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Previous studies have reported a potential negative correlation between physical activity (PA) and mobile phone addiction (MPA) among adolescents and young adults. To date, the strength of this correlation has not been well characterized.
This review and meta-analysis aimed to synthesize available empirical studies to examine the correlations between PA and MPA among adolescents and young adults. We also explored several potential moderators, including time of data collection, country or region, and type of population, associated with the relationship between PA and MPA.
Four electronic databases (PubMed, Scopus, PsycINFO, and Web of Science) were searched from database inception to March 2022 to identify relevant studies. The pooled Pearson correlation coefficients and their corresponding 95% CIs for the relationship between PA and MPA were calculated using the inverse variance method. The methodological quality of the included cross-sectional studies was determined based on the Joanna Briggs Institute appraisal checklist. The study conformed to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) guidelines.
In total, 892 relevant articles were identified, of which 22 were selected based on the inclusion and exclusion criteria. The final meta-analysis included 17 of the 22 studies. Results of random effects modeling revealed a moderate correlation between PA and MPA among adolescents and young adults (summary
Our results demonstrate a moderately negative relationship between PA and MPA among young adults. The strength of this relationship was not influenced by the time of data collection, country or region, or type of population.
Mobile phone addiction (MPA) is defined as an addictive behavior in which individuals show uncontrollable use of mobile phones that severely impairs their physical, psychological, and social functions [
Previous epidemiological surveys of MPA in different countries and regions in the past 5 years have revealed a high rate of MPA among adolescents and young adults. Recent surveys have also found that the rate of MPA among Brazilian adolescents aged 15 to 18 years was approximately 70.3% [
Numerous investigations have demonstrated that MPA negatively affects mental health by causing anxiety [
A variety of factors that influence MPA have been explored to develop interventions for preventing MPA in young populations, including physical activity (PA). Data show that PA has broad health benefits, including prolonged life expectancy and better physical and psychological well-being [
Some cross-sectional studies have predicted that higher levels of PA may reduce rates of MPA among adolescents and young adults, suggesting that there might be a negative correlation between PA and MPA [
To the best of our knowledge, no systematic review and meta-analysis has been conducted to examine the correlation between PA and MPA. Thus, an up-to-date literature review of previous findings on the relationship between PA and MPA is needed. This review identified three knowledge gaps. First, previous findings regarding the strength of the correlation coefficient between PA and MPA in adolescents and young adults are inconsistent. Only one, small-scale systematic review [
Therefore, this systematic review and meta-analysis is timely. We sought to examine the overall correlation between PA and MPA and address an important research topic. Furthermore, factors such as the time of data collection (ie, before or during COVID-19), country or region, and type of population (adolescents and young adults) are potential variables influencing the correlation between PA and MPA that we explored and examined with a subgroup analysis.
This systematic review and meta-analysis was conducted in line with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines [
We searched 4 electronic databases (PubMed, Scopus, PsycINFO, and Web of Science) from database inception until March 26, 2022, to identify relevant studies. A manual search was conducted of the retrieved publications to identify potentially missing studies. The search strategy consisted of 2 strings of keywords, including PA- and MPA-related terms. These included the following: (“cell phone” OR “cell phones” OR “cellular phone” OR “cellular phones” OR “cellular telephone” OR “cellular telephones” OR “mobile devices” OR “mobile phone” OR “smart phone” OR “smartphone”) AND (“addiction” OR “dependence” OR “dependency” OR “abuse” OR “addicted to” OR “overuse” OR “problem use” OR “compensatory use”) OR (“problematic smartphone use” OR “problematic smart phone use” OR “problematic mobile phone use” OR “problematic cell phone use” OR “problematic cellular phone use” OR “Nomophobia” OR “Phubbing” OR “fear of missing out” OR “FoMO” OR “smartphone separation anxiety” OR “smartphone use disorder” OR “compulsive mobile phone use”) AND (“physical activity” OR “walk*” OR “exercise*” OR “physical activity*” OR “strength training” OR “resistance training” OR “resistance exercise*” OR “conditioning muscle” OR “training” OR “leisure training” OR “leisure activities” OR “physical fitness” OR “motor activity”). The detailed search strategy is presented in
The identified and retrieved studies were imported into EndNote X7 software (Thompson Reuters). Duplicates were excluded using the deduplication function in Endnote. This screening and processing was conducted by 2 reviewers, who independently read the titles and abstracts and assessed the studies against predetermined inclusion criteria. The full text of the included studies was also independently examined by the 2 reviewers. Inclusion checklists were completed for each study, along with details on the decision to exclude. The reference list of each included study and the articles cited were thoroughly reviewed to ensure that no relevant studies were missed. At all stages, any discrepancies in the results obtained were resolved through consensus or by involving a third reviewer.
A study was deemed eligible if it included healthy adolescents or young adults aged between 11 and 24 years [
Data on PA were collected using measurement tools that included self-reported scales, questionnaires, and accelerometers. Data on different aspects of PA, such as steps taken; time spent each day engaging in light, moderate, and vigorous PA; and PA in different scenarios (ie, for leisure, with family, during active travel, or for work) were recorded. Measurements of MPA levels were collected using internationally used scales or questionnaires (eg, the MPA tendency scale, the mobile phone addiction tendency scale, or the smartphone addiction scale). The contents of the MPA measurement questionnaires or other questionnaires were required to include withdrawal, loss of control and escape, and other MPA symptoms. Studies that only provided data on the duration of mobile phone use were excluded.
Quantitative observational (cross-sectional and cohort/longitudinal) studies were included.
Studies were included if they were published in peer-reviewed journals and were written in English. If 2 studies were based on the same data set, the study published earlier was selected for inclusion in the review.
Case-control studies were excluded because they examined specific groups that were beyond the scope of this review. Furthermore, reviews, meta-analyses, commentaries, replies, clinical guidelines, conference abstracts, theses, and book chapters were also excluded.
A total of 892 studies were identified by reading the titles and abstracts. Among these, 46 candidate studies were identified after reading their full text. At this stage, 24 studies were excluded based on the above criteria. The remaining 22 studies were deemed eligible and included in the systematic review. The final meta-analysis included 17 of the 22 studies (
Two reviewers independently extracted data from the included articles and entered the data into a form tailored to the requirements of this review. The extracted data included (1) publication details (author, year, and country); (2) sample characteristics (sample size, sex of participants, and type of participant); (3) time of data collection; (4) measurements of PA and MPA; and (5) the main study outcome (ie, correlation coefficient).
Flow diagram of article screening process.
The Joanna Briggs Institute (JBI) appraisal checklist, which has 10 items, was used to examine the methodological quality of the included cross-sectional studies [
All statistical analyses were conducted with Comprehensive Meta-Analysis software (version 3; Biostat Inc).
All data were extracted from the included studies. The pooled Pearson correlation coefficients (with the corresponding 95% CIs) between PA and MPA were calculated with the inverse variance method. Subsequently, the Pearson correlation coefficients were transformed to Fisher
The Cochran Q test and the
To determine potential moderators of heterogeneity, subgroup analyses were carried out for country or region, population (college students and adolescents), and time of data collection (before or during COVID-19). All subgroup analyses were conducted with a mixed effects analysis. The random effects model was used to summarize the studies within the respective subgroups, and the fixed effects model was used to test for significant differences between the subgroups [
To determine the influence of individual studies on the summary correlation coefficients and test the robustness of the correlations between PA and MPA, sensitivity analyses were conducted by sequentially omitting one study at time [
Funnel plots were established to determine the existence of potential publication bias. Additionally, the Begg rank correlation test and Egger linear regression test were performed to determine publication bias, with
Other statistical analyses performed included valid measures of the association between PA and MPA, measured with the correlation coefficient (
Characteristics of the studies included in the review.
Study | Country | Size, n | Male, n | Population | Age (years) | Time period | MPAa measurement | PAb measurement |
|
1. Kim et al, |
South Korea | 110 | 67 | College students | Mean 21.03 (SD 1.61) | 2015 | SAPSc | 3D sensor pedometer | –0.798 |
2. Haug et al, |
Switzerland | 1519 | 732 | Adolescents | Range 16-21 | Feb 2015 to Jun 2015 | SAS-SVd | “Outside school: How many hours a week do you exercise or participate in sports that make you sweat or become out of breath?” | –0.019 |
3. Yang et al, |
China | 608 | 158 | College students | —e | Dec 2018 to Jan 2019 | MPATSf | PARS-3g | –0.124 |
4. Haripriya et al, 2019 [ |
India | 113 | 63 | College students | Mean 22.15 (SD 1.69) | Apr 2019 to May 2019 | SAPS | IPAQ-SFh | –0.335 |
5. Numanoğlu- |
Turkey | 388 | 129 | College students | Range 17-25 | Jan 2019 to Jun 2019 | SASi | IPAQ-SF | –0.112 |
6. Zhong et al, |
China | 394 | 115 | College students | — | Jul 29, 2020 | CSMDQj | PARS-3 | –0.190 |
7. Hosen et al, |
Bangladesh | 601 | 344 | College students | — | Oct 2020 to Nov 2020 | SABASk | Physical exercise questions (eg, at least 30 minutes daily walking, cycling, swimming, or other activities regularly) | –0.249 |
8. Li et al, |
China | 2407 | 280 | Adolescents | Mean 16.27 (SD 1.02) | Dec 2020 to Feb 2021 | Self-rating questionnaire for adolescent problematic mobile phone use | PA questionnaire Al | –0.235 |
9. Buke et al, |
Turkey | 300 | 166 | College students | Mean 21.36 (SD 2.33) | Apr 2020 | SAS-SV | IPAQm | –0.262 |
10. Abbasi et al, 2021 [ |
Malaysia | 250 | 145 | College students | — | May 2020 | SAS-SV | Physical activity questionnaire Bn | –0.201 |
11. Islam et al, |
Bangladesh | 5511 | 3254 | College students | Mean 21.20 (SD 1.70) | Jul 2020 | SABAS | Questions were asked regarding the engagement in infrequent activities (including home quarantine regular/frequent activities (ie, academic/other studies, social-media use, watching television, household chores, and professional activities) | –0.238 |
12. Ding et al, |
China | 1724 | 740 | College students | Mean 19.56 (SD 0.95) | Sep 2020 | MPATS | PARS-3 | –0.445 |
13. Halil, |
Pakistan | 236 | 123 | College students | — | 2020 to 2021 | SAS-SV | IPAQ-SF | –0.258 |
14. Guo et al, |
China | 1433 | 704 | College students | Mean 19.67 (SD 1.62) | Dec 2020 to Feb 2021 | MPATS | PARS-3 | –0.158 |
15. Saffari et al, |
Taiwan | 391 | 0 | College students | Mean 22.85 | Aug 2021 to Sep 2021 | SABAS | IPAQ-SF | –0.255 |
16. Lin et al, |
China | 1787 | 628 | College students | Range 18-22 | Aug 2020 to Sep 2021 | SAS | IPAQ-SF | –0.153 |
17. Chen et al, |
China | 9406 | 3516 | College students | Mean 19.58 (SD 1.07) | Mar 2022 to Apr 2022 | MPASo | IPAQ-Lp | –0.060 |
18. Venkatesh |
Saudi Arabia | 205 | 101 | College students | Mean 23.28 | Jan 2016 to Mar 2016 | SAS-SV | “Outside school: How many hours a week do you exercise or participate in sports that make you sweat or become out of breath?” | — |
19. Xie et al, |
China | 2134 | 917 | College students | Mean 19.25 (SD 1.42) | Jun 2014 to Dec 2014 | Self-rating questionnaire for adolescent problematic mobile phone use | During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? | — |
20. Pereira et al, 2020 [ |
Brazil | 667 | 308 | Adolescents | Range 13-18 | — | SAS-SV | IPAQ-SF | — |
21. Tao et al, |
China | 4624 | 2057 | College students | Mean 19.91 (SD 1.27) | May 2018 to Jun 2018 | Self-rating questionnaire for adolescent problematic mobile phone use | IPAQ-SF | — |
22. Zou et al, |
China | 251 | 52 | College students | Mean 19.01 (SD 0.85) | Apr 2019 to Jun 2019 | Self-rating questionnaire for adolescent problematic mobile phone use | IPAQ-Cq | — |
aMPA: mobile phone addiction.
bPA: physical activity.
cSAPS: Smartphone Addiction Proneness Scale.
dSAS-SV: Smartphone Addiction Scale–Short Version.
eNot available.
fMPATS: Mobile Phone Addiction Tendency Scale.
gPARS-3: Physical Activity Rating Scale–3.
hIPAQ-SF: International Physical Activity Questionnaire–Short Form.
iSAS: Smartphone Addiction Scale.
jCSMDQ: College Students Mobile Phone Dependence Questionnaire.
kSABAS: Smartphone Application-Based Addiction Scale.
lPhysical activity questionnaire A was derived from [
mIPAQ: International Physical Activity Questionnaires.
nPhysical activity questionnaire B was derived from [
oMPAS: Mobile Phone Addiction Scale.
pIPAQ-L: International Physical Activity Questionnaire–Long Form.
qIPAQ C: International Physical Activity Questionnaire–Chinese.
Statistics for each studya.
Study | 95% CI (total 95% CI –0.309 to –0.175) | Weight (total 100%) | |||
Kim et al, 2015 [ |
–0.798 | –0.190 to 0.184 | –0.031 | .98 | 4.48% |
Haug et al, 2015 [ |
–0.019 | –0.069 to 0.031 | –0.740 | .46 | 6.35% |
Yang et al, 2019 [ |
–0.124 | –0.202 to –0.045 | –3.066 | .002 | 6.06% |
Haripriya et al, 2019 [ |
–0.335 | –0.486 to –0.165 | –3.753 | <.001 | 4.60% |
Numanoğlu-Akbaş et al, 2020 [ |
–0.112 | –0.209 to –0.013 | –2.207 | .03 | 5.81% |
Zhong et al, 2021 [ |
–0.190 | –0.283 to –0.093 | –3.803 | <.001 | 5.82% |
Hosen et al, 2021 [ |
–0.249 | –0.323 to –0.172 | –6.220 | <.001 | 6.05% |
Li et al, 2021 [ |
–0.235 | –0.272 to –0.197 | –11.742 | <.001 | 6.42% |
Buke et al, 2021 [ |
–0.262 | –0.364 to –0.153 | –4.623 | <.001 | 5.62% |
Abbasi et al, 2021 [ |
–0.201 | –0.317 to –0.079 | –3.203 | <.001 | 5.46% |
Islam et al, 2021 [ |
–0.238 | –0.263 to –0.213 | –18.009 | <.001 | 6.50% |
Ding et al, 2021 [ |
–0.445 | –0.482 to –0.406 | –19.848 | <.001 | 6.37% |
Halil, 2021 [ |
–0.258 | –0.373 to –0.135 | –4.029 | <.001 | 5.41% |
Guo et al, 2022 [ |
–0.158 | –0.208 to –0.107 | –6.025 | <.001 | 6.34% |
Saffari et al, 2022 [ |
–0.255 | –0.345 to –0.160 | –5.136 | <.001 | 5.81% |
Lin et al, 2022 [ |
–0.153 | –0.198 to –0.107 | –6.513 | <.001 | 6.38% |
Chen et al, 2022 [ |
–0.060 | –0.080 to –0.040 | –5.825 | <.001 | 6.52% |
aHeterogeneity: Q=468.050;
Summary of pooled correlation between physical activity and mobile phone addiction. The blue diamond represents the overall pooled correlation for the random effects model [
As shown in
The time of data collection did not significantly moderate the effect sizes (between-subgroup
Similarly, we did not find significant moderator effect sizes for country or region (between-subgroup
In addition, there were no significant moderator effect sizes for the type of population (between-subgroup:
Subgroup analyses of summary correlation between PA and MPA.
Moderator | Studies, n | Summary |
Heterogeneity | ||||
|
|
||||||
|
.14 | ||||||
|
Before COVID-19 | 4 | –0.333 (–0.466 to –0.187) | <.001 | 97.555 | <.001 |
|
|
During COVID-19 | 13 | –0.207 (–0.285 to –0.126) | <.001 | 96.438 | <.001 |
|
|
.71 | ||||||
|
Developed regions | 2 | –0.446 (–0.616 to 0.236) | .39 | 99.133 | <.001 |
|
|
China | 7 | –0.201 (–0.311 to –0.127) | <.001 | 97.873 | <.001 |
|
|
Other developing regions | 8 | –0.217 (–0.326 to –0.103) | <.001 | 63.310 | <.001 |
|
|
.26 | ||||||
|
Young adults | 15 | –0.250 (–0.325 to –0.173) | <.001 | 96.681 | <.001 |
|
|
Adolescents | 2 | –0.129 (–0.333 to 0.086) | .24 | 97.787 | <.001 |
|
In the analysis that removed studies one at a time, no evident outliers were identified. Thus, the correlation coefficient for removing each study was in the range of
Subjectively speaking, we could not determine the existence of publication bias from the funnel plots for the summary correlation coefficients, as shown in
Funnel plots of (A) publication bias and (B) publication bias with trim and fill.
The methodological quality assessment results are shown in
Methodological quality of the studies.
Number | Study | Joanna Briggs Institute appraisal checklist items | Total score (%) | Overall risk of bias | |||||||||||
|
|
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
|
|
||
1 | Kim et al, 2015 [ |
1 | 1 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 1 | 15 (75) | Low | ||
2 | Haug et al, 2015 [ |
2 | 0 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 16 (80) | Low | ||
3 | Yang et al, 2019 [ |
1 | 2 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 18 (80) | Low | ||
4 | Haripriya et al, 2019 [ |
2 | 0 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 1 | 15 (75) | Low | ||
5 | Numanoğlu-Akbaş et al, 2020 [ |
2 | 0 | 0 | 0 | 2 | 2 | 2 | 2 | 1 | 2 | 13 (65) | Mid | ||
6 | Zhong et al, 2021 [ |
2 | 2 | 1 | 1 | 2 | 2 | 0 | 2 | 2 | 2 | 16 (80) | Low | ||
7 | Hosen et al, 2021 [ |
1 | 1 | 1 | 1 | 1 | 2 | 2 | 2 | 1 | 2 | 14 (70) | Low | ||
8 | Li et al, 2021 [ |
2 | 1 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 17 (85) | Low | ||
9 | Buke et al, 2021 [ |
1 | 1 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 1 | 15 (75) | Low | ||
10 | Abbasi et al, 2021 [ |
2 | 1 | 1 | 1 | 2 | 2 | 0 | 1 | 1 | 1 | 15 (75) | Low | ||
11 | Islam et al, 2021 [ |
1 | 0 | 1 | 2 | 2 | 2 | 2 | 2 | 1 | 2 | 15 (75) | Low | ||
12 | Ding et al, 2021 [ |
2 | 1 | 1 | 1 | 2 | 2 | 0 | 2 | 2 | 1 | 14 (70) | Low | ||
13 | Halil, 2021 [ |
2 | 0 | 1 | 1 | 2 | 2 | 0 | 2 | 2 | 2 | 14 (70) | Low | ||
14 | Guo et al, 2022 [ |
2 | 2 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 18 (80) | Low | ||
15 | Saffari et al, 2022 [ |
2 | 0 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 17 (85) | Low | ||
16 | Lin et al, 2022 [ |
2 | 0 | 0 | 0 | 2 | 2 | 2 | 2 | 2 | 1 | 13 (65) | Mid | ||
17 | Chen et al, 2022 [ |
2 | 2 | 0 | 1 | 2 | 2 | 0 | 2 | 2 | 2 | 15 (75) | Low | ||
18 | Venkatesh et al, 2019 |
1 | 0 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 1 | 14 (70) | Low | ||
19 | Xie et al, 2019 [ |
1 | 0 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 16 (80) | Low | ||
20 | Pereira et al, 2020 [ |
1 | 0 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 16 (80) | Low | ||
21 | Tao et al, 2020 [ |
2 | 1 | 1 | 2 | 2 | 2 | 0 | 2 | 2 | 1 | 15 (75) | Low | ||
22 | Zou et al, 2021 [ |
2 | 0 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 1 | 16 (80) | Low |
To the best of our knowledge, this is the first meta-analysis to explore pooled correlation coefficients of PA and MPA. Our analysis of 17 studies found a moderately negative correlation between PA and MPA, with a summary Pearson correlation coefficient of
The target subjects of research into MPA are adolescents and young adults, who are relatively less self-disciplined in controlling their frequency of mobile phone use and are more susceptible to smartphone use addiction compared to middle-aged or older adults [
Results of magnetic resonance imaging studies suggest that MPA is associated with structural brain abnormalities, like other types of addiction dependence. For example, the insula cortex participates in the formation of addictive behaviors, because these behaviors may influence the decision-making process in terms of choosing immediate rewards that are always associated with physiological state while eliciting strong interoceptive signals [
Notably, the time of data collection did not significantly influence the relationship between PA and MPA. Moreover, a moderate negative relationship was found between PA and MPA among adolescents and young adults before and during the COVID-19 pandemic. According to the compensatory internet use theory, when people encounter psychosocial problems in the real world, they are likely to use the internet or smartphones as a coping mechanism to alleviate negative emotions [
The present findings demonstrate that country or region do not have a significant moderating role on the relationship between PA and MPA. Notably, a medium-strength negative relationship between PA and MPA has been reported in China and other developing counties among adolescents and young adults. However, this correlation was not found in developed countries. This finding should be interpreted with caution, because it is based on 2 studies from developed countries. These 2 studies were carefully reviewed elsewhere [
Further analysis revealed that population type did not significantly affect the relationship between PA and MPA. This may be explained by the widespread use of mobile phones. This is especially true for young people, as their ownership rate for smartphones is very high. Additionally, subgroup analysis revealed that there was no significant correlation between PA and MPA among adolescents (
In conclusion, our study indicates that a low PA level contributes to MPA behavior. This is because low PA encourages a sedentary lifestyle among young adults. The PA guidelines of the World Health Organization encourage individuals of different ages to participate in PA. Previous studies have shown that increasing the PA level of young adults can reduce MPA behavior. We recommend higher PA levels than those stipulated in the guidelines of the World Health Organization, because more PA could bring more mental health benefits. From a practical perspective, the findings of this study may help to inform countermeasures to prevent MPA behavior among adolescents and young adults amid the COVID-19 pandemic and future public health crises.
All previous findings were objectively stated, analyzed, and interpreted using an appropriate research design. All original data were retained to provide a reference for future research. The repeatability and reproducibility of our analyses have been ensured. However, there are some limitations and potential sources of bias that need to be noted. First, only studies published in English were included in our meta-analysis. Second, the studies mainly provided cross-sectional data, which do not allow determination of causality in the relationship between PA and MPA. Third, we only analyzed a young population. Fourth, no study reported moderating variables between PA and MPA. Finally, although a sensitivity analysis was conducted, sources of bias were identified, and our results should thus be interpreted with caution. Further case-control and cohort studies are needed to test the benefits of PA on MPA in young adults.
Our findings demonstrate a moderate negative relationship between PA and MPA among young adults. The strength of the relationship between PA and MPA did not differ by time of data collection, country or region, or type of population.
Detailed search strategy.
Details of the scoring criteria in the JBI appraisal checklist. JBI: Joanna Briggs Institute.
Full details of coding forms for the subgroups.
Joanna Briggs Institute
mobile phone addiction
odds ratio
physical activity
Preferred Reporting Items for Systematic Review and Meta-analyses
This study received funding from the Research Foundation for Young Teachers of Shenzhen University (grant QNJS0274), the High-level Scientific Research Foundation for the Introduction of Talent of Shenzhen University (grant RC00228), the Natural Science Featured Innovation Projects in Ordinary Universities in Guangdong Province (grant 2021KTSCX297), and the Scientific Research Platform and Project of Colleges and Universities of the Education Department of Guangdong Province (grant 2022ZDZX2087).
WX and ZR were responsible for conceptualization of the research, investigation, and forming the hypothesis. JW and WX conducted the systematic search, data extraction, and quality assessment and data analyses. JW and WX wrote the first draft of the manuscript. JY, QS, LP, QEL, and ZR reviewed and edited the initial draft and its revisions. All authors agree with the results and conclusions. All authors read and approved the final manuscript.
None declared.