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Mental health (MH) is a concept that encompasses, among other variables, perceived self-efficacy, subjective well-being, competence, autonomy, intergenerational dependence and self-actualization of the individual's intellectual and emotional potential (World Health Organization - WHO, 2002). It is a general term to refer to psychological, mental, cognitive, and affective factors that promote or hind an individual's functioning. MH can be affected by mental disorders (in its cognitive, emotional or behavioural dimension) that can be explained by a combination of biological, psychological and social factors (American Psychiatric Association, 2013; WHO, 2002).
MH problems are prevalent in the general population all over the world (Reneses et al., 2015), having increased significantly in recent decades (Knapstad et al., 2021). Today, they represent one of the greatest public health concerns in the world (Storrie et al., 2010; WHO, 2014). According to the WHO, it is estimated that 10% to 20% of adolescents around the world, at any time of their lives, may have had some type of mental illness, with a peak occurrence up to the age of 25 years (Kessler et al., 2007). These numbers increase when we analyze only young people enrolled in higher education (Cvetkovski, et al., 2012; Stallman, 2010). According to the University Student Mental Health Survey (2018) one in five students have had MH problems, regardless of the years of enrolment. These MH problems in students enrolled in higher education are visible in the high levels of stress, anxiety and depression (Bayram & Bilgel, 2008; Bahhawi et al., 2018; Beiter et al., 2015; Eisenberg et al., 2013; Fernández-Rodríguez et al., 2019; Hussain et al., 2013; Ibrahim et al., 2013; Liu et al., 2019; Potrebny et al., 2017; Ramón-Arbués et al., 2020).
These MH issues affect their quality-of-life perception (QoL) (Gao et al., 2018; Islam, 2019; Sanil et al., 2018), that is, the meaning their perception of their position in life, in the context, culture and value system in which they are inserted, considering their objectives, expectations, standards and concerns (WHOQOL GROUP, 1994; 1998). Student with MH problems or poor QoL are associated with higher health care expenditure and poor school performance (Rimyall et al., 2021). In more severe cases, these MH problems associated with a poor QoL give rise to self-injurious and suicidal behaviours (Davis et al., 2020). On the other hand, there are several studies that show that better QoL of students is associated with better academic performance (Degoy & Berra, 2018; Molnár et al., 2020; Sundén, 2019).
The physical activity practice (PA), physical exercise (PE) or sport plays an important role in preventing the onset of cardiovascular or metabolic diseases (Coombes et al., 2015; Lee et al., 2012). PA, PE and sport are terms that describe different concepts. PA is defined as any body movement produced by skeletal muscle that result in energy expenditure. Energy expenditure can be measured in Kilocalorie. PE include a systematic planning of PA, with a defined structure and repetition, with a view to maintaining or improving one or more component of physical fitness, namely strength, cardiorespiratory, balance and flexibility capacity (Caspersen et al., 1985). There are several sport definitions, and they all have something in common: they all concern any type of PA or PE that result from a competition (Sutula, 2018).
In recent decades, PA/PE or sports practices have been associated with benefits in MH (Chekroud et al., 2018; Galper et al., 2006; Harvey et al., 2010), namely in reduction of depression, anxiety and stress (Cooney et al., 2013; Ensari et al., 2015; Fox, 1999; Gordon et al., 2018; Grasdalsmoen et al., 2020; Guszkowska, 2004; Jacinto et al., 2021; Kvam et al., 2016; Morres et al., 2019; Neves et al., 2014; Scully et al., 1998) and a better perception of QoL (Pucci et al., 2012).
Considering the obvious association between PA, PE and sport, MH, and the QoL perception in the general population, studies with students enrolled in higher education are rare. Knowing that school performance is an indicator of success in the future, it is important to know all the variables that can harm this success, in order to define effective intervention strategies. Today’s students are tomorrow’s future professionals, and the development of the world always depends on future generations. Thus, the aim of this study is to assess the relationship between PA/PE/sport, MH (stress, depression, and anxiety) and QoL perception of young people enrolled in higher education.
Method
Search strategy
The review was carried out in accordance with PRISMA protocol (Moher et al., 2009, 2015; Page et al., 2021) and the methods suggested by Bento (2014). The protocol was registered in the PROSPERO, with the number CRD42021286398. In the present study, the PICOS strategy (Methley et al., 2014; Nang et al., 2015) was defined according to the items: i) “P” (Patients) corresponded to participants enrolled in higher education, aged between 17 and 36 years, of any gender, race and ethnicity; ii) “I” (Intervention) corresponded to any PA, exercise and sport program, regardless of the duration of the intervention or the application of a questionnaire, in a cross-sectional study; III) “C” (Comparison) corresponded to the comparison before and after the intervention; iv) “O” (Outcome) corresponded to mood, depression, stress, anxiety, panic or phobia, as the first or second variable under study; v) “S” (Study Design) corresponded to intervention studies, randomized controlled trials (RCT’s) or not RCT’s, pilot studies or cross-sectional studies.
Inclusion/exclusion criteria
The inclusion criteria were studies with participants enrolled in higher education, aged between 17 and 36 years, of any gender, race and ethnicity; and studies that included any Physical activity, exercise and sport program, regardless of the duration of the intervention or the application of a questionnaire, in a cross-sectional study.
Study selection
A total of 200 studies were identified through a search carried out in the four databases. In a first phase, which included the reading of titles and abstracts, as well as the elimination of duplicate articles, 37 articles potentially relevant to the study were identified. Considering the defined eligibility criteria, after the complete reading of the articles, a sample of 16 articles was constituted for its full analysis (Figure 1).
Table 1 presents the characteristics of the studies included in the systematic review. From the sixteen studies included in this systematic review, seven are from the Asian continent (Almhdawi et al., 2021; Chellaiyan et al., 2018; Fukui et al., 2021; Hossen et al., 2020; Kayani et al., 2020; Li et al., 2015; Mak et al., 2018), four are from the European continent (Carpi et al. 2021; Herbert et al. 2020; Marschin & Herbert 2021; Ruotolo et al. 2021), four from the American continent (Brandão Pinto de Castro et al., 2017; Dinzeo et al., 2014; Miguel et al., 2021; Yorks et al., 2017) and one study belongs to a Eurasian country (Ozkul, 2021).
Ten studies used a cross-sectional methodology (Almhdawi et al., 2021; Brandão Pinto de Castro et al., 2017; Carpi et al. 2021; Chellaiyan et al, 2018; Hossen et al., 2020; Kayani et al., 2020; Mak et al., 2018; Miguel et al., 2021; Ozkul, 2021; Ruotolo et al. 2021). Five studies used an experimental metholodology, with three being randomized controlled trials (Fukui et al., 2021; Herbert et al., 2020; Li et al., 2015) and two not (Marschin & Herbert 2021; Yorks et al., 2017). We can also see that one study concerns the validation of a questionnaire (Dinzeo et al., 2014).
The results of this systematic review show that PA/PE/sport practiced of young people enrolled in higher education are correlated with the MH and QoL perception. This main result of this study can be presented as followed (Figure 2):
Table 1 Characteristics of the studies included in the systematic review.
| Author, year, Country | Aims | Sample | Study Design | Assessment | Results |
|---|---|---|---|---|---|
| Almhdawi et al. (2021) Jordania | Study the undergraduate healthcare university students' health-related QoL’s perception and its predictors during COVID-19. | N= 485; 20.6 ± 2y. Jordan university students. | Cross-Sectional. | Medical Outcomes Study Short Form - SF-12; Depression Anxiety Stress Scale (DASS 21); International Physical Activity Questionnaire - short form - IPAQ-SF; Neck Disability Index (NDI). | PA level was associated with health related QoL level (β = 1.81 [IC 95% 0.32 a 3.30],p<0.05). |
| Carpi et al. (2021) Italy | Study the levels of psychological well-being, stress and quality of life in students. | N= 407; Average age: 19.72y. Students from Medical course at Sapienza University of Rome. | Cross-Sectional. | Short Form 12: Psychological General Well-Being Index Perceived Stress Scale. | Regular physical exercise was associated with lower psychological distress (β = -0.62 [IC 95% 0.34 a 0.86],p<0.05) |
| Castro et al. (2017) Brazil | Assess specific factors related to lifestyle and QoL in undergraduates | N= 103. Undergraduate students of the Physical Education course at the State University of Rio de Janeiro. | Cross-Sectional. | Individual Lifestyle Profile | PA correlated with stress symptoms (r=0.226; p<0.05). |
| Chellaiyan et al. (2018) India | Study the physical inactivity prevalence among students and its association with anxiety, stress and depression. | N= 507. Students from the Faculty of Medicine of India. | Cross-Sectional. | Socio-demographic profile and anthropometry of the study participants. International Physical Activity Questionnaire (IPAQ); Perceived Stress Scale (PSS); Generalised Anxiety Disorder 7 (GAD-7); Beck Depression Inventory (BDI). | Significant association between depression and sedentary behaviour (p=0.049). |
| Dinzeo et al., (2014) United States of America | Describe the development and preliminary evaluation of one questionnaire. | N= 377; 18-25y (20.14 ± 1.73y). Students from a university in the northeast of the United States of America. | Feasibility, validation, and preliminary examination of the questionnaire. | Lifestyle and Habits Questionnaire; QoL Inventory; Stress Scale. | Physical health and exercise were the best predicted of QoL´s perception (r=0.434,p<0.001). |
| Fukui et al., (2021) Japan | PA improvement among college students. | N= 125; 21.6 ± 2.9y. Randomized group: intervention (stay-at-home exercise - trunk, upper extremity and lower extremity, for 8 week) and control. Students from a university in Hiroshima. | Randomized controlled trial study. | Short Form-8 (SF-8) 5-item World Health Organization Well-Being Index (WHO-5) Kessler Screening Scale for Psychological Distress (K6). | Significant interaction for the general health subscale of health related QoL (F=9.52), subjective well-being (F=6.70), and psychological stress (F=7.83) was detected (p<0.05) (positive effect on the MH). After intervention, MH variable increased (d=2) and WHO-5 scale score (d=0.96). The k-6 scale score decreased in the intervention group (d=1.94), |
| Herbert et al., (2020) Germany | Assess MH, well-being regular PA and explore the potential health benefits of short-term aerobic exercise on German university students. | N=185; 22.54 ± 2.93y. N= 30 aerobic exercise intervention group (6 weeks, 2x/week; 8-16 min/session; N= 10 laboratory pilot study group (2 weeks, 2x/week; 8-16 min/session); | Randomized controlled trial study. | Beck Depression Inventory State-Trait Anxiety Inventory Positive and Negative Affect Schedule Stress and Coping Inventory WHOQOL-BREF ( Global Physical Activity Questionnaire Eating Disorder Inventory | Regular PA was negatively correlated with depression (r=-0,22. p<0.05), trait anxiety (r=-0.26, p<0.001), body dissatisfaction (r=-0.21, p<0.05) and perceived psychosomatic stress (r=-0.21, p<0.01) and positively correlated with QoL (r=0.27, p<0.001). Decreased depressive symptoms in the intervention group (p<0,005,d=0,62), perceived stress (p< 0,001,d=0,72), perceived stress due to uncertainty (p< 0,001,d=0,77) and symptoms anxiety (p> 0,1,d=0,17). |
| Hossen et al., (2020) Bangladesh | Assess the sports and exercises impact on mental and physical health among the university students. | N= 639; 18-26y. 6 university students in Bangladesh. | Cross-Sectional. | General Anxiety Disorder-7 Patient Health Questionnaire-9 (PHQ-9). | Anxiety and depression were significantly lower in individuals who practiced PE (p<0.001). |
| Kayani et al., (2020) China | Assess the PA influence on academic anxiety | N=418; 18-36y. Pakistani university students. | Cross-Sectional. | PA Questionnaire; Self-enhancement and self-protection strategies scale;Self-criticism 6-item state and trait anxiety scale | Negative correlation between PA and anxiety (r=−0.281;p<0.01). |
| Li et al. (2015) China | Assess the effectiveness and safety of Baduanjin exercise on physical and MH of Fujian Traditional Chinese Medicine student. | N=222; 18-25y. Randomized groups: intervention group (N=101; 20.63 ± 1.03y) and control (N=105; 20.92 ± 1.15y) Intervention: beginning and ending posture exercise (12 weeks; 5 x week; 60 min/session). | Randomized controlled trial study. | The Symptom Checklist-90; Perceived Stress Scale; General Self-efficacy Scale; Self-Esteem Scale; Profile of Mood States; Mood and mindfulness (POMS scale): WHOQOL-BREF. | No significant changes in self-symptom intensity (p=0.713), stress (p=0.207), self-efficacy, self-esteem (p=0.278) (p=0.242), mood (p=0.682) and QoL (p=0.798). |
| Mak et al., (2018) China | Assess the relationships between socio-economic status, health-promoting lifestyles and QoL among Chinese nursing students. | N=539; 21.7 ± 2.08y. Hong Kong university students. | Cross-Sectional. | Health-Promoting Lifestyle Profile II (HPLP-II); Youth Risk Behavior Survey (YRBS); World Health Organization Quality of Life (WHOQOL)-BREF instrument; Socio-economic status. | Positive association between QoL’s perception and PA (p=0.018). |
| Marschin & Herbert, (2021) Germany | Study and compared the PA effects and cognitive intervention on MH among university students. | N=20; 22.54 ± 2.93y. Students from German universities. PA: endurance exercises, muscular strength, relaxation, and ballroom dance movements (1x week, 5 to 10 min). | Quasi-experimental study. | Perceived Stress Scale-10; Stress and Coping Inventory; Positive and Negative Affect Schedule; WHOQOL-BREF; Global Physical Activity Questionnaire; Beck Depression Inventory-II; Eating Disorder Inventory-2; Physical Activity Readiness Questionnaire; Balanced Inventory of Desirable Responding; Reasons for Exercise Inventory; D2-R Test for Attention. | Both interventions can reduce university students’ perceived stress, mood, and QoL’s perception across the term. The interaction effect of group × time on self-reported perceived stress, mood/affect and QoL was not significant. |
| Miguel et al., (2021) Brazil | Study associated factors with QoL’s perception of Brazilian medical students. | N= 1350; 22.8 ± 3.46y. | Cross-Sectional. | WHOQOL-BREF; VERAS-Q; Epworth Sleepiness Scale; Pittsburgh Sleep Quality Index; Beck Depression Inventory; Resilience Scale; State-Trait Anxiety Inventory; Interpersonal Reactivity Multidimensional Scale; Maslach Burnout Inventory; Dundee Ready Education Environment Measure | Physical health (included PA) was the most important factor predicting QoL’s perception. |
| Ozkul (2021) Turkey | Assess the QoL’s perception, PA level, sleep quality, stress, anxiety, depression levels and the relationship between the QoL’s perception and these factors among university students. | N=320; 20-22y. Physiotherapy students at Gazi university. | Cross-Sectional. | Short Form-36 (SF-36); Short Form-International Physical Activity Questionnaire (IPAQ); Pittsburgh Sleep Quality Index (PSQI); 10 item Perceived Stress Scale (PSS); Hospital Anxiety and Depression Scale (HADS). | Significative correlation between PA and general health (r=0.110;p<0.049) and MH (r=0.170;p<0.002). |
| Ruotolo et al., (2021) Italy | Assess the validity and the reliability of SF-12 Health Survey version 2 (SF-12v2) in QoL’s perception Italian students. | N=583; 23.14 ± 5.1y. | Cross-Sectional. | SF-12 Health Survey version 2 (SF-12v2). | Positive association between PA and MH (p=0.007). |
| Yorks et al., (2017) United States of America | Assess the relationship between PE and stress and QoL’s perception in a medical student (EUA) | N=69. Medical students at a university in the United States of America. Nonrandomized groups: Fitness class group (N= 25, group fitness class - 30 min, 1x week; 20-29y); Health-enhancement group (N= 29, PA alone or even with 2 partners, 2x week); control group (N=15) 12 weeks. | Nonrandomized, controlled study. | Perceived Stress Scale (PSS); QoL Visual Analog Scales (VASs). | Fitness class group decreased perceived stress (p=0.038) and increased physical QoL (p=0.007), mental (p=0.046) and emotional (p=0.004). Health-enhancement group improved mental QoL (p=0.023). |
Main results on the link between Physical Activity/Physical Exercise/Sport, Mental Health and Physical Activity/Physical Exercise/Sport and Quality of Life
Carpi et al. (2021), Castro et al. (2017), Herbert et al. (2020), Hossen et al. (2020), Marschin and Herbert (2021) and Yorks et al. (2017) claim that PA/PE/sport is associated with a reduction in stress symptoms and that its impact on anxiety is also evident (Herbert et al., 2020; Hossen et al., 2020; Kayani et al., 2020). For Marchin and Herbert, (2021), there is an association between PA/PE/sport and mood. Chellaiyan et al. (2018) and Herbert et al. (2020) state that physical inactivity is associated with the prevalence of depressive symptoms (and its relationship with MH is direct) (Fukui et al., 2021; Herbert et al., 2020; Ozkul, 2021; Ruotolo et al., 2021; York set al., 2017).
Almhdawi et al. (2021), Yorks et al. (2017), Dinzeo et al. (2014), Mak et al. (2018), Herbert et al. (2020) and Marschin and Herbert (2021) studies reveals that higher PA levels were related to better QoL perception, with one study claiming that PA is the most important factor (Miguel et al., 2021).For studies that performed correlations with PA/PE/sport, we found MH weak in general (Ozkul, 2021), with stress (Castro et al., 2017; Herbert et al., 2020), weak with correlated with symptoms anxiety (Herbert et al., 2020; Kayani et al., 2020;) and depression (Herbert et al., 2020) and weak to moderate with QoL (Dinzeo et al., 2014; Herbert et al., 2020).
Li at al (2015) in an experimental study found no significant differences between the PA/PE and QoL. Naturally, due to the weight of the studies, we would like to give greater prominence to the ranmized controlled studies. In the study by Herbert et al. (2020) PE intervention resulted in a decrease in depressive symptoms with a medium effect size. Fukui et al. (2021) showed large effect sizes with the intervention to increase QoL and MH and decrease depressive symptoms. Li at al (2015) in an experimental study found no significant differences between the PA/PE/sport and QoL.
Discussion
The present systematic review aimed to study the relationship between PA/PE/sport, and MH, namely stress, depression, anxiety and QoL perception, in young people (17 to 36 years old) enrolled in higher education.
Around the world, higher education students aren´t following the current PA recommendations (Irwin, 2004; Rhodes et al., 2017). The prevalence of sedentary lifestyles, namely low PA levels, is concerning health services once these behaviours increase individuals’ risk of cardiovascular or metabolic disease (Dumith et al., 2011; Lee et al., 2012; Rhodes et al., 2017). Low PA levels are also associated with mental disorders (Biddle & Asare, 2011; Teychenne, Ball & Salmon, 2010a, 2010b) and are considered the fourth leading cause of death worldwide (Lee et al., 2012). On the other hand, PA practice promotes academic performance (Asigbee, Whitney & Peterson, 2018; de Bruijn et al., 2018; Zhang et al., 2019), so students enrolled in higher education can have scholar benefits if they assume a more active lifestyle.
Mental disorders (e.g. depression, anxiety) can significantly and negatively affect performance and motor control, working memory, concentration and injury risk (Stults-Kolehmainen and Sinha, 2014), important dimensions in academic terms, for health and for QoL perception.
The political and cultural reality differs from continent to continent, as well as economic inequality, especially in high and middle-income countries, therefore, PA levels can also differ between countries or continents (SFM et al., 2020). In socioeconomically and culturally underdeveloped countries, the scarce PA prevalence in adolescents/students is real (Arat & Wong, 2017; Cihan, Bozdağ & VAR, 2018; Dinc et al., 2015; Rhodes et al., 2017; Khan et al., 2018; Gul et al., 2019; Uddin et al., 2020). In underdeveloped countries there are lack of resources, policies and planning to promote PA and respond to the comorbidities caused by its low levels. In developed countries, PA levels are similarly insufficient, due to rapid urbanization and globalization in recent years (Hallal et al., 2012).
The admission to higher education, the changes and challenges that this entails, may be associated with the emergence of comorbidities such as depression, anxiety, or the adoption of unhealthy lifestyles (Fernández Villa et al., 2013), namely a) stress during the academic phase; b) pressure resulting from external factors (e.g. exams); c) excessive workload; d) lack of leisure time; e) poor time management; f) competition; g) fear/concern about not meeting the parents’ expectations; h) new relationships; i) change of residence; j) biological factors (e.g. age, sex); k) incorrect use of the internet; l) smoking; m) bad eating habits (including excessive alcohol consumption); n) lack of sleep or PA; o) low self-esteem; p) lack of a stable partner; q) financial charges (Balapala & India, 2017; Bangasser et al., 2010; Gao, Ping & Liu, 2020; Ibrahim et al., 2013; Kruisselbrink Flatt, 2013; Kumaraswamy, 2013; Silveira et al., 2011). The levels of anxiety and depression can lead to self-injurious and suicidal behaviours (Davis, Doyle & Nahar, 2020), making it urgent to value the MH of these subjects, who often do not seek psychological help for fear of exposing the situation or speaking in public about their concerns, emotions or life habits (Fernández-Rodríguez, Soto-López & Cuesta, 2019).
Physical activity, Physical Exercise, Sports and Mental Health
The results of this systematic review are corroborated by Khanzada et al. (2015) study, in which was concluded that students who took PA/PE or sports had a low level of depression and anxiety.
This positive association between PA/PE/sports and MH is also clear when depressive symptoms are analyzed, which are more evident in sedentary students (Chellaiyan et al., 2018). Herbert et al. (2020) study showed that the more PA was practiced, the fewer were the depressive symptoms. Currently, this relationship is recognized not as a preventive measure, but as a treatment (Bushman, 2019; Dunn & Jewell, 2010).
Anxiety and depression were significantly lower in individuals who practiced PE in Hossen et al. (2020) study, where athletes and non-athletes were compared. These study results are consistent with other studies carried out previously (Craft et al., 2007; Pourranjbar et al., 2010; Proctor & Boan-Lenzo, 2010; Weber et al., 2018), reinforcing the idea that the PA/PE/sports can be one of the reasons for lower levels of anxiety and depression among athletes. On the other hand, PA/PE/sport practice is not only associated with a decrease in symptoms of anxiety and depression, but also with better school performance, a fact that is clear in most of the literature (Asigbee, Whitney & Peterson, 2018; Barbosa et al., 2020; de Bruijn et al., 2018; McPherson et al., 2018; Zhang et al., 2019). For Hossen et al. (2020), these symptoms can be reduced with the creation of sports practices and/or adherence to extracurricular activities.
Regular PA/PE practice was also associated with stress decrease in different studies (e.g.: Carpi et al., 2021; Castro et al., 2017; Herbert et al., 2020a; Marschin & Herbert, 2021; Yorks et al., 2017). Jackson (2013) research report reveal that individuals who engage in aerobic activity for 20 to 30 minutes per week feel calmer than those who don´t and that this effect can last for several hours after exercise.
In addition to these results, higher levels of anxiety were found in females and depression in males (Brand et al., 2012; Chan et al., 2010). On this issue, the research is not accurate: there are studies that reveal higher anxiety scores in women, but do not find differences between gender on depression values (Jörngården et al., 2006) and other studies point out to female gender having high levels of anxiety and depression (Li et al., 2021). However, most of the research seems to point out that the female gender has higher levels of both variables (Alibrahim et al., 2010; Alosaimi et al., 2014; Hou et al., 2020; Oliva et al., 2018; Shehatah et al., 2010; White et al., 1999). Several factors may be behind these results, as well as the different conclusions between the studies: the culture and the development of the country, the sample recruited characteristics (namely, convenience sample, greater number of one gender, professional situation, among others), current situation of the country/world (example COVID-19) or even the context.
The COVID-19 pandemic has worsened the university students´ MH. However, Fukui et al. (2021), when implementing an online PE program during the pandemic for students enrolled in higher education found out that the pandemic had had a positive impact on the MH of the students.
PE practice, namely aerobic, has been associated with MH (stress, depression and anxiety) and QoL perception (Jackson, 2013). Herbert et al. (2020) argueargues that short-term practice should be recommended for MH promotion. Such results are corroborated by Ozkul (2021), Yorks et al. (2017) and Ruotolo et al. (2021) studies since they show a significant correlation between PA/PE, general health and MH.
Physical activity, Physical Exercise, Sports and Quality of Life
This systematic review results show the impact of PA/PE/sports on QoL perception. Almhdawi et al. (2021), Yorks et al. (2017), Dinzeo et al. (2014), Mak et al. (2018) and Herbert et al. (2020) studies bring out that higher PA levels were related to better QoL perception, with one study claiming that PA is the most important factor (Miguel et al., 2021). These results are in agreement with Anokye et al. (2012), namely when we spoke about the population of various age groups or different clinical conditions.
PA/PE/sport have a direct impact on brain development, namely in the frontal and temporal area, due to the cortical activity they provoke. PA/PE/sport increase metabolism, oxygenation, blood flow, state of excitability and brain derived neurotrophic factor, affecting brain plasticity, stimulating the production of angiogenesis, neurotrophies, synaptogenesis and the release of endorphins (Corbett et al., 2013; Dishman & O’Connor, 2009; Harber & Sutton, 1984; Ringenbach et al., 2016; Vogt et al., 2012). These data may explain the relationship between MH, QoL perception and the significance of regular PA/PE/sport practice. In addition to physiological mechanisms, other factors may explain this relationship, namely psychological (e.g., distraction or mental time out, mastery and self-efficacy) or inflammatory mechanisms (e.g., link between the immune system and nervous system) (Mikkelsen et al., 2017).
Li et al. (2015) didn´t find any differences between the study groups about stress and QoL perception. The author justifies this fact with the participants characteristics (e.g., time to regular PA/PE practice or other sports activities). It is noteworthy that not even students from Sports Science put into practice what they learn during the course, such as healthy eating, regular practice of PE or healthy sleep habits (Brandão Pinto de Castro et al., 2017).
To sum up, this systematic review results show that PA/PE or sport practices are correlated with MH, promoting the QoL perception of young people enrolled in higher education.
PA/PE and/or sports have a direct impact on brain development, namely in the frontal and temporal area, due to cortical activity they incite. They increase metabolism, oxygenation, blood flow, excitability state and brain-derived neurotrophic factor, affecting brain plasticity, stimulating the production of angiogenesis, neurotrophins, synaptogenesis and the release of endorphins (Corbett et al., 2013; Dishman & O’Connor, 2009; Harber & Sutton, 1984; Ringenbach et al., 2016; Vogt et al., 2012), evidence that may justify the results found regarding the relationship between PA/PE/sport and MH and PA/PE/sport and QoL.
Limitations and future recommendations
There is a scarcity of intervention studies (experimental methodology, namely randomized controlled trials) that present PE programs or analyze PE programs impact on stress, depression, anxiety and QoL perception. This is a fundamental topic to continue the study of the relationship of the variables of interest. Due to the diversity of studies included in the presented systematic review, it limits to presentation and discussion of results. Even so, this is intended to be the first survey of the state of the art for suture studies.
At the same time, some studies included in this systematic review have some limitations, which may limit the magnitude of the results. Future studies should take into account the following limitations: i) non-representative sample of the entire young university population, institution, country or world (Almhdawi et al., 2021; Carpi et al., 2021; Dinzeo et al., 2014; Herbert et al., 2020; Hossen et al., 2020; Kayani et al., 2020; Li et al., 2015; Marschin & Miguel, 2021; Ozkul, 2021; Yorks et al., 2017), or sample convenience (Kayani et al., 2020); ii) use of assessment instruments that raised some difficulties in understanding the terminology (Hossen et al., 2020); iii) distance between data collection points (Hossen et al., 2020); iv) difficulty in collecting data, due to the university workload (Hossen et al., 2020); v) interviewer bias (Hossen et al., 2020); vi) response bias (Dinzeo et al., 2014; Kayani et al., 2020; Li et al., 2015; Mak et al., 2018); vii) absence of data prior to the COVID-19 pandemic; viii) difficulty to submit the assessment methodology (Almhdawi et al., 2021); ix) cross-sectional methodology (Brandão Pinto de Castro et al., 2017; Carpi et al., 2021; Mak et al., 2018; Miguel et al., 2021); x) unrepresentative data (Chellaiyan et al., 2018); xi) bias in sample selection (Dinzeo et al., 2014); xii) Hawthorne effect (Fukui et al., 2021); xii) COVID-19 pandemic situation (Fukui et al., 2021); xiii) high dropout rate (Fukui et al., 2021); xiv) unblinded participants and instructors/non-randomized study randomized (Li et al., 2015; Marschin & Herbert 2021; Yorks et al., 2017).
Physical inactivity is seen as a public health problem (Ozkul, 2021). Since higher education students tend to adopt sedentary lifestyles (Grasdalsmoen et al., 2019; Guthold et al., 2018), it is necessary to promote students physical activity in order to achieve the WHO recommendations (2020) and promote their MH and QoL perception through intervention strategies to enhance PA/PE/MH and QoL perception. It is important to encourage students to achieve PA recommendations, namely 150 to 300 minutes of moderate PA, or 75 to 150 minutes of vigorous PA per week (WHO, 2020), preferably in group or social activities (Yorks et al., 2017). Likewise, it is still necessary to identify the risk behaviours of the target population (Bore et al., 2016; Carpi et al., 2021; Dyrbye et al., 2006).
The Exercise is Medicine is an initiative of the American College of Sports Medicine (ACSM) that aims to highlight the importance of physical assessment and exercise prescription as diseases prevention and treatment. Calls on higher education institutions to promote PA as a vital sign of health or as “medicine” and encourages teaching and non-teaching staff (including students) to work together to improve the university campus health and well-being through steps: a) to include the PA/PE programs as a fundamental part of the daily routine (institutional paradigm shift); b) to provide the necessary tools for the development of healthy habits; 3) PA assessment and prescription, through health and fitness professionals (ACSM, 2019; Thompson et al., 2020). Another more extreme measure, which may have the opposite effect to what is intended, is the PA inclusion at academic cycles curriculum (Petruzzello & Box, 2020).
Considering the relevance of the relationship between PA/PE/sports practices, MH (namely, stress, depression and anxiety) and QoL perception, in a future study we intend to understand de mediation/moderation relationships between these variables.
Although the literature points out to the high prevalence of comorbidities in higher education students (that worsened with the COVID-19 pandemic), the present systematic review showed that PA/PE/sports are correlated with MH (namely, stress, depression and anxiety) of young adults enrolled in higher education and QoL perception.
Higher education institutions need to pay special attention to the young higher education student’s mental health. With government entities, higher education systems could define MH policies and create primary and secondary prevention measures. They could, for instance, i) develop more and better support services, adequate to the target population, to detect and treat students' psychiatric disorders and ii) include regular PA/PE/sport practice in their campus day-to-day life, rather than focusing only on academic average. Multidisciplinary interventions are essential for MH and well-being promotion, preventing school dropout and promoting QoL perception.
To have effective interventions, it is necessary to understand which students are at risk of developing mental disorders and design time-efficient PE programs, allowing them to exercise, even if they have a busy workday (Herbert et al. 2020).
Author’s contribution
Isabel Simões Dias: double check of the bibliographic research and evaluation of the methodological quality of the articles; supervised the construction and writing of the work and carried out a thorough review of it.
Miguel Jacinto: conception, research and writing of the manuscript.
Maria Odília Abreu: responsible for the double check of the bibliographic research and evaluation of the methodological quality of the articles; collaborated in the construction of the article and carried out a thorough review, having approved the final version.
Marta Fonseca: responsible for the double check of the bibliographic research and evaluation of the methodological quality of the articles; collaborated in the construction of the article and carried out a thorough review, having approved the final version.
