RESEARCH ARTICLE

Correlates of sedentary behavior in the

general population: A cross-sectional study
using nationally representative data from six
low- and middle-income countries
Ai Koyanagi1,2*, Brendon Stubbs3,4,5, Davy Vancampfort6,7

1 Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant
Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain, 2 Instituto de Salud Carlos III, Centro de Investigación
a1111111111 Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain, 3 Physiotherapy Department, South London
a1111111111 and Maudsley NHS Foundation Trust, Denmark Hill, London, United Kingdom, 4 Health Service and
a1111111111 Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College
a1111111111 London, De Crespigny Park, London, United Kingdom, 5 Faculty of Health, Social Care and Education,
a1111111111 Anglia Ruskin University, Chelmsford, United Kingdom, 6 Leuven Department of Rehabilitation Sciences,
Leuven, Belgium, 7 University Psychiatric Centre KU Leuven, Kortenberg, Belgium

* a.koyanagi@pssjd.org

OPEN ACCESS

Citation: Koyanagi A, Stubbs B, Vancampfort D

Abstract
(2018) Correlates of sedentary behavior in the
general population: A cross-sectional study using
nationally representative data from six low- and
middle-income countries. PLoS ONE 13(8): Background
e0202222. https://doi.org/10.1371/journal. Sedentary behavior (SB) is associated with adverse health outcomes independent of levels
pone.0202222
of physical activity. However, data on its correlates are scarce from low- and middle-income
Editor: David Alejandro González-Chica, University countries (LMICs). Thus, we assessed the correlates of SB in six LMICs (China, Ghana,
of Adelaide School of Medicine, AUSTRALIA
India, Mexico, Russia, South Africa) using nationally representative data.
Received: April 20, 2018

Accepted: July 30, 2018

Published: August 10, 2018

Methods
Cross-sectional, community-based data on 42,469 individuals aged 18 years from the
Copyright: © 2018 Koyanagi et al. This is an open
access article distributed under the terms of the World Health Organization’s Study on Global Ageing and Adult Health were analyzed. Self-
Creative Commons Attribution License, which reported time spent sedentary per day was the outcome. High SB was defined as 8 hours
permits unrestricted use, distribution, and of SB per day. The correlates (sociodemographic and health-related) of high SB were esti-
reproduction in any medium, provided the original
author and source are credited.
mated by multivariable logistic regression analyses.

Data Availability Statement: All data underlying

the findings are publicly available through http://
www.who.int/healthinfo/sage/en/.
Results
Funding: Ai Koyanagi’s work is supported by the
The overall prevalence (95%CI) of high SB was 8.3% (7.1–9.7%). In the overall sample, the
Miguel Servet contract financed by the CP13/ most important sociodemographic correlates of high SB were unemployment and urban res-
00150 and PI15/00862 projects, integrated into the idence. Physical inactivity, morbid obesity (BMI30.0 kg/m2), higher number of chronic con-
National R + D + I and funded by the ISCIII -
ditions, poor self-reported health, higher disability levels, and worse health status in terms of
General Branch Evaluation and Promotion of Health
Research - and the European Regional mobility, pain/discomfort, affect, sleep/energy and cognition were associated with high SB.
Development Fund (ERDF-FEDER). Brendon Several between-country differences were found.

PLOS ONE | https://doi.org/10.1371/journal.pone.0202222 August 10, 2018 1 / 14

 Correlates of sedentary behavior

Stubbs receives funding from the National Institute Conclusion

for Health Research Collaboration for Leadership in
Applied Health Research & Care Funding scheme. The current data provides important guidance for future interventions across LMICs to assist
These funders had no role in: design and conduct sedentary people to reduce their SB levels.
of the study; collection, management, analysis, and
interpretation of the data; and preparation, review,
or approval of the manuscript.

Competing interests: The authors have declared

that no competing interests exist.
Introduction
Sedentary behavior (SB) is defined as behaviors that involve sitting or reclining positions and
low levels of energy expenditure (1.5 metabolic equivalents) during waking hours [1]. There
is emerging evidence that SB is associated with adverse health outcomes across the lifespan,
from adolescents [2] through to older adults [3]. Specifically, SB has been associated physical
health conditions including obesity, type 2 diabetes, cardiovascular disease, and increased car-
diovascular-specific and overall premature mortality [4–6]. Moreover, more recent evidence
has suggested that SB is associated with some mental health comorbidities such as depression
[7] and anxiety [8]. Some authors have suggested that the adverse relationship between SB and
health outcomes may be independent of a person’s physical activity levels [9, 10].
Given the aforementioned deleterious outcomes, there has been an increasing emphasis on
research aimed at reducing SB among adults in the last decade. A meta-analysis [11] showed
that lifestyle interventions were able to reduce SB by 24 min/day (95%CI = 8 to 41 min/day,
n = 3981) and in terms of interventions focusing on SB only, SB was reduced by 42 min/day
(95%CI = 5 to 79 min/day, n = 62).
Whilst interventions focusing on SB may appear to show promise, more high quality
research is needed to determine if such interventions are sufficient to produce clinically mean-
ingful and sustainable reductions in sedentary time. An important step to aid the development
of effective interventions, is a clear understanding and comprehensive examination of modifi-
able correlates of SB, which can be targets for effective interventions, while non-modifiable
variables are important for targeting specific subgroups at increased risk. The focus to date on
variables that might influence SB has mostly been on individual level correlates such as biologi-
cal, psychological and behavioral factors [12]. However, it has become apparent that these are
not stand-alone factors and addressing them in isolation will not result in a significant change
in SB. Social, environmental and policy factors should also be taken into account. The current
rationale is that factors that influence SB can be conceptualized using models such as the
socio-ecological model [13, 14]. The socio-ecological model suggests that multiple relevant
attributes influence health behavior. These include intrapersonal (demographic, biological,
psychological, emotional and cognitive), interpersonal/ cultural (e.g., social support), physical
environment (e.g., distance to services and facilities, financial costs, enjoyable scenery), and
policy (laws, rules, regulations, codes) factors. Previous studies from the general population
have provided some evidence that older age, female gender, lower education, full-time employ-
ment status, a higher body mass index (BMI), a higher income/socio-economic status, smok-
ing, and the presence of depressive symptoms [13–15] are associated with more SB. Also,
previously reported environmental factors associated with more SB include lack of proximity
of green space, lack of neighborhood walkability, an unsafe environment, and bad weather
conditions [13–15].
A major deficit in the literature is that the current evidence regarding SB is predominantly
derived from studies conducted in high-income countries [15]. Given the markedly different
occupational and socio-cultural structures, methods of transportation, and environmental fac-
tors (e.g., safety, climate) in in low- and middle-income countries (LMICs), there is a need for

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 Correlates of sedentary behavior

context specific research in these settings [16]. Another important point is that almost three-
quarters of non-communicable disease-related deaths occur in LMICs. Thus, there is consider-
able potential for preventive interventions such as reducing SB in this neglected region in the
world [17]. This is especially important given that compared to high-income countries, many
people in LMICs, where two-thirds of the world’s population resides, have a much lower
capacity to pay for adequate healthcare. While 90% of the global burden of disease is concen-
trated in LMICs, only 12% of global health spending takes place in LMICs [18]. Moreover,
recently, several LMICs have started to adopt national policies or action plans to increase phys-
ical activity levels, but recommendations on how to reduce SB are currently lacking [19].
Another important point is that there is generally a paucity of large-scale multinational
studies exploring SB correlates. Clearly, undertaking multinational studies enables exploration
of SB correlates irrespective of national policies as well as available services and facilities, and
at the same time allow comparison between countries in order to speculate the role of such fac-
tors in different countries.
Thus, given the aforementioned gaps and limitations within the literature, we aimed to
investigate SB correlates among community-dwelling adults in six LMICs (China, Ghana,
India, Mexico, Russia, South Africa) that participated in the Study on Global Ageing and
Adult Health (SAGE). The selection of the correlates of SB (socio-demographics, health behav-
ior, mental and physical health) was based on past literature [13–15]. A secondary aim was to
compare differences in SB correlates across countries. The six countries included in our study
comprise a large proportion of the world population, and are representative of diverse geo-
graphical locations and socioeconomic levels.

Materials and methods

We conducted secondary data analysis of the Global Ageing and Adult Health (SAGE) survey
which was conducted in China, Ghana, India, Mexico, Russia, and South Africa between 2007
and 2010. The World Bank classification at the time of the survey for the included countries
were the following: Ghana (low-income country); China and India (lower middle-income
countries although China became an upper middle-income country in 2010); Mexico, South
Africa, Russia (upper middle-income countries). The dataset is publically available via the
WHO website (http://www.who.int/healthinfo/sage/en/) where the questionnaire of this survey
can also be found. Details of the survey methodology have been provided previously [20, 21].
In brief, in order to obtain nationally representative samples, a multi-stage clustered sampling
design method was used. The sample consisted of adults aged 18 years while those aged 50
years were oversampled. Trained interviewers conducted face-to-face interviews. The survey
response rates were: China 93%; Ghana 81%; India 68%; Mexico 53%; Russia 83%; South Africa
75%. Sampling weights were constructed to adjust for the population structure and non-
response. Details on sampling weights can be found elsewhere [21]. Ethical approval for this
survey was obtained from the WHO Ethical Review Committee and local ethics research review
boards: Shanghai Municipal Centre for Disease Control and Prevention, Shanghai, China;
Ghana Medical School, Accra, Ghana; International Institute of Population Sciences, Mumbai,
India; National Institute of Public Health, Cuernavaca, Mexico; School of Preventive and Social
Medicine, Russian Academy of Medical Sciences, Moscow, Russia; and Human Sciences
Research Council, Pretoria, South Africa. All participants provided written informed consent.

Sedentary behavior (Outcome variable)

Participants were asked to state the total time they usually spent (expressed in minutes per
day) sitting or reclining including at work, at home, getting to and from places, or with friends

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 Correlates of sedentary behavior

(e.g., sitting at a desk, sitting with friends, travelling in car, bus, train, reading, playing cards or
watching television). This did not include time spent sleeping. SB was assessed as a categorical
variable [<8 or 8 hours per day (high SB)] [22].

Socio-demographic variables
These included age (18–44, 45–64, 65 years), sex, highest level of education achieved (com-
pleted secondary or less), wealth, marital status (married/cohabiting or else), living arrange-
ment (alone: Y/N), setting (urban or rural), and employment status (engaged in paid work 2
days in last 7 days: Y/N), Wealth quintiles were created based on country-specific income.

Health behavior
These comprised of smoking (never, quit, current), alcohol consumption (never, non-heavy,
heavy [23]), and physical activity. The validated Global Physical Activity Questionnaire was
used to assess levels of physical activity [24]. Physical inactivity (i.e., not meeting the recom-
mended guidelines) was defined as <150 min of moderate-to-vigorous physical activity in a
typical week [25].

Physical health
A stadiometer was used to measure height, while weight was measured with a routinely cali-
brated electronic weighting scale. Body mass index (BMI) was calculated as weight in kilo-
grams divided by height in meters squared, and was categorized as <18.5 (underweight), 18.5–
24.9 (normal), 25.0–29.9 (overweight), and 30 (obese) kg/m2. The total number of chronic
physical conditions (angina, arthritis, asthma, stroke, diabetes, edentulism, cataract, chronic
obstructive lung disease, hypertension, hearing problems) was calculated. The participant was
considered to have the condition in the presence of self-reported diagnosis and/or symptom-
based diagnosis using algorithms (blood pressure in case of hypertension), observation by
interviewer (hearing problems), or self-reported conditions (edentulism: loss of all natural
teeth). Detailed information on the variables on chronic conditions are provided in S1 and S2
Tables. Details on mobility and pain/discomfort are provided in the section on health status
below.

Mental health
Variables pertaining to this domain included affect, sleep/energy, and cognition. Details on
these variables are provided on the section on health status below.

General health
‘In general, how would you rate your health today?’ was the question used to assess self-rated
health. Those who answered ‘bad’ or ‘very bad’ were considered to have poor self-rated health
[26]. The 12-item validated version of the World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0) was used to assess disability [27], and a scale ranging from 0 (no
disability) to 10 (maximum disability) was created [28].

Health status (mobility, pain/discomfort, affect, sleep/energy, cognition)

Ten health-related questions pertaining to five health domains were used to assess health sta-
tus: (a) mobility; (b) pain/discomfort; (c) affect; (d) sleep/energy; (e) cognition. Details of these
variables are provided in previous publications [29, 30]. Briefly, a scale ranging from 0 to 10
was created with factor analysis with polychoric correlations for each domain based on two

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 Correlates of sedentary behavior

questions assessing past 30-day health function (actual questions are provided in S3 Table).
Higher scores represented greater levels of impairment in health. The overall correlation coef-
ficients between the two questions in each domain were: mobility (0.57); pain/discomfort
(0.89); affect (0.82); sleep/energy (0.79); cognition (0.76).

Statistical analysis
The statistical analysis was done with Stata 14.1 (Stata Corp LP, College station, Texas). The
selection of the 22 correlates of SB was based on past literature [13–15]. We assessed the associ-
ation between the correlates (exposure) and SB (outcome) with multivariable logistic regres-
sion. First, we assessed the sociodemographic correlates of SB by constructing a model which
includes all the sociodemographic variables (age, sex, education, wealth, marital status, living
arrangement, setting, employment status). Next, we assessed the association between each of
the other correlates with SB while adjusting for all the sociodemographic variables mentioned
above. Analyses using the overall sample including all countries and country-wise analyses
were done. Country adjustment was done in the analysis using the overall sample by including
dummy variables for each country. All variables were included in the models as categorical
variables with the exception of number of chronic conditions, mobility, pain/discomfort,
affect, sleep/energy, cognition, and disability (continuous variables). The sample weighting
and the complex study design were taken into account in all analyses. Results from the regres-
sion analyses are presented as odds ratios (ORs) with 95% confidence intervals (CIs). The level
of statistical significance was set at P<0.05.

Results
A total of 42,469 (China n = 14,811; Ghana n = 5108; India n = 11230; Mexico n = 2742; Russia
n = 4355; South Africa n = 4223) individuals aged 18 years were included. The overall mean
(SD) age was 43.8 (14.4) and 50.1% were females. The overall prevalence (95%CI) of high SB
(i.e., 8 hours/day) was 8.3% (7.1–9.7%) with the corresponding country-wise figures being:
China 9.0% (7.5–10.9%), Ghana 6.4% (5.1–8.1%), India 5.2% (4.2–6.4%), Mexico 3.9% (2.3–
6.5%), Russia 17.7% (11.6–25.9%), and South Africa 4.6% (2.2–9.4%). The overall median
(IQR) time spent sedentary per day was 180 (120–300) min. The sample characteristics (overall
and by country) are provided in Table 1. Russia had the highest proportion of older people,
females, secondary education, urban residents, and people living alone. South Africa and
Mexico had a high proportion of obese individuals and people engaged in low levels of physical
activity.
In the overall sample, urban setting and unemployment were the only significant correlates
of high SB (Table 2). In the individual countries, older age was a significant correlate of high
SB only in Ghana, India, and Mexico, while males were more sedentary only in India and
South Africa. Higher education was significantly associated with high SB only in Mexico,
while the richer were more likely to have high SB in China and Ghana.
In terms of the other correlates, in the overall sample, current smoking, BMI 30 kg/m2,
greater number of chronic conditions, poor self-reported health, higher disability levels, and
worse health status in terms of mobility, pain/discomfort, affect, sleep/energy, and cognition
were significantly associated with high SB (Table 3). These factors were significant correlates
in at least three of the countries with the exception of smoking, BMI, and number of chronic
conditions. BMI<18.5 kg/m2 was associated with high SB only in South Africa (P<0.05). For-
mer smoking was a significant correlate of high SB only in India and Mexico.

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 Correlates of sedentary behavior

Table 1. Sample characteristics (overall and by country).

Characteristic Category Overall China Ghana India Mexico Russia S. Africa
Sedentary behavior 8 hours/day 8.3 9.0 6.4 5.2 3.9 17.7 4.6
Sociodemographics
Age (years) 18–44 55.3 49.9 55.4 62.5 63.1 48.5 60.2
45–64 34.4 40.4 33.4 28.8 26.9 33.6 31.8
65 10.3 9.8 11.2 8.6 9.9 17.9 8.0
Sex Female 50.1 49.1 50.0 49.1 52.0 55.0 52.8
Education Secondary 56.9 62.5 36.6 38.7 48.4 96.8 62.5
Marital status Married/cohabiting 80.8 89.0 72.6 81.9 69.7 61.1 52.8
Living arrangement Alone 5.7 5.8 6.3 0.8 0.7 18.8 9.5
Setting Urban 44.4 48.5 45.8 25.5 77.7 81.5 69.3
Employment status Unemployed 38.5 32.3 18.4 44.1 48.3 36.6 59.1
Health behavior
Smoking Never 60.5 64.3 84.0 55.2 59.4 58.6 69.7
Current smoker 35.2 32.2 8.2 42.5 25.0 28.9 24.2
Former smoker 4.3 3.5 7.8 2.3 15.6 12.5 6.1
Alcohol consumption Never 68.3 66.5 44.8 84.0 45.3 19.2 76.5
Non-heavy 26.3 24.9 52.5 15.3 45.6 70.8 15.4
Heavy 5.4 8.6 2.7 0.7 9.1 10.0 8.1
Physical inactivity Yes 17.9 23.1 15.7 12.5 28.8 11.0 42.0
Physical health
Body mass index (kg/m2) <18.5 16.8 4.1 9.2 36.0 0.9 1.5 3.2
18.5–24.9 55.3 63.8 56.9 52.6 21.4 41.5 35.3
25.0–29.9 20.9 27.3 21.8 9.1 49.1 36.6 28.5
30.0 7.0 4.9 12.1 2.3 28.5 20.4 33.0
No. of chronic conditions Mean (SD) 1.0 (1.2) 0.8 (1.0) 0.8 (0.9) 1.0 (1.3) 1.0 (1.2) 1.3 (1.6) 0.9 (1.0)
Mobilitya Mean (SD) 1.8 (2.4) 1.1 (1.8) 2.2 (2.5) 2.5 (2.6) 1.8 (2.5) 2.1 (2.6) 1.4 (2.5)
Pain/discomforta Mean (SD) 2.0 (2.4) 1.3 (2.0) 2.6 (2.5) 2.6 (2.7) 2.0 (2.4) 1.8 (2.4) 2.0 (2.6)
Mental health
Affecta Mean (SD) 1.6 (2.4) 0.6 (1.6) 2.0 (2.5) 2.6 (2.6) 2.1 (2.4) 1.4 (2.2) 2.2 (2.6)
Sleep/energya Mean (SD) 1.7 (2.3) 1.1 (1.9) 1.9 (2.5) 2.1 (2.5) 1.6 (2.2) 2.5 (2.4) 1.8 (2.6)
Cognitiona Mean (SD) 1.7 (2.4) 1.1 (2.0) 1.9 (2.5) 2.3 (2.6) 1.4 (2.0) 1.5 (2.2) 1.5 (2.4)
General health
Disabilitiyb Mean (SD) 1.0 (1.5) 0.4 (0.8) 1.2 (1.6) 1.6 (1.7) 0.9 (1.4) 1.1 (1.4) 1.1 (1.7)
Self-rated health Poor 11.3 11.4 9.2 11.3 7.2 11.4 10.0

Abbreviation: SD Standard deviation; S. Africa South Africa

Data are % unless otherwise stated.
Estimates are based on weighted sample.
a
Scores range from 0–10 with higher scores indicating worse health status.
b
Disability was assessed by WHODAS 2.0 with scores ranging from 0–10. Higher scores indicate higher levels of disability.

https://doi.org/10.1371/journal.pone.0202222.t001

Discussion
The current study provides a comprehensive overview of data on SB correlates in six LMICs,
which collectively account for 43% of the world’s adult population [20, 21]. The overall preva-
lence of high SB was 8.3%. The overall median amount of SB was 180 min/day. We found that
in the overall sample, being unemployed and living in an urban setting were the most impor-
tant sociodemographic correlates of high SB. In the health-related domains, smoking, physical

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 Correlates of sedentary behavior

Table 2. Sociodemographic correlates of highly sedentary behaviora estimated by multivariable logistic regression (overall and by country).
Characteristic Category Overall China Ghana India Mexico Russia S. Africa
OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI]
Age (years) 18–44 1.00 1.00 1.00 1.00 1.00 1.00 1.00
45–64 0.81 0.58 0.93 1.16 1.43 0.91 0.99
[0.60,1.08] [0.38,0.88] [0.52,1.66] [0.78,1.73] [0.58,3.48] [0.42,1.98] [0.37,2.67]
65 1.45 0.88 1.96 3.02 2.79 0.98 1.72
[0.95,2.20] [0.60,1.29] [1.18,3.24] [2.05,4.46] [1.15,6.80] [0.26,3.79] [0.63,4.72]
Sex Male vs. Female 1.21 1.18 0.67 1.49 0.87 0.87 5.94
[0.94,1.56] [0.87,1.61] [0.38,1.19] [1.02,2.17] [0.24,3.07] [0.53,1.42] [1.33,26.52]
Education Secondary vs. Else 1.01 0.90 1.00 1.02 2.37 0.80 0.98
[0.76,1.36] [0.56,1.46] [0.55,1.82] [0.64,1.63] [1.36,4.13] [0.45,1.44] [0.30,3.23]
Wealth Poorest 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Poorer 1.09 1.43 1.68 1.05 0.49 1.08 1.54
[0.75,1.56] [0.95,2.16] [0.87,3.23] [0.58,1.92] [0.12,1.90] [0.52,2.25] [0.29,8.03]
Middle 1.29 2.39 1.30 0.65 0.74 1.52 3.60
[0.79,2.09] [1.39,4.09] [0.62,2.72] [0.34,1.24] [0.15,3.55] [0.47,4.94] [0.65,19.84]
Richer 0.82 2.02 1.70 0.54 1.27 0.44 0.52
[0.54,1.24] [1.18,3.44] [0.84,3.44] [0.26,1.11] [0.30,5.29] [0.21,0.93] [0.08,3.23]
Richest 1.27 3.09 2.81 0.72 2.48 0.70 0.14
[0.81,2.00] [1.79,5.34] [1.16,6.80] [0.34,1.53] [0.69,8.92] [0.23,2.19] [0.02,1.12]
Marital status Not Married/cohabiting vs. Else 1.23 1.43 1.19 1.29 2.44 0.83 1.56
[0.96,1.60] [0.93,2.22] [0.69,2.05] [0.96,1.75] [0.76,7.85] [0.56,1.23] [0.46,5.27]
Living alone Yes vs. No 1.53 1.61 1.03 0.78 0.92 2.08 0.80
[0.90,2.60] [0.97,2.67] [0.51,2.06] [0.24,2.48] [0.30,2.84] [0.68,6.39] [0.18,3.67]
Setting Urban vs. Rural 1.69 1.95 1.07 1.64 5.92 1.07 2.76
[1.27,2.24] [1.24,3.07] [0.61,1.88] [0.98,2.73] [2.34,14.97] [0.54,2.14] [1.05,7.24]
Unemployment Yes vs. No 1.53 1.61 1.36 1.39 0.91 1.75 6.10
[1.11,2.12] [1.01,2.56] [0.82,2.25] [1.01,1.92] [0.29,2.88] [0.77,3.95] [1.50,24.75]

Abbreviation: S. Africa South Africa

Models are adjusted for all variables in the Table. The overall model is additionally adjusted for country.
a
Those reporting 8 or more hours per day spent sedentary were considered to be highly sedentary.

https://doi.org/10.1371/journal.pone.0202222.t002

inactivity, BMI 30 kg/m2, greater number of chronic conditions, poor self-reported health,
higher disability levels, and worse health status in terms of mobility, pain/discomfort, affect,
sleep/energy, and cognition were significantly associated with high SB. We also encountered
several between-country differences in terms of the correlates.

Sociodemographic SB correlates
Among the sociodemographic factors, being unemployed was an important sociodemographic
correlate of high SB levels overall. One hypothesis that might partially explain this association
is that those who are unemployed may also have several chronic physical and mental health
conditions, which in our study were associated with higher levels of SB. It might be speculated
as well that being employed increases levels of social connectedness, which may lead to less SB
and more opportunities for leisure time physical activity [31]. Another consideration is that
typical jobs in LMICs often involves manual labor, thus higher physical activity and less SB.
Apart from being unemployed, our study suggests that people living in urban environments
were more likely to engage in high SB than those living in rural areas. It might be hypothesized

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 Correlates of sedentary behavior

Table 3. Correlates (health behavior, physical health, mental health, general health) of highly sedentary behaviora estimated by multivariable logistic regression
(overall and by country).
Characteristic Category Overall China Ghana India Mexico Russia S. Africa
OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI] OR [95%CI]
Health behavior
Smoking Never 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Current smoker 1.49 1.15 0.54 1.37 2.50 2.81 0.65
[1.06,2.09] [0.70,1.89] [0.28,1.06] [0.90,2.08] [0.92,6.77] [1.44,5.49] [0.21,2.00]
Former smoker 1.11 0.82 0.80 3.58 5.21 1.16 0.42
[0.74,1.67] [0.51,1.33] [0.40,1.60] [1.77,7.25] [1.71,15.88] [0.65,2.10] [0.10,1.69]
Alcohol consumption Never 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Non-heavy 1.04 0.66 1.19 1.70 1.24 1.61 1.15
[0.74,1.47] [0.38,1.13] [0.69,2.05] [1.04,2.80] [0.49,3.13] [0.80,3.22] [0.33,4.05]
Heavy 0.92 0.75 0.23 0.97 0.47 1.41 1.05
[0.51,1.66] [0.33,1.69] [0.08,0.62] [0.36,2.62] [0.06,3.87] [0.53,3.73] [0.20,5.51]
Physical health
BMI (kg/m2) <18.5 1.11 1.47 0.82 0.83 1.00 1.01 10.37
[0.79,1.56] [0.54,4.03] [0.46,1.45] [0.62,1.11] [1.00,1.00] [0.41,2.50] [1.36,78.94]
18.5–24.9 1.00 1.00 1.00 1.00 1.00 1.00 1.00
25.0–29.9 1.02 1.15 1.58 1.45 0.84 0.60 1.96
[0.79,1.32] [0.81,1.63] [0.80,3.09] [0.82,2.56] [0.19,3.70] [0.41,0.88] [0.60,6.37]
30.0 1.54 1.37 1.67 1.18 1.85 1.14 2.22
[1.05,2.28] [0.74,2.55] [0.83,3.33] [0.44,3.21] [0.41,8.29] [0.61,2.16] [0.83,5.95]
No. of chronic conditions per increase in one condition 1.14 1.15 1.04 1.17 1.10 1.06 1.10
[1.03,1.26] [0.95,1.39] [0.86,1.25] [1.07,1.28] [0.81,1.49] [0.86,1.30] [0.72,1.67]
Mobilityb per unit increase 1.18 1.21 1.10 1.15 1.25 1.16 1.39
[1.12,1.25] [1.10,1.32] [0.97,1.23] [1.08,1.24] [1.04,1.51] [1.04,1.29] [1.16,1.68]
b
Pain/discomfort per unit increase 1.11 1.11 1.04 1.08 1.00 1.12 1.59
[1.06,1.16] [1.02,1.21] [0.94,1.15] [1.03,1.14] [0.82,1.22] [1.03,1.21] [1.29,1.95]
Mental health
Affectb per unit increase 1.16 1.14 0.94 1.13 1.07 1.26 1.24
[1.09,1.24] [1.04,1.24] [0.85,1.04] [1.05,1.20] [0.91,1.26] [1.07,1.49] [1.00,1.54]
Sleep/energyb per unit increase 1.15 1.09 1.03 1.10 1.02 1.27 1.28
[1.10,1.20] [1.02,1.18] [0.93,1.15] [1.04,1.15] [0.84,1.23] [1.14,1.41] [1.04,1.57]
Cognitionb per unit increase 1.07 1.02 0.96 1.08 1.16 1.11 1.43
[1.03,1.13] [0.94,1.10] [0.87,1.07] [1.02,1.15] [0.93,1.44] [1.01,1.24] [1.12,1.82]
General health
Self-rated health Poor vs. not poor 2.27 2.08 1.41 2.91 1.90 2.06 1.29
[1.74,2.96] [1.31,3.29] [0.90,2.19] [2.09,4.06] [0.66,5.45] [1.10,3.88] [0.72,2.34]
Disabilityc per unit increase 1.35 1.33 1.15 1.20 1.36 1.55 1.90
[1.26,1.44] [1.17,1.52] [0.99,1.33] [1.10,1.31] [1.11,1.68] [1.35,1.78] [1.49,2.41]

Abbreviation: S. Africa South Africa; BMI Body mass index

Models are adjusted for age, sex, education, wealth, marital status, living arrangement, setting, and unemployment. The overall model is additionally adjusted for
country.
a
Those reporting 8 or more hours per day spent sedentary were considered to be highly sedentary.
b
Scores range from 0–10 with higher scores indicating worse health status.
c
Disability was assessed by WHODAS 2.0 with scores ranging from 0–10. Higher scores indicate higher levels of disability.

https://doi.org/10.1371/journal.pone.0202222.t003

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 Correlates of sedentary behavior

that urban employment (e.g., service-based jobs) is more sedentary than rural employment
(e.g., farming). Cities in LMICs are also often more likely to have higher traffic and crime
which reduces activity and may promote more sedentary lifestyle. These factors are linked to
more motorized transport use and higher risk for depression [32], which in turn, are also
linked to SB. Evidence from prospective studies suggests that in cities, the built environment,
which can be defined as the totality of places built or designed, including buildings, grounds
around buildings, layout of communities, transportation infrastructure and parks and trails
[33], is an important determinant of TV viewing time and other screen behaviors [34]. A
4-year follow-up study in Australia [35] identified that adults in low-walkable neighborhoods
increased their TV viewing time compared with those who lived in high-walkable neighbor-
hoods. Given that much of the evidence on the relationship of environmental attributes
with SB comes from studies in Australia, Belgium, and the USA [34], the full range of
these environmental exposures and their impacts on SB remain to be examined in LMICs [36].
Also, differences between countries in LMICs need to be explored in more detail in terms of
its association with urbanicity as the association was particularly strong in South Africa and
Mexico.
Older age was associated with higher levels of SB in Ghana, India, and Mexico which is con-
sistent with previous data from the general population in Western countries [13]. Given the
unfavorable biomarker profile associated with SB in older adults [37], our data add to the need
to develop and test interventions to reduce SB in older age in LMICs.
Other socio-demographic factors showed mixed results depending on the country. For
example, in contrast with Western studies [13], Indian and South African men were more
likely to be highly sedentary. It might be that in these countries, particularly in more rural
areas, women are more responsible for the livelihood of the family, thus, spending less time
sedentary. Clearly, future research is required to clarify gender differences in SB in the LMIC
context. Nonetheless, the present findings suggest that interrupting sedentary time may be
especially important for men in India and South Africa.
Our data was in agreement with research conducted in Western countries [38], demon-
strating that richer people were more likely to be highly sedentary in China and Ghana. In
urban centers of LMICs, a more Western lifestyle may be evident such as the use of more
motorized transport, less labor-demanding jobs, and physically undemanding, mostly screen-
based leisure, which may account for the higher sedentary levels in richer individuals in these
settings.
More research to clarify the between-country differences (e.g., age difference) is needed but
it can be hypothesized that other country-specific factors, which were not accounted for in the
current analyses, are important for explaining SB. For example, job characteristics, access to
sports facilities, socio-cultural beliefs about being physically active, and the level of awareness
about the benefits of avoiding SB following public health campaigns should be explored in
more detail.

Health behavior correlates

In agreement with data from Western studies [13, 14], smoking and physical inactivity but not
alcohol consumption was associated with being more sedentary. SB, physical inactivity and
smoking may be reflecting a clustering of unhealthy lifestyles and behavior which is increasing
in LMICs [39]. The observation that high sedentary levels are also associated with physical
inactivity may especially be a relevant target for interventions, as recent findings suggest that
the hazardous effects of SB may be reduced if people are highly active [22].

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 Correlates of sedentary behavior

Health-related correlates
The current study suggests that SB is associated with a higher number of chronic conditions,
which is in line with the wider high-income literature [13–15]. Given the inability to ascertain
temporality with the SAGE cross-sectional design, it is plausible to suggest that multi-morbid
people engage in more SB because of the associated mobility restrictions, pain/discomfort, or
mental health burden (affect, sleep/energy problems) associated with chronic conditions. It is
however equally plausible as well to suggest that prolonged SB may precipitate the develop-
ment of chronic conditions, pain/discomfort, or mental health problems. Our data do suggest
that interventions focusing on reducing SB should consider chronic conditions, pain/discom-
fort, and mental health problems. In LMICs, chronic pain conditions are leading causes of
years lived with disability and a recent meta-analysis demonstrated that 35% of working adults
had chronic pain [40]. In addition, in Western populations, it has been established that chronic
pain is associated with higher SB levels, possibly due to psychological concerns about falling
and lower balance confidence [41]. Previous research has also demonstrated that people with
mental health problems may be more likely to have chronic pain [42, 43], which impacts upon
mobility [44], and this may predispose the individual to sedentary behavior [41]. Previous
research in Western populations has also demonstrated that SB may increase the risk of devel-
oping anxiety [6] and depression [5], possibly through increasing inflammatory markers [45].
Another hypothesis is that being sedentary and not engaging in activities may lead to social
solitude and withdrawal from interpersonal relationships, both of which have been linked to
increased feelings of social anxiety and depression [46]. Cognitive problems were another
important mental health correlate of high SB. Cognitive problems are associated with impair-
ments in executive functioning and this can result in an increased risk of falls, mainly in older
people. Falls are associated with a fear of falling again and avoidance of activities [47].
There were also some country-specific differences. For example, underweight was associ-
ated with high SB only in South Africa. Low body weight may be an indicator of malnourish-
ment or other serious health problems such as HIV, which is highly prevalent in South Africa,
and is associated with being more sedentary [48]. Differences in associations between SB and
mental and physical health parameters may also be explained by variations in the use of health
care services. It is possible for example that differences in out-of-pocket payments may influ-
ence our findings to some extent. When out-of-pocket payments are high, people often delay
or defer accessing or using services even if they believe to be in need. Out-of-pocket payments
account for a large share of total health expenditure in LMICs [49]. In 2010, out-of-pocket
expenditure as a percentage of total health expenditure was 35% in China, 28% in Ghana, 62%
in India, 47% in Mexico, 36% in the Russian Federation, and 7% in South Africa [49]. Defer-
ring treatment or receiving suboptimal treatment may mean that the underlying conditions
leading to SB may be more severe in some countries.

Limitations and future research

Whilst our data has a number of strengths, it should be considered in the light of some limita-
tions. First, the study is cross-sectional, therefore directionality cannot be deduced. Thus,
future prospective research is required to explore the directionality and mediators of the rela-
tionships observed in our study. Longitudinal studies will also allow identification of true
determinants of SB and clearly separate them from correlates. Second, SB was measured with a
self-report questionnaire, which is known to be prone to bias and less accurate than objective
assessments [50, 51]. It is well known that self-reported measures can underestimate sedentary
levels [52]. For instance, previous self-reported data on SB among older adults in the general
population found that high-income adults engaged in 5.3 hours of SB per day, while this figure

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 Correlates of sedentary behavior

increased to 9.4 hours per day when relying on objective measures [3]. In addition, since the
survey was conducted between 2007 and 2010, it is possible that our results may not reflect the
current situation in the countries included in the study. Finally, Given the large number of
comparisons made, there is the possibility for Type I errors.

Conclusions
Our data provides some guidance that in order to reduce the burden of SB, health policy mak-
ers in LMICs should focus on unemployed people and those living in urban centers. Our data
add additional, albeit cross-sectional evidence to previous concerns that urbanization, which
may offer many opportunities in LMICs, including potentially better access to mental and
physical health care, can also introduce new hazards such as a sedentary lifestyle and conse-
quently a higher risk for NCD. Finally, national health policies focusing on reducing SB should
consider a wide range of physical and mental health barriers.

Supporting information
S1 Table. Questions used to assess self-reported diagnosis.
(DOCX)
S2 Table. Questions and answer options used for symptoms-based diagnosis.
(DOCX)
S3 Table. Questions used to assess health status.
(DOCX)

Author Contributions
Conceptualization: Ai Koyanagi, Brendon Stubbs, Davy Vancampfort.
Formal analysis: Ai Koyanagi, Brendon Stubbs, Davy Vancampfort.
Funding acquisition: Ai Koyanagi.
Investigation: Ai Koyanagi, Brendon Stubbs, Davy Vancampfort.
Methodology: Ai Koyanagi, Brendon Stubbs, Davy Vancampfort.
Supervision: Brendon Stubbs, Davy Vancampfort.
Writing – original draft: Ai Koyanagi, Brendon Stubbs, Davy Vancampfort.
Writing – review & editing: Ai Koyanagi, Brendon Stubbs, Davy Vancampfort.

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