LMICs in Asia. As a result, the extent to which these findings are generalisable to other, particularly high-income, countries in Asia is unclear. This study also dichotomised both dependent and independent variables for meta-analysis purposes, which may have contributed to biases in the results, such as loss of information about individual differences and loss of effect.
This evidence shows that there is substantial scope for improving ATS prevalence in Asian countries, which less than half of adolescents using ATS in many countries. The prevalence of ATS varied between and within the three Asian subregions, as did the associations with individual factors (ie, age group, sex and BMI category). This suggests that targeted promotion to certain population subgroups may be useful. However, future research is needed to explore why these variations occur among these countries to inform future policies and practices on ATS. Noting the variation of ATS by age group among the countries, age of independent mobility, especially on Eastern Mediterranean countries, should be studied so that future interventions with focus of age groups are appropriately designed. Future interventions should also focus more on designing ATS interventions that target female adolescents in Eastern Mediterranean and South East Asia countries. Any policy actions or interventions will need to be contextually sensitive, cognisant of local built, social and natural environmental contexts that could influence ATS. Further studies are therefore needed to gather evidence on the roles that environmental factors, such as exposure to air pollution, high-density traffic, walkability and safety, play in influencing ATS across Asian countries.
The overall prevalence of adolescent ATS in Asia was 55%. The prevalence was lowest in UAE and highest in Myanmar. Overall, older adolescents, male adolescents and adolescents with underweight and normal BMI were more likely to actively travel to school than their counterparts. Although age, sex and BMI status were associated with the prevalence of ATS to varying degrees in the Eastern Mediterranean, South East Asia and Western Pacific regions, the main driver of variation within and between Asian countries remains unknown. Further investigations to identify other potential factors which account for differences in adolescent ATS prevalence across Asian countries is therefore needed to inform policy and practice.
The authors would like to thank Stephen Sharp of MRC Epidemiology Unit, University of Cambridge and Ihsan Fadilah of Eijkman-Oxford Clinical Research Unit, Jakarta, for the support on data analysis, and Bimandra Djaafara of Imperial College, London, for the assistance on map creation.
@rizkamaulida13, @DrErikaIkeda
RM designed the study with the supervision of EMFvS and TO. RM collected and managed the data assisted by EI. RM conducted the statistical analysis with guidance from EMFvS and EI. RM drafted the paper. All authors reviewed the results, edited the manuscript and agreed on the final version of the manuscript. RM is the guarantor of the study.
RM’s doctoral study is supported by Indonesia Endowment Fund for Education (201908220815174). EvS and EI are supported by the Medical Research Council (grant number MC_UU_00006/5). TO is supported by the National Institute for Health Research (NIHR) (16/137/34) using UK aid from the UK Government to support global health research.
The views expressed in this publication are those of the authors and not necessarily those of the funders. The funders had no role in the study.
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Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
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Data are available in a public, open access repository. Data are available on reasonable request. Original GSHS datasets are available publicly online at
Not applicable.
In each individual country, the GSHS was approved by the Ministry of Education, Ministry of Health or other institution in charge of the survey. Ethical approval was also obtained in all 31 individual countries. No reference numbers for these ethical approvals are available. Only those adolescents and their parents who provided written or verbal consent participated. As the current study used retrospective, de-identified, publicly available data, no separate ethics approval was required for the analysis of the data.